Exam 2 Flashcards
What is an adequate Exercise ECG test for noninvasive cardiac testing?
Patient can exercise to at least 85% of their target HR, which is defined as 220 minus patient age
What do we substitute heparin for in patients experiencing HIT?
direct thrombin inhibitors suchas bivalirudin, lepirudin, or argatroban
What are the mediators responsible for that are released during the aggregation phase?
Platelet aggregation to form a primary unstable clot
4 Complications associated with CVP line placement
- Pneumothorax
- Nerve injury
- Cardiac Tamponade
- Chylothorax
Describe the clinical presentation of mitral regurgitation?
- Systolic murmur heard best at the apex
- Holsystolic timing
- High pitched radiating to the axilla
What is LMWH effective at treating?
VTE prophylaxis is more compared to unfractioned heparin
What is the single greatest threat in sickle cell patients?
Acute chest syndrome
Where do we see more depolarization towards in right ventricular hypertrophy?
Toward the right, seen on V1
Describe Disseminated Intravascular Cogulopathy
Systemic activation of the coagulation system simultaneously leads to thrombus formation and exhaustion of platelets and coagulation factors
Describe remodeling as it occurs in heart failure (3 points)
- Heart changes shape, size and function to try to preserve CO
- Overtime this defense mechanism fails
- Will eventually cause myocardial dysfunction
Is valine or glutamate nonpolar (water insoluble)?
Valine is non-polar
3 Vasoconstrictors associated with the clotting cascades?
- Thromboxane A2
- Adenosine diphopshpate
- Serotonin
Describe the right side of the heart compared to the left side of the heart
Right heart is thinner, more compliant and weaker than the left heart
What doe chemoreceptors respond to?
Changes in pH (decreased) and blood oxygen tension
Comorbidities associated with left ventricular hypertrophy?
Aortic stenosis, chronic hypertension (increased afterload)
How much pressure do we add to help with atelectasis in patients placed under general anesthesia?
5 cmH2O
How long does vitamin k take to reverse coumadin anticoagulation?
6 to 8 hours
Heart rate and rhythm goal with mitral regurg?
High HR (90-100BPM) and NSR as the faster HR reduces regurgitant volume
What is the opening size and pressure gradient in moderate mitral stenosis?
1.1 to 1.4 cm^2 and 6-10 mmHg
Describe MET 1
Eating, working at a computer, or dressing
How is the amount of regurgitant blood flow associated with aortic regurg?
Bradycardia due to increased diastolic time, Elevated SVR and Bigger/Larger Opening
What is the typical hemoglobin level in patients with sickle cell disease?
5 to 8 g/dL
What is the name, source and vitamin k dependency of factor V?
- Name: Proaccelerin
- Source: Liver
- Vit. K Dependent: No
What is the role of calcium in platelet structure?
Plays a role in the coagulation cascade
Examples and effects of dihydropyridine CCB’s
- Examples
* suffix = dipine - Effects
- Targets vasculature smooth muscle mostly
- Reduction in vascular iCa+2 levels causes vasodilation
- Reduction in SVR (afterload)
What does PT measure?
Extrinsic and common pathway
When does primary hemostasis begin?
After vascular contraction causing tamponade if the injury is not resolved
3 Etiologies of Systolic Heart Failure?
- Myocardial ischemia
- Valve insufficiency/regurgitation
- Dilated cardiomyopathy
Walk through the path Nitric Oxide takes to cause muscle relaxation
- Nitric oxide synthetise acts on L-arginine to become nitric oxide
- Nitric oxide diffuses into the muscle cells and activates soluble guanylate cyclase
- This produces cycline guanosine monophosphate, a second messenger, which causes muscle relaxation
What does it mean to have myocardial infarct (transmural) mean?
Q-wave infarct
CVP waveform abnormalities associated with Atrial Fibrillation?
- Loss of a wave
- Prominent c wave
What are the common anticoagulation options for Factor V Leiden?
warfarin, unfractioned heparin, LMWH
Which precordial lead looks at the right atrium?
V1
When do PRBCs not contain leukocytes?
When they have been leukoreduced
What does the T-wave look like with myocardial ischemia?
Inverted, symmetrical T-wave on two leads, contiguous
What is Cushing triad a late sign of?
High and sustained intracranial pressure prior to cerebral herniation
What is the worst clinical sign of Aortic Stenosis?
Dyspnea because it indicates congestive heart failure
Why is bradycardia bad in aortic stenosis?
The fixed lesion at the aortic valve limits the amountof blood ejected during each cardiac cycle, which means bradycardia an significantly limit CO
Describe the pathophysiology effects on the heart in aortic stenosis
- Increased LV size
- Increased LV strain
- Increased filling pressures
- Increased end-diastolic pressure
- Decreased LV compliance
Which valvular diseases cause volume overload?
- Mitral regurgitation
- Aortic regurgitation
What % of atelectasis is present in patients who are under general anesthesia?
5%
Normal EF range?
60-70%
Why are we assessing the RIJ?
To determine if JVD is present or not
What is also activated when the clotting cascade is activated?
The process of fibrinolysis
What is the quickest way to reverse vitamin K antagonists such as warfarin?
FFP
What is cryoprecipitate from?
Protein fraction taken off the top of the FFP when being thawed
Describe PLT administration
- Obtain from whole blood or platepheresis donation
- Contains PLT only
- One bag = random value
- One bag pheresis = 250-300 mL
- One unit increases PLT by 5,000-10,000
What induction medication should we use in a patient who has an EF of <20?
Etomidate or none at all
Give examples of underlying disorders that can cause DIC
Trauma, amniotic fluid embolus, malignancy, sepsis, or incompatible blood transfusions
Within how much time are you required to use blood after pulling it out of the storage container?
30 minutes maximum
Describe the Allen’s test
Occlude the radial and ulnar artery, release ulnar artery and check blood flow
What are the signs of Cushing’s Triad?
- Widened PP 2. Abnormal Respirations 3. Bradycardia
What is the goal of afterload in mitral stenosis?
Maintain because decreases in SVR can illicit the baroreceptors to increase HR
What are the precordial leads?
V1, V2, V3, V4, V5, V6
Describe the Exercise Tolerance and Symptoms associated with a NYHA class 4?
- Exercise Tolerance: Severe Limitation
- Symptoms: Any physical activity brings on discomfort and symptoms occur at rest
When do most preoperative MI’s occur and what % of mortality does this account for?
24-48 hours post-op and 20% of mortality
Initial elevation, peak elevation and return to baseline times of Creatinine Kinase-MB (CK-MB)
- Initial: 3-12 hours
- Peak: 24 hours
- Return to Baseline: 2-3 days
When is S1 louder? Softer?
- Louder: Vigorously contracting ventricle
- Softer: Poorly contracting muscle
What does a 50% increase in heart rate do to MvO2 (Myocardial oxygen consumption)?
50% increase
Why do we see a higher Pulse Pressure in a line that is further away from the heart?
- SBP will be higher
- DBP will be lower
Stage 3 HTN or HTN crisis parameters
SBP: Greater than 180
and/or
DBP: Greater than 120
What mediators in the intima control blood flow by vasodilation?
Nitric Oxide and prostacyclin
What pathological process is mitral stenosis associated with in under-developed countries?
20-30 years after Rheumatic heart disease and pregnancy
Indications for FFP?
PT or aPTT > 1.5 times the mean control
Examples of slective beta-1 receptor antagonists
- acebutolol
- atenolol
- bisoprolol
- esmolol
- metoprolol
What O2 consumption at rest is equal to 1 MET?
3.5mL/kg/min
If you walked into an OR and saw this A-line waveform, where would you assume that it had been placed?
The femoral artery
Why does the RBC change shape in sickle cell disease?
Low oxygen, hypovolemia, stress (pain), hypothermia
What creatinine levels would indicate renal insufficiency?
>2.0mg/dL (176 mmol/L0
What does activation of Tissue Factor cause?
Activated the clotting cascade pathway when injury to the vessel occurs
What does 1 unit of cryoprecipitate raise fibrinogen levels by?
50mg/dL
what is the normal TT time?
30 seconds
Where are chemosensitive cells located?
The carotid bodies and the aortic body
With the Oculocardiac Reflex, what nerve control the afferent path?
The V1 of the Trigeminal Nerve
What is the mutation with beta thalassemia?
gamma 4
What is the normal progression of clotting cascade when enough fibrin has been made?
Activated protein C inactivated factor V, helping stop the clot from growing any larger than necessary (this is the beginning of fibrinolysis)
What is occuring in the graph as we move from Point A to B? Point A to C?
- Point A to B shows decreased contractility
- Point A to C shows increased contractility
What NYHA class is considered to be decompensated heart failure?
Class 4
What is the saying that goes with the extrinsic pathway to rememeber the clotting factors involved?
For 37 cents, you can purchase the extrinsic pathway
CVP waveform abnormalities during spontaneous or positive-pressure ventilation
Measures pressure at end-expiration
When is S2 louder? Softer?
- Louder: Hypertension
- Softer: Hypotension
Describe the steps associated with the extrinsic pathway (3)
- Tissue factor release from sub-endothelium during trauma. Tissue factor activates the extrinsic pathway
- Factor X actiation; Tissue factor activates factor 7; 7 activates 10 in the presence of Factor 4 (calcium)
- Prothrombin activator and platelet phospholipids activate factor 2 (thrombin); Factor 5 accelerates the positive feedback mechanism to increase production of prothrombin activator
What is a normal fibrinogen level?
=> 150 mg/dl
What is the mutation with alpha thalassemia?
beta 4
What does the ST elevation have to come from when evaluating for STEMI?
