Exam 2 Flashcards
What is the first messenger of a GPCR?
Ligand that binds the GPCR
What are examples of ligands?
NE, Epi, Ach
What does the effector of a GPCR do?
activates the 2nd messenger
What are the names of effectors?
Adenylate Cyclase, Phospholipase C, Guanylate Cyclase (nitrodilators)
What does a second messenger do?
elicits a specific response
What are the second messengers?
cAMP, cGMP, inositol triphosphate, diacylglycerol, Ca
Explain the GPCR pathway of Phenylephrine?
Phenylephrine binds to a A-1 Gq protein, Increasing phospholipase C, Increase IP3 DAG and Ca, causing muscle contraction
Explain the GPCR pathway of Precedex?
Precedex binds to a A-2 Gi protein, decreasing adenylate cyclase , decreasing cAMP, causing contraction and transient HTN
What happens in the Cardiac Myocyte when you give a Beta-1 or Beta-2 drug?
Activates adenylate cyclase, increasing cAMP, which increases protein kinase A, which increases calcium release and muscle contraction.
What happens in the smooth muscle when you give a Beta-2 drug?
Increases cAMP which inhibits myosin light chain kinase, leading to vasodilation
What are both endogenous and exogenous sympathomimetic drugs?
epinephrine, norepinephrine, and dopamine
What sympathomimetic drugs are just exogenous?
isoproterenol, and dobutamine
What is the naturally occurring catecholamine synthesized from tyrosine in the adrenal medulla?
Epinephrine
What are the catecholamines secreted by the adrenal medulla and their percentages?
80% Epi 20 % Norepinephrine
Do endogenous or exogenous catecholamines have a longer effect in the body?
Endogenous
What happens if you give MAOIs with Ephedrine?
HTN crisis or exaggerated response
What receptors does Epinephrine act on?
A-1, A-2, B-1, B-2
What is the Beta-1 effect seen with Epinephrine?
positive inotropy, chronotropy, and dromotropy
What is the Beta-2 effect seen with Epinephrine?
smooth muscle relaxation, mast cell stabilization
Which receptors does low dose Epi target more?
Beta more than alpha
At what dose of Epi do you see just Beta effects?
0.01-0.03 mcg/kg/min
At what dose of Epi do you see Beta and a little alpha effects?
0.03-0.1 mcg/kg/min
At what dose of Epi do you see Alpha and Beta effects?
Greater than 0.1 mcg/kg/min
What is epinephrine used to treat?
low CO, anaphylaxis, bronchospasm
If your patient is on Epi what lab value do you need to monitor?
blood sugar
Where is NE synthesized?
inside the nerve axon and stored in vesicles
What is the rate limiting step in NE synthesis?
conversion of tyrosine to dopa by tyrosine hydroxylase
What receptors does NE bind to?
A-1 > A-2 > B-1 > B-2
Does NE produce increased inotropy?
yes, it is not purely alpha selective
What is the dose range of NE?
0.01-0.4 mcg/kg/min or 1-20mcg/min
What vasopressor is not a great choice for someone with Right sided heart failure with hypotension? Why
NE, it causes pulmonary vasoconstriction, it increases right heart afterload. Choose Vasopressin instead.
What receptors does dopamine bind to?
Dopamine, alpha and beta
Dopamines beta-1 stimulation, indirectly stimulates the release of what catecholamine?
norepinephrine
What is considered low dose dopamine and what does low dose mainly affect?
2mcg/kg/min D1 and D2 receptors, dilating renal and mesenteric vascular beds
What is considered intermediate dose dopamine and what receptors does intermediate dose mainly affect?
2-10mcg/kg/min Dopa and beta-1 receptors
What is considered high dose dopamine and what receptors does high dose mainly affect?
10-20mcg/kg/min alpa receptors
What is dopamine used to treat?
cardiogenic shock, and low CO states
What metabolizes Dopamine? What instances may we see increased circulating levels?
MAO People taking psych meds, because they are MAOIs
What synthetic catecholamine increase HR independent of the SA node?
isoproterenol
What dose of isoproterenol is used to treat heart block?
