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CV Assessment Flashcards

1
Q

The goal of preop cardiac assessment

A

is to identify patients with heart disease who are at high risk for perioperative cardiac morbidity or mortality or those with modifiable conditions or risk.

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2
Q

5 steps of CV assessment

A

Step 1: urgency of surgery
Step 2: determine if active cardiac condition
Step 3: determine surgical risk
Step 4: assess functional capacity
Step 5: assess clinical predictors/ markers

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3
Q

Minor Clinical Predictors of Increased Cardiovascular Risk (6)

A 
1- Uncontrolled HTN
2- Advanced age >75 yrs old
3- Abnormal ECG
4- Low functional capacity
5- Hx CVA
6- Rhythm other than sinus rhythm
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4
Q

Intermediate Clinical Predictors of Increased Cardiovascular Risk (6)

A

1- Known CAD
2- Prior MI > 1 month and Q waves on ECG
3- History of mild, stable angina
4- Compensated or previous LV failure / CHF
5- Diabetes
6- Chronic renal insufficiency (CR > 2.0 mg/dL)

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5
Q

Major Clnical Predictors of Increased Cardiovascular Risk (6)

(Active Cardiac Conditions)

A

1- Unstable coronary syndromes
2- Acute or recent MI < 1 month
3- Unstable or severe angina
4- Decompensated CHF
5- Significant arrhythmias (SVT, Sympt Brady, Vent, complete AV)
6- Severe valvular disease (aortic stenosis)

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6
Q

The overall mortality risk of acute MI after GA is

Risk post intra ab/thor or long surg

A

about 0.3%

incidence is increased in the patient undergoing intra-thoracic or intra-abdominal surgery or surgery lasting longer than 3 hours

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7
Q

If history of prior MI, periop risk of reinfarction

> 6 months

3-6 months

< 3 months

mortality if reinfarction occurs

A

greater than 6 months ago, the incidence of

perioperative myocardial reinfarction is about 6%

3-6 months ago, the incidence is 15%

within 3 months, 30%
If reinfarction occurs, the mortality rate is @ 50%

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8
Q

Highest risk period of MI

A

< 30 days

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9
Q

ACC/AHA guidelines recommend wait for surg post MI

A

wait 4-6 weeks

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10
Q

High risk surgery (4)

A

1- Aortic surgery and other major vascular surgery
2- peripheral vascular surgery
3- emergent major operations (esp. elderly),
4-prolonged procedures with large fluid shifts/blood loss.
> 5% additional risk

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11
Q

Intermediate risk surgery (7)

A 
1- Intraperitoneal, 
2- intrathoracic, 
3- transplant, 
4- carotid endarterectomy,
5-  head and neck, 
6- major neurologic/orthopedic, and 
7- endovascular aneurysm repair.
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12
Q

Low risk surgery (6)

A 
1- Endoscopic procedures, 
2- superficial, 
3- biopsies,
4- cataract, 
5- breast surgery, 
6- GYN.
< 1%
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13
Q

Basic Components of CV assessment

A 
1- History taking
2- Medications 
3- Physical exam
4- Resting 12-Lead ECG, if indicated
within 30 days of surgery
(EKG indicated if ID cardiac risk)
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14
Q

Adjunct Testing

A 
Chest X-Ray
Labs  
Stress testing
Echocardiography
MRI
CAT scan
Coronary angiography 
(Gold Standard-for coronary anatomy)
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15
Q

Goal of history is to elicit

A

if there are clinical predictors of cardiac dx

severity
progression
functional limitations

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16
Q

Cardiac Specific Questions To Ask?

A 
Short of breath lying flat (orthopnea)? 
With exertion?
Congestive heart failure?
Heart attack? 
Angina (with activity/ @ rest), or chest pain/ pressure/ tightness related to your heart? Irregular heartbeat or palpitations?
Pacemaker? ICD?
Heart murmur?
Diagnostic tests, therapies, names of treating physician?
Problems with blood pressure or HTN?
PVD?
TIA/CVA?
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17
Q

ROS questions

A 
Diabetes?
Renal insufficiency?
High cholesterol?
Estrogen status?- post menopausal need supplements dues to cardio protectiom
Age and weight?
Fatigued?
Syncope?
Anemia?
Smoke or drink alcohol?
Illicit drug use?
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18
Q

Most significant evidence of cardiac dx evident by

A

Exercise tolerance - in the absence of significant lung disease, is the most “striking” evidence of decreased cardiac reserve.

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19
Q

How is exercise tolerance / functional capacity evaluated

A

Duke Activity Status Index

1-4 METS (eating, dressing, walking around house, dishwashing)
4-10 METS (climbing stairs, walk in neighborhood, heavy housework, golf, bowl, dance)
> 10 METS (strenuous sports ie:swimming, tennis, running, football, basketball)
Those patients unable to meet a 4-MET demand are considered to be at higher risk.