Baseline
What further pre-op cardiac testing do low risk surgeries require?
They do not require further preop cardiac testing unless the patient has an unstable cardiac condition
Most common reasons for aortic stenosis?
- Congenital defect - Bicuspid AV valve
- Calcification of the cusps
What amount of blood loss will cause fibrinogen levels to drop?
1.5L of blood loss
Examples and effects of Potassium Sparing Diuretics
- Examples
* Triamterene, amiloride - Effects
- Inhibits K excretion and Na reabsorption by the principal cells in the collecting ducts
- Acts independently of aldosterone
4 Descriptors of the 2nd heart sound, S2
- Closure of Aortic and Pulmonic valves
- Mark onset of diastole
- End of LV ejection and beginning of isovolumic relaxation
- Volume proportionate to LV pressure decrease at the end of systole
A-line waveform abnormaliy associated with Hypertrophic Cardiomyopathy?
- Spike and dome pattern (midsystolic obstruction)
What is the motor response in the Bezold-Jarish Reflex?
Efferent impulses to the heart cause hypotension, bradycardia, and coronary dilation
When is the primary plug (mesh) enough to maintain heomeostasis?
When the injury is minute and less threatening
What are the CNS and ECG changes associate with a serum Na+ of 110 mEq/L?
- CNS changes: Seizures and coma
- ECG changes: Vtach and Vfib
What is the name, source and vitamin k dependency of factor IX?
- Name: Christmas Factor
- Source: Liver and other tissues
- Vit. K Dependent: Yes
Which wave of a CVP waveform is only present in patients who are experiencing bradycardia?
h-wave
What causes afib in mitral stenosis?
Dilated left atrium which can acutely precipitate failure and chronically cause thrombosis
what is the normal aPTT?
25-35 seconds
What mediators are released by endothelial cells?
Vasoconstrictors and vasodilators (prostacyclin and nitric oxide)
Name the Areas associated with aucultation of the Cardiovascular system labeled 1-7
- Tricuspid Area
- Sternum
- Aortic Area
- Pulmonic Area
- Left Mid Clavicular Line
- Left Anterior Axillary Line
- Mitral Area
What is the name, source and vitamin k dependency of factor X?
- Name: Stuart-Prower Factor
- Source: Liver
- Vit. K Dependent: Yes
What are the waves labeled 1-6 in the image?
- a-wave
- c-wave
- x-descent
- v-wave
- y-descent
- h-wave
What is the role of actin and myosin in the platelet structure?
Contraction to form the platelet plug
What does management of DIC require?
Alleviating the underlying condition precipitating hemostatic activation
What are the 4 phases of hemostasis and coagulation?
- Vascular phase (vascular spasm)
- Primary homeostasis (Formation of platelet plug)
- Secondary hemostasis (Coag. and formation of fibrin)
- Fibrinolysis (Lysis of clot)
What patient population does Step 5 of the ACC/AHA cardiac guidelines consider?
Patients with poor or inderterminate functional capacity and need intermediate risk or vascular surgery
With valsalva maneuver, what cardiac effects occur due to inhibition of the SNS?
- Decreased heart rate 2. Decreased in myocardial contractility 3. Vasodilation
What does a 50% increase in the wall stress of the heart do to MvO2?
25% increase
What is the effect of bradycardia in Aortic Regurgitation?
Lower O2 requirement per beat but allows for longer diastolic time and therefore a reduction in CO d/t left ventricular volume overload
What pathological processes are associated with mitral stenosis in the US?
Calcification ddue to atherosclerosis and endocarditis
Why are chest compressions often ineffective in the case of aortic stenosis?
It is difficult to generate enough mechanical force to create adequate stroke volume across the setonitc valve
Where are platelets formed?
In bone marrow from megakaryocytes
How would you describe this A-line waveform and what pathology would you associate it with?
Bisferiens Pulse (double peak) is associated with Aortic Regurgitation
Describe LMWH
LMWHs have a more predictable pharmacokinetic response, fewer effects on platelet function, and a reduced risk for heparin-induced thrombocytopenia (HIT)
What EKG leads look at the inferior portion of the heart?
2, 3, avF
5 Procoagulants involved in the clotting cascade and their function?
- Coagulation Factors
- Collagen - Tensile Strength
- vWF - Adhesion
- Fibronectin - Mediates Cell Adhesion
- Thrombomodulin - Regulates anticoag pathway
What should hypotension be treated with in mitral stenosis?
Neo or vasopressin
Examples and effects of ACE inhibitors
- Examples
* Suffix = pril - Effects
* Inhibit AT2 mediated vasoconstriciton and aldosterone release
When does clot dissolution occur?
A couple minutes to days later after injury
What maintains SVR and preserves BP in a setting of low SV and CO?
Systemic vasoconstriction
What are 3 signs of vWF disorder that might not be noticed until a questionnaire/surgery?
- Easy bruising
- Recurrent epistaxis
- Menorrhagia
How long can cryo remain frozen up to?
Refrozen for up to 1 year
What is the normal pressure gradient for the aortic valve?
2-4 mmHg
Normal Pulse Pressure
40 mmHg
What produces prostacyclin?
Endothelial cells from prostaglandin
Which of the cardiac response to the Bezold-Jarish Reflex is the best for protecting the heart?
Coronary Dilation
What is the issue with Factor V Leiden?
A mutation causes activation of protein C does not work
What do tPA and urokinase cause?
Conversion of plasminogen to plasmin to break down fibrin to become fibrin degredation (split) products
What are the 5 steps of the intrinsic pathway?
- Blood trauma exposure to collage activates factor XII
- Factor XIIa activates XI, this step requires HMW kininogen, and is accelerated by prekalikrein
- Factor XIa activates IX
- Factor IXa and VIII activate X
- Prothrombin activator and tissue phospholipids activate factor IIa
What occurs as platelets undergo metamorphosis during the aggregation phase?
Platelets release the alpha and dense granules, the contractile granules, thrombin, and many important mediators in the blood in an effort to promote procoagulant activity
Normal SVR Index
1500-2400 dyes/sec/cm^-5/m^2
What must patients with sickle cell disease maintain?
A high and continuous rate of production of RBCs
Clinical Findings and Diangostic Tests associated with Secondary Hypertension due to Hyperadrenocorticism (Cushing’s Syndrome)
- Clinical Findings
- Weight gain (Trunchal obesity)
- Hyperglycemia
- Muscle and bone weakness
- Weakened Immunity
- Hirsutism (excess body hair in areas where hair is normally absent or minimal)
- Moon Face
- Diagnostic Tests
- Dexamethasone suppresion test
- Glucose tolerance test
- Urinary Cortisol
- Adrenal CT/MRI
What does a 50% increase in contractility do to MvO2?
45% increase
What are the two cases that we would insert a PA catheter?
- Open heart cases
- Neuro cases (rarely)
What does 1 unit of PRBC increase your Hgb and Hct by?
Hgb by 1 g/dL and Hct by 3%
Describe what platelets look like
Platelets are round and disk-like and circulate freely within the blood
Examples of prothrombotic disorders
F V leiden (too much clot secondary to mutation) and HIT
How long should it take for PF4/heparin immune complexes to clear from the circulation of a patient who experienced HIT?
3 months and we do not administer heparin to these patients anymore
What is the main mechanism involved in fibrinolysis?
The release of tissue plasminogen activator by endothelial cells
What is DDAVP?
A synthetic analogue of vasopressin and stimulates the release of vWF (from the intima) by endothelial cells
ECG characteristics of Atrial Hypertrophy?
- Best view is V1 because looking at right atria
- P wave is normally diphasic
What are the 8 expected Cardiac Reflexes?
- Baroreceptors 2. Valsalva 3. Cushing 4. Chemoreceptor 5. Bainbridge Reflex 6. Oculocardiac 7. Celiac 8. Bezolh-Jarish
What is the need for preoperative RBC transfusion dependent on for sickle cell patients?
The severity of SCD and the type of proposed surgery
What is the New York Heart Association classification of heart failure based on?
- Exercise tolerance
- Associated Clinical Symptoms
Where is the vascular phase localized to?
The injured area
What artery do leads 1, avL, v5, and v6 look at?
Circumflex artery
What is the name, source and vitamin k dependency of factor XII?
- Name: Hageman Factor
- Source: Liver
- Vit. K Dependent: No
What readings of transvalvular gradient and aortive valve area indicate critically severe aortic stenosis?
Transvalvular pressure gradients higher than 50 mmHG and aortive valve area of >0.7 cm^2
Pathologies associated with left axis deviation?
inferior MI, LVH, morbid obesity, pregnancy
Describe the valsalva maneuver
- Forced expiration against a closed glottis 2. Stimulates baroreceptors 3. Inhibits SNS and stimulates PNS 4. Increases Intrathoracic pressure
CVP waveform abnormalities associated with Pericardial constriction
- Tall a and v waves
- Steep x and y descents
- M or W configuration
What should your insufflation be?
15mmHg
What part of the brain is stimulated by cushings response?
the medulla to increase SNS response
When does the ejected SV re-enter the LV with aortic regurg?
During diastole
What is the saying tht goes with the intrinsic pathway?
If you can’t buy the intrinsic pathway for $12, you cam buy it for $11.98
What type of mechanism is the Bezold-Jarish Reflex?
Defense mechanism to help the heart
What do we consider the death spiral of Aortic Stenosis?
- Precipitous drop in bp causes myocardial ischemia
- Ischemic contractile dysfunction
- Decreased cardiac output
- Worsening hypotension
- Increased ischemia
CVP waveform abnormalities associated with Tricuspid stenosis
- Tall a wave
- Attenuation of y descent
What is the normal range for coronary blood flow?
