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Principles of Anesthesia > Exam 1: HTN, ischemic heart, HF, cardiomyopathies > Flashcards

Exam 1: HTN, ischemic heart, HF, cardiomyopathies Flashcards

1
Q

what is essential htn

A

a HTN state without a specific cause

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2
Q

what percent of HTN is essential

A

95%

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3
Q

what are causes of essential htn

A

genetics

increases SNS activity to stress

overproduction of sodium retaining hormones and vasoconstricors

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4
Q

what is patho of essential HTN

A

-high Na intake
-inadequate K and Ca
-increases Renin
-deficient vasodilators (prostaglandins, NO)
-medical diseases like DM and obesity

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5
Q

what are treatments for essential htn

A

lifestyle modification (alcohol, tobacco, exercise)
pharmacology (ACEI, ARBs, BB, CCBs, Diuretics)

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6
Q

what is BP goal for essential HTN

A

<140/90
prevents CVA

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7
Q

what are causes of secondary htn

A

renal artery stenosis, pheochromocytoma, primary aldosteronism

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8
Q

how is secondary HTN corrected

A

Sx correction (stent or open renal artery stenosis) (remove tumor for pheochromocytoma)

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9
Q

what percent of HTN is secondary

A

5%

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10
Q

what is the most common cause of secondary HTN

A

renal artery stenosis

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11
Q

what sound is associated with renal artery stenosis

A

abdominal bruit

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12
Q

if diastolic BP is above 125 it is likely to be

A

renal artery stenosis

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13
Q

how can hyperaldosterone be treated

A

spironolactone in females, amiloride in males

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14
Q

what must be monitored closely in HTN patients

A

renal function
K

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15
Q

what is the most common serious periop adverse event

A

CV complication

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16
Q

at what level should we keep patients MAP

A

20% and close to baseline

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17
Q

what are causes of decreased map intra op

A

meds
blood loss

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18
Q

what is the def of systemic HTN

A

BP >130/80 2 times 1-2 weeks apart

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19
Q

what is normal BP

A

<120/80

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20
Q

what is pre htn

A

120-139/80-89

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21
Q

what is stage 1 HTN

A

140-159/90-99

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22
Q

what is stage 2 HTN

A

> 160/>100

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23
Q

what is htn crisis

A

systolic >180 and/or diastolic >120

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24
Q

what can HTN crisis lead to?

A

end-organ damage, strain (ST changes, T wave change), LV hypertrophy, ischemia, atherosclerosis

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25
Q

what are EKG signs of blood pressure issue intraop

A

ST changes, T wave changes

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26
Q

when do we prescribe BP meds

A

CV event (heart attack, stroke)
DM
CKD
atherosclerosis

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27
Q

how does systolic BP change with age

A

increases

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28
Q

how does diastolic BP change with age

A

increases to peak at 50-59 then decreases

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29
Q

what can systemic HTN lead to

A

CHF
CVA
arterial aneurysm
end-stage renal

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30
Q

every 20 points above 120 increases disease risk by

A

2x

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31
Q

what is the most common organ damage from HTN

A

ischemic heart disease

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32
Q

chronic HTN leads to (complications)

A

-remodeling of arteries
-endothelial dysfunction
-irreversible end-organ damage
-vasculopathy:
-ischemic heart disease
-LVH
-CHF
-CVD
-stroke
-PVD
-nephropathy
-aortic aneurysm

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33
Q

how do you mitigate HTN risk

A

early intervention

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34
Q

what is the big problem with HTN

A

end organ damage

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35
Q

what does essential HTN lead to

A

ischemic heart disease
angina pectoris
LVH
CHF
Cerebrovascular disease
stroke
PVD
renal insufficiency

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36
Q

what labs do we monitor for HTN

A

-BUN/Creatinine- renal function
-potassium/electrolytes-meds affects
-blood glucose- 1/2 HTN patients have glucose intolerance

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37
Q

what can and EKG on HTN patients tell us

A

ischemia
LVH

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38
Q

what do you do if HTN patient has dyspnea of unknown origin

A

echo

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39
Q

what can angina be caused by

A

anxiety
acid reflux
esophageal spasm

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40
Q

what should you do if patients BP is 200/115

A

delay sx until BP is 180/110

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41
Q

do you stop DM drugs for sx

A

yes

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42
Q

do you stop ACE/ARBS for sx

A

potentially

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43
Q

do you stop BB for SX

A

NO

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44
Q

What drug ends in -sartan?

