Exam 1: HTN, ischemic heart, HF, cardiomyopathies Flashcards
1
Q
what is essential htn
A
a HTN state without a specific cause
2
Q
what percent of HTN is essential
A
95%
3
Q
what are causes of essential htn
A
genetics
increases SNS activity to stress
overproduction of sodium retaining hormones and vasoconstricors
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
5
Q
what are treatments for essential htn
A
lifestyle modification (alcohol, tobacco, exercise)
pharmacology (ACEI, ARBs, BB, CCBs, Diuretics)
6
Q
what is BP goal for essential HTN
A
<140/90
prevents CVA
7
Q
what are causes of secondary htn
A
renal artery stenosis, pheochromocytoma, primary aldosteronism
8
Q
how is secondary HTN corrected
A
Sx correction (stent or open renal artery stenosis) (remove tumor for pheochromocytoma)
9
Q
what percent of HTN is secondary
A
5%
10
Q
what is the most common cause of secondary HTN
A
renal artery stenosis
11
Q
what sound is associated with renal artery stenosis
A
abdominal bruit
12
Q
if diastolic BP is above 125 it is likely to be
A
renal artery stenosis
13
Q
how can hyperaldosterone be treated
A
spironolactone in females, amiloride in males
14
Q
what must be monitored closely in HTN patients
A
renal function
K
15
Q
what is the most common serious periop adverse event
A
CV complication
16
Q
at what level should we keep patients MAP
A
20% and close to baseline
17
Q
what are causes of decreased map intra op
A
meds
blood loss
18
Q
what is the def of systemic HTN
A
BP >130/80 2 times 1-2 weeks apart
19
Q
what is normal BP
A
<120/80
20
Q
what is pre htn
A
120-139/80-89
21
Q
what is stage 1 HTN
A
140-159/90-99
22
Q
what is stage 2 HTN
A
> 160/>100
23
Q
what is htn crisis
A
systolic >180 and/or diastolic >120
24
Q
what can HTN crisis lead to?
A
end-organ damage, strain (ST changes, T wave change), LV hypertrophy, ischemia, atherosclerosis
25
what are EKG signs of blood pressure issue intraop
ST changes, T wave changes
26
when do we prescribe BP meds
CV event (heart attack, stroke)
DM
CKD
atherosclerosis
27
how does systolic BP change with age
increases
28
how does diastolic BP change with age
increases to peak at 50-59 then decreases
29
what can systemic HTN lead to
CHF
CVA
arterial aneurysm
end-stage renal
30
every 20 points above 120 increases disease risk by
2x
31
what is the most common organ damage from HTN
ischemic heart disease
32
chronic HTN leads to (complications)
-remodeling of arteries
-endothelial dysfunction
-irreversible end-organ damage
-vasculopathy:
-ischemic heart disease
-LVH
-CHF
-CVD
-stroke
-PVD
-nephropathy
-aortic aneurysm
33
how do you mitigate HTN risk
early intervention
34
what is the big problem with HTN
end organ damage
35
what does essential HTN lead to
ischemic heart disease
angina pectoris
LVH
CHF
Cerebrovascular disease
stroke
PVD
renal insufficiency
36
what labs do we monitor for HTN
-BUN/Creatinine- renal function
-potassium/electrolytes-meds affects
-blood glucose- 1/2 HTN patients have glucose intolerance
37
what can and EKG on HTN patients tell us
ischemia
LVH
38
what do you do if HTN patient has dyspnea of unknown origin
echo
39
what can angina be caused by
anxiety
acid reflux
esophageal spasm
40
what should you do if patients BP is 200/115
delay sx until BP is 180/110
41
do you stop DM drugs for sx
yes
42
do you stop ACE/ARBS for sx
potentially
43
do you stop BB for SX
NO
44
What drug ends in -sartan?
