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Health Assessment > Ischemia Heart Disease (Exam 2) > Flashcards

Ischemia Heart Disease (Exam 2) Flashcards

1
Q

What percent of surgical patients have a risk factor for Ischemic Heart Disease?

A

30%

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2
Q

What are the 2 most common important risk factors for developing artherosclerosis?

A
  • Males
  • Age
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3
Q

What are the modifiable risk for Ischemic Heart Disease?

A
  • Hypercholesterolemia
  • Hypeternsion
  • Cigarette smoking
  • Diabetes Mellitus
  • Obesity
  • Sedentary Lifestyle
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4
Q

What are the non-modifiable risk factors for Ischemica Heart Disease?

A
  • Males
  • Age
  • Genetic/Family History
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5
Q

Define Angina Pectoris

A
  • Imbalance between coronary blood flow (supply) and myocardial oxygen consumption (demand)
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6
Q

Stable Angina, indicates they have a what percentage occlussion?

A

70%

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7
Q

What does the release of adenosine and bradykinin do to improve the balance between myocardial oxygen supply and demand?

A
  • Slow atrioventicular conduction
  • Decrease cardiac contractility.
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8
Q

What is the most common cause of impaired coronary blood flow resulting in angina pectoris?

A
  • Artherosclerosis
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9
Q

What is the one medication that is proven to be beneficial for cardiac patients?

A

Beta blockers

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10
Q

What are the most common signs and symptoms of Iscemic Heart Disease?

A
  • Retrosternal chest pain
  • Pressure
  • Heaviness
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11
Q

What 2 types of patient might have abnormal or no cardiac symptoms for IHD?

A
  • Women
  • Diabetes
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12
Q

What 3 non-medical factors induce angina?

A
  • Physical exertion
  • emotional tension
  • cold weather
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13
Q

What is Chronic Stable Angina?

A
  • Chest pain does not change in frequency or severity in 2- month period.
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14
Q

What is unstable angina?

A

*Chest pain that lasts longer than 10 minutes
* Chest pain increasing in frequency and/or severity without increase in cardiac biomarkers

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15
Q

What degree occlussion does someone have with chest pain that does not go away with rest or nitro?

A
  • 90-100%
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16
Q

Cardiac conditions that cause chest pain

A
  • Angina
  • Rest or unstable angina
  • Acute MI
  • Pericarditis
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17
Q

Vascular conditions that can cause chest pain

A
  • Aortic dissection
  • Pulmonary embolism
  • pulmonary hypertension
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18
Q

Pulmonary Conditions that can cause chest pain

A
  • pleuritis and/or pneumonia
  • tracheobronchitis
  • spontaneous pneumothorax
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19
Q

Gastrointestinal Conditions that can cause Chest Pain

A
  • Esophageal reflux
  • peptic ulcer
  • gallbladder disease
  • pancreatitis
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20
Q

Musculoskeletal disorders that can cause chest pain.

A
  • costochondritis
  • Cervical disk disease
  • trauma or strain
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21
Q

Infectious conditions that can cause chest pain

A
  • herpes zoster
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22
Q

Psychological conditions that can cause chest pain.

A
  • Panic disorder
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23
Q

What does an EKG show for IHD?

A
  • ST segment depression
  • Associated T wave inversion
  • ST elevation
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24
Q

How can you diagnosis IHD?

A
  • 12 lead EKG
  • Exercise Stress Test
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25
Q

What medications can you give for an Amniotic Fluid embolism?

A
  • Toradol
  • Zofran
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26
Q

What labs should you order for ISD?

A
  • Serial Troponins
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27
Q

The ____ the degree of ST- segment depression, the ____ the likelihood of significant coronary artery disease.

A
  • greater
  • greater
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28
Q

What has a greater sensitivity than exercise testing for detection of ischemic heart disease

A

Nuclear Stress Test

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29
Q

Why do we use Nuclear Stress tests to diagnose ISH?

A
  • Greater sensitivity
  • Assesses coronary perfusion
  • determines size of perfusion abnomality
  • Estimates LV systolic size and function
  • differentiates old vs new MI
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30
Q

What tracers are used during Stress Tests?

A
  • Thallium
  • Atropine, doBUTamine, pacing
  • adenosine, dipyridamole
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31
Q

What does an Echocardiography show?

A
  • Wall motion abnomalities
  • Valvular function
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32
Q

What does a Coronary angiography show?

A
  • determines location of occlusive disease
  • diagnose Prinzmetal angina
  • Assess results of angioplasty/stenting
  • DOES NOT measure stability of plaque
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33
Q

What is variant angina?

A
  • coronary vasospasm
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34
Q

How do we treat variant angina?

A
  • Calcium Channel Blockers
  • Verapomil
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35
Q

Treatment of IHD (nonmedications)?