A

arbs

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45
Q

what drug ends in prils

A

ACE

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46
Q

do you stop clonidine for sx

A

no
rebound HTN

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47
Q

why do you not stop BB or clonidine for sx

A

rebound htn

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48
Q

what also might you continue HTN meds for

A

end organ damage

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49
Q

what is another use for clonidine

A

ADHD

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50
Q

if are non medical causes of HTN

A

cocaine
amphetamines
anabolic steroids
white coat syndrome

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51
Q

what causes white coat syndrome

A

increased sympathetic response to stress

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52
Q

what is common intra op in htn patients

A

hypotension, myocardial ischemia

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53
Q

what are signs of sympathetic response in monitor

A

increased BP, increased HR

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54
Q

how do you treat sympathetic response intra op

A

increase gas, prop, give ketamine etc

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55
Q

what should you expect if a HTN patient has dizziness and syncope with position changes

A

cerebrovascular disease

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56
Q

preop htn on a patient with previous MI has a higher incidence of

A

re infarction

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57
Q

preo-op htn can lead to __________ with those undergoing carotid endartectomy

A

poorer neurological outcomes

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58
Q

in autoregulation curve, HTN results in a shift to the

A

RIGHT, meaning they are used to a higher BP and we dont want to drop them too low

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59
Q

how do we manage MAP on a patient who is HTN

A

keep it higher, closer to baseline. to ensure cerebral perfusion

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60
Q

how does PVD affect arterial line

A

harder to place

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61
Q

how do HTN med affect autonomic nervous system

A

impair function

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62
Q

what is an example of anti-HTN impairing autonomic nervous system function

A

PRE-OP:

orthostatic HTN

INTRA-OP:

profound hypotension with PP ventilation, blood loss, or position change

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63
Q

how do you control peep on a patient on anti-hypertensives

A

less peep to prevent hypotension

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64
Q

what do you do for hypotension intraop

A

decrease gas

ephedrine, phenylephrine

fluids, blood

IF NONE OF THESE WORK:

decrease TV

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65
Q

how does a large TV affect a dry patient

A

increased pulm pressure decreases venous return and thus decreases BP maybe increased HR

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66
Q

when do you cancel a case for HTN?

A

maybe for diastolic >110

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67
Q

what do you anticipate on induction with pre-op HTN patient

A

hypotension

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68
Q

what anesthesia technique increases sns stimuli

A

Direct laryngoscopy, tracheal intubation

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69
Q

how can you blunt SNS response to intubation

A

gas, propofol, labetalol, LTA, narcs

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70
Q

how long should DL last

A

15 seconds

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71
Q

T/F video laryngoscopy causes a less of a SNS response with intubation

A

T, so dont use as much induction drugs/dont rely on response to bring up BP/HR

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72
Q

if you turn up gas what else must you turn up

A

O2 flow

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73
Q

what drug can be changed to rapidly respond to BP changes

A

volatiles

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74
Q

if SBP is >170 what responds

A

baroceptor reflex

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75
Q

what can a large dose of phenylephrine result in

A

decreased HR from baroceptor response (so give atropine or glyco)

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76
Q

what does peri op HTN increase

A

blood loss
myocardial ischemia
cerebrovascular events

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77
Q

what other methods can be used to control HTN intraop

A

volatiles
N2O
opioids
antiHTN by bolus or drip

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78
Q

how do we treat intraop hypotension

A

decrease volatiles
increase IV fluids
albumin
ephedrine, phenylephrine

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79
Q

what rhythm can result from hypotension

A

junctional

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80
Q

how do you treat junctional

A

atropine

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81
Q

what med do you give with neo

A

robinol

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82
Q

if CO2 drops with no resp changes what will drop next

A

BP

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83
Q

what is the best way to fix hypotension

A

fix the cause, see if they are dry and need fluid/albumin

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84
Q

what leads to post op HTN

A

SNS activity
hypervolemia

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85
Q

what conditions does post op HTN lead to

A

myocardial ischemia, dysrhythmias, CHF, stroke, bleeding

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86
Q

what can BBs mask under anesthesia

A

hyperthyroid, hypoglycemia, inadequate anesthesia

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87
Q

what can NMB reversal with anticholinesterase lead to

A

marked brady (give robinol)

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88
Q

what is a HTN crisis

A

180/120

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89
Q

how does indigo charmine (sx dye) affect BP? SpO2

A

increases BP
intermittenly decreases SpO2

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90
Q

what are examples of end organ damage from HTN

A

encephalopathy
intracerebral hmmg
acute LV failure with pulm edema
unstable angina
acute MI
eclampsia
microangiopathic hemolytic anemia
renal insufficiency

