CV diseases Flashcards
stages of bp
Normal: <120/<80
Elevated: 120-129/<80
HTN Stage 1: 130-139 or 80-89
HTN Stage 2: 140 + or 90+
HTN Urgency: >180/120 no signs of end- organ dysfunction (prompt referral)
Emergency (urgency plus end organ dysfunction)
define htn
A PATHOLOGIC DYSREGULATION OF THE HOMEOSTATIC MECHANISMS THAT CONTROL BLOOD PRESSURE
can be essential or secondary
essential - no cause?
secondary is from a disease process that also causes htn
medications treat htn
Ca2+ channel blockers, Ace inhibitors, Angiotensin receptor blockers, Beta Blockers, Thiazide diuretics, direct renin inhibitors, Alpha-2 agonists
(need to know how these work)
how does HTN effect surgery/sedation:
- Defer elective surgery if not controlled
- Continue anti-HTN medications (especially B Blockers) except for ACE inhibitors/arbs and
diuretics - Consider pre-op labs (BMP, EKG) to look at kidney function (BUN/Cr) and potassium levels
- Intra-op BP within 20% of baseline
- Avoid Ketamine (sympathomimetic)
- Activate emergency system (911 vs Code Blue) for BP >180/120 with s/s of end organ dysfunction (MI, dyspnea, AMS, seizures, etc.)
- For HTN crisis, slowly reduce BP, too fast can lead to MI and cerebrovascular ischemia
- continue taking htn medications EXCEPT ARBs and ACE inh because this can cause refractory hypotension via anesthetic medications
angina
Reversible hypoperfusion of coronary artery system leading to chest pain
stable angina
reversible hypo perfusion of the Coronary artery system, Symptoms with exertion, relieved with rest (5-10 mins), indication that vessels are 70% + stenotic
unstable angina
symptoms with exertion and not relieved by rest, or chest pain at rest
STEMI
MI with st segment elevation, you see this in an occlusive thrombus, transmural infarct
NSTEMI
MI without st segment elevation
can see t wave inversion or st segment depression
due to partially occlusive thrombus, that results in subendocardial infarct.
Ischemic cardiac disease soundbite
in the cardiac tissue there is not enough oxygen for the demand needed. often secondary to stenotic and occluded coronary arteries.
MI soundbite
Infarct of myocardium secondary to hypoperfusion
how does stent effect your surgery?
non cardiac surgery can be carried out 6 weeks after stent
non emergent surgery should wait 6 mo regardless of stent type
keep on asa and clopidogrel if possible
give anxiolytics, profound local with cardiac restriction (40mcg, 2 carps?)
EKG
BP and HR 20% of baseline
how to calculate cardiac risk if symptoms of Acute Coronary Syndrome (ie chest pain
HEART score for major cardiac events
points for:
1) suspicious history
2) EKG changes concerning
3) age less than 45, 45-64, 65 plus
4) risk factors: THN, hypercholesterolemia, dm, obesity BMI greater than 30, smoking or smoking within 3 mo, positive family history, prior MI, PCI, cab, cv/tia, peripheral artery disease
5) troponin
rcri for and components
rcri revised cardiac risk index - 30 day risk of death, MI, cardiac arrest
1) elective surgery
2) hx of ischemic heart disease
3) CHF
4) strok/tia
5) pre-op tx with insulin
6) pre-op creatinine greater than 2 mg/dL
CHF soundbite
is THE HEART fails TO PUMP ENOUGH BLOOD TO MEET THE METABOLIC DEMANDS OF THE TISSUES
types:
preserved ejection fraction (diastolic) ef greater than 50% - issues with filling often secondary to wall thickness
reduced ejection fraction (systolic hf) - ef reduced less than 40%. often impaired contractility
CHF classification system
New York heart association classification - classified on physical activity limitation
-Class 1: Heart disease with no symptoms or
limitations of physical activity
- Class 2: No symp at rest, slight limitations with ordinary activity
- Class 3: Marked limitation of activity with minimal exertion
- Class 4: Symptoms at rest. Severe limitation of activity
s/s of CHF and workup and tx
edema, dvd, hepatomegaly, s3/s4
order ekg, echo, car, labs
bnp (35 pg/mL, 100 pg/mL) (non acute and acute)
and
diuretics, beta blockers
Cardiomyopathy soundbite and diagnostic test
is a disease process affecting the myocardium that impairs the heart’s ability to pump or fill
diagnostic test is echocardiogram
also can get CHF in cardiomyopathy
types of cardiomyopathy
- Hypertrophic Cardiomyopathy (non-obstructive type): MCC is HTN,
thickened walls, reduced space for blood
¡ Hypertrophic Obstructive Cardiomyopathy: Similar to above but with obstruction of outflow by interventricular septum blocking blood flowing out of the aorta. Genetic (AD). Common cause of young athletes dying
¡ Dilated Cardiomyopathy: Opposite from above, can FILL but can cannot pump, MCCs are MI, alcoholism
¡ Restrictive Cardiomyopathy: A little different, problems with filling and pumping, Rigidity of the myocardium, have histologic damage, infiltration, MCC is sarcoidosis, also can be amyloidosis, hemochromatosis, scleroderma, malignancy often from mets
atrial fibrillation soundbite
Abnormal electric foci in the atrium leading to irregularly irregular rhythm (as only some electricity gets to AV node) kk addition parenthesis
virchows triad, vte risk
endothelial damage, stasis of flow, hyper coagulable state
what used to predict stroke in fib