225-250mL/min or 4-7% of cardiac output
2 factors of Diastolic Heart Failure
- Decreased ventricular compliance, the heart is unable to relax and receive incoming volume
- Contractiliy is generally preserved until the late stage
Which valvular diseases cause pressure overload
- Mitral stenosis
- Aortic stenosis
What is the goal of afterload in in mitral regurgitation?
Decrease afterload to allow for more forward flow of blood
What immune complexes must be present to diagnose HIT?
IgG antibody, platelet factor 4 (PF4), and heparin
What is HELLP syndrome usually secondary to?
Secondary to pregnancy
What is the treatment of vWF disease, list them in order of which to try first
- Desmopressin
- Cryoprecipitate
- By the transfusion of the specific factor (factor 8 components)
How far is the blood pressure cuff inflated?
Beyond the point at which oscillation ceases and then is slowly deflated
What are 4 times that we see a decrease in coronary flow?
- Tachycardia 2. Decreased Aortic Pressure 3. Decreased vessel diameter (spasm or hypocapnia) 4. Increased end diastolic volume
What is the saying that goes with the common pathway?
The final common pathway can be purchased at the five and dime for 1 or 2 dollars on the 13th of the month
Clinical Findings and Diangostic Tests associated with Secondary Hypertension due to Coarctation of the Aort
- Clinical Findings:
- Upper limb BP > Lower limb BP
- Weak Femoral Pulse
- Systolic Bruit
- Diagnostic Tests
- Aortography
- Echocardiography
- CT/MRI
What is the effect of Nipride?
Reduction in afterload
What is the normal aortic valve area?
2.5 to 3.5 cm^2
What occurs during secondary hemostasis?
A series of enzymatic reactions that ultimately activate prothrombin to thrombin, the enzyme that converts soluble fibrinogen to fibrin
What clotting factor is tissue factor?
Factor 3
what is a normal ACT?
80-150 seconds
Examples and effects of beta-1 antagonists
- Examples
* Suffix = lol - Effects
- Reduced inotropy, chronotropy, and dromotropy
- Reduced renin release by juxtaglomerular apparatus
- B1 effect causes vasoconstriction in muscles (doesn’t lower BP)
What are the side effects associated with DDAVP adminsitration, especially if given too quickly?
- Headache
- Rubor
- Hypotension
- Tachycardia
- Hyponatremia
- Water intoxication
Examples and effects of non-dihydropyridine CCB’s
- Examples
- Verapamil (class = phenylalkylamine)
- Diltiazem (class = benzothiazepine)
- Effects
- Targets myocardium > vessels
- Reduced inotropy, chronotropy, dromotropy
- Reduced SVR
What is the Hering nerve a branch of?
Glossopharyngeal, CN 9
What is the purpose of cardiac reflexes?
To maintain cardiac function and homeostasis
What occurs during primary hemostasis?
Injured blood vessel attracts platelets, which is the main actor in this phase of coagulation
Other than ischemia, what is lead 2 good for detecting?
Cardiac arrhythmias
What pathological process is often a sign of valvular disease?
CHF
What is the normal auto-regulation of MAP range of coronary vasculature?
60-140 mmHG
What is the role of ADP in platelet structure?
PLT activation and aggregation
Mitral valve opening size?
4 to 6 cm^2
Which step in the intrinsic pathway is identical to the last step of the extrinsic pathway?
Prothrombin activation step
Where will we see QRS changes in left axis deviation?
QRS positive in lead 1 but negative in aVF
What factor is missing with hemophilia A?
Factor VIII
What is the equation for coronary perfusion pressure and what is the normal range for CPP?
- CorPP= DBP-LVEDP
- Normal CPP = 60-80 mmHg
What is the effect of Neosynephrine?
Increased SVR
What cells produce nitric oxide and prostacyclin that influence the adventitia?
Endothelial cells
3 ways to blunt the Oculocardiac Reflex?
- Retrobulbar block (prophylaxis) 2. Release of the offending stimulus (Tx) 3. Vagal response inhibited by anticholinergics such as glycopyrolate (prophylaxis)
3 factors associated with an Arterial Line?
- Allen’s Test 2. Zero, calibrate, and level 3. Phlebostatic axis
Describe which phase of the cardiac cycle and what mechanical event is associated with the x descent on a CVP waveform
- Phase of Cardiac Cycle
* Mid systole - Mechanical Event
* Atrial relaxation, descent of the base, systolic collapse
Treatment for right sided HF?
- Inotropes
- Decreasing PVR
- Nitric Oxide
Normal SVR?
800-1500 dynes/sec/cm^-5
What is TRALI normally caused by?
ABO mismatching
What is a molecule of hemoglobin made up of?
2 alpha chains and 2 beta chains
Describe the clinical presentation of aortic stenosis
- Systolic Murmur
- Heard midsystole
- Crescendo-decrescendo that radiates to carotids
- Concentric Hypertrophy
A-line waveform abnormaliy associated with Systolic left ventricular failure?
- Pulsus alterans (alternating pulse pressure amplitude)
Normal PVR Index?
250-400 dynes/sec/cm^-5/m^2
Define Ejection Fraction
Percentage of end-diastolic volume ejected during systole
5 Mechanisms of Primary HTN
- Chronic Vasoconstriction
- SNS overactivity
- Vasodilator deficiency (reductions in NO, prostaglandins)
- Collagen and metalloproteinase deposition in the arterial intima
- Diet (Increased Na+ intake)
What component will not be measured on an ABG?
Hgb will not be on an ABG
Initial elevation, peak elevation and return to baseline times of Troponin I
- Initial: 3-12 hours
- Peak: 24 hours
- Return to Baseline: 5-10 days
Where is the Mitral valve auscultated?
5th ICS, left mid-clavicular line
What is the purpose of the exam being performed in the picture?
Palpation of the Precordium to Determine the Location of the PMI
What precordial leads look at the ventricles?
V4-V6
Clinical Findings and Diangostic Tests associated with Secondary HTN due to Renovascular Disease
- Clincal Findings
- Bruit (epigastric or abdominal)
- Severe HTN in young patient
- Diagnostic Tests
- CT angiography
- MRA
- Aortogrpahy
- Duplex Ultrasonography
Describe MET 3
Walking one or two blocks on level ground
In patients with vWF disease, what should be confirmed before surgery?
Normalization of the bleeding time and improved levels of Factor VIII
What is the name, source and vitamin k dependency of factor VII?
- Name: Proconvertin
- Source: Liver
- Vit. K Dependent: Yes
What would labs look like for a DIC patient?
Reductions in PLT, prolongation PT, PTT and thrombin time (TT) along with elevated concentrations of soluble fibrin degradation products
What EKG leads look at the septal portion of the heart?
v1 and v2
What occurs once vessels vasodilate?
The increase in blood flow limits the activity or procoagulant mediators by simply washing the procoagulant mediators away
Describe which phase of the cardiac cycle and what mechanical event is associated with the c wave on a CVP waveform
- Phase of Cardiac Cycle
* Early systole - Mechanical Event
* Isovolumic ventricular contraction, tricuspid motion toward the right atrium
What are the two causes of hypertension and of those two, which is the most common one?
HTN is caused by increased CO and/or SVR, with increased SVR being the most common cause
Where do we see volume overload in mitral regurgitation?
The left atrium
What microvascular bleeding with hypofibrinogenemia would be an indication for the use of cryoprecipitate?
- DIC with fibrinogen <80-100 mg/dL
- Hemorrhage or massive transfusion with fibrinogen <100-150 mg/dL
What happens to atrial kick in ventricular compliance?
Decreased ventricular compliance cause exaggeration of the atrial kick (40% of CO)
Describe the clinical presentation of aortig regurgitation
- Diastolic murmur
- Decrescendo, high pitched Holodiastolic
- Eccentric Hypertrophy
- LV cavity inreases in size out of proportion to the LV wall thickness
- Large V wave in PA catheter suggstive of LV dilation
Describe which phase of the cardiac cycle and what mechanical event is associated with the h wave on a CVP waveform
- Phase of Cardiac Cycle
* Mid to late diastole - Mechanical Event
* Diastolic plateau
What is the single most important protein involved in clotting?
Fibrin
How are hemodynamics tolerated in valvular disease?
At first they are tolerated but as overload occurs we will see cardiac muscle dysfunction
What occurs during the activation phase of platelet clot formation? (5)
- Tissue factor causes the platelet to undergo conformational transformation as it becomes activated
- Structure swells and becomes oval and irregular
- GP2b-3a project themselves from the platelet surface
- Gp2b-3a complex links other activated platelets together in an effort to form a primary platelet plug
- When this action is complete, the platelets seal and heal the site of injury within the blood vessel
5 Significant Arrythmias considered in the AHA/ACC Step 2 guidelines
- Mobitz 2
- 3rd degree heart block
- SVT or A-fib with rapid ventricular rate or new onset
- Symptomatic ventricular arryhthmias or bradycardia
- New ventricular tachycardia
How many clotting factors are there?
12 clotting factors
When are coronary arteries perfused the most?
During Diastole
With the Oculocardiac Reflex, what nerve controls the efferent reflex?
Vagus
What does Factor VIII concentrate contain?
Factor VIII and vWF
What is our goal for cardiac priming?
To increase supply and decrease demand
Anesthesia Management descriptor associated with Aortic Regurgitation
Full, fast, forward
What does it mean when we say someone is in heart failure?
The Ventricle has failed to the point that it is unable to fill and or empty out
What are the proposed mechanisms of acute chest syndrome?
Thrombosis, embolism (clot and fat), and infection
What occurs during the adherence phase?