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91
Q

what is the goal of htn emergency

A

decrease MAP by 20% in first hour then gradually over the next 2-6 hours

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92
Q

what are clinical indicators of HTN

A

chest crackles
swelling
JVD

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93
Q

when a HTN crisis is associated with encephalopathy what drug do you avoid

A

hydralazine

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94
Q

what med is a good choice fro myocardial ischemia or cocaine overdose

A

nitroglycerine

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95
Q

what meds do you avoid in cocaine OD

A

labetalol, beta blockers (cause coronary vasospasm)

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96
Q

what toxicity does nipride lead to

A

cyanide toxicity

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97
Q

what do you want to block in pheochromocytoma FIRST

A

alpha blockade first, beta blocker second

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98
Q

what is the difference between HTN crisis and HTN urgency

A

HTN urgency doesnt have end organ damage

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99
Q

what are s/s of HTN urgency

A

HA, epistaxis, anxiety

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100
Q

what are causes of periop HTN

A

pain, anxiety, hypothermia

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101
Q

what beta blocker has a shorter DOA so is good to test response

A

esmolol

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102
Q

what beta blockers do you avoid with asthma

A

non-selective (labetalol)

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103
Q

what beta blockers are safe with asthma

A

esmolol metoprolol

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104
Q

what is acute postop HTN

A

increase in SBP more than 20% on admin to PACU
increase DBP above 110
SBP above 190 and or DBP above 100 on two consecutive readings

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105
Q

T/F elevated BP can lead to increased bleeding, bruising, and swelling

A

true

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106
Q

what are complications of post op HTN

A

bleeding
dehiscence
MI
dysrhythmias
CHF exacerbation with pulm edema
cerebral mmhg
stroke
TIA
encephalopathy

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107
Q

what are cuases of post of HTN

A

preexisting
chronic HTN med withdrawal
sx stress
pain
ANS activation
RAAS activation
Emergency delirium/anxiety
shivering

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108
Q

what helps with clonidine withdrawal

A

precedex

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109
Q

how can you blunt SNS response to intubation

A

gas, propofol, labetalol, LTA, narcs

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110
Q

what is the most common cause of RV failure

A

LV failure

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111
Q

in Systolic heart failure_______ is fixed so CO is dependent on ______

A

SV
HR

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112
Q

how does tachycardia affect CO in systolic HF

A

increases CO

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113
Q

how does tachycardia affect CO in diastolic HF

A

decreased CO

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114
Q

how is EF in systolic HF

A

decreased

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115
Q

how is EF is diastolic HF

A

preserved

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116
Q

what are s/s LV failure

A

high LVEDV
dyspnea
orthopnea
Paroxsymal nocturnal dyspnea (sleep apnea)
pulmonary edema

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117
Q

what position do you avoid in LV failure

A

steep Trendelenburg (heart cant handle increase in venous return)

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118
Q

what are s/s RV failure

A

peripheral edema
congestive hepatomegaly
RUQ pain
jaundice
increased LFTs

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119
Q

what are causes of RV failure

A

pulmonary HTN
RV MI
LV failure

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120
Q

what law tells us that increased volume in LV will increase SV

A

frank-starling

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121
Q

what do we try to avoid/treat in HF

A

remodeling

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122
Q

what is cardiac remodeling

A

changes in size, shape, and function of the LV (hypertrophy,dilation)

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123
Q

what causes LV hypertrophy

A

chronic pressure overload

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124
Q

what causes LV dilation

A

volume overload

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125
Q

what kind of remodeling causes wall thinning

A

dilation

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126
Q

what are other forms of remodeling

A

increased interstitial collagen deposition
myocardial fibrosis
scar formation from myocyte death

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127
Q

if BNP is < 100 HF is __________

A

unlikely

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128
Q

if BNP is 100-500 HF is __________

A

intermediate probability

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129
Q

if BNP is >500 HF is __________

A

diagnosable

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130
Q

T/F ECG has a high predictive value for HF

A

F, has a low predictive value

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131
Q

what can ECG detect in HF patients

A

previous MI
conduction abnormalities
dysrhythmias

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132
Q

T/F x-ray is the first indicator of pulmonary edema

A

F, lags 12 hours behind clinical evidence

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133
Q

what is the most useful test for the diagnosis of HF

A

ECHO
also tells us EF and ventricle size

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134
Q

if EF is low what kind of monitor do you want with anesthesia

A

arterial line

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135
Q

what two electrolytes do we monitor with CHF patients. Why?