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20
Q

Angina sign of…

Angina in AS…

Angina with esophageal spasm…

A

Angina – sign of imbalance between myocardial oxygen supply vs. demand

Aortic Stenosis pts may experience angina despite normal coronaries.

Esophageal spasm caused by heartburn can result in angina-like pain and can be relieved by NTG.

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21
Q

% of ischemic episodes in cad wo angina

% of MI wo angina

A

80%

10-15%

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22
Q

Prinzmetal’s Angina def..

% of lesion % with spasm

associated co disease

A

Vasospastic angina that occurs at rest.

In 85%, there is a fixed proximal lesion in a major artery. 15% have just spasm.

Patients have a higher incidence of migraine HA and Raynaud’s perhaps due to a basic vaso-spastic disease.

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23
Q

Things to know about AICD pacer (6)

What to do during surgery

When should it be evaluated

A

1- The indication for insertion of the pacemaker or ICD
2- The underlying rhythm and rate
3- The type of pacemaker ( demand, fixed, or radiofrequency), the chamber paced, and the chamber sensed
4- Have the pacemaker or defibrillator interrogated by a qualified member of CIED
5- Note current settings and battery life
6- Evaluate effect of magnet

  • Inactivate ICD tachyarrhythmia detection and put defibrillator pads on
  • Device should be evaluated within 3-6 months before surgery
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24
Q

Electromagnetic interference occurs w and inhibits

A

can occur with electrocautery, which can inhibit pacemaker firing

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25
Q

Have a magnet immediately available for

A

convert to a fixed rate (asynchronous mode)

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26
Q

Grounding pads should be placed

A

as far from the pulse generator and leads as possible

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27
Q

Bi vs monopolar

A

Bipolar electrocautery is preferred; avoid monopolar

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28
Q

Additional monitoring with pacer aicd (2)

A

1- Monitor some form of blood flow (pulse oximetry, intra-arterial BP measurement)

2- Have external pacing available

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29
Q

Components of physical exam (6)

A 
1- overall appearance 
2- Heart
3- neck
4- lungs
5- vs
6- extremities
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30
Q

Overall appearance

A

Obesity
SOB
Sternal incision, pacemaker box

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31
Q

Heart

A

Heart sounds

Murmurs

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32
Q

AV

A

2nd IC rt sternal border

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33
Q

PV

A

2nd IC LT sternal border

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34
Q

TV

A

4 or 5th IC lt sternal border

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35
Q

MV

A

5th IC let mid clavicular

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36
Q

Neck

A

JVD

Carotid Bruit

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37
Q

Lungs

A 
Lung sounds (rales)
SOB, effort
38
Q

Vital signs

A

(BP in both arms)

39
Q

Extremities

A

Peripheral edema
Pulses
Clubbing
Skin color

40
Q

Major risk for cv mortality

A

HTN

41
Q

HTN increases the incidence of (4)

A

1-stroke,
2- CHF,
3- MI
4- progression to renal insufficiency and malignant hypertension

42
Q

Treat HTN if

A

SBP > 160 mmHg and diastolic BP >90 mmHg

Beta-blockers may have a protective benefit

43
Q

If patient has long-standing severe HTN or uncontrolled HTN

Consideration: surgery, labs, meds

A

1- may need to delay surgery to control BP

2- need ECG and serum CR/BUN

3- If on diuretics, CHEM 7

4- Continue meds

5- Antianxiolytics

44
Q

ACC/AHA Beta Blocker Therapy

recommendations

A

ACC/AHA recommendations:
1- Continue beta blocker therapy bc
Discontinuation may increase perioperative CV morbidity
2- Give beta blockers to high risk patients having vascular surgery

45
Q

Heart Failure def..

Caused by.. (2)

A

Abnormal contractility or abnormal relaxation of the heart muscle

Can be caused by HTN, IHD

46
Q

HF suspected Symptoms (10)

A 
1-  orthopnea, 
2- docturnal coughing, 
3- fatigue, 
4- peripheral edema, 
5- 3rd/4th heart sound, 
6- resting tachycardia, 
7- rales, 
8- JVD, 
9- ascites
10- LVH on ECG should raise suspicion
47
Q

Decompensated HF/ LV function level of risk and plan

A

is high-risk and elective surgery should be postponed.

48
Q

When a Patient has Heart Failure.. tests plan (5)

labs, meds, tests

A 
1- ECG
2- Chem 7, BUN/ CR
BNP (Brain naturetic peptide)
< 100pg/mL
3- CXR, if suspected pulmonary edema
4- Echo, as objective measure of  LVEF
5- Continue all medications, including beta blockers, hydralazine, nitrates, digoxin, ACEIs, ARBs, diuretics,  anticoagulants (if possible)
49
Q

Valvular Abnormalities

Identify and evaluate..

greatest risk..