A
  • Cessation of smoking
  • Ideal body weight
  • diet
  • exercise
  • treatment of hypertension
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36
Q

Mortality differences between young people and old people with MIs?

A
  • Collateral Circulation, old people will survive
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37
Q

Medication to treat IHD?

A
  • ASA
  • platelet glycoproteinIIb/IIIa receptor antagonist
  • Thienopyridines (P2Y12 inhibitor)
  • Nitrates
  • BB
  • CCB
  • ACE-i
  • Statins
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38
Q

ASA

A
  • inhibits COX-1… thromboxane A2
  • Irreversible, platelet life span(7-14 days)
  • 75 -325 mg/day
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39
Q

Thienopyridines (P2Y-12 inhibitors)

A
  • clopidogrel
  • Prasugrel (effient)
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40
Q

Clopidogrel

A
  • Inhibits ADP receptor P2Y-12 and platelet aggregation
  • Irreversible, platelet life span
  • D/C ~ 80% of platelets recover to normal function
  • PRODRUG — 10-20% of people hypo/hyper response; PPI
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41
Q

Prasugrel (Effient)

A
  • Inhibits ADP receptor P2Y12 and platelet aggregation
  • Higher risk of bleeding
  • MORE POTENT and PREDICTABLE THAN PLAVIX
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42
Q

Nitrates

A
  • Dilate coronary arteries and collaterals
  • Decrease peripheral vascular resistance
  • Decreases preload
  • Potential anti-thrombotic effects
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43
Q

Nitrates drug interactions

A
  • Synergistic with beta-blockers/calcium channel blockers
  • Contraindicated with aortic stenosis and hypertrophic cardiomyopathy
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44
Q

Beta Blockers

A
  • Only drug to prolong life in CAD pts
  • Anti-ischemic, anti-hypertensive, anti-dysrhythmic
  • Decreases risk of death and reinfarction in MI pts
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45
Q

What does blocking B1 do?

A

*decreases Heart rate
* increases diastolic time
* decreases myocardial contractility
* decreases myocardial oxygen demand

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46
Q

Name 4 B-1 blockers

A
  • atenolol
  • metoprolol
  • acebutolol
  • bisprolol
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47
Q

Name (2) B-2 adrenergic blockers? And what do you need to be concerned about?

A
  • propanolol
  • nadolol
  • Pulmonary complications
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48
Q

Calcium Channel Blockers

A
  • Uniquely effective for decreasing frequency/severity of spasm
  • Dilate coronary arteries
  • Decrease
    1. Vascular smooth muscle tone
    2. Contractility
    3. Oxygen consumption
    4. Systemic BP
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49
Q

ACE inhibitors

A
  • stops the angiotensin convering enzyme from converting angiotensin 1 to angiotensin 2
  • Treats:
    1. HTN
    2. Heart Failure
    3. Cardioprotective
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50
Q

What does Angiotensin increase?

A
  • Myocardial hypertrophy
  • intestinal myocardial fibrosis
  • coronary vascoconstriction
  • inflammatory responses
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51
Q

Statins

A
  • Coronary Plaque Stabalization
  • Decreases
    1. Lipid oxidation
    2. Inflammation
    3. Matric malloproteinase
    4. Cell death

REDUCES OVERALL MORTALITY IN SURGICAL PATIENTS

52
Q

When does Revascularization happen?

A
  • Failure of medical therapy
  • 50% L main coronary artery
  • 70% epicardial coronary artery
  • Impaired EF <40%

CABG > PCI

53
Q

Can OMI/STEMI have ST elevation?

A
  • Yes
  • Just might not be present on the left side of the heart.
54
Q

Define Acute Coronary Syndrome?

A
  • Acute or worsening imbalance of myocardial oxygen supply to demand.
55
Q

Name 4 causes of ACS

A
  • Atheromatous plaque
  • coagulation cascade
  • thrombin generation
  • arterial occlusion
56
Q

How do we diagnosis a STEMI?

A
  • ST Elevation on EKG
  • Rise in cardiac markers – Troponin
  • Some evidence of myocardia ischemia. —LBB,Q wave
57
Q

What is more specific CKMB or Troponin?

A

Troponin

58
Q

When will you see an increase in Troponin for an MI patient?

A
  • Within 3 hours after MI
59
Q

What abnormalities will you see on imaging studies for an MI?

A
  • LLB or abnormal EKG
  • regional wall motion abnormalities
60
Q

What does CKMB lab test tell us?

A
  • There has been some type of muscle death has occured
  • Not specific to cardiac muscle.
61
Q

Drug therapy for an MI

A
  • MONA
  • P2Y -12 inhibitors
  • Platelet glycoprotein IIa/IIIb
  • Unfractionated heparin
  • BB
  • RAAS
62
Q

What is the primary goal in management of STEMI?