A

potassium/magnesium
diuretics

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136
Q

what are s/s of electrolyte abnormalities we may see on monitor

A

dysrhythmias

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137
Q

what is class 1 HF (minimal)

A

No limitation of physical activity
no fatigue, dyspnea,palpitations

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138
Q

what is class 2 HF (mild)

A

Slight limitation of physical activity
comfortable at rest, symptoms occur with ordinary exertion

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139
Q

what is class 3 HF (moderate)

A

marked limitation of physical activity, comfortable at rest, symptoms occur with less than ordinary exertion

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140
Q

what is class 4 HF (severe)

A

unable to carry on any physical activity without discomfort, angina, or symptoms of myocardial insufficiency
may be present at rest, discomfort with physical activity

141
Q

what is the long term goal of treating CHF

A

prolong life by slowing or reversing the progression of ventricular remodeling

142
Q

what kind of diuretic is potassium sparing

A

spironolactone

143
Q

what is the first line therapy in patients with HF

A

aldosterone antagonists

144
Q

what medications are good for patients with systolic HF

A

ACEI
BBs

145
Q

what medications promote reverse remodeling in HF patients and are good for first line therapy

A

ACEI

146
Q

what medication is proven to decrease ventricular remodeling and to potentiate reverse remodeling

A

ACEI

147
Q

what conditions are we cautions in giving BBs to

A

DM/hypoglycemia
reactive airway
slowed heart rhythm (brady)
heart blocks
asthma

148
Q

what medication do we continue periop in HF patients

A

BB
ACEI
ARBs
prepare for HYPOTENSION

149
Q

how does an increase in calcium affect cardiac contractility

A

increases contractility

150
Q

what are symptoms of HF that would preclude a patient from elective surgeries

A

orthopnea
rales on exam
dyspnea on exertion
use of digoxin, diuretics
history of CHF

151
Q

what do we give with etomidate to limit BP changes

A

steroid

152
Q

what medication do you give with ketamine do decreases secretions

A

robinol

153
Q

what induction medication do you give to patients with decreased ventricular function

A

ketamine

154
Q

what does ketamine increase

A

BP, PA pressures, HR, CO, myocardial oxygen consumption

155
Q

what do we give with ketamine to lessen emergence delirium

A

midazolam/versed

156
Q

what medications do you give with ketamine for induction

A

versed
robinol

157
Q

what medication do we give with narcotics to preserve HR

A

robinol/atropine

158
Q

how do volatile anesthetics affect BP? how do you treat this

A

decrease
give fluids, albumin, cystalloids in preop

159
Q

how does pancuronium affect heart

A

increased HR
increase likelihood of dysrhythmias

160
Q

what do we implant in HF patients to prevent sudden death

A

ICDs
help prevent dysrhythmias from remodeling of heart from HF

161
Q

what usually causes sudden death in patients with HF

A

dysrhythmias

162
Q

what do we use to read oxygen saturation in LVAD patient

A

cerebral oximeter and art line (ABGs)

163
Q

what device will you use to get art line in LVAD patient

A

ultrasound, no radial pulse

164
Q

what medication will LVAD patients always get

A

ABX, increased risk of infection from device

165
Q

LVAD patients are __________ dependent so _______ is very important

A

flow
volume

166
Q

what drugs do we avoid in LVAD patients

A

vasoconstrictive

167
Q

do we use spontaneous ventilation in LVAD patients

A

No, can lead to increase in CO2 (which causes vasoconstriction)

168
Q

what three things do we avoid in LVAD patients

A

impedance of flow to LV
increase in CO2
Vasoconstrictive drugs

169
Q

how does an increase in HR or contractility affect hypertrophic cardiomyopathy

A

decrease diastolic filling time

170
Q

what do you avoid in hypertrophic cardiomyopathy

A

increased HR
hypovolemia
vasodilators
PP ventilation
decrease in afterload
hypotension

171
Q

what is common cause of cardiomyopathy

A

genetic

172
Q

how do you manage induction BP in a patient with hypertrophic cardiomyopathy

A

maintain, dont let it drop

173
Q

what do you want in hypertrophic cardiomyopathy

A

decreased HR (volatiles, BBs)
increased preload
increased afterload/maintain BP

174
Q

what is a common cause of sudden cardiac death in young people

A

hypertrophic cardiomyopathy

175
Q

what is the most effective drug fro treating a fib in hypertrophic cardiomyopathy patients

A

amiodarone

176
Q

what is the most common cardiomyopathy

A

dilated

177
Q

what are S/S dilated cardiomyopathy

A

angina
TR?
dysrhythmias
all four chambers dilated
global hypokinesis

178
Q

what is treatment for dilated cardiomyopathy

A

BBs
anticaoags
ICD
lifestyle changes (diet, no smoking, no alcohol, exercise)
heart transplant

