CV pathophysiology Flashcards
1
Q
high risk procedures for a patient with CAD include (4)
A
emergency surgery (esp in elderly)
open aortic surgery
peripheral vascular surgery
long surgical procedures with volume shifts and/or blood loss
2
Q
general risk factors for cardiac risk patients include (6)
A
high risk surgery
hx of ischemic heart disease (unstable angina confers greatest risk of perioperative MI)
CHF
CVD
DM
serum creatinine >2
3
Q
risk of reinfarction after MI is:
>6 mo:
3-6 mo:
<3 mo:
A
> 6 mo: 6%
3-6 mo: 15%
<3 mo: 30%
4
Q
intermediate risk surgeries include (5)
A
CEA
head and neck surgery
intrathoracic or inter peritoneal surgery
ortho surgery
prostate surgery
5
Q
low risk surgeries include (5)
A
endoscopic procedures
cataract surgery
superficial procedures
breast surgery
ambulatory procedures
6
Q
NYHA classification, level of impairment, and functional limitation (4 classes)
A
7
Q
which classes of NYHA patients should be referred to a cardiologist before surgery
A
class 3 or 4
unless its a minor procedure under MAC
8
Q
PAOP is a surrogate for
A
LVEDP
ex) CPP=DBP-LVEDP but only have PAOP
9
Q
CKMB initial elevation, peak elevation, return to baseline after MI
A
initial: 3-12h (same as Troponin I and T)
peak elevation: 24h
return to baseline: 2-3d
10
Q
Troponin I initial elevation, peak elevation, return to baseline after MI
A
initial: 3-12h (same as CKMB and troponin T)
peak elevation: 24h
return to baseline: 5-10d
11
Q
Troponin T initial elevation, peak elevation, return to baseline after MI
A
initial: 3-12h (same as CKMB and Troponin I)
peak elevation: 12-48h
return to baseline: 5-14d
12
Q
best leads to use to detect an MI and WHY
A
leads II, V5.
lead II: aids in ID of inferior wall ischemia. also monitors for dysrhythmias where QRS is narrow and P wave is crucial for dx
V5: classic teaching says this is best for LV ischemia but new data says maybe V3/4 is best,
CHOOSE V4 on NCBRNA***
13
Q
CVP and PAOP may over estimate LVEDV for any condition that does what?
A
reduces ventricular compliance
14
Q
name examples that would shift the compliance curve to the red (highest) (5)
A
age >60y
ischemia
pressure overload hypertrophy (aortic stenosis or HTN)
hypertrophic obstructive cardiomyopathy
pericardial pressure (increased external pressure)
15
Q
etiology of HFrEF (systolic failure)
A
pumping problem
MI
valve insufficiency
dilated cardiomyopathy
16
Q
etiology of HF with preserved EF (diastolic failure) (7)
A
filling problem
MI
valve stenosis
HTN
hypertrophic cardiomyopathy
cor pulmonale **
obesity*
17
Q
compare systolic HF and diastolic HF in terms of
EDV
EDP
ESV
SV
LV mass
LV geometry
A
18
Q
which drugs can reverse cardiac remodeling
A
ACEI’s and spironolactone (aldosterone antagonists)
19
Q
compare anesthetic management of systolic HF and diastolic HF in terms of
preload
afterload
contractility
HR
A
20
Q
most common cause of RV failure
A
LV failure
21
Q
tx for RV failure includes
A
inotropes (milrinone, dobut)
pulmonary vasodilators (inhaled NO or sildenafil, PDE5)
reverse cause of increased PVR
22
Q
conditions that increase PVR (5)
A
increased PEEP
N2O
Hothermia
acidosis
hypercarbia
23
Q
list 4 physiologic adaptations of HF
A
- SNS activation
- excessive vasoconstriction
- fluid retention
- myocardial remodeling
24
Q
3 physiologic functions of BNP
A
- natriuresis
- diuresis
- vasodilation
25
how does CHF effect beta receptors?
causes down regulation of beta receptors
26
most common cause of constrictive pericarditis
cardiac surgery
27
the patient has an aortic balloon pump. which part of this arterial BP waveform corresponds with diastolic augmentation and improvement of coronary BF?
remember balloons inflates during diastole. pressure is higher than unassisted systole. balloon deflates during systole to decrease after load.