A
  • To re-establish blood flow in the obstructed coronary artery ASAP
63
Q

What medication do we use for Reperfusion Therapy?

A
  • Steptokinase
  • Reteplase
  • TPA
  • tenecteplase
64
Q

When do we administer Thromboltics to MI patients?

A
  • within 30-60 minutes
  • no longer than 12 hours after symptoms begin.
65
Q

What is better for MI patients, PCI or thrombolytics?

A

PCI

66
Q

Indications for a PCI

A
  • Contraindications to thrombolytic therapy
  • Severe HF and/or pulmonary edema
  • Symptoms present for 2-3 hours
  • Mature Clot
67
Q

How does Dr Cornellius differentiate between major and minor surgery for counterindication to thrombolytic therapy?

A
  • Can the surgery site be compressed.
68
Q

What are counterindations for thrombolytic therapy?

A
  • Surgery: major vs minor
  • Uncontrolled HTN
  • aneurysm
  • Inracranial bleeds
  • Received thrombolyitics in the past 3 - 6 months.
  • Active bleeding
69
Q

What are you at a risk for when given multiple dose of thrombolytics?

A
  • Anaphylatic Reaction
70
Q

Indications for a CABG

A
  • Abnormal Coronary Anatomy
  • Failed angioplasty
  • Evidence of infarction- related ventricular septal repture
  • Mitral Regurg
71
Q

Does reperfusion occur faster in PCI or CABG?

A

PCI

72
Q

Name 5 causes of Angina/NSTEMI

A
  • Rupture or erosion of coronary plaque
  • Dynamic obstruction due to vasoconstriction
  • Worsening coronary luminal narrowing
  • inflammation
  • myocardial ischemia
73
Q

Presentation of Angina at rest

A
  • chest pain lasting > 10 minutes
74
Q

Presentation of Chronic angina

A
  • After interventions
  • 2 month mark
  • more frequent and easily provoked
75
Q

Presentation of New-onset angina

A
  • Diagnosis of exclusion
  • severe, prolonged or disabling
  • they feel like they are going to die.
76
Q

What are the treatments for Angina/NSTEMI?

A
  • Bedrest, oxygen, analgesia, BB
  • Nitro
  • CCB
  • ASA/Clopidogrel/ticarelor/heparin
77
Q

What therapy is NOT indicated for Angina/NSTEMI

A
  • Thrombolytics
  • Can increase mortality
78
Q

What is Percutaneous Coronary Intervention (PCI)?

A
  • Alternative to CAGB
  • Balloon angioplasty, bare-metal stent, drug eluding stent
  • Destruction of endothelium
79
Q

What are the 2 main Risks with a PCI?

A
  • thrombosis
  • increased risk of bleeding
80
Q

What is the most significant independent predictor of stent thrombosis in patient’s who have had a PCI?

A
  • P2Y-12 inhibitors discontinuation.
81
Q

What are the 2 most common medications in Dual Antiplatlet Therapy (DAPT)?

A
  • ASA
  • P2Y-12 inhibitors
81
Q

When should you D/C DAPT meds for surgical bleeding risk? And who should you always consult?

A
  • 5 days- clopidogrel or ticagrelor
  • 7 days - prasugrel
  • continue ASA is possible
    * ALWAYS CONSULT THE PTS CARDIOLOGIST
82
Q

How do you reverse ASA or Plavix?

A
  • Give platelets
83
Q

When can you have surgery done after having an angiolasty without stenting?

A

2 - 4 weeks

84
Q

How long do you have to wait to have surgery after a bare metal stent placement?

A
  • 30 days - 12 weeks
85
Q

How long do you have to wait to have surgery after a CABG

A
  • 6 - 12 weeks
86
Q

How long do you have to wait to have surgery after a drug-eluting stent placement?

A
  • 6-12 months
87
Q

What is the purpose of a Pre-Op assessment?

A
  • Determine presence of risk factors
  • Evaluate METs
  • Co-existing non-cardiac disease
  • physical exam
  • Specialized testings
88
Q

What 2 non-cardiac disease are we most concerned about?

A
  • diabetes
  • HTN
89
Q

During pre-op assessment, what co-existing disease are we concerned about with Coronary Syndrome?

A
90
Q

Do we stop B-blockers before surgery?

A

No

91
Q

If someone is on a Beta Blocker and are bradycardic, what medication works better? Glycopyrrolate or Atropine?

A
  • Glycopyrrolate
92
Q

Why would we give an alpha-2 agonist to a patient with Angina/NSTEMI?

A
  • sedation - precedex
  • decreases sympathetic outflow
  • decrease BP
  • Decrease HR
93
Q

Per Cornelius, what is the enemy of any angina/NSTEMI patient?