179
Q

what is issue with regional anesthesia in pregnant patient with cardiomyopathy

A

patient is anticoagulated
do GA for C sec

180
Q

what causes secondary cardiomyopathy

A

abnormal pathophys (amyloid, sarcoid)

181
Q

how is systolic funciton in secondary cardiomyopathy

A

normal, preserved EF

182
Q

how does secondary cardiomyopathy appear

A

Systolic function is usually normal –> normal EF
Cardiomegaly may be absent
Atrial fibrillations and clots are common
Abnormal EKG/conduction abnormalities
Pulmonary congestion
Enlarged atria, normal ventricle
Fixed SV is important
Keep in NSR
Bradycardia might precipitate heart failure

183
Q

what kind of disease is cor pulmanale

A

lung disease

184
Q

how does Co pulmonale develop

A

RV enlargement that progresses to HF

185
Q

what is a potential cause of cor pulmonale

A

pulmonary hTN

186
Q

how does RV appear in cor pulmonale

A

hypertrophic

187
Q

what are S/S cor pulmonale

A

peripheral edema
syncope with activities
splenomegaly
peaked p waves in leads 2, 3, aVF
RBBB
RA/RV hypertrophy

188
Q

what ECG changes occus in cor pulmanale

A

peaked p waves in leads 2, 3, aVF
RBBB

189
Q

how do you care for cor pulmonale

A

ventilate well
avoid pulmonary HTN
lung optimization
control acute/chronic lung infections
ventilate alveoli
avoid bronchospasms
maintain high O2
avoid hypoxia and arterial vasoconstriction

190
Q

how do you treat bronchospasm

A

increase volatiles, give 100% O2

191
Q

in diastolic HF EF is ___________
in systolic HF EF is ________

A

preserved
decreased

192
Q

what is considered a preserved EF

A

> 40%

193
Q

sleep apnea is a sign of which HF

A

left

194
Q

what causes a low cardiac output failure

A

blockage

195
Q

what causes a high cardiac output failure

A

decreased function/increase burden

196
Q

what do we want to avoid in cardiomyopathy

A

remodeling

197
Q

what does echocardiogram show

A

EF
LV structure and function
structural abnormalities
presence of diastolic dysfunction
right ventricular dysfunction

198
Q

what are the 2 most important risk factors for ischemic heart disease

A

male gender
increasing age

199
Q

what are other risk factors for ischemic heart disease

A

high cholesterol
systemic hypertension
cigarette smoking
diabetes mellitus
obesity
sedentary lifestyle
family hx of premature ischemic heart disease

200
Q

what is angina pectoris

A

chest pain caused by inadequate flow of blood and oxygen to the heart

201
Q

what are the first manifestations of ischemic disease

A

angina pectoris
acute myocardial infarction

202
Q

what is a major cause of sudden cardiac death

A

dysrhythmias

203
Q

what occurs with an extreme imbalance in coronary blood flow

A

CHF, dysrhythmias, MI

204
Q

how is angina pectoris usually described

A

pressure or heaviness

205
Q

where does pain from angina pectoris radiate

A

neck, left shoulder, left arm, lower jaw, occasionally to the back, down the rights arm

206
Q

T/F angina pectoris pain radiates below the level of the diaphragm

A

False

207
Q

T/F angina can be felt as epigastric pain

A

True

208
Q

T/F angina can feel like dyspnea

A

True

209
Q

what is the pattern of angina pain

A

ebbs and flows

210
Q

what is the goal of managing angina pain

A

balance supply and demand
maintain BP, HGB, O2

211
Q

what causes increased demand on the heart

A

tachycardia
HTN
exercise
stress

212
Q

what two factors confirm myocardial ischemia

A

ST segment depression
anginal pain

213
Q

what ECG changes are common with Myocardial Ischemia

A

ST depression
T wave inversion

214
Q

if a patient has inverted T waves from previous MI how can they appear in current Mi

A

normal/upright

215
Q

what is a positive test for exercise elctrocardiography

A

1 mm ST downsloping during or within 4 minutes after exercise

216
Q

what test do we use to detect signs of ischemia and establish its relationship to chest pain

A

exercise elctrocardiography (stress test)

217
Q

the greater the degree of downsloping of the ST segment, the ________________ the likelihood of CAD

A

greater

218
Q

what do we do if patient cannot undergo exercise ECG

A

non-invasive imaging tests use IV infusion of dobutamine or cardiac pacing
then do echo or radionuclide scan

219
Q

what test do we use for wall motion analysis, and EF

A

echocardiography

220
Q

what is the test for assessing coronary perfusion using traces like thalium and technetium