arbs
45
what drug ends in prils
ACE
46
do you stop clonidine for sx
no
rebound HTN
47
why do you not stop BB or clonidine for sx
rebound htn
48
what also might you continue HTN meds for
end organ damage
49
what is another use for clonidine
ADHD
50
if are non medical causes of HTN
cocaine
amphetamines
anabolic steroids
white coat syndrome
51
what causes white coat syndrome
increased sympathetic response to stress
52
what is common intra op in htn patients
hypotension, myocardial ischemia
53
what are signs of sympathetic response in monitor
increased BP, increased HR
54
how do you treat sympathetic response intra op
increase gas, prop, give ketamine etc
55
what should you expect if a HTN patient has dizziness and syncope with position changes
cerebrovascular disease
56
preop htn on a patient with previous MI has a higher incidence of
re infarction
57
preo-op htn can lead to __________ with those undergoing carotid endartectomy
poorer neurological outcomes
58
in autoregulation curve, HTN results in a shift to the
RIGHT, meaning they are used to a higher BP and we dont want to drop them too low
59
how do we manage MAP on a patient who is HTN
keep it higher, closer to baseline. to ensure cerebral perfusion
60
how does PVD affect arterial line
harder to place
61
how do HTN med affect autonomic nervous system
impair function
62
what is an example of anti-HTN impairing autonomic nervous system function
PRE-OP:
orthostatic HTN
INTRA-OP:
profound hypotension with PP ventilation, blood loss, or position change
63
how do you control peep on a patient on anti-hypertensives
less peep to prevent hypotension
64
what do you do for hypotension intraop
decrease gas
ephedrine, phenylephrine
fluids, blood
IF NONE OF THESE WORK:
decrease TV
65
how does a large TV affect a dry patient
increased pulm pressure decreases venous return and thus decreases BP maybe increased HR
66
when do you cancel a case for HTN?
maybe for diastolic >110
67
what do you anticipate on induction with pre-op HTN patient
hypotension
68
what anesthesia technique increases sns stimuli
Direct laryngoscopy, tracheal intubation
69
how can you blunt SNS response to intubation
gas, propofol, labetalol, LTA, narcs
70
how long should DL last
15 seconds
71
T/F video laryngoscopy causes a less of a SNS response with intubation
T, so dont use as much induction drugs/dont rely on response to bring up BP/HR
72
if you turn up gas what else must you turn up
O2 flow
73
what drug can be changed to rapidly respond to BP changes
volatiles
74
if SBP is >170 what responds
baroceptor reflex
75
what can a large dose of phenylephrine result in
decreased HR from baroceptor response (so give atropine or glyco)
76
what does peri op HTN increase
blood loss
myocardial ischemia
cerebrovascular events
77
what other methods can be used to control HTN intraop
volatiles
N2O
opioids
antiHTN by bolus or drip
78
how do we treat intraop hypotension
decrease volatiles
increase IV fluids
albumin
ephedrine, phenylephrine
79
what rhythm can result from hypotension
junctional
80
how do you treat junctional
atropine
81
what med do you give with neo
robinol
82
if CO2 drops with no resp changes what will drop next
BP
83
what is the best way to fix hypotension
fix the cause, see if they are dry and need fluid/albumin
84
what leads to post op HTN
SNS activity
hypervolemia
85
what conditions does post op HTN lead to
myocardial ischemia, dysrhythmias, CHF, stroke, bleeding
86
what can BBs mask under anesthesia
hyperthyroid, hypoglycemia, inadequate anesthesia
87
what can NMB reversal with anticholinesterase lead to
marked brady (give robinol)
88
what is a HTN crisis
180/120
89
how does indigo charmine (sx dye) affect BP? SpO2
increases BP
intermittenly decreases SpO2
90
what are examples of end organ damage from HTN
encephalopathy
intracerebral hmmg
acute LV failure with pulm edema
unstable angina
acute MI
eclampsia
microangiopathic hemolytic anemia
renal insufficiency
91
what is the goal of htn emergency
decrease MAP by 20% in first hour then gradually over the next 2-6 hours
92
what are clinical indicators of HTN
chest crackles
swelling
JVD
93
when a HTN crisis is associated with encephalopathy what drug do you avoid
hydralazine
94
what med is a good choice fro myocardial ischemia or cocaine overdose
nitroglycerine
95
what meds do you avoid in cocaine OD
labetalol, beta blockers (cause coronary vasospasm)
96
what toxicity does nipride lead to
cyanide toxicity
97
what do you want to block in pheochromocytoma FIRST
alpha blockade first, beta blocker second
98
what is the difference between HTN crisis and HTN urgency
HTN urgency doesnt have end organ damage
99
what are s/s of HTN urgency
HA, epistaxis, anxiety
100
what are causes of periop HTN
pain, anxiety, hypothermia
101
