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Health Assessment Exam 2 > CV Assessment > Flashcards

CV Assessment Flashcards

1
Q

What are the 5 steps of the cardiac pre-op assessment?

A
  1. Urgency of surgery
  2. Determine if active cardiac condition
  3. Determine surgical risk
  4. Assess functional capacity
  5. Assess clinical predictors/markers
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2
Q

What are some MINOR clinical predictors of increased cardiac risks?

A
  • Uncontrolled HTN
  • Abnormal ECG
  • Low functional capacity
  • Rhythm other than sinus rhythm
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3
Q

What are some INTERMEDIATE clinical predictors of increased cardiac risk?

A
  • Known CAD
  • Prior MI > 1 month and Q waves on ECG
  • History of mild, stable angina
  • Compensated or previous LV failure/CHF
  • Diabetes
  • Chronic renal insufficiency (CR > 2.0mg/dL)
  • Cerebrovascular disease (stroke, TIA)
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4
Q

What are some MAJOR clinical predictors of increased cardiac risk? (active cardiac conditions)

A
  • Unstable coronary syndromes
  • Acute or recent MI < 1 month
  • Unstable or severe angina
  • Decompensated CHF
  • Significant arrhythmias
  • Severe valvular disease
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5
Q

What is the overall mortality risk of acute MI after GA and what increases this risk?

A

0.3%, increased with intra-thoracic or intra-abdominal surgery or surgery lasting longer than 3 hours.

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6
Q

What is the mortality risk of acute MI after GA if the pt has a history of a prior MI? What is the mortality rate if reinfarction occurs?

A
  • If the MI was greater than 6 months ago, the incidence is 6%
  • If the MI was 3-6 months ago, the incidence is 10%
  • If the MI was within 3 months, the incidence is 30%
  • If reinfarction occurs the mortality rate is 50%
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7
Q

When is the highest risk period for reinfarction during GA? How long do ACC/AHA guidelines recommend waiting post MI before elective surgery?

A

Highest risk period is within 30 days after acute MI. The ACC/AHA guidelines recommend waiting at least 4-6 weeks post MI before elective surgery.

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8
Q

What surgeries are considered high risk for MI?

A
  • Intraperitoneal
  • Intrathoracic
  • Aortic surgery/other major vascular surgery
  • Emergent major operations (especially in the elderly)
  • Prolonged procedures with large fluid shifts/blood loss
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9
Q

What surgeries are considered to be intermediate risk for MI?

A
  • Carotid endarterectomy
  • Peripheral vascular surgery
  • Head and neck
  • Neurologic/orthopedic
  • Endovascular aneurysm repair
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10
Q

What are some CV adjunct tests that can be performed?

A
  • Chest x-ray
  • Labs
  • Stress testing
  • Echocardiography
  • MRI
  • CAT scan
  • Coronary angiography (gold standard for coronary anatomy)
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11
Q

What are some questions to ask during the CV history?

A
  • Do you have shortness of breath lying flat (orthopnea)?
  • Do you have shortness of breath with exertion?
  • Do you have congestive heart failure?
  • Do you have a history of a heart attack?
  • Do you have angina with activity or at rest? Chest pain/pressure/tightness related to your heart? What are the precipitating factors, associated symptoms, frequency, duration and methods of relief?
  • Do you have an irregular heartbeat or palpitations?
  • Do you have a pacemaker or ICD?
  • Do you have a heart murmur?
  • Have you had any previous diagnostic tests or therapies?
  • Who is your treating physician(s)?
  • Do you have problems with blood pressure or HTN?
  • Do you have PVD?
  • Do you have a history of TIA/CVA?
  • Do you have diabetes?
  • Renal insufficency?
  • High cholesterol?
  • Estrogen status?
  • Age and weight?
  • Fatigued?
  • Syncope?
  • Anemia?
  • Smoke or drink alcohol?
  • Illicit drug use?
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12
Q

What is the most striking evidence of decreased cardiac reserve?

A

Exercise tolerance in absence of significant lung disease.

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13
Q

Describe the levels of the Duke Activity Status Index.