2-20mcg/min
What is the dose of Isoproterenol for septal myectomy gradient testing?
5-10mcg bolus
What receptors does isoproterenol bind to?
nonselective Beta
What is Dobutamine?
synthetic sympathomimetic amine
What receptors does Dobutamine affect?
Beta 1 >> Beta2
Dobutamines Beta1 effects cause what hemodynamic changes?
Inotropy, with less effect on SVR
What is the dose of Dobutamine?
2-20mcg/kg/min
What is Dobutamine used to treat?
cardiogenic shock, septic shock, heart failure, used in stress testing
Which vasopressor is a pure alpha agonist?
Phenylephrine
What is the dosage range of Phenylephrine on a pump?
0.1-1mcg/kg/min
Why does Phenylephrine cause reflex bradycardia?
baroreceptor stimulation.
Where is vasopressin stored and produced?
produced in the hypothalamus and stored in the posterior pituitary
What stimulates vasopressin release?
increased osmolarity and hypovolemia
What is the action of vasopressin?
vasoconstriction, dilates renal afferent, pulmonary and cerebral arteries
What is the classification of Milrinone?
PDE 3 inhibitor
What does PDE 3 do? What does inhibiting it do?
PDE3 breaks down cAMP into AMP. Inhibiting that breakdown increases the amount of cAMP available for cardiac muscle contraction. In the smooth muscle it decreases SVR.
What are the overall effects of milrinone?
increases inotropy
decreases SVR, preload, and PVR
no change in chronotropy
If you start Milrinone on your patient with Left HF, what other medication do you likely need to start?
vasopressin
Giving a rapid loading dose of Milrinone will cause what?
hypotension
PDE5 drugs are selective for what? what does this cause?
cGMP, dilation of vascular and pulmonary beds.
Does NTP or NTG release NO spontaneously?
NTP
How does NO cause relaxation?
NO yields guanylate cyclase, guanylate cyclase catalyzes the conversion of GTP to cGMP, increased cGMP causes vasodilation
Does NTP reduce preload or afterload?
BOTH preload and afterload.
What is the dose range of NTP?
0.3-10 mcg/kg/min
How many cyanide molecules are in NTP?
5 cyaninde molecules
What doses of NTP causes cyanide toxicity?
>500mcg/kg administered faster than 2mcg/kg/min
Describe the highlights of NTP metabolism.
metabolism by plasma hemoglobin
1 cyanide molecule binds methemoglobin
other 4 undergo rhodanese conversion to thiocyanate (requires B12)
renal elimination
How does B12 deficiency affect NTP metabolism?
not enough B12 leads to anaerobic metabolism
What are S/S of cyanide toxicity?
metabolic acidosis, increased SVO2, tachycardia, tachyphylaxis
What are the treatment options for cyanide toxicity?
sodium nitrite, sodium thiosulfate, vitamin B12, methylene blue 1-2mg/kg
Where does NTG work? arteries, veins, both?
veins
What happens to filling pressures, wall tension, and MVO2 in someone on NTG?
all decrease
Why is NTG the primary treatment for angina?
decrease preload and cardiac work
Discuss NTP’s affect on afterload and preload, onset, and duration
decrease afterload > preload, rapid onset, duration 1-3 minutes.
Discuss NTG’s affect on afterload and preload, onset, and duration
decrease preload, onset 1-2 minutes, duration 10 minutes
Where does hydralazine work?
relaxation of arterial smooth muscle
What is the dose, onset and duration of hydralazine?
dose: 2.5-20mg onset: 2-20min (5 minutes) duration: 12 hours
Hydralazine’s decrease in afterload may cause increase in what?
heart rate
What is the onset, duration, receptor and dose of esmolol?
onset 2 min, duration 10-15min, receptor Beta 1, and bolus dose 10-30mg, gtt 100-300mcg/kg/min
What is the onset, duration, receptor and dose of metoprolol?
onset 1-2 min, duration 5-8 h, receptor Beta 1, and bolus dose 5-15mg
What is the onset, duration, receptor and dose of labetalol?
onset 2-5 min, duration 12-6h, receptor Beta and alpha 7:1, and bolus dose 5-10mg
What induction medications are cardiac stable, and which are cardiac depressive?
stable: etomidate 0.3mg/kg, ketamine 0.5-1.5mg/kg, fentanyl 3-10mcg/kg depressive: propofol 1-2mg/kg, inhaled anesthetics
What does Propofol do to blood pressure in healthy adults?
decrease blood pressure
What are patient characteristics indicative of propofol induced hypotension?