what beta blocker has a shorter DOA so is good to test response
esmolol
102
what beta blockers do you avoid with asthma
non-selective (labetalol)
103
what beta blockers are safe with asthma
esmolol metoprolol
104
what is acute postop HTN
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
105
T/F elevated BP can lead to increased bleeding, bruising, and swelling
true
106
what are complications of post op HTN
bleeding
dehiscence
MI
dysrhythmias
CHF exacerbation with pulm edema
cerebral mmhg
stroke
TIA
encephalopathy
107
what are cuases of post of HTN
preexisting
chronic HTN med withdrawal
sx stress
pain
ANS activation
RAAS activation
Emergency delirium/anxiety
shivering
108
what helps with clonidine withdrawal
precedex
109
how can you blunt SNS response to intubation
gas, propofol, labetalol, LTA, narcs
110
what is the most common cause of RV failure
LV failure
111
in Systolic heart failure_______ is fixed so CO is dependent on ______
SV
HR
112
how does tachycardia affect CO in systolic HF
increases CO
113
how does tachycardia affect CO in diastolic HF
decreased CO
114
how is EF in systolic HF
decreased
115
how is EF is diastolic HF
preserved
116
what are s/s LV failure
high LVEDV
dyspnea
orthopnea
Paroxsymal nocturnal dyspnea (sleep apnea)
pulmonary edema
117
what position do you avoid in LV failure
steep Trendelenburg (heart cant handle increase in venous return)
118
what are s/s RV failure
peripheral edema
congestive hepatomegaly
RUQ pain
jaundice
increased LFTs
119
what are causes of RV failure
pulmonary HTN
RV MI
LV failure
120
what law tells us that increased volume in LV will increase SV
frank-starling
121
what do we try to avoid/treat in HF
remodeling
122
what is cardiac remodeling
changes in size, shape, and function of the LV (hypertrophy,dilation)
123
what causes LV hypertrophy
chronic pressure overload
124
what causes LV dilation
volume overload
125
what kind of remodeling causes wall thinning
dilation
126
what are other forms of remodeling
increased interstitial collagen deposition
myocardial fibrosis
scar formation from myocyte death
127
if BNP is < 100 HF is __________
unlikely
128
if BNP is 100-500 HF is __________
intermediate probability
129
if BNP is >500 HF is __________
diagnosable
130
T/F ECG has a high predictive value for HF
F, has a low predictive value
131
what can ECG detect in HF patients
previous MI
conduction abnormalities
dysrhythmias
132
T/F x-ray is the first indicator of pulmonary edema
F, lags 12 hours behind clinical evidence
133
what is the most useful test for the diagnosis of HF
ECHO
also tells us EF and ventricle size
134
if EF is low what kind of monitor do you want with anesthesia
arterial line
135
what two electrolytes do we monitor with CHF patients. Why?
potassium/magnesium
diuretics
136
what are s/s of electrolyte abnormalities we may see on monitor
dysrhythmias
137
what is class 1 HF (minimal)
No limitation of physical activity
no fatigue, dyspnea,palpitations
138
what is class 2 HF (mild)
Slight limitation of physical activity
comfortable at rest, symptoms occur with ordinary exertion
139
what is class 3 HF (moderate)
marked limitation of physical activity, comfortable at rest, symptoms occur with less than ordinary exertion
140
what is class 4 HF (severe)
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
what is the long term goal of treating CHF
prolong life by slowing or reversing the progression of ventricular remodeling
142
what kind of diuretic is potassium sparing
spironolactone
143
what is the first line therapy in patients with HF
aldosterone antagonists
144
what medications are good for patients with systolic HF
ACEI
BBs
145
what medications promote reverse remodeling in HF patients and are good for first line therapy
ACEI
146
what medication is proven to decrease ventricular remodeling and to potentiate reverse remodeling
ACEI
147
what conditions are we cautions in giving BBs to
DM/hypoglycemia
reactive airway
slowed heart rhythm (brady)
heart blocks
asthma
148
what medication do we continue periop in HF patients
BB
ACEI
ARBs
prepare for HYPOTENSION
149
how does an increase in calcium affect cardiac contractility
increases contractility
150
what are symptoms of HF that would preclude a patient from elective surgeries
orthopnea
rales on exam
dyspnea on exertion
use of digoxin, diuretics
history of CHF
151
what do we give with etomidate to limit BP changes
steroid
152
what medication do you give with ketamine do decreases secretions
robinol
153
what induction medication do you give to patients with decreased ventricular function
ketamine
154
what does ketamine increase
BP, PA pressures, HR, CO, myocardial oxygen consumption
155
what do we give with ketamine to lessen emergence delirium
midazolam/versed
156
what medications do you give with ketamine for induction