cha2ds2vasc
CHF
htn
age greater than 65, and greater than 75
Diabetes
stroke
vascular disease
female
predict bleeding risk for people on aticoag in atrial fibrillation
HASBLED
Cardiac Transplant considerations with surgery
- full medical with their transplant team
Heavily immunosuppressed
¡ Resting HR of 90-100
¡ Transplanted heart is denervated, no symp/parasymp inputs, DOES NOT respond to indirect-acting meds (neostigmine, glycol, atropine)
¡ Ephedrine is decreased
¡ Norepi, Epi, B Blockers work
¡ Residual atrial tissue from the original heart, uncommon but does happen, can cause a double P wave on EKG
secondary htn can be caused by
pheochromocytoma
renal artery stenosis
polycythemia vera
cushings syndrome
coarctation of the aorta
hyperaldosteronism
pregnancy
renal parenchymal disease
poorly controlled htn can cause
remember can be associated:
L ventricular hypertrophy
ischemic heart disease
chf
renal insufficiency
retinopathy/vision loss
tia/stroke
PVD
amlodipine, felodipine, diltiazem, verapamil are examples of htn, cad
ca channel blockers - vasodilation by decreasing calcium ion influx
decrease oxygen demand by decreasing heart rate and contractility (only some of the above…)
-pril (lisinopril, fosinopril, knalapril, captopril, ramipril)
ace inhibitors -
block the conversion of angiotensin 1 to 2 which inhibits vasoconstriction and decreases aldosterone effects which decreases blood pressure
CAD - the decreased vasoconstriction decreases the after load and helps prevent aberrant cardiac remodeling
- sartan
losartan, valsartan, olmesartan, telmisartan
Angiotensin II receptor blockers (ARBs)
block the effects of angiotensin II which inhibits vasoconstriction and decreases aldosterone effect like ace inhibitors
-lol, metoprolol, atenolol, esmolol, carvedilol, labetalol and effect of local? htn, cad
beta blockers
block beta adrenergic receptors - decreasing myocardial contractility and rate, decrease renin production, relaxation of smooth muscles
CAD - decrease oxygen demand by decreasing heart rate and contractility
amide anesthetics metabolism can be reduced in people taking beta blockers
hydrochlorothiazide and chlorthalidone
thiazide diuretics
block reabsorption of NaCl in the nephron decreasing intravascular volume
intraoperative hypotension treat with
ephedrine or phenylephrine, phenylephrine can cause reflex bradicardia
ace inh and arbs - with sedation consideration
intraoperative refractory hypotension and
check bmp to rule out hypokalemia
atherosclerosis soundbite and pathophys ACS
hardening of the arteries due to lipid accumulation within the arterial wall
lipids get in via endothelial damage, if the fibrous cap ruptures there is a thrombotic lipid core and can cause ACS/infarction of that tissue
dyslipidemia and contributing factors to CAD
total cholesterol of greater than 240 mg/dl
elevated ldl
(and elevated hdl) - protective against atherosclerosis
-tobacco - enhances oxidation of ldl, endothelial dysfunction, increased platelet adhesiveness
-htn - damages endothelium - increases permeability of lipoproteins
-diabetes - glycosylation of ldls to increase their effect
-lack of physical activity
-estrogen protective, postmenopausal women increase risk
workup for angina
stress test,
pharmacologic testing with dipyridamole thallium when unable to exercise,
echocardiogram (wall fin, EF, valvular function), and
coronary angiography for stenotic coronary arteries (which is the gold standard)
isosorbide mononitrate or nitroglycerin
nitrates -
ventilation, decrease preload and dilates coronary arteries
ranolazine
inhibits sodium channels in myocardial cells which leads to less contractility
which drugs increase the amount of time the heart spends in diastole?
calcium channel blockers and beta blockers
important with CAD people because this is when coronary perfusion occurs - in diastole, makes sense
clopidogrel, prasurgel, ticagrelor
adp receptor inhibitors
decrease add activation of platelet aggregation to prevent coronary thrombosis
-statin, atorvastatin, simvastatin
hmm coa reductase inhibitors that decrease circulating LDL levels, decreasing atherosclerosis
mets and when to consider cardiac testing/hospital
strenuous/jumping rope - greater than 10 METS
7-10 - jogging/calisthenics
4-6 - power walking, sex, leisure biking
less than 4 mets, consider cardiac testing/hospital setting
surgical mgmt of CHF patient
positioning,
oxygen
BMP - hypokalemia because of diuretics, etc
Avoid NSAIDs - puts at risk for renal failure
careful with fluids
tx in hospital setting
types of acute coronary syndrome
check: per Andrew OSFC
Angina (unstable?) - will likely clinically be reversible with rest or nitro and NEGATIVE for troponins. could potentially see ST depression??
NSTEMI - positive for trops, could see st depression or inverted T waves- and is an endocardial infarct
STEMI - positive for troponins, st elevation and is a transmural infarct
if you have a transplanted heart what medications will work and what medications won’t work?
only medications that work directly on the heart WILL work: Epi, beta blockers an glucagon? (per nick OSFC)
for example indirect will not work - like phenylephrine
s3 heart sound
look up