28
which region of the pressure volume loop corresponds to S3 heart sound?
best heard during the middle 1/3 of diastole after S2 (aortic valve closure)
gallop, suggestive of HF but can be a normal finding in children and teens.
29
with a patient who has an LVAD, CO is highly dependent on
preload
30
mnemonic for debakey classification of aneurysm: BAD
B: both (type 1)
A: ascending (type 2)
D: descending (type 3)
31
stage 1 HTN
130-139 SBP OR 80-89 DBP
32
stage 2 HTN
SBP >140 OR DBP >90
33
stage 3 HTN (hypertensive crisis)
SBP >180 and/or DBP >120
34
cerebral auto regulation happens between a CPP of
50-150mmHg
35
what does chronic HTN do to cerebral auto regulation
36
SBP and DBP that permit anesthesia delay
SBP >180 and DBP >110
37
when does a HTN crisis turn into a HTN emergency
evidence of end organ damage ex) encephalopathy, stroke, papilledema, CHF, renal dysfunction
38
coarctation of aorta clinical findings and diagnostic tests
clinical findings: upper limb BP > lower limb BP, weak femoral pulse, systolic bruit, HTN
dx tests: aortography, echo, CT/MRI
39
renovascular disease clinical findings (3) and diagnostic tests (4)
clinical findings: HTN, bruit, severe HTN in young patient
dx tests: CT angiography, MRA, aortography, duplex ultrasonography
40
hyperadrenocorticism (cushings disease) clinical findings and diagnostic tests
clinical findings: HTN*, weight gain (truncal obesity), hyperglycemia, muscle and bone weakness, weakened immunity, hirsutism, moon face
dx: dexamethasone suppression test, glucose tolerance test, urinary cortisol, adrenal CT/MRI
41
hyperaldosteronism (conns disease) clinical findings and diagnostic tests
clinical findings: HTN*, hypokalemia, alkalosis, fatigue/weakness, parasthesia, nocturnal polyuria/polydipsia
dx: Cp aldosterone, Cp renin, Cp K, urinary potassium
42
pheochromocytoma clinical findings and diagnostic tests
clinical findings: HA, palpitations, diaphoresis
dx: plasma metanephrines, urinary catecholamines, urinary vanillylmandelic acid (VMA)
43
pregnancy induced HTN clinical findings (4) and diagnostic tests (4)
clinical findings: peripheral and pulmonary edema, HA, sz, RUQ pain
dx: urinary protein, platelet count, uric acid, CO
44
how alpha 1 antagonists decrease BP
decrease iCa2+ and decrease SVR
45
how B1 antagonists decrease BP
decrease inotropy, chronotropy, HR, dromotropy, and renin release from juxtaglomerular apparatus
46
selective B1 antagonists
acebutolol
atenolol
bisoprolol
esmolol
metoprolol
47
non selective b1 and b2 antagonists
nadolol
pindolol
propanolol
sotalol
timolol
48
mixed a1/b1/b2 antagonists
bucindolol, carvedilol, labetalol
49
how a2 agonists decrease BP
decrease SNS outflow
50
how CCB's (dihydropiridines) decrease BP
decrease intravascular calcium and decrease SVR
51
how CCB's (non dihydropiridines including verapamil and diltiazem) decrease BP
targets myocardium more than vessels
deceased inotropy, chronotropy, dromotropy, svr
52
what hydralazine dilates primarily and how it decreases BP
arteriodilator that increases NO and decreases SVR (after load)
53
what SNP dilates primarily and how it decreases BP
equal arterial and venodilator and increases NO, decreases SVR (after load) and decreases venous return (preload)
54
what NTG primarily dilates and how it decreases BP
primarily venules, increases NO, decreases venous return (pre load)
55
MOA of ACEI's
inhibits ATII mediated vasoconstriction and inhibits aldosterone release
56
MOA of AT2 receptor blockers
inhibits ATII mediated vasoconstriction and inhibits aldosterone release
57
MOA of loop diuretics and examples
Inhibits Na/K/2Cl transporter in thick portion of ascending loop of henle. increased diuresis and decreased venous return
ex) furosemide, bumetanide, ethacrynic acid
58
MOA of thiazide diuretics and examples
inhibits Na/Cl transporter in distal convoluted tubule
diuresis- decreased venous return
ex) HCTZ, metolazone, indapamide, chlorthalidone
59
MOA of K sparing diuretics and examples
inhibits K excretion and Na reabsorption by principal cells in collecting ducts.