- vWF mobilizes and emerges from the endothelial lining
- Gp1b receptors emerge from the surface of platelet
- Gp1b attaches to vWF and attracts platelets to the endothelial lining
- vWF makes platelets “sticky” and allows them to adhere to the site of injury
What is the name, source and vitamin k dependency of factor XIII?
- Name: Fribrin Stabilizing Factor
- Source: Liver
- Vit. K Dependent: No
What is the first and most frequent manifestatin of sickle cell disease?
Vaso-occlusive crisis and is secondary to tissue ischemia and infarction
What is the goal of preload in mitral regurgitation
Maintain or increase preload to compensate with the loss of blood to the left atrium
How do fibrinolytics such as tPA, streptokinase, and urokinase act?
They convert plasminogen to plasmin, which in turn cleaves fibrin, thereby causing clot dissolution
Clinical Findings and Diangostic Tests associated with Secondary Hypertension due to Hyperaldosteronism (Conn’s Disease)
- Clinical Findings
- Hypertension, Paresthesia
- Hypokalemia, Alkalosis
- Fatigue/weakness
- Nocturnal Polyuria (excess urination) and Polydipsia (excess thirst)
- Diagnostic Tests
- Ceruloplasmin (Cp) aldosterone, renin, potassium
- Urinary potassium
A-line waveform abnormaliy associated with Aortic Regurgiation?
- Bisferiens pulse (double peak)
- Wide pulse pressure
Preload/Afterload/Contractility/Heart Rate characteristics in Systolic HF
- Preload: Already high
- Afterload: Decrease to reduce myocardial workload and maintain CPP
- Contractility: Augment with inotropes as needed (dobutamine)
- Heart Rate: Usually high d/t incresed SNS tone, if EF is low then higher HR needed to preserve CO
What causes the Bezold-Jarish Reflex?
Irritants stimulate the left ventricle; Can be chemical such as dobutamine
What leads to progressive dyspnea on exertion in mitral stenosis?
Fluid in the pulmonary interstitial space, decreased pulmonary compliance and increased work of breathing
What can you use for hemophilia patients?
Cryoprecipitate
What would we be looking at to diagnose right atrial hypertrophy?
- Initial component of the P-wave will be taller, wider and bigger
- Height of P-wave will be >2.5 mm in any lead, but V1 will be the best
What are considered to be the bipolar limb leads?
Lead 1, 2 and 3
What is the role of throbosthenin in platelet structure?
PLT contraction
When does backflow occur in mitral regurgitation?
During ventricular systole (isovolumic contraction)
6 Etiologies of Diastolic Heart Failure
- Myocardial Ischemia
- Valve stenosis
- Hypertension
- Hypertrophic cardiomyopathy
- Cor pulmonale
- Obesity
2 Valvular diseases considered in the AHA/ACC step 2 guidelines
- Severe Aortic Stenosis
- Severe Mitral Stenosis
6 Drug classes that target the kidneys for treatment of hypertension
- ACE inhibitors
- AT-2 receptor blockers
- Loop diuretics
- Thiazide diuretics
- Potassium sparing diuretics
- Aldosterone antagonists
What is a normal vector?
0 to +90 degrees
What are the 4 key things included in the intima (endothelial) layer?
- vWF
- Tissue Factor
- Prostacyclin
- Nitric Oxide
2 Characteristics of S4 heart sound
- Caused by atrial systole
- Heard before S1
Describe the processes included in the response shown in the graph 1-4
- Increased arterial Pressure
- Increased action potentials in afferents of Vagus Nerve (Aortic Arch) and Hering’s Nerve (Carotid Sinus) to Cardiovascular Centers in the Medulla
- 3 Responses
- Decreased contractility, SV, and CO
- Venous blood vessels dilate, decrease venous return and decrease CO
- Arterial blood vessels dilate to reduce SVR
- Efferent Response of the Vagus Nerve to decrease heart rate and decrease CO
What do we lok at to determine ventricular hypertrophy?
Look at the QRS wave
4 Measures of ventricular output
- CO 2. SV 3. LVSW 4. LVSWI
What is the RBC life span in sickel cell disease?
12 to 17 days compared to 120 days for normal RBCs
5 Differences that you’ll see in a femoral artery A-line waveform than an Aortic Arch waveform
- Wider pulse pressure
- Delayed upstroke
- Delayed, slurred dicrotic notch
- More prominent diastolic waveform
- Increased SBP and decreased DBP
What is the carpentier classification of mitral stenosis?
Posterior leaflet are labeled P1, P2 and P3, with P1 being laterally oriented and P3 medial
Describe the Bainbridge reflex
An increase in right-sided filling pressure sends vagal afferent signals to the cardiovascular center in the medulla. This causes inhibition of parasympathetic activity, leading to increased heart rate.
3 Characteristics of S3 heart sound
- Suggests flaccid and inelastic heart, think heart failure
- Heard during middle 1/3 of diastole after S2
- Gallop rhythm described as rumbling sound
What occurs when the hgb molecule is exposed to low concentrations of oxygen in sickle cell disease?
The hgb molecule becomes unstable, polumerizes with other hgb S molecules and becomes damaged and moreprone to hemolysis and removal by the spleen
How do endothelial cells modulate hemostasis by synthesizing and secreting?
- Procoagulants (initiators of coag)
- Anticoagulants (inhibitors of coag)
- Fibrinolytics (to dissolve the clot)
If you walked into an OR and saw this A-line waveform, where would you assume that it had been placed?
Aortic Arch
Related comorbidities of right atrial hypertrophy?
Hypervolemia, tricuspid regurg, long term pulmonary hypertension
What is the assocaited action with AHA/ACC Step 3 guidelines?
Proceed to surgery if patient meets this criteria
Which layer of the vessel wall is extremely thrombogenic and very active?
Media
What is the role of serotonin in platelet structure?
Activates nearby platelets, serotonin is a vasoconstrictor
What are the causes of heart rate alterations in the OR?
- Temp 2. Waking up 3. Hypovolemia
Describe HIT
An autoimmune-mediated (IgG) drug reaction occurring in as many as 5% of patients after exposer to unfractioned heparin or rare cases LMWH
6 Components of the Lee Revised Cardiac Risk Index
- High risk surgery
- Ischemic heart disease
- History of CHF
- History of cerebrovascular disease
- DM requiring insulin
- Creatinine >2.0mg/dL
What does heparin inhibit?
Thrombin
What does a 50% increase in volume work of the heart do to MvO2?
4% increase
Is calcium considered a second messenger?
Yes
Normal range for HR, SBP, DBP, PCWP, CVP
- HR = 50
- SBP = 100 mmHg
- DBP = 55 mmHg
- PCWP = 15 mmHg
- CVP = 10 mmHg
What is the adminstration dose of DDAVP and when would we see the maximal effect?
IV dose of 0.3 mcg/kg in 50mL of normal saline over 15 to 20 minutes, the maximal effect in 30 minutes and lasts from 6 to 8 hours
Name 3 antifibrinolytic agents
- Tranexamic acid (do not give to stroke patients)
- Aminocaproic acid
- Aprotinin
What is the hallmark sign of pulmonary artery rupture?
Hemoptysis
What are the 5 steps associated with the common pathway?
- Prothrombin activator changes prothrombin (2) to thrombin (2a)
- Prothrombin changes fibrinogen to fibrin in the presence of calcium
- Fibrin is added to the aggregated platelet plug
- Activated fibrin-stabilizing factor (XIIIa) cross-links fibrin fibers to complete the clot
- Clot is formed. Stays in place until vascular tissue is repaired
What does treatment of DIC include?
Blood component transfusions to replete coagulation factors and platelet consumed in the process
Describe HELLP syndrome
- Hemolysis of red cells
- Elevated liver enzymes
- Low platelet count
What is the most common form of blood pressure monitoring in the OR?
NIBP
What is occuring in the graph when we move from Point A to C? Point A to B?
- A to C represents decreased preload
- A to B represents increased preload
Describe which phase of the cardiac cycle and what mechanical event is associated with the y descent on a CVP waveform
- Phase of Cardiac Cycle
* Early Diastole - Mechanical Event
* Early ventricular filling, diastolic collapse
Clinical Findings and Diangostic Tests associated with Secondary Hypertension due to Pregnancy-Induced HTN
- Clinical Findings
- Peripheral and pulmonary edema
- Headache
- Seizure
- RUQ pain
- Diagnostic Tests
- Urinary protein
- Platelet count
- Uric Acid
- Cardiac Output
Name the structures labeled 1-9
- SA node
- Middle Internodal Tracts
- Posterior Internodal Tracts
- Purkinje Fibers
- Right Bundle Branch
- Left Bundle Branch
- Bundle of His
- AV Node
- Anterior Internodal Tract
Describe a sequestration crisis
- Occurs when the splenic removal of RBCs exceeds the rate of RBC production
- Severe anemia and hemodynamic instability can occur
- History of sequestration crisis may be an indication for early splenectomy
What is occuring the graph when we move from Point A to B? Point A to C?
- Point A to B shows increased afterload
- Point A to C shows decreased afterload
What can we predict if the pressure volume loop has widened or increased?
The heart’s workload has increased
What is blood pressure regulated by?
Feedback network consisting of SNS (baroreceptors), RAAS, and vasopressin
What is the heart rate and rhythm goal in mitral stenosis
NSR but low end of normal as tachycardia can cause increased Left atrial pressure and decreased CO
What does HIT result in?
Platelet activation and potential for venous and arterial thromboses
What is frequently assessed to evaluate cardiac reserve?
Exercise tolerance
What are the two causes of increased heart rate with the Bainbridge reflex?
