Ex2 Flashcards
HTN Ischemic heart disease HF antithrombotics Clotting factors, trauma, blood disorders
1
Q
BP =
A
BP = CO x SVR
2
Q
SVR is determined by
A
vascular tone of systemic vessels
3
Q
most common CV pathology
A
HTN
4
Q
HTN stage 1
A
SBP:130-139 mmHg
DBP: 80-89 mmHg
5
Q
HTN stage 2
A
SBP: 140+ mmHg
DBP: 90+ mmHg
6
Q
pts with preop HTN are
A
4x more likely to die from CV issue in surgery
7
Q
causes of HTN
A
ANS
RAAS
impaired endothelial function
8
Q
HTN renal SE
A
incr GFR
proteinurea
ESRD
9
Q
HTN cancellectomy
A
SBP > 180
DBP > 100
10
Q
pts on beta blockers prior to surgery should
A
continue beta blockers day of surgery
11
Q
should pts who are not on beta blockers be given them day of surgery
A
no
12
Q
should you continue ACe or ARBs day of surgery
A
discontinue unless HF pt
13
Q
should you continue clonidine day of surgery
A
yes
14
Q
what HTN drugs have acute withdrawal symptoms
A
clonidine
beta blockers
15
Q
HTN pts have a _______ BP perioperatively and ____________ intraoperatively.
A
periop: volatile BP
intraop: hypotension
16
Q
sympathetic activation during induction increases BP/HR: normotensive
A
BP: 20-30 mmHg
HR: 15-20 bpm
17
Q
sympathetic activation during induction increases BP/HR: untreated HTN
A
SBP: 90 mmHg
HR: 40 bpm
18
Q
causes of periop HTN
A
difficult to predict
multi-factoral
19
Q
intraop HTN crisis
A
BP > 160/90
SBP elevation of 20%
persists for 15+ mins
20
Q
goal of HTN crisis managment
A
halt vascular damage
reverse pathology
preserve organ function
21
Q
edema
A
excessive vasoconstriction
impaired microcirculation
22
Q
ischemia
A
increased risk of hypoperfusion
23
Q
normal cerebral autoregulation
A
60-160 mmHg
24
Q
when should you treat HTN
A
base on pts baseline
no consensus
- 20% baseline
- MAP > 65
25
HTN risk
organ ischemia risk
26
hTN risk
bp related bleeding risk
27
what surgeries require more tight BP regulation
cardiac
28
high baseline
BP: 80-110%
SBP: < 160 mmHg
29
normal baseline
BP: 90-110%
MAP: 65-95 mmHg
30
low baseline
BP: 100-120% baseline
MAP: > 60 mmHg
31
pts with intraop HTN should be managed with
IV antihypertensives until oral meds can be resume
32
CCB drugs
nicardipine
clevidipine
33
best drug for HTN
CCB
fast onset
34
which CCB has shorter half life
clevidipine
35
nicardipine CI
adv aortic stenosis
36
clevidipine CI
soy
egg
poor lipid metabolism
37
CCB dose adjustment for eldery
nicardipine: no
clevidipine: lower dose
38
vasodilators
nipride
NTG
hydralazine
39
nipride
venous/arterial vasodilator
40
NTG
venous/coronary artery vasodilator
41
hydralazine
direct vasodilator
42
which vasodilator requires art line
nipride
43
which vasodilator can cause tachyphylaxis and cyanide toxicity
nipride
44
which vasodilator is a bolus dose
hydralazine
45
which vasodilator is not potent enough alone to effectively lower bP
NTG
46
which vasodilator should you not use in renal dysfunction
nipride
47
which vasodilator requires lower dose for eldery
nipride
48
when do you use NTG
pts with ACS or acute pulm edema
49
which vasodilator is not a first line agent for HTN
hydralazine
50
adrenergic receptor blockers
esmolol
labetalol
phentolamine
fenoldapam
ACE inhibitor
51
esmolo
beta1 selective blocker
52
labetalol
alpha 1 blocker
non selective beta blocker
53
phentolamine
non selective alpha blocker
54
fenoldopam