>50yo ASA 3-4, MAP <70, co-administered with fentanyl
Why does propofol cause hypotension?
decreases SNS tone, vasodilation
What is the induction dose of Propofol?
2mg/kg
What is the mechanism that Etomidate causes adrenocortical dysfunction?
inhibition of 11 beta-hydroxylase and 17 alpha hydroxylase
What is the induction dose of etomidate?
0.3mg/kg
Explain how Ketamine is cardiac stable?
activates the SNS that causes endogenous release of NT and inhibition of NE uptake
How does ketamine affect blood pressure, heart rate, contractility, and CVP?
increases BP, increase HR, increase Contractility, and increases CVP
What does ketamine cause in the critically ill patient?
negative inotropic effect, due to a decrease in intracellular calcium
What inhaled anesthetic causes the least reduction in SVR?
Sevo
Explain the mechanism behind inhaled anesthetics being cardiodepressant?
They reduce Ca++ influx through the sarcolemma and depress depolarization-activated Ca++ release from the sarcoplasmic reticulum
Which inhaled anesthetic causes the least effect on HR?
sevo
What gases increase HR above 1 MAC?
Iso and Des
Coronary steal is greatest with which anesthetic gas?
Iso
Which gas produces the least amount of coronary vasodilation?
Sevo
Are gases proarrythmic and antiarhythmic?
proarhythmic
What are the key events in isovolumetric contraction?
LV pressure > LA Pressure 1st heart sound LV pressure increases LV volume constant
What are the key events in ventricular ejection?
LV Pressure > aortic pressure, Ejection of SV, Rapid ejection during 1st 1/3, Reduced ejection during last 2/3
What is the only phase of the ventricular pressure volume loop that requires ATP during diastole?
isovolumetric relaxation
What are the key events in isovolumetric relaxation?
Aortic pressure > LV pressure, 2nd heart sound, LV pressure decreases, LV volume constant, Only phase during diastole that requires ATP, Dicrotic notch
What are the key events of rapid ventricular filling?
LA pressure > LV pressure, LV volume increases, LV pressure constant, 80% of ventricular filling occurs during rapid and reduced phases
What is occurring during reduced ventricular filling (diastole)?
LV fills but at a slow rate
What is final segment of diastole and what is occurring?
LA contraction, 20% ventricular filling End of atrial contraction = EDV
Where is EDV and ESV measured?
EDV is always the bottom right corner ESV is always the bottom left corner
Complete the Wiggers diagram.
.
Complete the pressure volume loop.
.
Patients who had Rheumatic fever typically have which valvular abnormalities?
AV and MV stenosis
What are risk factors for AV stenosis? (5)
older age, male, smoker, HTN, HLD
What is the normal AV diameter?
2cm
What is the normal AV area?
2-4cm
What is the normal AV gradient?
2-5mmHg
Symtoms of AV stenosis do not occur until valve area has decreased by how much?
50%, 1-2cm
What is the triad of symptoms characteristic of AV stenosis?
SAD - syncope, angina, dyspnea
What is a critical AV area?
<0.8cm2
What AV area and gradient are considered mild AV stenosis?
>1.5cm <20mmHg
What AV area and gradient are considered moderate AV stenosis?
1-1.5cm 20-40mmHg
What AV area and gradient are considered severe AV stenosis?
