Exam 2: Cardiac Flashcards
What is required for the diagnosis of myocardial infarction (MI)?
Rise and/or fall of cardiac biomarkers with at least one value > 99th percent of upper limit reference range AND >1 of the following:
* Ischemic symptoms
* New ischemic ECG changes
* Image evidence of nonviable myocardium
* Imaging showing new regional wall motion abnormalities
These criteria help in confirming MI in patients presenting with chest pain or other ischemic symptoms.
What are the two main types of myocardial infarction?
Type 1 and Type 2 MI
Type 1 MI is spontaneous and related to a primary event, while Type 2 MI is related to an imbalance between myocardial oxygen supply and demand.
What is a key characteristic of Type 1 myocardial infarction?
Related to a primary event such as plaque erosion, rupture, fissuring, or dissection
Type 1 MI can lead to ST-elevation MI (STEMI) or Non-ST-elevation MI (NSTEMI).
What does Type 2 myocardial infarction result from?
Imbalance between myocardial oxygen supply and demand resulting from prolonged tachycardia, coronary spasm, anemia, hypertension
Type 2 MI typically leads to NSTEMI only.
What is the recommended time frame for coronary angiography in patients with Non-ST-elevation MI?
Within days of symptoms after initiation of medical treatment in risk stratification
This approach helps in evaluating the severity and management of coronary lesions.
What is the difference between systolic heart failure and diastolic heart failure?
Systolic HF has reduced ejection fraction; Diastolic HF has preserved ejection fraction
Both types can be chronic or acute.
What is the significance of troponin elevation in chronic heart failure?
Chronic HF is often associated with sustained troponin elevation
This can indicate underlying myocardial injury or stress.
What is the recommended duration of dual antiplatelet therapy (DAPT) for angioplasty with drug-eluting stents?
6 months DAPT
This is crucial to prevent thrombotic events after stent placement.
What functional capacity assessment question can be asked to evaluate cardiac risk preoperatively?
Can you climb two flights of stairs without stopping and without chest pain or shortness of breath?
This helps to gauge the patient’s exercise tolerance and risk for major adverse cardiac events (MACE).
What does a PRE-OP ECG assess for?
Suspected valvular disease, left or right ventricular function, pulmonary hypertension, cardiomyopathies
It is indicated to address specific clinical questions arising from patient history or examination.
What is the role of echocardiography in heart failure?
Detects myocardial ischemia and provides information on cardiac function
It is not recommended for routine preoperative assessment but can be useful in specific cases.
What is the definition of heart failure?
Impaired ventricular filling or limited ventricular ejection where cardiac output declines below the minimum needed to meet metabolic demands
This condition can lead to symptoms such as fatigue, dyspnea, and edema.
What are the common laboratory tests for heart failure optimization?
Treatment of hypertension, heart rate control, management of arrhythmias, diuresis for symptomatic improvement, correction of anemia
Addressing these factors can significantly improve patient outcomes.
When should antihypertensive medications be continued or resumed in relation to surgery?
Continue until 1 day before surgery and resume within 48 hours
This is important to manage blood pressure effectively around the time of surgical intervention.
What is the most common type of stenotic valvular disease?
Aortic stenosis
Mitral stenosis is also prevalent but less common than aortic stenosis.
What type of murmur is associated with mitral regurgitation?
High pitched holosystolic murmur
This can indicate significant valvular dysfunction and may require intervention.
What are the symptoms that may indicate a new diagnosis of heart failure?
Fatigue, dyspnea, edema, congestion
These symptoms warrant further evaluation to confirm or rule out heart failure.
What are ABP and VPB?
Atrial premature beats and ventricular premature beats
Depolarizations initiated by ectopic foci outside the SA node, very common, can be with or without cardiac disease.
What is Supra Ventricular Tachycardia?
A rapid heart rate originating above the ventricles, can involve focal or reentrant mechanisms
Includes atrial tachycardia, AV reentry tachycardia, and bypass mediated tachycardia (e.g., WPW).
What characterizes Wolf-Parkinson White syndrome?
Symptomatic arrhythmia in the presence of an accessory pathway
Features short P-R interval, delta wave, and wide QRS; ablation is the treatment of choice.
Define Ventricular Tachycardia.
3 or more VPBs at a rate of 100 or greater
Requires cardioversion and is associated with CAD.
What is Long QT Syndrome?
A disorder arising from mutations in cardiac ion channels resulting in prolonged QT
Can be inherited or acquired, often treated with beta blockers and ICD.
What are the characteristics of Atrial Fibrillation?
Most common arrhythmia preoperatively, irregular R-R intervals, no distinctive P waves
Associated with CAD, hypertension, and increased risk of thromboembolism.
What is a First Degree Conduction Block?
Slowing of conduction between atria and ventricles without completely blocked impulses
Characterized by a prolonged PR interval.
Describe a Second Degree Conduction Block.
Intermittent failure of supraventricular impulses, some P waves not followed by QRS
Includes Type 1 (progressive lengthening of PR interval) and Type 2 (intermittently blocked P waves).
What occurs in a Third Degree Conduction Block?