dopa 1 receptor selective agonist
55
ACE inhibitor CI
pregnancty
acute MI
bilateral renal artery stenosis
56
is an ACE inhibitor useful intraoperatively
no
57
fenoldapam CI
incr ocular pressure
incr intracranial pressure
sulfite allergy
58
labetalol CO
reactive airway disease
COPD
59
esmolol CI
concurrent BB therapy
bradycardia
decompensated HF
60
avoid labetalol in
2nd/3rd degree Heart block
bradycardia
61
which drug can be used in HTN emegencies caused by catecholamine excess
phentolamine
62
which drug increases renal perfusion
fenoldapam
63
which drug is good for hyperadrenergic syndromes
labetolol
64
preferred drugs (4) for perioperative HTN
clevidipine
esmolol
nicardipine
NTG
65
acute post-op HTN
SBP: 180+ or 20% incr
DBP: 110+
66
acute post op HTN causes
failure to take beta blockers
hypervolemia (fluid overload)
overactive sympathertics
67
1st line acute post op HTN
esmolol
labetalol
68
2nd line acute post-op HTN
clevidipine
nicardipine
69
3rd line acute-post op HTN
ACE inhibitor
hydralazine
70
what should you resume after acute post-op HTN
resume oral antihypertensives
71
most important factor for ischemia
O2 demand/O2 supply balance
72
treatment goals of chronic coronary heart disease
prevent myocardial infarction
reduce symptoms of angina
73
Type 1 demand
thrombosis
74
Type 2 demand
non-thrombotic
Ischemic
75
reduce angina/ischemia symptoms
sublingual NTG
beta blockers
CCB
nitrates
ranolazine
PCI
CABG
76
how do beta blockers reduce ischemia/angina symptoms
decr HR
decr inotropy
DECR DEMAND
77
where do nitrates act
venous
78
how do nitrates reduce ischemia
incr capacitance
decr preload
WALL TENSION
DECR DEMAND
79
where do CCB work
arterial
80
how do CCB reduce ischemia
decr afterload
decr contractility
decr HR
DECR DEMAND
81
renolazine affects
decr angina without changing BP or HR
82
order of drugs for reducing ischemia
1st: beta blockers
2nd: CCB
3rd; nitrates
4th: ranolazine
83
drugs to prevent MI/death
aspirin
statins
beta blockers
ACEs
ARBS
84
statins mechanism
lower cholesterol
anti-inflammatory effect on vasculature
85
NSTE-ACS treatments
aspirin
NTG
anti-thrombotics
statins
beta blockers
86
aspirin dose
262-325 mg
81 mg indefinite dose
87
how should aspirin be taken
chew it
88
what is NTG function in NSTEMI
helps decr pain symptoms
89
NTG administration
sublingual every 5 mins
3 doses
90
DAPT
aspirin
+
P2Y12 inhibitor
91
common P2Y12 inhibitors
clopidogrel
prasugrel
ticagrelor
92
parenteral anticoagulant
UFH
LMWH
93
how many anithrombotics should be administered for NSTEMI
3 antithrombotics to stop the active clot from growing
94
statins short term function
reduce inflammation
improve endothelial function
95
statins long term function
cholesterol reduction
96
beta blockers function in NSTEMI
decr arrythmias
decr O2 demand
reduce progression
97
medical managment goal
decr demand
98
PCI goal
incr supply
99
CABG goal
incr supply
100
CABG indication
disease in left main coronary artery
disease in 3 or more coronary vessels
EF < 40%
101
STEMI primary treatment goal
open vessel
102
fibrinolysis protocol
30 mins
103
PCI protocol
90 mins
104
STEMI treatment
aspirin
NTG
antithrombotics
statins
beta blockers
105
when is the risk of deaths due to CAD
closest to the event
- 33% in first 3 weeks
- 50% in first 3 months
106
Post ACS big 5
aspirin