versed
robinol
157
what medication do we give with narcotics to preserve HR
robinol/atropine
158
how do volatile anesthetics affect BP? how do you treat this
decrease
give fluids, albumin, cystalloids in preop
159
how does pancuronium affect heart
increased HR
increase likelihood of dysrhythmias
160
what do we implant in HF patients to prevent sudden death
ICDs
help prevent dysrhythmias from remodeling of heart from HF
161
what usually causes sudden death in patients with HF
dysrhythmias
162
what do we use to read oxygen saturation in LVAD patient
cerebral oximeter and art line (ABGs)
163
what device will you use to get art line in LVAD patient
ultrasound, no radial pulse
164
what medication will LVAD patients always get
ABX, increased risk of infection from device
165
LVAD patients are __________ dependent so _______ is very important
flow
volume
166
what drugs do we avoid in LVAD patients
vasoconstrictive
167
do we use spontaneous ventilation in LVAD patients
No, can lead to increase in CO2 (which causes vasoconstriction)
168
what three things do we avoid in LVAD patients
impedance of flow to LV
increase in CO2
Vasoconstrictive drugs
169
how does an increase in HR or contractility affect hypertrophic cardiomyopathy
decrease diastolic filling time
170
what do you avoid in hypertrophic cardiomyopathy
increased HR
hypovolemia
vasodilators
PP ventilation
decrease in afterload
hypotension
171
what is common cause of cardiomyopathy
genetic
172
how do you manage induction BP in a patient with hypertrophic cardiomyopathy
maintain, dont let it drop
173
what do you want in hypertrophic cardiomyopathy
decreased HR (volatiles, BBs)
increased preload
increased afterload/maintain BP
174
what is a common cause of sudden cardiac death in young people
hypertrophic cardiomyopathy
175
what is the most effective drug fro treating a fib in hypertrophic cardiomyopathy patients
amiodarone
176
what is the most common cardiomyopathy
dilated
177
what are S/S dilated cardiomyopathy
angina
TR?
dysrhythmias
all four chambers dilated
global hypokinesis
178
what is treatment for dilated cardiomyopathy
BBs
anticaoags
ICD
lifestyle changes (diet, no smoking, no alcohol, exercise)
heart transplant
179
what is issue with regional anesthesia in pregnant patient with cardiomyopathy
patient is anticoagulated
do GA for C sec
180
what causes secondary cardiomyopathy
abnormal pathophys (amyloid, sarcoid)
181
how is systolic funciton in secondary cardiomyopathy
normal, preserved EF
182
how does secondary cardiomyopathy appear
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
what kind of disease is cor pulmanale
lung disease
184
how does Co pulmonale develop
RV enlargement that progresses to HF
185
what is a potential cause of cor pulmonale
pulmonary hTN
186
how does RV appear in cor pulmonale
hypertrophic
187
what are S/S cor pulmonale
peripheral edema
syncope with activities
splenomegaly
peaked p waves in leads 2, 3, aVF
RBBB
RA/RV hypertrophy
188
what ECG changes occus in cor pulmanale
peaked p waves in leads 2, 3, aVF
RBBB
189
how do you care for cor pulmonale
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
how do you treat bronchospasm
increase volatiles, give 100% O2
191
in diastolic HF EF is ___________
in systolic HF EF is ________
preserved
decreased
192
what is considered a preserved EF
>40%
193
sleep apnea is a sign of which HF
left
194
what causes a low cardiac output failure
blockage
195
what causes a high cardiac output failure
decreased function/increase burden
196
what do we want to avoid in cardiomyopathy
remodeling
197
what does echocardiogram show
EF
LV structure and function
structural abnormalities
presence of diastolic dysfunction
right ventricular dysfunction
198
what are the 2 most important risk factors for ischemic heart disease
male gender
increasing age
199
what are other risk factors for ischemic heart disease
high cholesterol
systemic hypertension
cigarette smoking
diabetes mellitus
obesity
sedentary lifestyle
family hx of premature ischemic heart disease
200
what is angina pectoris
chest pain caused by inadequate flow of blood and oxygen to the heart
201
what are the first manifestations of ischemic disease
angina pectoris
acute myocardial infarction
202
what is a major cause of sudden cardiac death
dysrhythmias
203
what occurs with an extreme imbalance in coronary blood flow
CHF, dysrhythmias, MI
204
how is angina pectoris usually described
pressure or heaviness
205
where does pain from angina pectoris radiate
neck, left shoulder, left arm, lower jaw, occasionally to the back, down the rights arm
206
T/F angina pectoris pain radiates below the level of the diaphragm
False
207
T/F angina can be felt as epigastric pain
True
208
T/F angina can feel like dyspnea
True
209
what is the pattern of angina pain