acts independently of aldosterone
ex) triamterene, amiloride
60
MOA of aldosterone antagonists and examples
inhibits K excretion and Na reabsorption by principal cells in collecting ducts.
blocks aldosterone at mineralocorticoid receptors
ex) spironolactone
61
compare and contrast dihydropiridines and non dihydropiridines in terms of
target
clinical effects
examples
62
which CCB impairs contractility the most
verapamil
63
only CCB shown to reduce M&M from cerebral vasospasm
nimodipine
64
clevidipine MOA
arterial vasodilator that reduces SVR without affecting preload
65
contraindications to clevidipine (3)
allergy to eggs, soy, egg products, soy products, severe AS***, impaired lipid metabolism
66
compare and contrast constrictive and acute pericarditis in terms of
cause
s/sx
tx
anesthetic management
67
becks triad
JVD (decreased venous return to right heart)
HoTN (decreased SV)
muffled heart tones (fluid accumulation around sac)
68
does pericardial effusion affect diastolic filling time or ventricular compliance
no because it doesn't increase pericardial pressure
69
best method of dx for cardiac tamponade
TEE
70
what pathophysiological issue is outlined by this pressure volume loop (green part)
cardiac tamponade. decreased LVEDV (loop shifts to left), decreased SV (loop is narrower), decreased ventricular compliance (notice higher slope during ventricular filling)
71
presentation of cardiac tamponade
becks triad (muffled heart tones, HTN, JVD), pulsus paradoxus, kussmauls sign (increased CVP and JDV during inspiration), reduced EKG voltage, compression of heart, lungs, trachea, esophagus
72
drugs to avoid and drugs that are safe to use during cardiac tamponade as well as other anesthetic management techniques
maintain SNS since SV is severely decreased and this helps with compensation
maintain spontaneous ventilation- PPV can impair venous return and CO
-local anesthesia is preferred for pericardiocentesis with spontaneous ventilation
73
hemodynamic goals for cardiac tamponade:
HR
preload
contractility
afterload
HR: maintain. since SV is reduced, CO is dependent on HR
preload: maintain or increase.
contractility: maintain or increase (inotropes)
afterload: maintain. essential to decrease SV and CO
74
patients at high risk for infective endocarditis that need prophylactic abx (6)
previous infective endocarditis
prosthetic heart valve
unprepared cyanotic congenital heart disease
repaired congenital heart defect if repair is less than 6 months old
repaired congenital heart defect that have residual effects and impaired endothelialization at the graft site
heart transplant with valvuloplasty
75
abx prophylaxis is not required for patients with a hx of (3)
unrepaired cardiac valve disease including mitral valve prolapse
CABG
coronary stent placement
76
procedures where abx prophylaxis to protect against endocarditis include
dental procedures with gingival manipulation and/or damage to mucosal lining
resp procedures that perforate mucosal lining with incision or biopsy
biopsy of infective lesions in skin or muscle
77
IV abx of choice if PCN allergic
clinda 600mg or for peds 20mg/kg
78
three things that determine BF through LVOT
1. systolic LV volume
2. force of LV contraction (decreasing contractility decreases obstruction and increases CO)
3. transmural pressure
79
LVOT is caused by
congenital hypertrophy of intraventricular septum
systolic anterior motion of anterior leaflet of mitral valve. occurs during systole!