- Direct effect on the SA node by stretching the atrium 2. Inhibition of parasympathetic activity in the medulla
What is the role of growth factor in platelet structure?
repairs damaged vessel walls
normal BT?
3-10 minutes
What is the most common hereditary bleeding disorder?
vWF disorder
Where is Erb’s point located?
3rd left ICS, left sternal border
Describe the activation of Chemoreceptors
Arterial partial oxygen pressure (PaO2) of less than 50 mmHg or in conditions of acidosis, the chemoreceptors send their impulses along the sinus nerve of Hering and the Vagus nerve to the chemosensitive area in the medulla.
What is the role of fibrin-stabilizing factor?
Cross links to fibrin, this is needed to mesh and form the plug
What 3 key biomarker are released when myocardial ischemia occurs?
- creatinine kinase-MB (CK-MB) = most sensitive
- Troponin I
- Tropinin T
What drugs do we avoid in mitral stenosis?
Those that can cause increases in heart rate such as anticholinergics, ketamine or atracurium
What occurs when we have profound bradycardia in patients with mitral regurgitation?
Acute left ventricular fluid overload
What is the name, source and vitamin k dependency of factor VIII:C?
- Antihemophiliac factor
- Source: Liver
- Vit. K dependent: No
Where is the sensory receptor found for the Bainbridge reflex?
Right atrium by the SA node
When does contractility become an issue with Aortic Stenosis?
Late in the disease state
What are the two fibrinogenic factors?
Kallikrien and neutrophil elastase
What does it mean to have poor R wave progession?
As we move from V1 to V6 the R-wave should get larger, with almost no S-wave showing
Describe the 4 active cardaic conditions associated with AHA/ACC Guidelines: Step 2
- Unstable Coronary Syndrome
- Decompensated Heart Failure
- Significant Arryhthmias
- Severe Valvular Disease
Normal PT?
12-14 seconds
What is Step 4 of the AHA/ACC cardiac guidelines for surgey?
Good >= METS (can walk flight of stairs without symptoms)
Causes of decreased O2 supply in the event of MI?
Decreases in HR/BP and increased PAOP
When should DDAVP be given if indicated in patients with vWF?
60 minutes before the surgery
What it the factor of coronary supply and demand that is present in both?
Heart Rate
What EKG leads look at the anterior portion of the heart?
v3 and v4
What dose Cryoprecipitate contain?
Factors 1, vWF (8), VIII, XIII
What are the two antifibrinolytics most commonly given?
TXA and Aminocaproic acid
What is the opening size and pressure gradient of severe mitral stenosis?
0.6 to 1 cm^2 and >10 mmHG
What does reciprocal change indicate?
Increased likelihood of complications
4 Filling pressures of the heart
- LVEDP 2. LAP 3. PCWP 4. PADP
Describe which phase of the cardiac cycle and what mechanical event is associated with the a wave on a CVP waveform
- Phase of Cardiac Cycle
* End diastole - Mechanical Event
* Atrial contraction
What is considered the universal donor?
O negative
What is the normal fetal hemoglobin?
alpha 2 gamma 2
What lowers the longer we store blood?
The levels of 2,3-DPG drop
How often should you release tourniquets during surgeries on patients with sickle cell disease?
Every hour at least, 2 hours at the maximum
What is normal Cardiac index?
2.8-4.2L/min/m^2
What blood levels do we watch in patients with CAD?
Hgb levels
3 Keys to a basic cardiac exam
- Inspection 2. Palpation 3. Ausculation
2 Anticoagulants involved in the clotting cascade and their function
- Antithrombin 3 - Degrades factors II, IX, X, XI, XII
- Tissue pathway factor inhibitor - Inhibits tissue factor
What is considered the universal acceptor/recipient?
AB positive
What type of medications can be used to decrease LAP in mitral stenosis?
Diuretics
What type of injuries is the vascular phase good for?
Small injuries
5 things associated with RCRI or Modified Goldman Index Hx of CHF
- Hx CHF
- Pulmonary edema
- Paroxysmal nocturnal dyspnea
- Bilateral rales or S3 gallop
- Chest radiograph showing pulmnary vascular redistribution
4 Factors of Coronary demand
- Heat Rate 2. Preload 3. Afterload 4. Contractility
What does damaged or injured endothelium activate?
Platelet and coagulation cascades
What is the percentage of vaso-occlusive crisis occuring in the perioperative period?
10%
Examples and effects of Thiazide Diuretics
- Examples
* HCTZ, metolazone, indapamide, chlorthalidone - Effects
- Inhibits NaCL transporter in the DCT
- Diuresis causes reduced preload
What do we consider the utility of 12 lead EKG?
Rhythm, conduction delays, damage, infection
Describe the 3 pathologies included with the AHA/ACC description of Decompensated Heart Failure
- CHF
- New Onset
- NYHA Class 4
What mutation occurs in sickle cell?
Substitution of glutamage by valine at the 6th position of the beta chain
How can the Celiac reflex be initiated indirectly in the clinical setting?
Pneumoperitoneum (Insufflation of peritoneum from CO2 in abdomen)
What factor does calcium bind to?
Factor 4
What does heparin derive its anticoagulant effect by?
By activating antithrombin III
What are the primary hormones involved in the vascular phase?
Endothelins, which cause vasoconstriction
Where is the Tricuspid vale auscultated?
4th left ICS, left sternal border
What is Cushing’s response?
Physiologic response to CNS ischemia caused by increased ICP
What is normal stroke volume range?
50-110mL/beat
How do we determine that diastolic time is decreased?
The hart rate is increased
What are patients who develope HIT during heparin therapy at increased risk for?
Thrombosis (30-70%)
Gp2b-3a is affected by which antiplatelet drug?
Reopro
How do we decrease water intoxication, hyponatremia and consequent seizures associated with DDAVP administration?
Administration of water, orally or IV, should be restricted for 4 to 6 hours after the use of DDAVP
Describe the action associated with AHA/ACC Guidelines: 5 with >=3 clincical predictors
Consider testing if it will change management
When is the QRS more negative? more upright?
QRS is more negative in V1 and upright in V4
What is a major anesthesia consideration for patients with sickle cell disease?
Normothermia and hydration with intravenous fluids
What EKG leads look at the lateral portion of the heart?
1, avL, v5, v6
4 Anesthesia considerations for patients with vWF disease?
- Avoid traumas during the anesthesia
- Arterial puncture is not recommended
- Laryngeal trauma during tracheal intubation may cause hematoma leading to postop airway obstruction
- IM meds are avoided
What is the most important thing to maintain in patients who have aortic stenosis?
Normal Sinus Rhythm
What bone disorder can heparin cause?
Osteoporosis
Indications for the use of cryoprecipitate?
- Microvascular bleeding with hypofibrinogenemia
- Prophylaxis in patients with hemophilia A and vWD
- Prophylaxis for patients with congenital dysfibrinogenemias
What is the role of phospholipids in platelets?
- Substrates to prostaglandin synthesis
- Produce thromboxane A2 which activates PLT
What is left ventricular failure treated with in regard to aortic regurg?
Inotropic agents or vasodilators
How would you describe this A-line waveform and what pathology would you associate it with?
Pulsus Parvus (Narrowed Pulse Pressure) is associated with Aortic Stenosis
Explain the constituents of CPDA-1
- Citrate for chelation of calcium to prevent clotting
- Phosphate as a buffer
- Dextrose as a fuel source
- Adenine as a substrte for the synthesis of ATP extending storage time from 21 to 35 days
Examples and effects of Aldosterone Antagonists
- Examples
* Spirinolactone - Effects
- Inhibits K excretion and Na reabsorption by the principal cells in the collecting ducts
- Blocks aldosterone at mineralcorticoid receptors
What would a patient be complaining of with an acute MI?
Chest pain that is heavy, pressure, elephant on your chest
What are the 3 options available before elective noncardiac surgery with patients who have multiple cardiac clincal predictors?
- Revascularization by surgery
- Revascularization by PCI with or without stents
- Optimal medical management
What is normal and what is abnormal about patients labs when diagnosing vWF disease
- PT and aPTT are often normal
- BT is prolonged
If inserted in the proper position, where would we find the tip of a PA catheter?
Zone 3
What would we look at to diagnose left atrial hypertrophy?
Terminal portion of the P-wave will be larger
What interventions do we utilize to decrease O2 demand in the event of MI?
- Beta blocker to HR <80 bpm
- Increase depth of anesthesia
- Vasodilators
- Nitroglycerin
When should we starting thinking HIT may be a possible diagnosis?
Any patient experiencing thrombosis or thrombocytopenia during or after heparin adminstration
What does aPTT measure?
intrinsic and common pathway
Describe the 4 facts (including risk reduciton and surveillance) associated with AHA/ACC Guidelines: Step 1
- Emergent cases proceed immediately
- Focus on perioperatie surveillance and risk reduction
- Surveillance: serial ECGs, cardiac enzymes, monitoring
- Risk reduction: Beta-adrenergic blockers, statins, pain management
What is the name, source and vitamin k dependency of factor III?
- Name: Tissue Factor or Thrombo-plastin
- Source: Vascular wall and extracellular membrane, released from injured cells
- Vit. K Dependent: n/a
What type of surgeries are considered high risk?
Vascular and intermediate risk surgeries
What happens during the aggregation phase when the injury is large?
Activation of the coagulation clotting cascade is required for permanent repair to create and stabilize a secondary clot to cease bleeding
Describe Primary HTN
No identifiable cause, this is 95% of all HTN cases
What type of smooth muscle plays a big role in elevated SVR?
Vascular smooth muscle (intracellular Ca++ concentration)
Which patient population is Factor V Leiden more common in?