ebbs and flows
210
what is the goal of managing angina pain
balance supply and demand
maintain BP, HGB, O2
211
what causes increased demand on the heart
tachycardia
HTN
exercise
stress
212
what two factors confirm myocardial ischemia
ST segment depression
anginal pain
213
what ECG changes are common with Myocardial Ischemia
ST depression
T wave inversion
214
if a patient has inverted T waves from previous MI how can they appear in current Mi
normal/upright
215
what is a positive test for exercise elctrocardiography
1 mm ST downsloping during or within 4 minutes after exercise
216
what test do we use to detect signs of ischemia and establish its relationship to chest pain
exercise elctrocardiography (stress test)
217
the greater the degree of downsloping of the ST segment, the ________________ the likelihood of CAD
greater
218
what do we do if patient cannot undergo exercise ECG
non-invasive imaging tests use IV infusion of dobutamine or cardiac pacing
then do echo or radionuclide scan
219
what test do we use for wall motion analysis, and EF
echocardiography
220
what is the test for assessing coronary perfusion using traces like thalium and technetium
nuclear stress imaging
221
in nuclear stress testing, traces (are/are not) picked up in damaged areas
are not
222
which test is useful for assessing coronary perfusion with greater sensitivity than exercise testing
Nuclear Stress Imaging
223
what is the most important indicator of CAD
size of the perfusion abnormality
224
what test provides the best information about the condition of the coronary arteries
coronary angiography
225
what test is used for diagnosis of coronary spasm
coronary angiography
226
what patients should have coronary angiography
continued chest paid despite medical therapy
those considering revascularization
pts at risk (pilots)
227
where is the most dangerous lesion (what artery)
left main coronary artery
228
what is treatment for ischemic heart disease
lifestyle
stop smoking
maintain ideal body weight
treat systemic HTN
lower LDL with diet and/or drugs
229
what level should LDL be kept below
160 mg/dL
230
what medications are used to manage ischemic heart disease
Beta Blockers
Calcium Channel Blockers
ACEI
ARBS
231
in patients with systemic HTN and LV dysfunction what meds do we use
ACEI
ARBs
232
what is the initial therapy of choice for chronic stable angina
BB
233
what is the end goal of beta blocker therapy for ischemic heart disease
decrease myocardial oxygen demand
234
what beta blockers do you avoid is asthma
non-selective (propranolol, nadolol)
235
what are contraindications for BB treatment of ischemic heart disease?
uncontrolled CHF (intensify LV failure)
2nd/3rd degree AV block
bradycardia
SSS
severe reactive airway disease
236
what medication is recommended for all patients with ischemic heart disease
low dose ASA
237
what platelet inhibitor decreases risk of stroke and MI more than ASA
clopidogrel (plavix)
238
what patients do we not give ASA to
patients >70, at greater risk of falls
239
how long does ASA last for
7 days
240
what can beta blockers mask in DM patients
hypoglycemia
241
T/F you continue BBs through periop period
true
242
what are the actions of CCBs on ischemic heart disease
decrease vascular smooth muscle contractility
dilate coronary arteries
increased coronary blood flow
decreased contractility
decreased O2 consumption
decreased systemic B/P
243
what is the action of organic nitrates
-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
how do organic nitrates affect venous return
decreased venous return, so decreased left ventricular filling pressure, volume, and myocardial oxygen consumption
245
what is the most common side effect of organic nitrate treatment for ischemic heart disease
Headache
246
what can happen to a hypovolemic pt who receives organic nitrates
hypotension
247
T/F tolerance develops with sustained use of organic nitrates
true
248
when do we do a CABG, PTCA, or place a coronary artery stent (revascularization)
-left main stenosis of more that 50%
-epicardial coronary artery stenosis of 70% or greater
-CAD with EF <40%
249
presence of hypokinetic or akinetic LV means a ___________ prognosis for revascularization therapy
poor
250
how long must a PTCA heal
2-3 weeks
251
how long does it take a bare metal stent to heal
12 weeks
252
how long does it take a drug eluding stent to heal
one year for complete endothelialization
253
your patient experiences their baseline ischemic type chest pain, what is this
stable angina
254
your patient experiences ischemic type chest pain, that is new onset or a change from baseline, what is this
acute coronary system
255
what test do you do for acute coronary system
12-lead ECG
256
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?
