Ischemic Heart Disease Flashcards
What are the risk factors for ischemic heart disease?
30% surgical pts
Angina pectoris, acute MI, and sudden death
Dysrhythmias
The two most important risk factors for the development of atherosclerosis involving the coronary arteries are _____ and increasing ______
male gender; increasing age
Angina pectoris is caused by ____
Imbalance between coronary blood flow (supply) and myocardial oxygen consumption (demand)
Stable angina typically develops in the setting of _____ occlusion or significant (>70%) chronic narrowing of a segment of coronary artery.
partial
_______ is the most common cause of impaired coronary blood flow resulting in angina pectoris, but it may also occur in the _____ of coronary obstruction as a result of myocardial hypertrophy, severe aortic stenosis, or aortic regurgitation
atherosclerosis ; absence
What can induce angina?
Physical exertion, emotional tension, and cold weather may induce angina
Which statement best describes chronic stable angina?
Chronic stable angina refers to chest pain or discomfort that does not change appreciably in frequency or severity over 2 months or longer.
chronic angina pectoris that becomes more frequent and more easily provoked
Describe unstable angina
angina at rest (typically lasting >10 minutes unless interrupted by antianginal medication),
Do patients with typical ECG evidence of AMI need an echo?
no
Troponin levels remain elevated for bumps in ___ hours, elevated for up to 2 weeks
3-4 hours
The greater the degree of _________ , the greater the likelihood of significant coronary artery disease.
ST-segment depression
Look at Picture
:) you can do it
What results in sudden cardiac death
overdose, cardiomyopathy, atherosclerosis
What results in coronary bloodflow being decrease?
reduction in lumen size, MI, hypotension
- we cause hypotension
What are signs you’ll see during anesthesia that they are having low coronary blood flow?
EKG changes
Stable angina is chest pain that ____ _____ with rest
goes away
When you have angina youll see slow ___ _____ and _____ cardiac contractility
AV conduction; decrease
There are weird presentations of cardiac pain in ___ and _____
diabetics and women
How to differentiate cardiac from other pain?
touch it, give GI cocktail, if its pericarditis they will feel better with sitting up
- could be PE and you will see it on a blood gas. They could be confused and air hungry
- AAA: tearing pain in the back and chest
Unstable angina
Chest pain increasing in frequency and/or severity without increase in cardiac biomarkers
- no increase in CKP
chronic stable chest pain can be caused by
- distal occlusions
After a EKG and labs are done for a chest pain patient, what else would you do?
Stress test
____ stress test is more accurate because it provides nuclear imaging
Chemical
- greater sensitivity
what abnormality can you see on an ultrasound with chest pain?
- valve function
- wall motion abnormalities
gold standard for looking at coronary blood flow is
angiography
- can see little. occlusions that result in hypoperfusion
How do we treat stable angina?
- reverse reversible factors (DM, weight, get off the couch, GLP-1)
- treatment of HTN
What is the dose for daily aspirin?
75-325mg/day
“Baby aspirin” is 81mg/day
What is the life span of a platelet
7-14 days
Platelet glycoprotein IIb/IIIa receptor antagonists (abciximab, eptifibatide, tirofiban) work by…..
Inhibit platelet activation, adhesion, and aggregation
- given IV
Clopidogrel is _____
irreversible
- just like the other drugs
How do you assess platelet function?
Platelet function panel and TEG (thromboelastagram)
Effient is very ___
predictable
- cardiologist will use this pre or post intervention for a cath
Patients who take chronic nitrates ____________ respond well to doses
do not
- they wont respond
what is the only medication that prolongs life span with CAD?
beta blockers
- when you induce anesthesia you will see an induced hypotension
With beta 2 blockers we would worry about what complications?
pulmonary
propranolol is used for __ and ____
anxiety and tremors
describe the difference in metoprolol, esmolol, and labetolol
metoprolol is more for contractility and esmolol is more for HR
labetolol is in the middle
When do you start a patient on a CCB?
when the BB doesn’t work
ACE inhibitors are very ____
cheap
- patients will be put on this early because it isnt expensive
Why do we put patients on statins
Small reduction in mortality in patients undergoing surgical procedures
- coronary plaque stabilization
2 primary interventions for revascularization are
CABG and PCI
- over 50% LAD occlusion = CABG
- over 70% epicardial coronary artery = CABG
- impaired EF < 40% = CABG
What do we do in PCI?
- angioplasty: balloon into the plaque and pushing it against the wall
- placement of a stent and then use the balloon to open the stent
- transluminal interventions: grinds the plaque off the walls of the vessels
ACS is
Acute or worsening imbalance of myocardial oxygen supply to demand
ACS chart
STEMI Diagnosis
How do you know if the patient has a new LBBB?
must have an old 12 lead
Troponin is more specific for ____ than CK-MG
cardiac damage
Troponin
Increase within ___ hours after myocardial injury
3
Drug therapy for ACS
MONA????
Oxygen
Aspirin
Morphine causes hypotension – fentanyl is starting to be used
Torodol – decreased ???
Nitrates
P2Y12 inhibitors (clopidogrel, prasugrel, or ticagrelor)
Platelet glycoprotein IIb/IIIa inhibitors
Unfractionated heparin
β blockers
RAAS
What medications are in reperfusion drug therapy
TPA, streptokinase, reteplase, tenecteplase
What is the time frame for thrombolytics
should be initiated within 30 to 60 minutes of hospital arrival and within 12 hours of symptom onset. Thrombolytic therapy restores normal antegrade blood flow in the occluded coronary artery.
indications for PCI
Indications
Contraindication to thrombolytic therapy
Severe HF and/or pulmonary edema
Symptoms present for 2 - 3 hours
Mature clot
Causes of unstable angina
chronic angina patients will have very ____ blood flow through their vessels
litte
Do we use thrombolytics for NSTEMI?
no
What is DAPT therapy
Dual antiplatelet therapy
ASA and P2y12 inhibitor
if a patient has had coronary intervention you dont want to take them to the OR for ____ to a _____
6 months to a year
You can give a 1:1 ratio of glycopyrrolate and neostigmine to reduce ____
reduce the bradycardia with neostigmine
RCRI test
What are the active cardiac conditions we worry about?Unstable coronary syndromes
- Acute (MI ≤ 7 days) or recent MI (>7 days but ≤ 1 month ago) with evidence of important ischemic risk
- > 60 days post MI ideal
Unstable or severe angina
Decompensated heart failure
Severe valvular heart disease
- Severe aortic stenosis or severe mitral stenosis
Significant dysrhythmias
- High-grade atrioventricular block, Mobitz type II atrioventricular block, third-degree heart block, and symptomatic supraventricular and ventricular tachydysrhythmias
Age
How do you prevent ischemia in the OR?
Prevent
- Persistent tachycardia
- Systolic HTN
- SNS stimulation
- Arterial hypoxemia
- Hypotension
Etomidate will be induction of choice
May want an arterial line before induction