A

nuclear stress imaging

221
Q

in nuclear stress testing, traces (are/are not) picked up in damaged areas

A

are not

222
Q

which test is useful for assessing coronary perfusion with greater sensitivity than exercise testing

A

Nuclear Stress Imaging

223
Q

what is the most important indicator of CAD

A

size of the perfusion abnormality

224
Q

what test provides the best information about the condition of the coronary arteries

A

coronary angiography

225
Q

what test is used for diagnosis of coronary spasm

A

coronary angiography

226
Q

what patients should have coronary angiography

A

continued chest paid despite medical therapy
those considering revascularization
pts at risk (pilots)

227
Q

where is the most dangerous lesion (what artery)

A

left main coronary artery

228
Q

what is treatment for ischemic heart disease

A

lifestyle
stop smoking
maintain ideal body weight
treat systemic HTN
lower LDL with diet and/or drugs

229
Q

what level should LDL be kept below

A

160 mg/dL

230
Q

what medications are used to manage ischemic heart disease

A

Beta Blockers
Calcium Channel Blockers
ACEI
ARBS

231
Q

in patients with systemic HTN and LV dysfunction what meds do we use

A

ACEI
ARBs

232
Q

what is the initial therapy of choice for chronic stable angina

A

BB

233
Q

what is the end goal of beta blocker therapy for ischemic heart disease

A

decrease myocardial oxygen demand

234
Q

what beta blockers do you avoid is asthma

A

non-selective (propranolol, nadolol)

235
Q

what are contraindications for BB treatment of ischemic heart disease?

A

uncontrolled CHF (intensify LV failure)
2nd/3rd degree AV block
bradycardia
SSS
severe reactive airway disease

236
Q

what medication is recommended for all patients with ischemic heart disease

A

low dose ASA

237
Q

what platelet inhibitor decreases risk of stroke and MI more than ASA

A

clopidogrel (plavix)

238
Q

what patients do we not give ASA to

A

patients >70, at greater risk of falls

239
Q

how long does ASA last for

A

7 days

240
Q

what can beta blockers mask in DM patients

A

hypoglycemia

241
Q

T/F you continue BBs through periop period

A

true

242
Q

what are the actions of CCBs on ischemic heart disease

A

decrease vascular smooth muscle contractility
dilate coronary arteries
increased coronary blood flow
decreased contractility
decreased O2 consumption
decreased systemic B/P

243
Q

what is the action of organic nitrates

A

-cause dilation of coronary arteries and collateral vessels, and improve coronary blood flow
-decreased SVR lead to decreased afterload and decreased myocardial oxygen consumption

244
Q

how do organic nitrates affect venous return

A

decreased venous return, so decreased left ventricular filling pressure, volume, and myocardial oxygen consumption

245
Q

what is the most common side effect of organic nitrate treatment for ischemic heart disease

A

Headache

246
Q

what can happen to a hypovolemic pt who receives organic nitrates

A

hypotension

247
Q

T/F tolerance develops with sustained use of organic nitrates

A

true

248
Q

when do we do a CABG, PTCA, or place a coronary artery stent (revascularization)

A

-left main stenosis of more that 50%
-epicardial coronary artery stenosis of 70% or greater
-CAD with EF <40%

249
Q

presence of hypokinetic or akinetic LV means a ___________ prognosis for revascularization therapy

A

poor

250
Q

how long must a PTCA heal

A

2-3 weeks

251
Q

how long does it take a bare metal stent to heal

A

12 weeks

252
Q

how long does it take a drug eluding stent to heal

A

one year for complete endothelialization

253
Q

your patient experiences their baseline ischemic type chest pain, what is this

A

stable angina

254
Q

your patient experiences ischemic type chest pain, that is new onset or a change from baseline, what is this

A

acute coronary system

255
Q

what test do you do for acute coronary system

A

12-lead ECG

256
Q

your patient has acute coronary syndrome and their 12-lead ECG shows ST-segment elevation and is troponin/CK-MB positve. what does your patient have?

A

STEMI

257
Q

your patient has acute coronary syndrome and their 12-lead ECG shows NO ST-segment elevation and is troponin/CK-MB positve. what does your patient have?

A

NSTEMI

258
Q

your patient has acute coronary syndrome and their 12-lead ECG shows NO ST-segment elevation and is troponin/CK-MB negative. what does your patient have?