80
if the patient has bare metal stent, delay surgery for
30 days
81
how long to wait for surgery if patient got angioplasty without stent
2-4 weeks
82
for stable ischemic heart disease, first generation drug eluding stents you should wait ______ months and current generation you can wait ______ months
12 months minimum for first gen
6 months minimum for current gen
83
for acute coronary syndrome, wait for surgery after insertion of drug eluding stent for
12 months minimum
84
after a CABG, wait how long until surgery
6 weeks
3 months preferred
85
stop ASA how many days before surgery if not absolutely contraindicated?
3 days
86
stop clopidogrel how many days before surgery
7 days
87
stop ticlodipine how many days before surgery
14 days
88
best outcome for stent occlusion is if intervention happens in
<90m
89
key facts of roller pump for CPB
compresses blood tubing that mechanically pumps blood forward
pump flow remains constant regardless of afterload
roller pump is more likely to entrain air if venous reservoir runs dry, which can lead to air embolism
90
key facts of centrifugal pump for CPB
non occlusive, uses gravity and spins blood through a cone.
less traumatic to blood cells
reduces pressure if increased after load is detected and has less chance of VAE
does have lack of an occlusion point. therefore if theres an excessively high after load, blood backs up towards venous circulation which reduces patients circulating BV.
91
oxygenator in CPB
point in CPB where gas exchange occurs.
membrane oxygenator uses blood membrane gas interface. safer.
92
you can prime CPB with
blood or balanced salt solution (mannitol, albumin, heparin, HCO3-)
93
ACT for CPB
>400 seconds
94
where is anterograde cardioplegia introduced
aortic root (where circulation gets to coronary arteries). aortic valve must be competent and the aorta must be clamped.
95
where is retrograde cardioplegia introduced
coronary sinus
96
the tip of an aortic balloon pump should be positioned
2cm distal to the left SCA
97
indications for IABP (4)
cardiogenic shock
MI
intractable angina
difficult separation from CPB
98
contraindications for IABP (4)
severe AI
descending aortic disease (aneurysm)
severe PVD
sepsis
99
how to confirm position of IABP (3 tests)
CXR, fluoro, TEE
100
outline arterial waveform and IABP
inflation correlates with dichrotic notch on aortic pressure wave form
101
deflation of IABP during systole correlates with what on EKG
R wave
102
when a patient has an LVAD, CO is dependent upon (3)
1. LV preload
2. Pump speed
3. pressure gradient across the pump (after load)
103
how LVAD works
pumps blood from LV to aorta
inflow of cannula is inserted into apex of LV. blood is returned to aorta through outflow cannula
104
with an LVAD, what are some issues the patient cannot have in order to receive it (4)
PFO, AI, tricuspid regurgitation, competent aortic valve
105
if a patient has an LVAD and the flow is non pulsatile how can you measure SpO2/NIBP (3)
aline, serial ABG's, cerebral oximetry
106
describe LV suck down when patient has LVAD
LV preload low, pump speed high. part of LV is sucked into LV cavity-occludes inflow cannula
five IVF and reduce pump speed
107
outline the crawford classification of aortic aneurysms
Type 1: outlines all or most of descending aorta and only upper part of abdominal aorta
Type 2: outlines all or most of descending aorta and most of of abdominal aorta
Type 3: only lower part of descending thoracic aorta and most of abdominal aorta
Type 4: none of descending thoracic aorta and most of abdominal aorta
108
classification of aortic dissection: stanford
type A: involves ascending aorta
type B: does not involve ascending aorta
109
classification of aortic dissection: debakey
BAD mnemonic
type 1: tear in ascending aorta and dissection along entire aorta
type 2: tear in ascending aorta and dissection only in ascending aorta
type 3: tear in proximal descending aorta with
3a: dissection limited to thoracic aorta
3b: dissection along thoracic and abdominal aorta