<1cm >40mmHg
As AV stenosis worsens what happens to valve area and gradient?
valve area gets smaller Gradient gets larger
Is AV stenosis a volume or pressure problem? what does it lead to in the muscle?
pressure. Concentric hypertrophy, sarcomeres in parallel
Is AV stenosis a volume or pressure problem? what does it lead to in the muscle?
pressure. Concentric hypertrophy, sarcomeres in parallel
What are the resulting effects of AV stenosis causing concentric hypertrophy?
increase LV mass -> decrease compliance -> diastolic dysfunction -> increase in late filling = normal SV
In AV stenosis what is vital for adequate LV filling?
atrial kick
In the compensatory phase of AV stenosis, LV mass increases, having what effect on O2 supply and demand?
MVO2 is increased (increased demand) Myocardial O2 supply is decreased
What causes MVO2 to be increased in AV stenosis?
increased mass, isovolumetric contraction requires more energy, prolonged ejection phase (more afterload to overcome)
What causes myocardial O2 supply to decrease in AV stenosis?
increased LVEDP (decreases CPP), absent systolic coronary flow, prolonged ejection reduces perfusion interval, subendocardial capillaries compressed
What causes myocardial O2 supply to decrease in AV stenosis?
increased LVEDP (decreases CPP), absent systolic coronary flow, prolonged ejection reduces perfusion interval, subendocardial capillaries compressed
How does AV stenosis lead to LV failure?
.
What happens to pulse pressure, systolic upstroke, and amplitude of the A-line tracing in AV stenosis?
pulse pressure narrow systolic upstroke decreased amplitude decreased
What pressure volume loop is consistent with AV stenosis?
.
What happens to pulse pressure, systolic upstroke, and amplitude of the A-line tracing in AV stenosis?
pulse pressure narrow systolic upstroke decreased amplitude decreased
What are appropriate induction meds for someone with AV stenosis?
Narcotic based Etomidate or Ketamine Consider having esmolol easily accessible
What is the most important pre-CPB goal if your patient is having a AVR for AV stenosis?
maintain CPP
How do you treat HoTN in a patient with AV stenosis?
Phenylephrine
In AV stenosis what is your SVR goal to help perfuse the subendocardium?
high SVR
In AV stenosis what is your goal for preload, afterload, contractility, rate, and PVR?
increase preload, afterload maintain contractility and PVR decrease rate
How do symptoms of acute vs chronic AR differ?
acute: sudden dyspnea, CV collapse chronic: asymptomatic for years
What is the vena contracta?
narrowest point of AR and corresponds to the size of the regurgitant orifice
What vena contracta area and regurgitant volume are considered mild AV regurg?
<0.3cm <30mL/beat
What vena contracta area and regurgitant volume are considered mild AV regurg?
<0.3cm <30mL/beat
What vena contracta area and regurgitant volume are considered severe AV regurg?
>0.6cm >60mL/beat
Is AV regurg a volume or pressure problem? what does it lead to in the muscle?
volume, eccentric hypertrophy, sarcomeres in series
What are the compensatory mechanisms of acute AV regurg?
increased SNS tone (HR and contractility, fluid retention via aldosterone)
Acute AV regurg causes what changes to LVEDP, LVEDV, and SV?
increases LVEDV, LVEDP and decreases SV
Acute AV regurg causes what changes to LA wall tension and contractility?
increased wall tension, decrease contractility
Does acute or chronic AV regurg cause systolic and diastolic failure leading to cariogenic shock?
acute
What happens to MVO2 demand in acute AV regurg?
increased, due to increased compensatory SNS tone leading to ischemia
Chronic AV regurg causes what changes to LVEDP, LVEDV, and SV?
increased LVEDV, no change to LVEDP (essentric hypertrophy compensation), increased SV (but not pumping well)
Does AV regurg cause a narrow or wide pulse pressure on A-line tracing?
wide
Does chronic Lv regurg cause a HF?
systolic HF, due to increased LV systolic pressure but decreased LV systolic function
What happens to ESV, EDV and isovolumetric relaxation tracing on a pressure volume loop in AV regurg?
increased ESV and EDV isovolumetric relaxation is sloped to the right
What is the bunny ears on A-line tracing called in a patient with AV regurg?
pulsus bisferiens
In AV regurg what is your goal for preload, afterload, contractility, rate, and PVR?
increase preload and rate maintain contractility, and PVR decrease afterload
What is the main anesthetic goal of AV regurg?
prevent further increases in LV wall stress
What is the basic management of AV regurg? (3 words)
Full, Fast, and Forward
What pressure volume loop is consistent with AV regurg?