A

Unstable angina

259
Q

what is the best lab for myocardial injury

A

troponin

260
Q

which is more specific for myocardial injury Troponin or CK-MB

A

Tropinin

261
Q

when to troponin level rise with myocardial injury, how long does it stay elvated

A

3 hours
7-10 days

262
Q

what are treatments for unstable angina/NSTEMI

A

bed rest
supplemental O2
Analgesia
BBs
CCBs
SL or IV NTG to improve O2 supply
ASA, clopidogrel, heparin therapy

263
Q

what is a good medication to alleviate anxiety pre-op

A

scopolamine
sedation and amnesia without changes in HR

264
Q

how long do we wait from stent placement till surgery

A

90 days

265
Q

what history findings are indicative of ischemic heart disease

A

angina pectoris
dyspnea
limited exercise tolerance
peripheral edema

266
Q

what monitoring do we do for patients at high risk for myocardial ischemia

A

A-lines, PA caths, TEE,

267
Q

what is the most common endocrine disease associated with ischemic heart disease

A

DM

268
Q

what are preop goals for MI patients

A

decrease myocardial oxygen requirements
improve coronary blood flow

269
Q

what is the goal HR from BB

A

50-60

270
Q

do we stop BB for surgery

A

NO

271
Q

what is the treatment for excessive bradycardia

A

atropine/glycopyrrolate

272
Q

does atropine cross BBB

A

yes

273
Q

why is atropine not good for elderly

A

crosses BBB

274
Q

what drug can we use for excessive beta antagonist activity

A

isoproterenol

275
Q

what medication can reverse beta blockade if pure beta blockade has caused myocardial depression

A

Dobutamine

276
Q

what are the anesthesia pre-op implications for Myocardial ischemia

A

risk factors
angina
previous cardiac surgery
anticipation of blood loss

277
Q

what do we do for a patient with known ischemic heart disease

A

get CV clearance?

278
Q

what are intraoperative goals to manage myocardial ischemia

A

modulate SNS response and provide quick control of hemodynamics
-prevent ischemia
-balance O2 supply and demand

279
Q

what symptoms do we avoid in ischemic heart disease patients

A

persistant tachycardia
systolic HTN
SNS activation
arterial hypoxemia
diastolic hypotension

280
Q

be cautious of drugs that __________ HR in CV patients

A

increase

281
Q

which is more likely to cause ischemia tachycardia or HTN

A

tachycardia

282
Q

what are some patient factors that affect O2 supply to myocardia

A

BP
Hgb

283
Q

what is recommendation for HR and BP values intraop

A

maintain within 20% of normal values

284
Q

how long should laryngoscopy last to avoid excessive SNS stimulation

A

15 seconds

285
Q

what induction drug do we avoid in patients are risk of myocardial ischemia

A

ketamine

286
Q

what two leads detect most significant ST segment changes

A

leads 2 and V5

287
Q

what does ST segment changes in V5 reflect

A

LAD decreased perfusion

288
Q

what does ST segment changes in lead 2 reflect

A

RCA decreased perfusion

289
Q

what are the leads for RCA

A

2, 3, aVF

290
Q

what are leads for circumflex

A

1, aVL

291
Q

what are leads for LAD

A

v3-v5

292
Q

what aspect of heart is RCA associated with

A

RA
RV
SA node
AV node
inferior LV

293
Q

what aspect of heart is circumflex associated with

A

lateral LV

294
Q

what aspect of the heart is LAD associated with

A

anterolateral LV

295
Q

what must ST elevation be to diagnose MI

A

> 1 mm in two or more limb leads
2 mm in two or more precordial leads

296
Q

what must ST depression be to diagnose MI

A

> 2mm in at least 2 of the 3 leads v1-v3

297
Q

what are postoperative goals for Myocardial ischemia

A

prevent ischemia
monitor for injury
treat myocardial ischemia or infarction

298
Q

how does intraop hypothermia affect O2 demand

A

leads to shivering which increases demand

299
Q

how does prolonged hemodynamic changes affect O2 demand

A

increased demand

300
Q

what are some causes of increase myocardial O2 demand in post op period

A

shivering
pain
hypoxia
hypercarbia
sepsis
hemorrhage
hemodynamic changes

301
Q

how does emergence affect hemodynamics

A

changes, be ready with lido, narc, prop?

302
Q

what is the intrinsic HR of an implanted heart

A

110

303
Q

T/F implanted hearts have no sympathetic, parasympathetic, or sensory innervation

A

true

304
Q

T/F in implanted heart the P wave is no longer the pacemaker

A

T, the p wave cannot transverse the suture line and has no influence on chronotropic heart activity

305
Q

T/F robinol, atropine, ephredrine, and dopamine work on implanted hearts

A

F, these are indirect acting catecholamines and do not work

306
Q

T/F Isoproterenol and Epinephrine work on implanted hearts

A

T, they are direct acting

307
Q

what complications can antirejection drugs cause

A

nephrotoxicity

308
Q

T/F patients with implanted hearts can feel angina

A

false

309
Q

T/F patients with implanted hearts have an exagerrated response to larygoscopy and intubation

A

false

310
Q

what indication of anesthetic depth is blunted in heart transplant patient

A

elevated heart rate
make sure patient is not lite, anticipate need for narcotic/multimodal need

311
Q

what is a transplanted patient dependent on for CO

A

preload/volume

312
Q

what is most common cause of death in transplanted patient

A

opportunistic infection (immunosuppresion)

313
Q

most transplant patients are emergent so full stomach is a concern, how do we combat this

A

give pepcid/bicentra preop
use RSI, get cuff up fast

314
Q

What is the defasciculating dose?