110
which crawford type aneurysms are the most difficult to repair
crawford type 2 and 3
111
which kind of aortic dissections are a surgical emergency
debakey 1 or 2 or stanford a (consider AI as well). this involves acute dissection of ascending aorta
112
dissection of descending aorta management
medical
113
how is AAA most commonly detected and what is the triad
pulsatile abdominal mass
HoTN, back pain, pulsatile abdominal mass
most aneurysms rupture in left retroperitoneum
114
most common cause of postop death after AAA repair
MI
115
which factors increase following cross clamp removal during AAA repair
PVR and total body O2 consumption increase
116
applying aortic cross clamp creates central hypervolemia by
reducing venous capacity
shifting greater proportion of blood volume to proximal clamp
increasing venous return
117
removing aortic cross clamp creates central hypovolemia by
restoring venous capacity
shifting greater proportion of blood to lower body
decreasing venous return
creating capillary leak that contributes to loss of intravascular volume
118
what is an EVAR
minimally invasive approach for correcting AAA
119
anesthetic management of EVAR patient
continuously monitor BP with aline
patient will receive IV contrast dye
maintain UOP
120
describe endoleak
when original graft fails to prevent blood from entering aortic sac. some resolve spontaneously while some need a new graft or open repair
121
2 posterior spinal arteries
aorta--> segmental a--> posterior radicular a -->posterior spinal artery
aorta --> SCA --> vertebral artery -->posterior spinal artery
122
what part of SC does posterior spinal arteries perfuse
posterior 1/3 of SC (in green)
123
what part of SC does anterior spinal artery perfuse
anterior 2/3 of SC (yellow)
124
where does artery of adamkeweisz most commonly originates from
T11-12
125
becks syndrome aka anterior spinal artery syndrome sx
flaccid paralysis of LE's
bowel and bladder dysfunction
loss of temperature and pain sensation
touch and proprioception are preserved
126
which spinal tracts are perfused via anterior blood supply
corticospinal tract (motor, flaccid paralysis)
autonomic motor fibers (bowel and bladder dysfunction)
spinothalamic (sensory tract, loss of pain and temperature sensation)
127
spinal cord protection strategies during thoracic cross clamp includes
moderate hypothermia (30-32c)
CSF drainage
proximal HTN during xclamp (MAP 100)
avoidance of hyperglycemia
SSEP/MEP monitoring
partial CPB (LA to femoral artery)
drugs (corticosteroids, CCB's, and/or mannitol)
128
what does SSEP monitor
only monitors posterior cord
129
sign of impending stroke during CEA
amaurosis fugax (blindness in one eye)
emboli travel from ICA to ophthalmic artery
130
ways to monitor neurological integrity and cerebral perfusion
keep patient awake
EEG
cerebral oximetry
transcranial doppler
SSEP
carotid stump pressure
131
after aortic cross clamping, reduce aortic BP to <
145mmHg systolic
132
postop considerations for CEA
hematoma
RLN injury
hemodynamic instability
carotid denervation
133
carotid artery angioplasty stenting (CAS)
uses percutaneous trans vascular access to pass stent into carotid artery
maintain ACT >250s
balloon inflation can activate baroreceptor reflex, pretx
filter placed beyond angioplasty balloon
embolic CVA treated with recombinant tissue plasminogen activator
134
in the patient with right subclavian steal syndrome, arterial flow is diverted from the
right vertebral artery to right SCA
135
describe subclavian steal syndrome
occlusion of sublavian or innominate a. proximal to origin of ipsilateral vertebral artery
-results in reversal of BF where vertebral BF flows toward ipsilateral SCA
136
s/sx subclavian steal syndrome (think brain and ipsilateral arm)
syncope, vertigo, ataxia, hemiplegia
arm ischemia, weak pulse
137
3 best EKG leads to monitor for intraop ST changes
V3, V4, V5
138
most common cause of secondary HTN
renal artery stenosis
139
dresslers syndrome
acute pericarditis after MI