ACE/ARB
beta blocker
clopidogrel/prasugrel/ticagrelor
statins
107
BIG 5 function
reduces 6 month mortality by up to 90% in pts with ACS
108
MINS
elevated troponin < 30 days after non cardiac surgery
109
MINS risk factors
recent MI
unstable angina
recent PCI
old age
110
what will impact MINS risk
surgical and patient factors
111
do you continue beta blockers for mINS
continue prior beta blockers
112
do you continue statins for MINS
yes
113
do you continue antiplt therapy for mins
patient and procedure specific
114
do you continue ACE/ARB for MINS
continue for HF or poorly control HTN
115
unstable CAD pt treatment
IV nitrates
IV heparin
arrythmias
intra-aortic baloon pump
116
balloon is up during
diastole
blood back to heart
117
balloon is down during
systole
blood sucked into syst circulation
118
intraoperative Ischemia treatment: tachycardia
anesthetic
analgesic
beta blocker
119
intraop ischemis treatment: afib/flutter
stable: BB or CCB
unstable: sync cardioversion
120
when do you consider transfusion
HgB <7 g/dL
121
what should you not give in post op for ischemia
NSAIDS
COX2 inhibitors
(Toradol)
***incr risk of thrombosis**
122
what drugs are commonly given for angina
ACE
ARB
BB
SGLT2 (diabetes)
123
what drugs do you give for HFrEF: EF <40%
neprilysin inibitor (Valsartan/sacubitril)_
ACE
ARB
BB
MRA - spironolactone
SGLT2 - "flozin"
diuretics
hydral-nitrates (african american)
124
what drugs do you give for HFmrEF: EF 41-49%
diuretics
maybe
SGLT2
125
what drugs do you give for HFpEF: > 50%
diuretics
maybe
SGLT2
126
when should diuretics be prescribed in HF
all patients with evidence of fluid retention
127
which diuretics are better for HF
loop diuretics are better than thiazide
128
do diuretics slow progression of HF
no - they just decrease symptoms
129
should you continue BB perioperatively for HF
yes -continue BB in HF pts
130
do you continue or stop ACE/ARB/ARNI in HF pts perioperatively?
continue if EF < 50%
consider stopping if risk of hypotension
or just dont take dose in AM of surgery
131
do you continue or stop aldosterone antagonists in HF perioperatively?
continue aldo antagonists if renal function is stable
132
do you continue or hold SGLT2i in HF pts perioperatively?
hold due to incr risk of post-op euglycemic ketoacidosis
133
treat intraop severe HTN in HF pts
vasodilator (nitroprusside)
134
treat intraop fluid overload/pulm edema in HF pts
NTG
diuretic
135
treat intraop low CO in HF pts
inotrope
vasodilator
136
treat intraop arrythmias in HF pts
amiodarone
lidocaine
137
treat intraop hypotension in HF pts
vasopressor (phenylephrine)
NOT fluid bolus
138
warm
CI > 2.2
139
wet
PCWP > 18 mmHg
(preload)
140
cold
CI < 2.2
141
dry
PCWP < 18 mmHg
(preload)
142
warm and wet
want to reduce preload:
give diuretic
NTG
143
cold and wet
inotropes
diuretics
NTG
144
if they have low BP and are cold and wet avoid:
milrinone
dobutamine
145
use diuretics
when pt is fluid overloaded
preferrably loops
146
BMS reendotheliazation
1-3 months
147
DES reendothelization
1 year
148
risk of thrombosis with stents is highest
closest to stent placement
149
which stent type requires longer course of antithrombotics
DES
150
DES thrombotic prohphylaxis for SIHD
6 months clopidogrel
151
DES thrombotic prophylaxis for ACS
12 months
- clopidogrel
- prasugrel
- ticagrelor