Pregnant women who have had repeated missed abortions or recurrent late fetal losses
What two leads should have a positive QRS?
Leads 2 and aVF
Along with being a powerful vasodilator, what else does prostacyclin do?
Intereferes with platelet formation and aggregation
Why does cryoprecipitate pse an increased risk of infection?
It is not submitted to viral attenuation
What are the 3 conditions that are included in the category of unstable coronary syndrome?
- Unstable or severe symptoms
- Acute MI within 7 days = postpone elective surgery
- Recent MI within 7 to 30 days w/ myocardium at risk = postpone elective surgery
What are the CNS and ECG changes associate with a serum Na+ of 120 mEq/L?
- CNS: Confusion and restlessness
- ECG changes: Widening of QRS
Describe heparin
Negatively charged, carbohydrate (CHO) containing glucuronic acid residues
What does too much infusion of RBC cause? and what would we see?
Too much RBC would cause hypocalcemia, you would see tetany, decreased BP and Chvostek’s sign
What does the Allen’s Test assess?
Collateral blood flow in the arm
What is the antidote for magnesium?
Calcium
What does it mean when we say that a recent MI has at risk myocardium?
The patient has a positive stress test and persistent symptoms
What is the most important thing to do with HELLP syndrome?
Stabilize the mom
What does a 50% increase in pressure work (Incr. SVR) of the heart do to MvO2?
50% increase
2 Consequences of Systolic Heart Failure?
- The heart can’t squeeze well, blood remains in ventricle
- Less O2 rich blood to peripheral circulation
Complications associated with PA cath insertion
- Pulmonary artery rupture
- Arrhythmias
What are two things that cause a decreased oxygen fraction?
- Left shift oxyhemoglobin dissociation curve 2. Decreased capillary density
Name the values that can be measured on the X-axis of this Ventricular Function Curve and what they represent. Do the same for those on the Y-axis.
- X-axis values represent filling pressures
- LVEDP
- LAP
- PCWP
- PADP
- Y-axis values represent measures of ventricular output (volumes)
- CO
- SV
- LVSW
- LVSWI
How are platelets cleared?
Macrophages in the reticuloendothelial system and the spleen
Examples and effects of Venodilators
- Examples
- Nitroglycerine
- Sodium Nitroprusside (Dilates arteries and veins equally)
- Effects
- Increased nitric oxide levels causes vasodilation
- Reduction in venous return (preload)
What are the clinical features we should monitor for with sickle cell patients?
Asthma (incidence 50%) and pulmonary hypertension (Incidence 10%)
What mediators in the intima control blood flow by vasoconstriction?
Thromboxane A2 and Adenosine Diphosphate (ADP)
Increase in what pressure leads to impairement in right sided heart failure?
Increased pulmonary vascular resistance impairs the RV function
What is the Bainbridge reflex elicited by?
Stretch receptors located in the right atrial wall and the cavoatrial junction
What does leukoreduction of PRBC help prevent?
Cytomegalovirus and transfusion-related acute lung injury (TRALI)
If the patients is in the Right lateral position, what is the effect on the blood pressure of the right arm? Left arm?
Right arm will be 15mmHg higher L arm will be 15mmHg lower
What is the function of nitric oxide?
Vasodilates, promotes smooth muscle relaxation
What are the Vitamin K-Dependent coagulation factors?
Factors II, VII, IX, X
What are patients with coagulopathies undergoing neuraxial blocks at increased risk for?
Developing a hematoma and compression of neurological structures
What does the PAOP waveform look like with a hypertrophied left atrium?
Prominent a wave and decreased y descent
What is the heart rate and rhythm goal in patients who have aortic stenosis?
Heart rate of 70-80 BPM and Normal Sinus Rhythm
Examples and effects of alpha-2 agonists
- Examples
* clonidine, dexmedetomidine - Effects
* Decreased SNS outflow
What do we palpate and why do we palpate it for a cardiac exam?
Palpation of the Precordium to determine the location of the PMI (point of maximal impulse)
3 phases of platelet formation
- Adherence
- Activation (confirmational change occurs)
- Aggregation
What does the spleen do with platelets?
Spleen sequesters up to 1/3 of the circulating platelets for later use
How can remodeling of the heart be reversed by?
- ACE inhibitors
- Aldosterone inhibitors
When viewing the chest x-ray post CVP line placement, where should the tip of the line be?
T4-T5 interspaces
When does the clot form with extrinsic pathway?
Clot forms within 12 to 15 seconds
What factor is vWF?
Factor 8c, antihemophillic factor
Describe the Oculocardiac Reflex/Five and Dime Mechanism
Traction on the extra ocular muscles (medial rectus), conductive, or orbital structures causes hypotension and a reflex slowing of the HR as well as arrhythmia’s
What direction does the blood move in with mitral regurg?
- Through the aorta to circulation
- Through the incompetent mitral valve to LA
What is the name, source and vitamin k dependency of factor IV?
- Name: Calcium
- Source: Diet
- Vit. K dependent: n/a
What is the biggest indicator for giving cryo?
Fibrinogen levels
CVP waveform abnormalities associated with Cardiac Tamponade
- Dominant x descent
- Attenuated y descent
What does it mean to have a myocardial infarction (non-transmural)?
non-Qwave infarct
What class of receptor are the baroreceptors in the Carotid Sinus and Aortic Arch considered?
Mechanoreceptors
3 adverse effects of increased PVR?
- Hypoxia
- Hypercarbia
- Acidosis
What is the hallmark and criteria for HIT?
Hallmark finding decrease in PLT <100,000, and occurs 5-14 days after initial therapy
What class of medication is Digitalis and what is the main effect?
- Class
* Cardiac Glycoside - Main effect
* Increased contractility
What is the first clotting factor to drop during acute hemorrhage?
Fibrinogen
What does fibrin production require?
All of the clotting factors
What does coumadin interfere with?
Hepatic synthesis of vitamin K-dependent coagulation factors
CVP waveform abnormalities associated with Right ventricular ischemia
- Tall a and v waves
- Steep x and y descents
- M or W configuration
What does TT (thrombin time) measure?
Common pathway integrity
Examples and effects of alpha-1 antagonists
- Examples
- Suffix = zosin
- phenoxybenzamine and phentolamine (a1 and a2)
- Effects
- Reduction in vascular iCa+2 causes vasodilation
- Reduced SVR (afterload)
What is the valsalva maneuver helpful in testing?
integrity of sutures
How dose the chemosensitive receptor respond to signals from chemoreceptors?
Stimulation of respiratory centers to increase ventilator drive
What are we looking for during this assessment and what are the structures labeled 1-5?
We are assessing RIJ for JVD
- External Jugular Vein
- Path of IJ
- Clavicular Head of SCM (Sternocleidomastoid Muscle)
- Clavicle
- Sternal Head of SCM
What effect does hypervolemia have in mitral stenosis?
Causes increases in LA pressure which causes backflow and pulmonary congestion
What do we treat tachyarrhythmias with in mitral stenosis?
Amiodarone, beta-blockers, calcium channel blockers, digoxin or cardioversion
Normal MAP
70-105 mmHg
What effect does activated protein C have on factor V Leiden?
Activatd protein C cannot easily stop factor V Leiden from making more fibrin
4 Factors of Coronary supply
- Coronary artery anatomy 2. Diastolic Pressure 3. Diastolic Time 4. O2 extraction (Hgb and SaO2)
What population of patients require pharmacologic stress testing with medications such as dobutamine or dipyridamole?
Those who cannot exercise, have pacemakers, have significant bradycardia or recieve high-dose beta-adrenergic blockers
How would you define asymptomatic patients with average functional capacity?
The patient has the ability to walk one to two flights of stairs or four blocks on a level surface, can proceed directly to surgery
Examples and effects of Mixed alpha-1, beta-1 and beta-2 antagonists
- Examples
* bucindolol, carvedilol, labetolol - Effects
- Mixed effects at each receptor
- Labetolol alpha:beta antagonistic potency
- IV = 1:7
- PO = 1:3
When can we consider cell saver for patients with sickle cell disease?
Patients who are afebrile
What benefit do high-dose steroids (>24 mg of beta or dexamethasone in 24 hours) show in HELLP syndrome?
Acceleration of fetal lung maturity and prevention of worsening in platelet count or even increase platelet count in women with HELLP syndrome
What are considered to be vascular surgeries?
- Aortic and other major vascular surgery
- Peripheral vascular surgery
What is the cardiac effect of the valsalva maneuver due to increased intrathroacic pressure?
decreased venous return and decreased blood pressure
A-line waveform abnormaliy associated with Cardiac Tamponade?
- Pulsus paradoxus (exaggerated decrease (>10mmHg) in systolic blood pressure during spontaneous inspiration)
Describe the Curves labeled A, B and C on the Ventricular Function Curve shown.
A. Shows a hyperdynamic ventricular function curve, representing heart failure with preserved ejection fraction
B. Shows a normal ventricular function curve
C. Shows a ventricular function curve of a failing ventricle
What is the mean pressure gradient and valve area in severe aortic stenosis?
Mean pressure gradient of 40-50 mmHG and valve area of 0.7 to 1.0 cm^2
What is the name, source and vitamin k dependency of factor VIII: vWF?
- Name: Vonwillibrand factor
- Source: Vascular endothelial Cells
- Vit. K Dependent: n/a
What causes increased O2 demand in Myocardial Ischemia?
Increased heart rate, blood pressure, PAOP
What is the MET test used to express?
Functional capacity or exercise capacity of a patient
What is the heart rate and rhythm goal in aortic regurg?