.
Hypotension in a patient with AV regurg should be treated with which vasopressor?
Ephedrine
What gas is preferential to use in AV regurg?
Iso - increases HR and decreases SVR
After bypass what drug may be needed in someone with AV regurg? Why?
Inotrope due to essentric hypertrophy
What is the overall most common cause of MV stenosis?
rheumatic fever, endocarditis and calcification in the US
What symptoms are seen with MV stenosis?
pulmonary congestion, decreased CO (LV under filled). RV failure/overload
What valve area and mean gradient are consistent with mild MV stenosis?
>1.5cm area <5 mmHg gradient
What valve area, mean gradient, and symptoms are consistent with moderate MV stenosis?
1-1.5cm area 5-10 mmHg gradient
What valve area, mean gradient, and symptoms are consistent with severe MV stenosis?
<1cm area >10 mmHg gradient
What happens to valve area and mean gradient as Mv stenosis gets worse?
valve area decreases, and mean gradient increases
What MV area is consistent with symptoms of tachycardia and increased CO?
1.5-2.5cm
What MV area is consistent with symptoms at rest?
<1cm
When the PA systolic pressure reaches ___ in MV stenosis, repair is needed?
>50mmHg
What is the normal MV valve area?
4-6cm
Severe MV disease is diagnosed when valve area is how much?
<1cm
How does MV stenosis affect LVEDV?
decreases
How does tachycardia in MV stenosis affect LVEDV?
decreases
What is the pathway for tachycardia in MV stenosis leading to pulmonary edema?
increased HR -> increased LAP -> increase PAP -> pulm. edema
Does PAOP overestimate or underestimate actual LVEDV/LVEDP in MV stenosis?
overestimate (remember stenosis is a increased PRESSURE problem)
MV stenosis is most likely to cause which dysrhythmias?
A-fib
What are the pathways for MV stenosis leading to decreased lung compliance and increased work of breathing, tricuspid regurg, and vasoconstriction
.
What pressure volume loop is consistent with MV stenosis?
.
What happens to EDV, ESV and SV on a V. pressure volume loop of MV stenosis?
decreased EDV, slight decrease in ESV, decreased SV very minimal changes
Which wave on a PAC (a,c,v,x,y) is affected in MV stenosis?
cannon A wave
What is the basic three word management for MV stenosis?
Slow, full and constructed
In MV stenosis what is your goal for preload, afterload, contractility, rate, and PVR?
increase preload maintain afterload, contractility, decrease rate and PVR
You are waking a patient up with MV stenosis during a non cardiac surgery, what do you want to avoid? Why?
Apnea, increases PVR (hypercarbia and hypoxia)
What is really important to pay attention to during induction for a patient with MV stenosis?
HR, because CO is fixed, they are
Do you manage pre-CPB hypotension with volume or pressors in a patient with Mv stenosis?
pressors, usually not hypovolemic
Does MV regurg occur during systole or diastole?
systole
What are causes of acute MV regurg?
papillary muscle dysfunction, MI, trauma
MV regurg causes fluid overload in which chamber?
LV
What vena contracta area and regurgitant volume are considered mild MV regurg?
<0.3cm <30mmHg
What vena contracta area and regurgitant volume are considered moderate MV regurg?
0.3-0.6cm 30-60mmHg
What vena contracta area and regurgitant volume are considered severe MV regurg?
>0.7cm >60
In acute MV regurg what happens to LVDP, SV, and LA pressure?
increased LV diastolic pressure decreased SV increased LA pressure -> pulm edema
Which wave on a PAC (a,c,v,x,y) is affected in MV regurg?
large V waves
In chronic MV regurg what happens to LV compliance, EF, and LV pressure?
increased LV compliance normal EF decreased LV pressure
Is MV regurg a volume or pressure problem? what does it lead to in the muscle?
volume, essentric hypertrophy (sarcomeres in series)
What pressure volume loop is consistent with MV regurg?