152
BMS thrombosis prophylaxis
1 month clopidogrel
153
hemorrhagic risk is determined by
surgery
154
stop clopidogrel
5 days before
155
resume clopidogrel
24-72 hrs
156
stop prasugrel
7 days prior
157
low hemorrhagic risk
+
low thrombotic risk
continue aspirin
stop clopidogrel
158
med hemorrhagic risk
+
low thrombotic risk
continue aspirin
stop clopidogrel
159
high hemorrhagic risk
+
low thrombotic risk
Stop aspirin
Stop clopidogrel
160
low hemorrhagic
+
mod thrombotic
continue aspirin
continue clopidogrel
161
mod hemorrhagic
+
mod thrombotic
continue aspirin
stop clopidogrel
162
high hemorrhagic
+
mod thrombotic
continue aspirin
stop clopidogrel
163
low hemorrhagic
+
high thrombotic
continue aspirin
continue clopidogrel
164
mod hemorrhagic
+
high thrombotic
continue aspirin
stop clopidogrel
bridge
165
high hemorrhagic
+
high thrombotic
continue aspirin
stop clopidogrel
bridge
166
bridge therapy drugs
GPiib/iiia inhibitors
167
high thrombotic risk: heart valves
mitral valve prosthesis
ball/disc aortic valves
recent stroke
recent TIA
168
mod thrombotic risk: heart valves
bileaflet aortic valve
+ afib
+ stroke
+ TIA
+ HTN
+ diabetes
+ CHF
+ 75+ years old
169
low thrombotic risk: heart valve
bileaflet aortic valve with no additional risk factors
170
high thrombotic risk: afib
CHAD score >=7
thrombembolism w/in 3 mos
rheumatic valvular disease
171
mod thrombotic risk: afib
CHAD score 5-6
thromboelmbolism > 3 months
172
low thrombotic risk: afib
CHAD score: 0-4
no thromboembolism
173
if your risk risk of stroke is greater than ____%, pts should be taking ______
if risk of stroke is > 2%, pts should take anticoagulation meds
174
CHAD score
1 point:
CHF
EF<40%
HTN
diabetes
vascular disease
65-74 years old
female
2 points:
75+ years old
stroke
TIA
thromboembolism
175
high thrombotic risk: venous
VTE < 3months
severe thrombophilia
176
mod risk: VTE
VTE 3-12 months
non-severe thrombophilia
recurrent VTE
cancer w/in 6 months
177
low risk: VTE
VTE > 12 months ago
no additional risk factors
178
what HAD-BLED is high risk of bleeding
>= 3
179
HAS-BLED mod risk bleeding
2
180
HAS-BLED low risk bleeding
0-1
181
when do you interrupt anticoagulation therapy
intermediate surgical bleeding risk
high surgical bleeding risk
182
when do you consider interrupting anticoagulation therapy
low surgical risk
+
pt related bleeding factors
183
when should you not interrupt anticoagulation therapy
low bleeding risk surgery
absence of pt related factors
184
pt related bleeding factors
major bleed w/in 3 months
PLT abnormality
aspirin use
high INR
prior bleed w/bridging
185
what should you check for pts on warfarin
INR day of surgery
186
normal INR
<1.2
187
pt is on warfarin
INR prior to surgery is >3
discontinue warfarin 5+ days prior
188
pt is on warfarin
INR prior to procedure is 2-3
discontinue 5 days prior
189
pt is on warfarin
INR is <2 prior to surgery
discontinue 3-4 days prior
190
which DOAC has renal impacts
dabigatran
191
which DOACs have less renal impacts
apixaban
edoxaban
rivaroxaban
192
what is DOAC interruption based on
renal function
193
do you bridge DOACs
no
194
do you bridge warfarin
potentially
195
do you bridge warfarin with low thrombotic risk
no bridge
196
do you bridge warfarin with mod thrombotic risk
increased bleed: no bridge
prior stroke: bridge