A

1-4 METS: eating, dressing, walking around the house, dishwashing

4-10 METS: climbing stairs, walking in the neighborhood, heavy housework, golfing, bowling dancing

> 10 METS: strenuous sports

Patients unable to meet a 4 MET demand are considered to be at higher risk

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14
Q

What percent of ischemic episodes in CAD occur without angina?

A

80%

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15
Q

What percent of acute MIs are silent?

A

10-15%

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16
Q

What is Prinzmetal’s angina?

A

Vasospastic angina that occurs at rest.

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17
Q

What percent of patients with Prinzmetal’s angina have a fixed proximal lesion in a major artery?

A

85%, 15% just have spasm.

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18
Q

What other disorders to patients with Prinzmetals angina have a higher incidence of?

A

Migraine headaches and Raynaud’s.

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19
Q

What things should you know about a patient with a pacemaker/ICD?

A
  • Indication for the pacemaker/ICD?
  • Underlying rhythm and rate
  • The type of pacemaker, the chamber paced, and the chamber sensed
  • Have the pacemaker or defibrillator interrogated, noting current settings and battery life
  • Evaluate effect of magnet
  • Inactive ICD tachyarrhythmia detection and put defibrillator pads on
  • Device should be evaluated within 3-6 months before surgery
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20
Q

What precautions should be taken for a patient with a pacemaker/ICD?

A
  • Electromagnetic interference can occur with electrocautery, which can inhibit pacemaker firing
  • Have a magnet immediately available: most pacemakers can be converted to a fixed rate by placing a magnet over the pacemaker box
  • Grounding pads should be as far from the pulse generator and leads as possible
  • Bipolar electrocautery is preferred; avoid monopolar
  • Monitor some form of blood flow (pulse ox, intra-arterial BP measurement)
  • Have external pacing available.
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21
Q

What is involved in the physical CV exam?

A

Overall appearance: obesity, SOB, sternal incision, pacemaker box

Heart: Heart sounds/murmurs

Neck: JVD, Carotid bruit

Lungs: Lung sounds, SOB, effort

Vital signs: BP in both arms

Extremities: peripheral edema, pulses, clubbing, skin color

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22
Q

How is hypertension defined?

A

BP readings greater than 140/90

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23
Q

When should HTN be treated?

A

When SBP >160 and diastolic >90

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24
Q

What drugs may have a protective benefit for HTN patients?

A

Beta blockers

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25
Q

What are risk factors of HTN?

A
  • Major risk factor for cardiovascular mortality

- Increases incidence of stroke, CHF, MI and progression to renal insufficiency and malignant hypertension

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26
Q

What interventions should be taken for a pre-op patient with hypertension?

A
  • May need to delay surgery
  • Need ECG and CR/BUN
  • If on diuretics get a chem 7
  • Continue meds
  • Anxiolytics
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27
Q

What are the ACC/AHA recommendations for beta blocker therapy perioperatively?

A
  • Continue beta blocker therapy because discontinuation may increase perioperative CV morbitiy
  • Give beta blockers to high risk patients having vascular surgery
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28
Q

Describe heart failure.

A

Abnormal contractility or abnormal relaxation of the heart muscle

29
Q

What are some causes of heart failure?

A

HTN, IHD.

30
Q

What are some symptoms of heart failure?

A
  • Orthopnea
  • Nocturnal coughing
  • Fatigue
  • Peripheral edema
  • 3rd/4th heart sounds
  • Resting tachycardia
  • Rales
  • JVD
  • Ascites
  • LVH on ECG
31
Q

When should surgery be postponed for a patient with heart failure?

A

-Decompensated heart failure or left ventricle function is high risk and elective surgery should be postponed

32
Q

What tests should be ordered for patients with HF?

A
  • ECG
  • Chem 7
  • BUN/CR
  • BNP <100pg/mL
  • CXR if suspected pulmonary edema
  • Echo to measure LVEF
33
Q

What should be done for a patient with a valvular abnormality?