Failure of supraventricular impulses to reach ventricles
Results in atria and ventricles being paced separately, usually requires a pacemaker.
What are the two types of Bundle Branch Blocks?
Right Bundle Branch Block (RBBB) and Left Bundle Branch Block (LBBB)
RBBB is more common and can occur without underlying disease, while LBBB is often associated with heart disease.
What is the incidence of Congenital Heart Disease?
6 per 1000 incidence, more common in females
Requires in-depth testing such as CXR, EKG, MRI, CT, Holter Monitor, and Stress Test.
What is the significance of pulmonary hypertension?
Mean pulmonary artery pressure (mPAP) > 25 mmHg at rest
Diagnosed via right heart catheterization; a 6-minute walking test can help identify disease severity.
List common causes of Peripheral Artery Disease.
- Smoking
- Diabetes
- Hypertension
- Sleep apnea
- Autoimmune diseases
Often related to atherosclerosis.
What are the two main types of Cardiac Implantable Electronic Devices (CIED)?
Implantable cardioverter defibrillators (ICD) and pacemakers
Increased technology complexity makes management more challenging.
What happens to defibrillators during surgery?
Monopolar cautery can impact defibrillators, while bipolar usually has minimal impact
Most common is disabling the unit during surgery; must know magnet response.
What is the typical system of a pacemaker?
Includes a pulse generator and 1 to 3 leads
Leads allow for pacing and are usually sensing.
Fill in the blank: The Frank-Starling mechanism drives heart function in a _______ heart.
[denervated]
True or False: Patients with heart transplants should stop immunosuppressive agents before surgery.
False
Immunosuppressive agents have multiple side effects and interactions.
What is the precordium?
Area on anterior chest overlying heart and great vessels
How many chambers does the heart have?
Four chambers: two atria and two ventricles
What are the two major circulatory loops in the body?
Pulmonary circulation and systemic circulation
What is the pericardium?
Tough, fibrous, double-walled sac that surrounds and protects the heart
What is the myocardium?
Muscular wall of the heart
What is the endocardium?
Thin layer of endothelial tissue that lines inner surface of heart chambers and valves
What is the function of heart valves?
Prevent backflow of blood
What are the two types of atrioventricular (AV) valves?
- Tricuspid valve (right AV valve)
- Bicuspid or mitral valve (left AV valve)
What are the two semilunar (SL) valves?
- Pulmonic valve (right side of heart)
- Aortic valve (left side of heart)
When do the AV valves open?
During heart’s filling phase, or diastole
What happens during the heart’s pumping phase, or systole?
AV valves close to prevent regurgitation of blood back into atria
What is diastole?
Ventricles relax and fill with blood; 2/3 of cardiac cycle
What is systole?
Heart’s contraction, blood pumped from ventricles fills pulmonary and systemic arteries; 1/3 of cardiac cycle
What is the first heart sound (S1)?
Occurs with closure of AV valves; signals beginning of systole
What is the second heart sound (S2)?
Occurs with closure of semilunar valves; signals end of systole
What does a third heart sound (S3) indicate?
Occurs when ventricles resistant to filling during early rapid filling phase (protodiastole)
What does a fourth heart sound (S4) indicate?
Occurs at end of diastole, at presystole, when ventricle is resistant to filling
What are the characteristics of heart sounds?
- Frequency or pitch: high or low
- Intensity or loudness: loud or soft
- Duration: very short for heart sounds; silent periods are longer
- Timing: systole or diastole
What is automaticity in the heart?
Ability to contract by itself, independent of any signals or stimulation from the body
What is the pacemaker of the heart?
Sinoatrial (SA) node
What does the P wave in an ECG represent?
Depolarization of atria
What is cardiac output (CO)?
Volume of blood pumped by the heart per minute; CO = HR x SV
What is preload?
Venous return that builds during diastole
What is afterload?
Opposing pressure ventricle must generate to open aortic valve against higher aortic pressure
What are the characteristics of the carotid artery pulse?
- Smooth rapid upstroke
- Summit rounded and smooth
- Downstroke more gradual with dicrotic notch
What does the jugular venous pulse reflect?
Atrial contraction and central venous pressure (CVP)
What changes occur in blood volume during pregnancy?
Blood volume increases by 30% to 40%
What is isolated systolic hypertension?
Increase in systolic BP due to thickening and stiffening of the arteries
What is the effect of aging on dysrhythmias?
Presence of supraventricular and ventricular dysrhythmias increases with age
What is the importance of lifestyle habits in cardiac disease?
Lifestyle habits play a significant role in the acquisition of heart disease
What should be assessed when evaluating carotid arteries?
Palpate one carotid artery at a time and auscultate for presence of carotid bruit
What is the recommended position for assessing jugular veins?
Supine with head and chest slightly elevated
What are the auscultatory areas for heart valves?
- Second right interspace: aortic valve area
- Second left interspace: pulmonic valve area
- Left lower sternal border: tricuspid valve area
- Fifth interspace at around left midclavicular line: mitral valve area
What is the aortic valve area location?
Interspace
What is the location of the pulmonic valve area?