If symptoms..

A

Identify type of valvular lesion
Evaluate clinical symptoms and testing data

Severe aortic stenosis poses the greatest risk, if valve area is < 1cm2

If symptoms, postpone surgery

50
Q

If prosthetic heart valve in place 2 medication considerations

A

1- May need to bridge anticoagulant therapy

2- May need SBE (subacute bacterial endocarditis) prophylaxis

51
Q

Diastolic murmurs

A

Diastolic murmurs always pathologic and require further evaluation

52
Q

Arrhythmias of greatest risk (2)

A

SVT and ventricular arrhythmias associated with perioperative risk

53
Q

LBBB is strongly associated with…

if new, order…

A

associated w/ CAD

If new, stress testing or consultation needed

54
Q

Postpone surgery if having these arrhythmia.. (5)

A 
1- Uncontrolled atrial fibrillation
2- Ventricular tachycardia
3- New-onset atrial fibrillation
4- Symptomatic bradycardia
5- High-grade or third degree HB
55
Q

Meds to look for

A 
Beta blockers
Statins
ACE inhibitors/ ARBs
Calcium channel blockers
Nitro for angina
Diuretics
Antiarrhythmics
56
Q

In medication hx, Must ask about these 2..

A

Need to ask about anticoagulants and antiplatelet medications

57
Q

Anti platelet discontinuation

A

Antiplatelet (ASA, Plavix)

Discontinue 7-10 days prior surgery

58
Q

Anticoagulants (Coumadin, LMWH) discontinuation

A

Anticoagulants (Coumadin, LMWH)
Discontinue 3-5 days (Coumadin)
INR <1.5
Discontinue 12 hours prior (LMWH)

59
Q

Fibrinolytic drugs discontinuation

A 
Fibrinolytic drugs (TPA,Streptokinase, Urokinase)
Usually cannot discontinue
60
Q

Order CXR preop if: (3)

A

1- Over 75 years old
2- History of CHF
3- Symptomatic cardiovascular disease

61
Q

CXR is specific for (4)

not specific for..

A

1- Cardiomegaly
2- Pulmonary vascular congestion/ pulmonary
3- edema (CHF)
4- Pleural effusions

Not specific for Ischemic Heart Disease

62
Q

12-Lead ECG reviewed for (6)

A

1) Acute Myocardial ischemia
2) Prior myocardial infarction
3) Rhythm or conduction disturbances
4) Cardiomegaly or ventricular hypertrophy
5) Other ECG abnormalities,
6) Electrolyte imbalances

63
Q

ECG Indicators of Acute Ischemia (5)

A

5 Principle Indicators:

1- ST segment elevation , ≥1mm 
2- T wave inversion 
3- Development of Q waves 
4- ST segment depression, flat or downslope of  ≥1mm
5- Peaked T waves
64
Q

Inferior II, III, AVF

A

RCA

65
Q

Lateral I, AVL, V5, V6

A

LCA circumflex

66
Q

Antero-Septal

V1,V2, V3,V4

A

LAD

67
Q

Posterior V1, V2, V3

A

RCA

68
Q

When to do an 12-Lead ECG? (2)

When to maybe do an EKG (2)

Not needed in

A

1- At least 1 clinical risk factor having vascular surgery
2- Known CAD, PVD, CVD having intermediate or high risk surgery

Maybe, if—
1- No clinical risk but vascular surgery
2- At least 1 clinical risk factor having intermediate or high risk surgery

Not needed in asymptomatic patients having low risk surgery

69
Q

ACC/AHA recommends ECG

A

within 30 days of surgery

70
Q

Lab DataTo ascertain general medical condition related to comorbidities

A 
K+
BUN/ Cr
ABG’s
Hbg/ Hct
INR/ PT
71
Q

Treadmill Exercise Stress Testing

Looks for..

Procedure..

A

Simulates sympathetic nervous system stimulation by increasing BP and HR and therefore increasing myocardial O2 demand and consumption w/ exercise

Looks for ischemic changes

72
Q

Treadmill st interpreted based on: (5)

A

a) Duration of exercise the patient can perform
b) Max. HR achieved
c) Time of onset of ST depression
d) Degree of ST depression
e) Time until resolution of the ST segment

73
Q

Positive test

Predicts..

Determined by (2)..