A
  • Tachycardia
94
Q

What medication do you need to hold 24 hours before surgery?

A

ACE-i

95
Q

What are the Inflammatory responses to surgery?

A
  • Hypercoagulable state
  • Plaque rupture
96
Q

What medication do you give to stop the inflammatory response from surgery?

A

Statins

97
Q

What medications do you give to stop the neuroendocrine response from surgery?

A
  • Alpha-2 analgesics
98
Q

What is the most common tool stratifiy cardiac patients and determine if they are healthy enough for surgery?

A
  • Revised Cardiac Risk Index (RCRI)
99
Q

What does the RCRI do?

A
  • Prediction tool recommended by ACC/AHA
  • Estimates risk of cardiac complications
  • Low risk: <1%: < or = 1 RCRI
  • high risk : > 1%: > or = 2 RCRI
100
Q

What are the 6 components of RCRI?

A
  1. High-risk surgery
  2. Ischemic Heart Disease
  3. Congestive Heart Failure
  4. Cerebrovascular disease
  5. Insulin-dependent diabetes mellitus
  6. Preoperative serum creatine components > 2 mg/dL
101
Q

How do we measure Functional Capacity?

A
  • METs
  • 1 MET = 3.5mL/kg/min
102
Q

What METs do you need to have before qualifying for surgery?

A

> or = 4 METs

103
Q

Urgency of Surgery: Emergency

A
  • Life or limb would be threatened if surgery did not proceed within 6 hours or less
  • can do surgery w/out pre-op cardiac assessment
  • focus on surveillance and early treatment
104
Q

Urgency of Surgery: Urgent

A
  • life or limb would be threatened if surgery did not proceed within 6 to 24 hours
105
Q

Urgency of Surgery: Time-sensitive

A
  • delays exceeding 1 to 6 weeks would adversely affect patient outcomes.
106
Q

What 6 conditions can significantly increase the risk of perioperative adverse cardiac events?

A
  1. Unstable Coronary Syndromes
  2. Unstable or severe angina
  3. Decompensated heart failure
  4. Severe valvular heart disease
  5. Significant dysrhythmias
  6. Age
107
Q

What are our anesthesia goals for cardiac patients?

A
  • Prevent Myocardial ischemia
  • Monitor for ischemia
  • Treat ischemia
108
Q

What 5 things do we want to prevent during anesthesia?

A
  • Persistent tachycardia
  • Systolic HTN
  • SNS stimulation
  • Arterial hypoxemia
  • Hypotension
109
Q

During anesthesia we want to maintain HR abd BP within what % of baseline?

A

20%

110
Q

Name 9 conditions that can decrease oxygen delivery

A
  1. Decreased coronary blood flow
  2. Tachycardia
  3. Hypotension
  4. Hypocapnia
  5. Coronary artery spams
  6. Decreased oxygen content
  7. anemia
  8. arterial hypoxemia
  9. shift oxyhemoglobin dissociation curve to the left.
111
Q

Name 6 things that can increase oxygen requirements

A
  1. SNS stimulation
  2. Tachycardia
  3. Hypertension
  4. Increased Myocardial contractility
  5. increased afterload
  6. increased preload
112
Q

Anesthetic considerations for Cardiac patients to prevent SNS response.

A
  • parolytic agent
  • DL < 15 seconds
  • volatile anesthetics
  • nitrous oxide
  • opioids
  • neuraxial anasthetics
113
Q

What medication do you give a tachycardic cardiac patient?

A

esmolol

114
Q

What medication do you give to a bradycardic cardiac patient?

A
  • Glycopyrolate
  • Gradual increase in HR
115
Q

What medications do you give a hypotensive cardiac patient?

A
  • Ephedrine
  • Phenylephrine
  • Fluids
  • blood
116
Q

What are our most common used telemetry Leads to monitor patient?

A
  • II
  • IV
117
Q

What does lead 2 show us?

A
  • Inferior part of the heart
118
Q

What part of the heart does lead 5 show us?

A
  • Anterior, lateral
119
Q

What leads show the Right Coronary Artery?

A
  • 2
  • 3
  • avF
120
Q

What leads show the Circumflex Artery?

A
  • 1
  • aVL
121
Q

What leads show the left anterior descending artery?

A
  • V3-V5
122
Q

Where does the RCA supply blood?

A
  • Rt Atrium
  • Rt Ventricle
  • SA node
  • inferior aspect of left ventricle
  • AV node
123
Q

Where does the Circumflex supply blood?

A
  • Lateral aspect of left ventricle
124
Q

Where does the Left Anterior Descending Artery supply blood?

A
  • Anteriolateral descending coronary artery

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