.
What changes are seen in EDV and isovolumetric contraction in a MV regurg pressure volume loop waveform?
EDV increased, sloping left isovolumetric contraction
What is the basic three word management for MV regurg?
Full, Fast, Forward
In MV regurg what is your goal for preload, afterload, contractility, rate, and PVR?
increase rate maintain preload, contractility decrease afterload, PVR
What are the goals of MV regurg management?
decrease regurg volume to increase CO avoid Pulm congestion
What mediations are potentially required after MVR for regurg?
inotropes
What symptoms are seen with TV stenosis?
JVD, liver congestion, volume overload in the LE
What is the valve area of the TV?
7-9cm
What is the normal gradient across the TV?
1mmHg
Reductions in blood flow are not seen until TV area is reduced to what size?
1.5cm, gradient of 3mmHg
In TV stenosis what is your goal for preload, afterload, contractility, rate, and PVR?
increase preload, afterload maintain contractility, and PVR decrease rate
Which wave on a CVP (a,c,v,x,y) is affected in TV stenosis?
cannon A wave
How do you manage multiple valvular lesions?
manage the most lethal
Ebsteins anomaly is seen in which valvular lesion?
TV regurg
Symptoms of increased RV afterload are consistent with which valve lesion?
TV regurg
Which wave on a CVP (a,c,v,x,y) is affected in TV regurg?
V wave
What is the goal in managing TV regurg?
maintain adequate right side forward flow
How can we decrease PVR in TV regurg?
hyperventilate
After coming off pump for TVR for regurg which medication may you need to start?
Milrinone, Epi, Vaso, NO
In TV regurg what is your goal for preload, afterload, contractility, rate, and PVR?
increase preload, rate maintain afterload, contractility decrease PVR
Why is NE contraindicated in TV regurg?
Pulm vasoconstriction
What are symptoms of Pulm stenosis?
tachypnea, syncope, angina, hepatomegaly, peripheral edema
What is the normal pressure gradient across the pulm valve?
5mmHg
What pressure gradients are characteristic of mild, moderate, and severe P. stenosis?
mild 15-36mmHg moderate 36-64mmHg severe >64mmHg
How is P. stenosis managed unlike other stenotic lesions?
increased HR
In P. stenosis what is your goal for preload, afterload, contractility, rate, and PVR?
increase preload, and rate maintain afterload, and contractility decrease PVR
What is the most common cause of P. regurg?
annular dilation from pulm. HTN
In tamponade is diastolic or systolic function affected more?
diastolic
What is Becks triad?
HoTN, JVD, muffled heart tones
What is pulsus paradoxus?
decreased SBP >10mmHg during inspiration
What is kussmals sign?
increased CVP and JVD during inspiration
Tamponade increases intra-epicardial pressure leading to what?
decrease in diastolic filling
Tamponade increases intra-epicardial pressure leading to what changes in LV pressure and LV volume?
increased LV pressure, decreased LV volume
How does increased LV pressure from tamponade affect coronary perfusion and v. filling?
decreased coronary perfusion, decreased v. filling
How does decreased v. volume from tamponade affect Co and SV?
decreased SV and CO (increased contractility, HR and renal fluid retention to compensate)
How do you manage a patient with tamponade?
give fluids, don’t induce until tamponade is relieved or wait until the patient is draped and everyone is READY
Why do you want to keep a patient with tamponade breathing spontaneously?
PPV decreases venous return and can lead to cardiac collapse
How can you induce the patient with tamponade and prevent decreasing their SNS?
Ketamine or inhalation induction (also keeps them breathing spontaneously!)