STEMI
257
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?
NSTEMI
258
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?
Unstable angina
259
what is the best lab for myocardial injury
troponin
260
which is more specific for myocardial injury Troponin or CK-MB
Tropinin
261
when to troponin level rise with myocardial injury, how long does it stay elvated
3 hours
7-10 days
262
what are treatments for unstable angina/NSTEMI
bed rest
supplemental O2
Analgesia
BBs
CCBs
SL or IV NTG to improve O2 supply
ASA, clopidogrel, heparin therapy
263
what is a good medication to alleviate anxiety pre-op
scopolamine
sedation and amnesia without changes in HR
264
how long do we wait from stent placement till surgery
90 days
265
what history findings are indicative of ischemic heart disease
angina pectoris
dyspnea
limited exercise tolerance
peripheral edema
266
what monitoring do we do for patients at high risk for myocardial ischemia
A-lines, PA caths, TEE,
267
what is the most common endocrine disease associated with ischemic heart disease
DM
268
what are preop goals for MI patients
decrease myocardial oxygen requirements
improve coronary blood flow
269
what is the goal HR from BB
50-60
270
do we stop BB for surgery
NO
271
what is the treatment for excessive bradycardia
atropine/glycopyrrolate
272
does atropine cross BBB
yes
273
why is atropine not good for elderly
crosses BBB
274
what drug can we use for excessive beta antagonist activity
isoproterenol
275
what medication can reverse beta blockade if pure beta blockade has caused myocardial depression
Dobutamine
276
what are the anesthesia pre-op implications for Myocardial ischemia
risk factors
angina
previous cardiac surgery
anticipation of blood loss
277
what do we do for a patient with known ischemic heart disease
get CV clearance?
278
what are intraoperative goals to manage myocardial ischemia
modulate SNS response and provide quick control of hemodynamics
-prevent ischemia
-balance O2 supply and demand
279
what symptoms do we avoid in ischemic heart disease patients
persistant tachycardia
systolic HTN
SNS activation
arterial hypoxemia
diastolic hypotension
280
be cautious of drugs that __________ HR in CV patients
increase
281
which is more likely to cause ischemia tachycardia or HTN
tachycardia
282
what are some patient factors that affect O2 supply to myocardia
BP
Hgb
283
what is recommendation for HR and BP values intraop
maintain within 20% of normal values
284
how long should laryngoscopy last to avoid excessive SNS stimulation
15 seconds
285
what induction drug do we avoid in patients are risk of myocardial ischemia
ketamine
286
what two leads detect most significant ST segment changes
leads 2 and V5
287
what does ST segment changes in V5 reflect
LAD decreased perfusion
288
what does ST segment changes in lead 2 reflect
RCA decreased perfusion
289
what are the leads for RCA
2, 3, aVF
290
what are leads for circumflex
1, aVL
291
what are leads for LAD
v3-v5
292
what aspect of heart is RCA associated with
RA
RV
SA node
AV node
inferior LV
293
what aspect of heart is circumflex associated with
lateral LV
294
what aspect of the heart is LAD associated with
anterolateral LV
295
what must ST elevation be to diagnose MI
>1 mm in two or more limb leads
>2 mm in two or more precordial leads
296
what must ST depression be to diagnose MI
> 2mm in at least 2 of the 3 leads v1-v3
297
what are postoperative goals for Myocardial ischemia
prevent ischemia
monitor for injury
treat myocardial ischemia or infarction
298
how does intraop hypothermia affect O2 demand
leads to shivering which increases demand
299
how does prolonged hemodynamic changes affect O2 demand
increased demand
300
what are some causes of increase myocardial O2 demand in post op period
shivering
pain
hypoxia
hypercarbia
sepsis
hemorrhage
hemodynamic changes
301
how does emergence affect hemodynamics
changes, be ready with lido, narc, prop?