A
  • Identify the type of valvular lesion
  • Evaluate clinical symptoms and testing data
  • Severe aortic stenosis poses the greatest risk if the valve area is less than 1cm2
  • If they are symptomatic you may want to postpone surgery
  • Diastolic murmurs are always pathologic and require further evaluation
  • If the patient has a prosthetic heart valve you may need to bridge anticoagulant therapy and may need subacute bacterial endocarditis prophylaxis
34
Q

How should you manage a patient with arrhythmias?

A
  • SVT and ventricular arrhythmias are associated with perioperative risk
  • LBBB is strongly associated with coronary artery disease
  • If new LBBB stress testing or consultation is needed
35
Q

When should you postpone surgery for patients with arrhythmias?

A
  • Uncontrolled or new onset a fib
  • Ventricular tachycardia
  • Symptomatic bradycardia
  • High-grade or third degree HB
36
Q

What are some common medications that cardiac patients may be on?

A
  • Beta blockers
  • Statins
  • Aspirin
  • Ace inhibitors/ARBs
  • Calcium channel blockers
  • Nitro
  • Diuretics
  • Antiarrhythmics
37
Q

When should Aspirin and Plavix be discontinued prior to surgery?

A

7-10 days prior

38
Q

When should coumadin be discontinued before surgery and what should the INR be before surgery?

A

Discontinue 3-5 days, INR <1.5

39
Q

When should LMWH be discontinued before surgery?

A

12 hours prior

40
Q

When should you order a chest x-ray before surgery?

A
  • Pt is over 75 years old
  • History of CHF
  • Symptomatic cardiovascular disease
41
Q

What pathologies can you see with a chest x-ray?

A
  • Cardiomegaly
  • Pulmonary vascular congestion/pulmonary edema
  • Pleural effusions
42
Q

When should a pre-op ECG be ordered?

A
  • At least 1 clinical risk factor having vascular surgery
  • CAD, PAD, CVD having intermediate or high risk surgery
  • Maybe if no clinical risk but vascular surgery or at least 1 clinical risk factor having intermediate or high risk surgery
  • Do not get on asymptomatic patients and low risk surgery
43
Q

What should the pre-op ECG be reviewed for?

A
  • Acute myocardial ischemia
  • Prior myocardial infarction
  • Rhythm or conduction disturbances
  • Cardiomegaly or ventricular hypertrophy
  • Other abnormalities/electrolyte imbalances
44
Q

What are the 5 principle indicators of ischemia on an ECG?

A
  • ST segment elevation greater than 1 mm
  • ST segment depression, flat or downslope of greater than 1mm
  • T wave inversion
  • Peaked T waves
  • Development of Q waves
45
Q

What are the inferior leads and what artery supplies this area of the heart?

A
  • AVF, II, III

- RCA

46
Q

What are the posterior leads and what artery supplies this area of the heart?

A
  • V1, V2, V3

- RCA

47
Q

What are the antero-septal leads and what artery supplies this area of the heart?

A
  • V1, V2, V3, V4

- LAD

48
Q

What are the lateral leads and what artery supplies this area of the heart?

A
  • I, AVL, V5, V6

- Circumflex branch of LCA

49
Q

When should a pre-op ECG be performed?

A

Within 30 days of surgery

50
Q

What lab data could be useful for the cardiac patient?

A
  • K+
  • BUN/Cr
  • ABGs
  • Hgb/Hct
  • INR/PT
51
Q

Describe treadmill stress testing.

A

-Simulates sympathetic nervous system stimulation by increasing BP and HR and therefor increasing myocardial O2 demand and consumption.

52
Q

What is looked for with treadmill stress testing and what is it interpreted based on?

A
  • Look for ischemia by ECG changes
  • Interpreted based on:
  • Duration of exercise the patient can perform
  • Max HR achieved
  • Time of onset of ST depression
  • Degree of ST depressoin
  • Time until resolution of the ST segment
53
Q

What ECG criteria and non-ECG responses indicate a positive treadmill stress test?

A

ECG criteria:
-ST-segment depression>2.5mm
-ST-depression occurring in first 3 minutes of test
-Serious ventricular arrhythmias
-Prolonged duration of ST depression in post recovery period
Non-ECG criteria:
-If increase in BP or HR occurs at time of ST depression
-If hypotension occurs it is an ominous sign

54
Q

Describe pharmacologic stress testing and what patients it is used on.