Second left interspace
Where is the tricuspid valve area located?
Left lower sternal border
What is the mitral valve area location?
Fifth interspace at around left midclavicular line
What should be noted when assessing heart rate and rhythm?
Describe characteristics
What should be identified while auscultating the heart?
S1 and S2
What characteristics should be described when listening for extra heart sounds?
Describe characteristics
What should be assessed when listening for murmurs?
Timing, loudness, pitch, pattern, quality, location, radiation posture and change of position
What position change can be used as a screening measure to detect hypertrophic cardiomyopathy?
Standing to squatting
How is central venous pressure (CVP) estimated?
By assessing jugular venous distention
What test should be performed if venous pressure is elevated or heart failure is suspected?
Abdominojugular test
What occurs during the immediate newborn period regarding circulation?
Transition from fetal to pulmonic circulation
What is the normal heart rate range for newborns immediately after birth?
100 to 180 beats per minute (bpm)
What should be noted about extracardiac signs in newborns?
Skin, liver size, and respiratory status
Do murmurs in the immediate newborn period necessarily indicate congenital heart disease?
No, they do not necessarily indicate congenital heart disease
What are common characteristics of murmurs in the immediate newborn period?
- Grade 1 or 2 * Systolic * No other signs of heart disease * Disappear in 2 to 3 days
What should be noted regarding the absence of murmurs in newborns?
It does not ensure a healthy heart
What signs may indicate heart disease in infants?
- Poor weight gain * Developmental delay * Persistent tachycardia * Tachypnea * Dyspnea on exertion * Cyanosis * Clubbing
When does clubbing of fingers and toes usually appear in relation to cyanotic defects?
Late in the first year
What is the characteristic rhythm in infants?
Sinus dysrhythmia
What is common in children regarding heart murmurs?
Innocent (or functional) murmurs
What percentage of children may demonstrate innocent murmurs?
30% occurrence, or nearly all children
What are the characteristics of most innocent murmurs?
- Soft * Relatively short systolic ejection murmur * Medium pitch; vibratory * Best heard at left lower sternal or midsternal border
What should be taught to parents about innocent murmurs?
That the murmur is just a ‘noise’ with no pathologic significance
What vital sign changes occur in pregnant women?
- Increase in resting pulse rate of 10 to 15 bpm * Drop in BP from normal prepregnancy level
How is the apical impulse position affected during pregnancy?
Higher and lateral compared with normal position
What is a mammary soufflé?
Occurs near term or when the woman is lactating
What cardiovascular changes occur in aging adults?
- Gradual rise in systolic blood pressure * Widening of pulse pressure * Increased left ventricular wall thickness
What increases with age in relation to heart rhythms?
Presence of supraventricular and ventricular dysrhythmias
What are common ischemic conditions affecting the heart?
- Angina pectoris * Prinzmetal or variant angina * Acute coronary syndrome (ACS)
What are examples of non-ischemic heart conditions?
- Pericarditis * Mitral valve prolapse * Aortic dissection * Secondary pulmonary HTN
What are some pulmonary causes of chest pain?
- Pulmonary embolism * Pneumonia * Pneumothorax
What gastrointestinal issues can cause chest pain?
- Gastroesophageal reflux * Esophageal spasm * Cholecystitis * Pancreatitis
What dermatologic condition can cause chest pain?
Herpes Zoster
What musculoskeletal/neurologic issues can lead to chest pain?
- Costochondritis * Chest wall muscle strain
What psychogenic factors can cause chest pain?
- Depression * Anxiety
What are the variations in heart sounds?
- S1: Loud, faint, varying intensity, split * S2: Accentuated, diminished, normal splitting, fixed split, paradoxical split, wide split
What are the types of abnormal heart sounds?
- Systolic: Ejection click, aortic prosthetic valve sounds, midsystolic click * Diastolic: Opening snap, mitral prosthetic valve sound, third heart sound, fourth heart sound, summation sound, pericardial friction rub
What are signs of abnormal pulsations in the precordium?
- Thrill at the base * Lift (heave) at the left sternal border * Volume overload at the apex * Pressure overload at the apex
What are examples of congenital heart defects?
- Patent ductus arteriosus (PDA) * Atrial septal defect (ASD) * Ventricular septal defect (VSD) * Tetralogy of Fallot * Coarctation of the aorta
What are types of murmurs caused by valvular defects?
- Midsystolic ejection murmurs: Aortic stenosis, pulmonic stenosis * Pansystolic regurgitant murmurs: Mitral regurgitation, tricuspid regurgitation * Diastolic rumbles: Mitral stenosis, tricuspid stenosis * Early diastolic murmurs: Aortic regurgitation, pulmonic regurgitation
What should be observed and palpated in the neck during a cardiovascular examination?
- Carotid pulse * Jugular venous pulse * Estimate jugular venous pressure
What should be inspected and palpated in the precordium?
- Describe location of apical pulse * Note any heave (lift) or thrill
What should be done during auscultation of the heart?
- Identify anatomic areas noting rate and rhythm * Listen in systole and diastole for murmurs * Repeat with bell * Listen at apex and base