no prior stroke: no bridge
197
do you bridge warfarin with high thrombotic risk
bleed w/in 3 months: no bridge
all others: bridge
198
when should you stop UFH
4 hrs prior
199
monitor UFH residual effect with
ACT
PTT
200
stop LMWH prior to procedure
24 hrs
201
monitor residual effects of LMWH
antifactor 10a
202
when do you start pre-op bridging
INR<2
(typically 2-3 omitted doses)
203
restart warfarin post-op
12-24 hrs
204
how long does anticoag effect take after restarting warfarin
2-3 days
205
start LMWH/UFH bridge: low bleeding risk
24 hrs post op
206
start LMWH/UFH bridge: high bleeding risk
48-72 hrs post op
207
when do you discontinue post-op bridge
INR>2
208
DOAC onset time
2-3 hrs
209
restart DOAC: low bleeding risk
<24 hrs
210
restart DOAC: high bleeding risk
48-72 hrs
211
what should you monitor when restarting DOAC
renal function
212
stop heparin before neuraxial
6 hrs
213
restart heparin after neuraxial
2 hrs
214
LMWH before neuraxial
high dose: 24 hrs
low dose: 12 hrs
215
LMWH restart neuraxial: low risk
4 hrs
216
LMWH restart: mod-high risk neuraxial
12 hrs
217
stop fondiparinux before neuraxial
4 days
218
restart fondaparinux before neuraxial
6-24 hrs
219
stop warfarin before neuraxial
5 days
INR < 1.2
220
restart warfain after neuraxial
next day
221
desmopressin (DDAVP) mechains
incr endothelial release of Factor VII and vWF
incr tissue plasminogen activator
incr plasmin
222
Desmopressin indications
mild hemophilia A w/FVIII >5%
vWF disease
223
Desmopressin CI
SIADH
GFR < 50 ml/min
224
Desmopressin SE
antidiuretic (water retention)
hypotension
premature labor
thrombosis
225
warfarin reversal options
vit K (phytonadione)
PCC
FFP
226
PCC contain
vit-K dependent clotting factors
227
what must you give with PCC
vit K
228
DOAC reversals
idarucizumab (dabigatran)
andexanet alfa (apixaban/rivaroxaban)
229
apixaban
rivaroxaban reversal
1st: andexanet
2nd: PCC
3rd: activated charcoal
230
bextrixaban
edoxaban
reversals
1st: andexanet
2nd: PCC
3rd: activated charcoal
231
TXA mechansims
blocks binding of plasminogen to fibrin
prevents activation of plasminogen to plasmin
232
TXA indications
reduce surgical blood loss
reverse fibrinolytics
treat traumatic hemorrhage
233
TXA SE
theomboembolism
seizures
234
EACA SE
renal dysfunction
thromboembolisms
235
what is used as replacement of fibrinogen in hypofibrinogenemia
cryoprecipatate
236
cryo contains (5)
fibrinogen
vWF
Factor 8
Factor 13
fibronectin
237
PCC indications (5)
reversing warfarin (unactivated)
reversing fondaparinux (activated)
reversing DOAC
bleeding (cardiac, hepatic, trauma)
bleeding hemophilia A/B (activated)
238
PCC SE
thrombosis
239
which PCC contain heparin
unactivated 4 factor
240
what should you give to pts with thrombotic thrombocytopenic purpura?
FFP
241
FFP indication (3)
surgery w/abnormal coag
warfarin reversal
thrombotic thrombocytopenic purpura
242
1 mL of FFP =
1 unit of coag factor activity
243
how much FFP
15-20 mL/kg for 20-30% increase
244
how to treat factor VIII deficiency
give factor VIII
245
how to ID factor VIII deficiency
prolonged aPTT
normal PT
246
rFVIIa indication (2)
prevent csurgical bleeding w/hemophillia (F8/9)
uncontrollable bleeding
247
rFVIIa SE
serious arterial/venous thrombosis events
248
what does hydralazine isosorbide do
decr afterload
decr prelaod