A
  • Useful in patients unable to exercise
  • Looks for ischemia by perfusion imaging, not ECG changes
  • IV injection of 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 are of decreased perfusion only during stress shows ischemia, whereas a constant perfusion defect suggests old MI
  • Areas of redistribution defects are at higher risk of ischemia and infactrion
55
Q

When do you request cardiac stress testing?

A

-Active cardiac conditions (unstable coronary syndromes, unstable or severe angina, reent MI, decompensated HF, significant arrhythmias, severe valvular disease)
-3 or more clinical risk factors and poor functional capacity having vascular surgery
-Maybe if:
~At least 1-2 clinical risk factors and poor functional capacity having intermediate risk surgery if it will change management
~At least 1-2 clinical risk factors and good functional capacity having vascular surgery

56
Q

What can be determined from an echocardiogram?

A
  • Measurement of the dimensions of cardiac chambers and vessels and the thickness of the myocardium
  • Global ventricular systolic function: EF
  • Regional wall motion abnormalities
  • Valve structure and motion
  • Can detect blood flow and measure gradients
  • Chamber enlargement
  • Detection of pericardial fluid
57
Q

Describe what a stress echo looks for, what an abnormal result consists of and what it predicts.

A
  • Looks 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 on infusion of dobutamine
  • Highly predictive of adverse cardiac events
58
Q

When do you order a pre-op Echo?

A
  • Current or prior HF with worsening dyspnea or other change in clinical status
  • Dyspnea of unknown origin
  • Maybe for aortic stenosis
59
Q

What is the best method for defining coronary anatomy?

A

Coronary angiography

60
Q

What information is obtained from coronary angiography?

A
  • Diffuseness of obstructive disease
  • Adequacy of any previous angioplasties or bypass grafts
  • CA spasms
  • LV pressures, volumes, and EF
  • Valvular lumen area and valve gradients: pressure gradients across valves and shunts as well as degree of regurgitation, PA pressures, CO and SVR
61
Q

What is the gold standard test for undergoing cardiac surgery?

A

Coronary angiography

62
Q

When should a patient have a pre-op cath?

A
  • Stable angina with left main CAD
  • Stable angina with 3 vessel disease
  • Stable angina with 2 vessel disease with significant proximal LAD lesion and EF <50% or demonstrable ischemia on noninvasive stress testing
  • High-risk unstable angina or non-ST elevation MI
  • Acute ST-elevation MI
63
Q

How long after a balloon angioplasty should a pt wait before surgery?

A

At least 14 days

64
Q

How long after a Bare-metal stent should a pt wait before surgery?

A

At least 30-45 days

65
Q

How long after a drug-eluting stent should a patient wait before surgery?

A

At least 365 days

66
Q

What are MRIs used to assess and what can they detect/determine in cardiac patients?

A
  • Used to assess function and viability of myocardium
  • Sensitive in detecting infarctions using gadolinium
  • Good at determining intracardiac tissue characterization
67
Q

What conditions are considered high risk for development of subacute bacterial endocarditis?

A
  • Prosthetic heart valves
  • History of infective endocarditis
  • Unrepaired cyanotic congenital heart disease
  • Repaired congenital heart defect with prosthetic material or device, during the 1st 6 months after the procedure
  • Repaired congenital heart disease with residual defects
  • Cardiac transplant recipients with cardiac valvular disease
68
Q

For patients with high risk of subacute bacterial endocarditis when is antibiotic prophylaxis recommended?

A
  • All dental procedures that involve manipulation for gingival tissue, perforation or oral mucosa, or the periapical region of teeth
  • Invasive respiratory tract procedures with incision or biopsy or respiratory mucosa
  • NOT recommended in genitourinary or gastrointestinal tract surgery unless there is a current UTI
69
Q

Describe the dosing of antibiotics for subacute bacterial endocarditis.

A
  • All administered as a single dose given 30-60 min before surgery
  • Ampicillin 2 gmIV or Cefazolin 1 gm IV of Ceftriaxone 1 gm IV
  • If PCN allergy use clindamycin 600mg IV

Health Assessment Exam 2 (6 decks)

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