302
what is the intrinsic HR of an implanted heart
110
303
T/F implanted hearts have no sympathetic, parasympathetic, or sensory innervation
true
304
T/F in implanted heart the P wave is no longer the pacemaker
T, the p wave cannot transverse the suture line and has no influence on chronotropic heart activity
305
T/F robinol, atropine, ephredrine, and dopamine work on implanted hearts
F, these are indirect acting catecholamines and do not work
306
T/F Isoproterenol and Epinephrine work on implanted hearts
T, they are direct acting
307
what complications can antirejection drugs cause
nephrotoxicity
308
T/F patients with implanted hearts can feel angina
false
309
T/F patients with implanted hearts have an exagerrated response to larygoscopy and intubation
false
310
what indication of anesthetic depth is blunted in heart transplant patient
elevated heart rate
make sure patient is not lite, anticipate need for narcotic/multimodal need
311
what is a transplanted patient dependent on for CO
preload/volume
312
what is most common cause of death in transplanted patient
opportunistic infection (immunosuppresion)
313
most transplant patients are emergent so full stomach is a concern, how do we combat this
give pepcid/bicentra preop
use RSI, get cuff up fast
314
What is the defasciculating dose?
give a bit of roc before succs to occupy ACTH receptor so succs doesnt cause contraction as much
315
what kind of muscle relaxants do you use in transplanted heart
non-histamine releasing muscle relaxants (all but mivacurium/atracurium)
316
what gas do you avoid in transplanted heart
N2O (pulm htn/air embolism)
317
what do you take into account for patient on antirejection drugs
watch for nephrotoxicity (drugs that are renal excreted/metabolized)
watch for refractory hypotension related to steroid need (stress dose)
318
what are signs of rejection
dysrhythmias
CHF
319
T/F CCBs are as effective as BBs in decreasing the incidence of MI
false
320
T/F CCBs are contradindicated in patients with CHF, or severe aortic stenosis
true
321
what conditions are organic nitrates relatively contraindicated in
hypertrophic obstructive cardiomyopathy
severe aortic stenosis
322
what does excessive Angiotensin 2 lead to
myocardial hypertrophy
interstitial myocardial fibrosis
increased coronary vasoconstriction
endothelial dysfunction
323
what patients are ACEI recommended for
HTN
LV dysfunction
diabetes
324
what is a risk of TPA
increased bleeding, brain bleeds
325
what is purpose of PCI
increased blood flow
326
what is purpose of BB treatment
decreased HR leads to decreased demand
327
what is purpose of ASA or clopidogrel therapy
decrease clotting
328
what is purpose of morphine or SL NTG therapy
vasodilation leading to increased O2
329
when do we do an emergency CABG
coronary anatomy precludes PCI
failed angioplasty
evidence of infarction-related ventricular septal rupture
mitral regurge
330
what are two large risks of PCI
thrombosis
increased bleeding 2/2 dual anti-platelet therapy
331
T/F D/C ASA in drug eluding stent patients
F, continue
332
when is angina considered unstable
- lasts > 20 min
- more frequent
-more easily provoked
-new onset, severe, prolonged, disabling
- onset occurs at rest
333
what are periop risks for MI
increased myocardial O2 consumption
alterations in coagulation leading to thrombosis
changes in vascular tone and endothelial function
334
how long do wait to do elective surgery after bare metal stent
4-6 weeks or
90m days
335
what drug can increase myocardial contractility in presence of beta blockade
calcium
336
what can acute withdrawal of beta blockers lead to
rebound HTN
tachycardia
337
what medications can you give to blunt HR increase from tracheal intubation
esmolol infusion
fentanyl
remifentanil
dexmedetomidine
338
what do you do to gas to decrease HR
increase
339
how does a dry patient respond to increased gas
decreased BP
340
how do volatiles affect hemodynamics
decrease myocardial O2 requirements
decrease in coronary perfusion pressure
341
when LV function is extremely poor what can be used as the sole anesthetic
narcotics
342
T/F regional anesthesia is contraindicated in ischemic heart disease
false
343
what muscle relaxants are safe in ischemic heart disease
minimal HR BP effects
ROC
VEC
CIS
344
T/F pancuronium is safe in ischemic heart disease
F, causes tachycardia
345
when reversing a patient what is your anticholinergic of choice
glycopyrolate (doesnt affect HR as much)
346
what is the standard for intraoperative diagnosis of myocardial ischemia
transesophageal echocardiography
347
what catecholamines work on transplanted hearts
isoproterenol
epinephrine
348
which is preferred for anesthesia management in transplanted hearts GA or regional
general
349
what leads to refractory hypotension in heart transplant patients
stress dose steroids