A

give a bit of roc before succs to occupy ACTH receptor so succs doesnt cause contraction as much

315
Q

what kind of muscle relaxants do you use in transplanted heart

A

non-histamine releasing muscle relaxants (all but mivacurium/atracurium)

316
Q

what gas do you avoid in transplanted heart

A

N2O (pulm htn/air embolism)

317
Q

what do you take into account for patient on antirejection drugs

A

watch for nephrotoxicity (drugs that are renal excreted/metabolized)
watch for refractory hypotension related to steroid need (stress dose)

318
Q

what are signs of rejection

A

dysrhythmias
CHF

319
Q

T/F CCBs are as effective as BBs in decreasing the incidence of MI

A

false

320
Q

T/F CCBs are contradindicated in patients with CHF, or severe aortic stenosis

A

true

321
Q

what conditions are organic nitrates relatively contraindicated in

A

hypertrophic obstructive cardiomyopathy
severe aortic stenosis

322
Q

what does excessive Angiotensin 2 lead to

A

myocardial hypertrophy
interstitial myocardial fibrosis
increased coronary vasoconstriction
endothelial dysfunction

323
Q

what patients are ACEI recommended for

A

HTN
LV dysfunction
diabetes

324
Q

what is a risk of TPA

A

increased bleeding, brain bleeds

325
Q

what is purpose of PCI

A

increased blood flow

326
Q

what is purpose of BB treatment

A

decreased HR leads to decreased demand

327
Q

what is purpose of ASA or clopidogrel therapy

A

decrease clotting

328
Q

what is purpose of morphine or SL NTG therapy

A

vasodilation leading to increased O2

329
Q

when do we do an emergency CABG

A

coronary anatomy precludes PCI
failed angioplasty
evidence of infarction-related ventricular septal rupture
mitral regurge

330
Q

what are two large risks of PCI

A

thrombosis
increased bleeding 2/2 dual anti-platelet therapy

331
Q

T/F D/C ASA in drug eluding stent patients

A

F, continue

332
Q

when is angina considered unstable

A
  • lasts > 20 min
  • more frequent
    -more easily provoked
    -new onset, severe, prolonged, disabling
  • onset occurs at rest
333
Q

what are periop risks for MI

A

increased myocardial O2 consumption
alterations in coagulation leading to thrombosis
changes in vascular tone and endothelial function

334
Q

how long do wait to do elective surgery after bare metal stent

A

4-6 weeks or
90m days

335
Q

what drug can increase myocardial contractility in presence of beta blockade

A

calcium

336
Q

what can acute withdrawal of beta blockers lead to

A

rebound HTN
tachycardia

337
Q

what medications can you give to blunt HR increase from tracheal intubation

A

esmolol infusion
fentanyl
remifentanil
dexmedetomidine

338
Q

what do you do to gas to decrease HR

A

increase

339
Q

how does a dry patient respond to increased gas

A

decreased BP

340
Q

how do volatiles affect hemodynamics

A

decrease myocardial O2 requirements
decrease in coronary perfusion pressure

341
Q

when LV function is extremely poor what can be used as the sole anesthetic

A

narcotics

342
Q

T/F regional anesthesia is contraindicated in ischemic heart disease

A

false

343
Q

what muscle relaxants are safe in ischemic heart disease

A

minimal HR BP effects
ROC
VEC
CIS

344
Q

T/F pancuronium is safe in ischemic heart disease

A

F, causes tachycardia

345
Q

when reversing a patient what is your anticholinergic of choice

A

glycopyrolate (doesnt affect HR as much)

346
Q

what is the standard for intraoperative diagnosis of myocardial ischemia

A

transesophageal echocardiography

347
Q

what catecholamines work on transplanted hearts

A

isoproterenol
epinephrine

348
Q

which is preferred for anesthesia management in transplanted hearts GA or regional

A

general

349
Q

what leads to refractory hypotension in heart transplant patients

A

stress dose steroids

Principles of Anesthesia (4 decks)

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