What drugs should you avoid inducing with in someone with tamponade?
large doses of gases, propofol, thiopental, high dose opioids, neuraxial
What drugs should you induce with in someone with tamponade?
ketamine, N2O, benzos, low dose opioids, etomidate
In tamponade what is your goal for preload, afterload, contractility, rate?
maintain/increase preload, contractility, rate maintain afterload
Which cardiomyopathy is characterized by Eccentric left/right ventricle that results in systolic/diastolic dysfunction?
Dilated
Which cardiomyopathy is characterized by Stiff/noncompliant ventricles and Decrease in EDV despite normal systolic function?
restrictive
Which cardiomyopathy is characterized by LV hypertrophy resulting in decreased LV chamber size and LVOT obstruction?
Hypertropic
Which cardiomyopathy is characterized by Fatty tissue infiltrates and Dilation/outflow tract obstruction of the RV?
arrythmogenic right ventricular
What is the most common cause of sudden death in peds and young adults?
hypertropic cardiomyopathy
What are the major changes that occur with hypertropic cardiomyopathy?
ventricular hypertrophy, decreased v chamber size, increased v wall thickness, impaired v relaxation
What ion channels are affected in hypertropic cardiomyopathy?
calcium channels
Hypertrophy of the interventricular septum in hypertropic cardiomyopathy leads to what?
LVOT obstruction
What is the gradient that results from a LVOT obstruction?
Ao < LV
What is SAM?
anterior leaflet of the MV getting sucked into the LVOT due to interventricular hypertrophy and the Venturi effect
How does hypertropic cardiomyopathy affect systolic and diastolic function and LVEDP?
systolic and diastolic dysfunction, elevated LVEDP
How does hypertropic cardiomyopathy affect myocardial O2 demand and supply?
decrease in supply increase in demand
In hypertropic cardiomyopathy what is your goal for preload, afterload, contractility, and rate?
increase preload and afterload low normal heart rate decrease contractility
How is increased preload beneficial in managing hypertropic cardiomyopathy?
opens the LVOT, prevents SAM
How is increased afterload beneficial in managing hypertropic cardiomyopathy?
opens LVOT my preventing septum from obstructing flow
How is decreased contractility beneficial in managing hypertropic cardiomyopathy?
decreases amount of obstruction of the LVOT, increase forward flow
What is the most common form of cardiomyopathy?
dilated
Dilated cardiomyopathy causes essentric or concentric hypertrophy of the right or left ventricle?
essentric, both ventricles
What happens to MVO2, LVEDV and LVEDP in dilated cardiomyopathy?
MVO2 increase as LVEDV and LVEDP increase
Dilated cardiomyopathy causes regurg of which valve?
aortic
Dilated cardiomyopathy decreases EF, causing what alterations in catecholamines, cortisol, and RAAS?
increased catecholamines, and cortisol, and activation of RAAS
Dilated cardiomyopathy will eventually lead to which type of heart failure?
biventricular. Starts with LV failure.
How do you manage a patient with dilated cardiomyopathy in the OR?
avoid increased afterload and myocardial depression, they rely on SNS activity
What is the most sensitive intraoperative monitor for detecting ischemia?
TEE
Which lead is best for detecting ischemia?
V5
What are the earliest signs of MI intraop?
diastolic dysfunction (increased LVEDP, decreased compliance)
What are late signs of MI intraop?
ECG changes (ST depression/elevation, T wave inversion)
Is systolic dysfunction a supply or demand ischemia?
supply
Is diastolic dysfunction a supply or demand ischemia?
demand
Does systolic dysfunction lead to concentric or essentric hypertrophy?
essentric to preserve SV
Does diastolic dysfunction lead to concentric or essentric hypertrophy?
concentric
Systolic dysfunction is measured by EF. What EF is mild, moderate, and severe?
mild 45-55% moderate 30-44% severe <30%
What causes Systolic dysfunction?
CAD, DCM, volume overload
What causes Diastolic dysfunction?
OCM, chronic HTN, obesity
Does Systolic HF lead to Diastolic HF or does Diastolic HF lead to Systolic HF?
Diastolic HF leads to Systolic HF
Which genders are systolic and diastolic HF common in?
systolic males diastolic females