Want a slight Sinus Tachycardia (80-100 PBM) to shorten diastolic filling time and reduce regurgitant blood flow, allowing for increased CO
What is the name, source and vitamin k dependency of factor I?
- Name: Fibrinogen
- Source: Liver
- Vit. K Dependent: No
What is the function of prostacyclin?
Vasodilates, inhibits platelet aggregation, promotes smooth muscle relaxation
Anesthetic issues involved with magnesium? (3)
- MGSO4 may prolong NMBD due to inhibition of ACh release (preeclamptic patients have decreased plasma cholinesterases)
- Sedatives and opiates must be decreased
- Exaggerated hypotension response to regional anesthesia
What is the sensory response in the Bezold-Jarish Reflex?
Afferent impulses sent to CN X to brain
What is the lifespan of platelets?
1-2 weeks
CVP waveform abnormalities associated with Atrioventricular dissociation?
Cannon a-wave
What is the hallmark of systolic heart failure?
Descreased EF with an increase in LVED (volume overload causes systolic dysfunction)
How would we differentiate Prinzmetal’s angina from an MI?
ST elevation with clean coronary artery, patient will be having coronary spasms and need CCB
Initial elevation, peak elevation and return to baseline times of Troponin T
- Initial: 3-12 hours
- Peak: 24 hours
- Return to Baseline: 5-14 days
What causes an increase in cerebral perfusion pressure?
Increased heart rate, blood pressure or contractility
What type of hypertrophy is associated with aortic regurgitaton?
Eccentric Hypertrophy
How would you describe major cardaic events?
Cardiac death, nonfatal MI, or nonfatal cardiac arrest
Classic signs of Aortic Stenosis?
Angina pectoris, syncope and dyspnea on exertion
What medication can be used off label for HIT?
Fondaparinaux, a factor Xa inhibitor
LVEDV, LVEDP, LVESV, Stroke Volume, LV Mass and LV Geometry in Diastolic HF?
- LVEDV: Normal
- LVEDP: Increased
- LVEDV: Normal
- Stroke Volume: Normal
- LV Mass: Increased
- LV Geometry: Concentric Hypertrophy
How do we make the diagnosis of Acute chest syndrome?
New lung infiltrates on a chest radiograph in the presence of any of the following: Chest pain, cough, dyspnea, wheezing or hypoxemia with no ekg changes
What form, activated or inactivated, are coagulation proteins normally in?
Inactivated
What pathway, extrinsic or intrinsic pathway is tissue factor associated with?
Extrinsic Pathway
Decribe the clinical presentation of mitral stenosis
- Diastolic murmur best heard at the apex
- Mid-diastolic timing
- Low pitched and radiates to the axilla
Clinical Findings and Diangostic Tests associated with Secondary Hypertension due to Pheochromocytoma
- Clinical Findings
- Headache
- Palpitations
- Diaphoresis
- Diagnostic Tests
- Plasma metanephrines
- Urinary catecholamines and vanillylmandelic acid (VMA)
What does the inhibition of the parasympathetic system do with Chemoreceptor response?
Increased heart rate and myocardial contractility
At what serum platelet level would you consider infusing?
<100,000/microliter
Name the structures/nerves labeled 1-7
- Cranial Nerve 9 - Glossopharyngeal (afferent)
- Cranial Nerve 10 - Vagus (afferent)
- Cranial Nerve 10 - Vagus (efferent)
- Sympathetic (efferent)
- Cardio regulatory center in medulla
- SA node
- Adrenal Medulla
When does oscillation in cuff pressure begin, peak and disappear?
Begins: Systolic pressure Peak: MAP Disappears: Diastolic pressure
Normal PVR?
150-250 dynes/sec/cm^-5
Describe MET 2
Walking down stairs, walking in your house, or cooking
Examples of non-selective beta-1 and beta-2 antagonists
- nadolol
- pindolol
- propranolol
- sotalol
- timolol
What can many of the clinical manifestations of sickle cell disease be explained by?
Obstruction of small blood vessels, tissue ischemia, and chronic anemia
What does ACT measure?
Adequacy of heparinization
4 drug classes that target the myocardium and vascular smooth muscles to reduce hypertension
- Calcium Channel Blockers (dihydropyridines)
- Calcium Channel Blockers (non-dihydropyridines)
- Arteriodilators
- Venodilators
What is the formula for Cardiac Index?
CO/BSA
Why is too fast of a HR bad in mitral regurg?
Increases O2 demand and decreases O2 supply
What lab values do we monitor when administering heparin?
ACT and PTT
3 Fibrinolytics and their function
- Plasminogen - Converts to plasmin
- tPA - Activates plasmin
- Urokinase - Activates plamin
What artery do leads v3 and v4 look at?
left anterior descending artery
Why is PAOP not a reliable assessment of LV filling pressure?
PAOP overestimates LVEDP
General description of Systolic Heart Failure
Ventricle does not empty well
What converts the amino acid L-arginine to nitric oxide?
Nitric oxide synthetase
What is the motor response from the Celiac Reflex?
Stimulation causes bradycardia, apnea, and hypotension
You place a CVP line and aspiriate bright red blood, what does this tell you?
The line is not in a vein, but an artery (not supposed to be there)
What is the anesthesia management descriptor for mitral valve stenosis
Full, slow, constricted
What does the QRS in V1 look like in right ventricular hypertrophy?
Progressively more smaller
What occurs when the intrinsic and extrinsic pathways merge?
They form the common pathway and thrombin activation occurs
What occurs that causes an aplastic crisis?
Suppression of RBC production by a viral infection such as parovirus B19
What is the procedure to cause valsalva with a vented patients?
Disconnect patient from vent and manually breathe for them, turn APL to 30, give breath and hold until told to release
What causes a decreased arterial oxygen content (CaO2)?
- Hypoxemia 2. Anemia
Examples and effects of Loop Diuretics
- Examples
* Furosemide, bumetanide, ethacrynic acid - Effects
- Inhibits NaK2Cl transporter in thick ascending loop of henle
- Diuresis causes reduced venous return (preload)
Describe the Celiac reflex?
Traction on the mesentery or the gallbladder or stimulation of the vagus nerve in other areas of the body, such as the thorax and abdominal cavity
What is the name, source and vitamin k dependency of factor XI?
- Name: Plasma thromboplastin antecedent
- Source: Liver
- Vit. K Dependent: No
What does the blood pressure cuff sense?
Oscillations that correlate with arterial pulsation
Aortic Stenosis surival years when angina, syncope or failure present themselves as symptoms
- Angina: 5 years
- Syncope: 3 years
- Failure: 2 years
How do you resolve the Celiac reflex?
Stopping the initiating stimulus
Describe Chylothorax and when you are at highest risk for causing this
- Chylothorax is a collection of lymph fluid in the pleural space.
- You are at highest risk for causing a chylothorax if you are placing a CVP line on the left side
When is the incidence of acute chest syndrom higher?
In children and it may be related to infection
Describe the action associated with AHA/ACC Guidelines: 5 with 1-2 clincical predictors
Proceed to surgery with HR control or consider noninvasive testing if it will change management
What does activation of vWF cause?
Adherence of platelets to the subendothelial layer
What activator is released by the kidneys during fibrinolysis?
Urokinase, as a means of preventing small clots gletting lodged in the kidney tissue
Which layer of the vessel wall controls blood flow by influencing the vessel’s degree of contraction?
Adventitia (most outter layer)
What is the role of glycoproteins with the external structure of platelets?
- Adheres to injured endothelium, collagen and fibrinogen
- Gp1B sticks/attaches PLT to vWF
- Gp2B-3a complex links activated PLT together to form a plug
LVEDV, LVEDP, LVESV, Stroke Volume, LV Mass and LV Geometry in Systolic HF?
- LVEDV: Increased
- LVEDP: Increased
- Stroke Volume: Decreased or normal
- LV Mass: Increased
- LV Geometry: Eccentric Hypertrophy
What are the 5 procedures considered to be low risk surgeries?
- Endoscopic procedures
- Superficial procedures
- Cataract surgery
- Breast surgery
- Ambulatory surgery
Is heart rate or contractility the issue in the Bainbridge reflex?
Heart Rate
Where is it best to take blood pressure?
Higher in the arm
What do heigh parameters of a pressure volume loop measure?
Ventricular pressure
What is the action associated with Step 2 of the AHA/ACC guidelines for surgical procedures
If one of the conditions are met, postpone the surgery until stabilized or corrected
Which gives faster results, calcium chloride or calcium gluconate?
Calcium chloride
What do we see on the ECG in left ventricular hypertrophy?
- Larger QRS, S in V1 and Taller R V5
- Depth of S in V1 and height of R in V5 = 35mm
What % of risk would >=3 points on the Revised Cardiac Risk Index or Modified Goldman Index indicate?
5.4%
Comorbidities associated with Right ventricular hypertrophy?
pulmonary HTN, mitral stenosis, pulmonary stenosis
At what point in the perioperative setting should we place a CVP line?
Usually depends on how fast you are, but you generally want to place it in the pre-op setting so that you do not delay surgery
What is the goal of afterload in aortic stenosis?
Maintain or increase systemic vascular resistance to maintain CO
General description of Diastolic Heart Failure
The ventricle does not fill properly
Why do we give anticoagulants to patients with Factor V Leiden, other than DVT prophylaxis?
Improved placental blood flow is likely to lead to better pregnancy outcomes
How do we reverse heparin?
Protamine, a positively charged polypeptide, rapidly reverses heparin
Describe FFP (5)
- Plasma separated from RBC and PLT
- Source of antithrombin III
- One bag = 200-250mL
- Expires 12 months after donation
- Dose 10-15 mL/kg
What are PRBCs derived from?