A

predictive of CAD

1- ECG criteria
ST-segment depression > 2.5mm
ST-depression occurs early in test (first 3 minutes)
Serious ventricular arrhythmias
Prolonged duration of ST depression in post recovery period

2- Non-ECG responses
If increase in BP or HR occurs at time of ST-depression
If hypotension occurs
Hypotension an ominous sign

74
Q

Pharmacologic Stress Testing useful for…

Looks for ischemia by…

A

Useful in patients unable to exercise

Look for ischemia by perfusion imaging, not ECG changes

75
Q

Pharm ST components

A

IV injection of gamma-emitting radiopharmaceutical (thallium) that permits the imaging of blood within the heart and lungs.

Dipyridamole or adenosine administered as a vasodilator to increase coronary blood flow

The area of decreased perfusion (cold spot) only during stress shows ischemia, whereas a constant perfusion defect suggests old MI.

Areas of redistribution defects are at higher risk of ischemia and infarction

76
Q

When to Request Stress Testing? (2)

A 
1-Active cardiac condition
Unstable coronary syndromes
Unstable or severe angina
Recent MI 
Decompensated HF
Significant arrhythmias
Severe valvular disease

2-
3 or more clinical risk factors and poor functional capacity having vascular surgery

77
Q

When Maybe to Request Stress Testing?

A

Maybe if:
1- At least 1-2 clinical risk factors and poor functional capacity having intermediate risk surgery if it will change management

2- At least 1-2 clinical risk factors and good functional capacity having vascular surgery

78
Q

Echocardiography 7 measurements

A

1-Measurement of the dimensions of cardiac chambers and vessels and the thickness of the myocardium
2-Global ventricular systolic function: EF
3-Regional wall motion abnormalities
4-Valve structure and motion
5-Can detect blood flow and measure gradients
6-Chamber enlargement
7- Detection of pericardial fluid

79
Q

Stress Echocardiography looks for

abnormal results consist of..

A

1- Look for regional wall motion abnormalities under stress.

An abnormal result consists of new regional wall motion abnormalities or worsening of existing regional wall motion abnormalities during an infusion of dobutamine (exercise/stress)

80
Q

Highly predictive of adverse cardiac events

A

Abnormal stress echo

81
Q

When to Order a Preop Echo

3

A

1-Current or prior heart failure
with worsening dyspnea or other change in clinical status
2-Dyspnea of unknown origin
3-?Aortic stenosis

82
Q

Coronary Angiography Information obtained (7)

A

1- Diffuseness of obstructive disease
2-Adequacy of any previous angioplasties or bypass grafts
3-CA spasms
4- LV pressures, volumes, and EF
LV dysfunction: akinesis, dyskinesis, low EF, high LVEDP
5-Valvular lumen area and valve gradients
Pressure gradients across valves and shunts, as well as degree of regurgitation
6-PA pressures
7- CO and SVR

83
Q

Provides best method defining coronary anatomy

A

Coronary Angiography

84
Q

Gold standard test for undergoing cardiac surgery

A

Coronary Angiography

85
Q

When to Have a Preop Catheterization? 5

A

1- Stable angina with Left main CAD

2- Stable angina with 3-vessel disease

3- Stable angina 2-vessel disease with significant proximal LAD lesion and EF <50% or demonstrable ischemia on noninvasive stress testing

4- High-risk unstable angina or non-ST elevation MI

5- Acute ST-elevation MI

86
Q

MRI used for (3)

A

1- Used to assess function and viability of myocardium

2- Highly sensitive in detecting infarctions using gadolinium

3- Also good at determining intracardiac tissue characterization

87
Q

BALLOON ANGIOPLASTY and surgery time

A

wait >14 days

88
Q

BARE-METAL STENT and surgery time

A

wait > 30-45 days

89
Q

DRUG-ELUTING STENT and surgery time

A

wait > 365 days

90
Q

Subacute Bacterial Endocarditis (SBE) Prophylaxis recommended for

Patients..

Procedures..

not recommended for..

A

For patients with
1- high cardiac risk, antibiotic prophylaxis is recommended for:

2- All dental procedures that involve manipulation for gingival tissue, perforation of oral mucosa, or the periapical region of teeth

3- Invasive respiratory tract procedures with incision or biopsy of respiratory mucosa

NOT recommended in genitourinary or gastrointestinal tract surgery

91
Q

High-Risk Cardiac Conditions requiring SBE prophylaxis (6)

A

High-Risk Cardiac Conditions
1- Prosthetic heart valves

2- History of infective endocarditis

3- Unrepaired cyanotic congenital heart disease

4- Repaired congenital heart defect with prosthetic material or device, during the 1st 6 months after the procedure

5- Repaired congenital heart disease with residual defects

6- Cardiac transplantation recipients with cardiac valvular disease

92
Q

Subacute Bacterial Endocarditis (SBE) Prophylaxis

TX

A

single dose
given 30-60 min. before procedure

Ampicillin 2 gm IV
Or Cefazolin 1 gm IV
Or Ceftriaxone 1 gm IV

If PCN allergic, Clindamycin 600 mg IV

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