Whole blood from which the plasma has been removed
Examples and effects of Arteriodilators
- Examples
- Hydralazine
- Sodium Nitroprusside (Dilates arteries and veins equally)
- Effects
- Increased nitric oxide levels result in vasodilation
- Reduction in SVR
What is the strongest clot?
Fibrin
What type of hypertrophy of the left atrium do we see in mitral regurgitation?
eccentric hypertrophy
Why are we cautious with fluid resuscitation in Aortic Regurgitation?
Overzealous fluid admin can lead to acute decompensation of the LV and Pulmonary Edema
What type of drug and what is the effect of Milrinone?
- Type of Drug
* PDE inhibitor - Effect
* Increased contractility
Equation for SVR index?
(MAP-CVP)/CI * 80
What is the hgb/hct goal in sickle cell patients?
hgb 10, hct 30%
When do most alterations occur with sickle cell?
When hgb S is exposed to low concentrations of oxygen (O2 tension of 40-45 mmHg which is an O2 sat of about 80-85%)
Preload/Afterload/Contractility/Heart Rate characteristics in Diastolic HF
- Preload: Volume required to stretch noncompliant ventricle, LVEDP does not correlate with LVEDV (TEE is best)
- Afterload: Use neo to keep elevated to perfuse a thick myocardium and maintain CPP
- Contractility: Usually normal
- Heart Rate: Slow/normal increase in diastolic time and CPP
Stage 1 HTN parameters?
SBP: 130-139
or
DBP: 80-89
What is the severity of aortic stenosis based on?
Transvalvular gradient and valve size
What does Class 3 CHF describe? Class 4?
- Class 3: Symptoms with minimal activity but comfortable at rest
- Class 4: Symptoms at rest (this is decompensated)
A-line waveform abnormaliy associated with Aortic Stenosis?
- Pulsus Parvus (narrow pulse pressure)
- Pulsus Tardus (delayed upstroke)
What do we see with excess magnesium levels?
Loss of deep tendon reflexes, skeletal weakness, hypoventilation, and cardiac arrest
Stage 2 HTN Parameters
SBP: Greater than 140
or
DBP: Greater than 90
6 Causes of Secondary Hypertension
- Coarcation of the aort
- Renovascular disease
- Hyperadrenocorticism (Cushing’s Syndrome)
- Hyperaldosteronism (Conn’s Disease)
- Pheochromocytoma
- Pregnany-induced HTN
Does factor VIII concentrate unergo viral attenuation?
Yes
What pathologies will we see in right axis deviation? (QRS will be negative in lead 1)
Vertical heart, RVH, anterolateral MI, Marfan’s Disease
Which layer of the vessel wall contains collagen and fibronectin?
Media
How is storage of blood achieved?
Adding Citrate phosphate dextrose adenine (CPDA-1)
Describe which phase of the cardiac cycle and what mechanical event is associated with the v wave on a CVP waveform
- Phase of Cardiac Cycle
* Late Systole - Mechanical Event
* Systolic filling of the atrium
What is the treatment for and how do we reduce the postop incidence of acute chest syndrome?
Treatment is supportive, preoperative transfusion and postoperative incentive spirometry
What are considered intermediate risk surgeries?
- Intraperitoneal and intrathoracic surgery
- Carotid Endarterectomy
- Head and neck surgery
- Orthopedic surgery
- Prostate surgery
What is the goal for preload in mitral stenosis?
maintain to normal preload
Examples and effects of AT2 Receptor blockers
- Examples
* Suffix = sartan - Effects
* Inhibits AT2 mediated vasoconstriction and aldosterone release
5 things associated with RCRI or Modified Goldman Index Hx of Ischemic Heart Disease Component
- Hx MI
- Hx positive exercise test
- Current complaints of chest pain considered secondary to ischemia
- Use of nitrate therapy
- ECG w/ pathological Q waves
What is the therapeutic range of Magnesium?
4-6 mEq/L
How is pulmonary venous pressure affected in mitral stenosis?
PVP is increased in association with increases in LAP
Describe the use of MGSO4 with HELLP syndrome (5)
- Decrease CNS irritability (raises seizure threshold)
- Decrease activity at the neuromuscular junction (weakness)
- Relax uterine and vascular smooth muscle (increased uterine blood flow)
- Usually given as 4g load over 5 minutes followed by 1-2g/hr
- MGSO4 does cross the placenta (baby will show symptoms)
What must be done to confirm a diagnosis of hypertension?
Two separate occasions of elevated blood pressure readings no sooner than 1-2 weeks apart
What is a catastrophic sign when it comes to cardiac reflexes?
Bradycardia
What are the augmented or unipolar limb leads?
aVR, aVF, aVL
When is a preoperative echocardiogram indicated in patients who have sickle cell disease?
Patients with limited physical activity, hypoxemia, respiratory distress, or symptoms consistent with cor pulmonale
What does myocardial infarction result from?
Excessive supply/demand
5 Clinical predictiors associated with Step 5 of the AHA/ACC cardiac guidelines
- Ischemic Heart Disease
- Compensated or prior HF
- Cerbrovascular disease
- Diabetes mellitus
- Renal insufficiency
CVP waveform abnormalities associated with Tricuspid regurgitation
- Tall systolic c-wave
- Loss of x descent
Describe Secondary HTN
Has identifiable cause, 5% of all HTN cases
Describe the goal of preload in Aortic Stenosis
Want increased preload to maintain adequate LVEDP to fill the non-compliant valve
How many PLT does it take to form a mesh?
7-10 platelets (this is not a strong clot)
What artery do leads 2, 3 and avF look at?
Right coronary artery
What do we treat hypotension with in regards to Aortic Stenosis?
Alpha 1 agonists to increase SBR and coronary perfusion without tachycardia
What is Factor V Leiden associated with?
An increased risk of developing DVT with or without PE, meaning patients will be on anticoagulants
What is the mutation associated with sickle cell?
the beta chain is BS2 instead of just the normal 2 beta chain
7 Factors that increase Oxygen demand of the heart?
- Tachycardia 2. Hypertension 3. SNS stimulation 4. Increased wall tension 5. Increased end diastolic volume 6. Increased afterload 7. Increased contractility
What is the goal of afterload in aortic regurgitation?
Want to decrease afterload to make it easier for blood to be ejected from the heart
What artery do leads v1 and v2 look at?
left anterior descending artery
What do fibrin split products look at?
Fibrinogen pathways
Interventions to increase O2 supply in the event of an MI?
- Anticholinergic
- Pacing
- Vasoconstrictor
- Reduction in depth of anesthesia
- Nitroglycerine, inotropes
Explain the position of platelet flowing in the blood vessel
Platelets are smaller than some other constitutes in fluid blood, they tend to be pushed aside, strategically positioned near the vessel-wall srugace when they can then “react” in the event of injury
What are the CNS and ECG changes associate with a serum Na+ of 115 mEq/L?
- CNS changes: Somnolence and nausea
- ECG changes: Elevated ST segments and widened QRS
What are the substances collectively referred to as prostanoids or eicosanoids?
- Prostacyclin
- Leukotriene
- Thromboxane
What has been implicated as causes of postoperative acute chest syndrome with sickle cell disease?
Pain and narcotic induced hypoventilation, regional anesthesia may be central to help reducing the incidence of ACS
Why is antifibrinolytic therapy generally contraindicated in DIC?
Potential for catastrophic thrombotic complications, so do not give TXA, aprotinin, or aminocaproic acid
What must we have to indicate a myocardial infarct on 12 lead ECG?
QRS must be 1mm wide, 2mm deep or 1/3 QRS tall in at least 2 related leads
What leads on the EKG are the most cost effective in detecting ischemia?
Lead 2, V4 and V5
What is the name, source and vitamin k dependency of factor II?
- Name: Prothrombin
- Source: Liver
- Vit. K Dependent: Yes
How long does it take for the intrinsic pathway to form a clot?
6 minutes
What is important about Preload in Aortic Regurgitation?
Want to maintain or increase preload as avoiding hypovolemia is important
What is the hallmark of diastolic HF?
Symptomatic HF with normal EF
3 examples of antiplatelet drugs?
Plavix, reopro, aggrostat
4 descriptors of the 1st heart sound, S1
- Closure of mitral and tricuspid valve
- Marks onset of systole
- End of LV filling and beginning of isovolumic contraction
- Volume proportionate to force of contraction
What usually brings the process of HELLP syndrome to a halt?
Control of the hypertension and completion of the delivery
What do width parameters of a pressure volume loop measure?
Ventricular volume
What will provide a more rapid reversal of coumadin?
Prothrombin complex concentrates, recombinant factor VIIa and FFP
What is the goal of contractility in mitral regurg or mitral stenosis?
Maintain because it is not often an issue in either
What does the net external work output of pressure volume loops measure?
Myocardial workload
What do endothelins stimulate with tissue injury?
They stimulate smooth muscle contraction and stimulate cell division of endothelial cells, smooth muscle cells and fibroblasts, thus aiding repair of the damaged site
What does treatment of secondary HTN revolve around?
Treating the cause to restor the BP to normal ranges
What are common echocardiographic findings in patients with sickle cell disease?
Left ventricular hypertrophy, right ventricular dilation and atrial enlargement
What would be considered unstable or severe unstable coronary syndrome?
- Angina at rest
- Increasing symptoms (intensity, frequency, duration)
- Duration >30 minutes
- Less responsive to medical therapy such as MONA
What type of hypertrophy is seen in the left atrium with mitral stenosis?
Concentric hypertrophy
What does FFP contain?
All of the clotting factors
How would you differentiate pericarditis from MI on EKG?
ST elevation in every lead
