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COEXISTING > ISCHEMIC HEART DISEASE > Flashcards

ISCHEMIC HEART DISEASE Flashcards

1
Q

risk factors for development of CAD

A

**male gender
**increasing age
hypercholesterolemia
HTN
cigarette smoking
DM
obesity
sedentary lifestyle
family hx
personality (stress, type A)

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2
Q

stable angina

A

partial occlusion or chronic narrowing of a segment of coronary artery

  • no change in frequency, severity, or duration x2months
  • occurs in a predictable pattern, predictably relieved
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3
Q

angina pectoris

A

imbalance between myocardial oxygen supply & demand

  • release of adenosine & bradykinin = pain, slowing of AV conduction rate, decreased contractility
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4
Q

unstable angina

A
  • angina at rest
  • angina of new onset
  • increase in severity or frequency of previously stable angina
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5
Q

major treatment categories of CAD

A
  1. lifestyle modification
  2. pharmacologic therapy
  3. revascularization
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6
Q

pharmacologic therapy for CAD

A
  1. antiplatelet drugs (aspirin 81mg, plavix/ticlid if indicated)
  2. BB (decrease O2 demand via decreased HR & contractility, increased supply via increased coronary perfusion time)
  3. CCB (long acting); uniquely effective in variant angina
  4. nitrates (dilate coronaries & collaterals –> increased supply)
  5. ACEI/ARBs
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7
Q

ACS pathophysiology

A 
hypercoaguable state: 
- focal disruption of plaque
susceptible plaques = fibrous cap + lipid-rich core
- triggers coagulation cascade:
-- thombus formation
-- vasoconstriction
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8
Q

diagnosis of acute MI

A

2 of:

  1. chest pain
  2. serial EKG changes indicative of MI
  3. increase & decrease of serum cardiac enzymes
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9
Q

MI treatment

A
  1. evaluate hemodynamic stability/tx if necessary
  2. 12 lead EKG
  3. administer O2
  4. pain relief: IV morphine (reduce catechol)
  5. nitroglycerin (dilate)
  6. aspirin/plavix (decrease further thrombus formation)
  7. reperfusion therapy (tPA, streptokinase) w/in 30-60mins of arrival (RISK: ICH)
  8. coronary angioplasty (preferred to reperfusion) w/in 90mins of arrival
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10
Q

acute MI complications

A
  1. cardiac dysrhythmias (including vfib, vtach, afib, HB)
  2. pericarditis (px worse w/ inspiration & lying down; auscultate friction rub)
  3. mitral regurg (ischemia of papillary m. or vent m. @ attachment point) –> papillary m. rupture?
  4. ventricular septal rupture
  5. CHF & cardiogenic shock (hypotension/oliguria)
  6. myocardial rupture
  7. RV infarction (isolated RV infarct is unusual)
  8. CVA
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11
Q

preoperative MI factors that change incidence

A
  1. preoperative medical condition
  2. specific surgical procedure
  3. surgeon skill
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12
Q

surgery-induced risk factors of MI

A
  1. inflammatory response = hypercoaguable state (lead to decreased O2 supply)
  2. neuroendocrine response = increased HR/BP (increased O2 demand)
  3. postop shivering = increased O2 demand
  4. decreased Hct = decreased O2 supply
  5. hypoxia = decreased O2 supply
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13
Q

major clinical predicators of increased perioperative CV risk

A
  • unstable coronary syndromes (acute/recent MI, unstable or severe angina)
  • decompensated HF
  • significant dysrhythmias (AVB, symptomatic ventricular dysrhythmias, supraventricular dysrhythmias w/ rapid ventricular rate)
  • severe valvular heart dz
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14
Q

intermediate clinical predictors of increased perioperative CV rsik

A
  • mild angina
  • h/o MI
  • compensated or h/o HF
  • DM
  • renal insufficiency
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15
Q

minor clinical predictors of increased perioperative CV risk

A
  • advanced age (>70)
  • abnormal EKG (LV hypertrophy, LBBB, ST abnormalities)
  • rhythm other than SR
  • low functional capacity
  • h/o CVA
  • uncontrolled HTN
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16
Q

best evidence of decreased cardiac reserve (in the absence of significant lung disease)

A

exercise tolerance

  • if pt can climb 2-3 flights of stairs w/out symptoms, it is likely that cardiac reserve is adequate
17
Q

elective surgery after angioplasty?

A
  • wait 4-6 weeks
  • 6 weeks after bare metal stent placement
  • 12 months after drug-eluting stent placement
18
Q

high risk surgery

A
  • emergency major surgery
  • AAA repair or other major vascular surgery
  • peripheral vascular operation
  • prolonged procedures w/ large fluid shifts/blood loss:
    • thoracotomy
    • major abdominal operation
19
Q

preoperative management goals w/ ischemic heart disease patient

A
  1. determining the extent of ischemic heart disease & any previous interventions
  2. determining severity & stability of the disease
  3. reviewing medical therapy & noting any drugs that can increase bleeding/contraindicate a particular anesthetic technique
20
Q

Lee Revised Cardiac Risk Index
PREOP
(6 independent predictors of major cardiac complications)

A
  1. high risk surgery
  2. ischemic heart disease
  3. CHF
  4. cerebrovascular disease
  5. IDDM
  6. creatinine >2.0mg/dL
21
Q

preop algorithm for pts with ischemic heart disease

A
  1. emergent/urgent surgery?
    - optimize & proceed
  2. elective surgery?
    - unstable CAD/change in cardiac condition –> get cardiac consult
    - stable –> stratify risk further:

risk stratification:
for high/intermiedate risk procedure w/ moderate/minor risk factors:
1. prior revascularization?
- prior CABG w/ stable medical condition = proceed to OR
- prior PCI = consider type of stent & proceed accordingly
2. no prior revascularization?
- stable CAD = proceed to OR
- unstable or unable to assess = obtain noninvasive testing FIRST

22
Q

functional capacity evaluation & documentation

A

expressed as metabolic equivalent of task (MET)

  • 3.5mL/kg O2 consumption = 1 MET
  • increased risk w/ poor functional capacity, <4MET

4MET = baking, dancing, golfing, walking

23
Q

intermediate risk surgery

A
  • carotid endarterectomy
  • head/neck surgery
  • orthopedic surgery
  • prostate surgery
  • intraperitoneal & intrathoracic surgery
24
Q

low risk surgery

A
  • endoscopic
  • superficial
  • cataract
  • breast
25
Q

who gets further cardiac evaluation preoperatively?

A

2 of:

  1. high risk surgery
  2. low exercise tolerance
  3. moderate clinical risk factors
26
Q

interventions that can modulate triggers of perioperative cardiac events

A
  1. statins = decrease plaque buildup
  2. antiplatelet/angicoagulants = decrease thrombus formation
  3. oxygen = decrease hypoxia
  4. transfusion = increase hct/O2 delivery
  5. nitroglycerin = prevent vasoconstriction
  6. maintain BP = ensure adequate coronary flow
  7. alpha2 agonists/analgesics = attenuate neuroendocrine response to surgery (catechol release)
  8. normothermia = prevent shivering (O2 demand)
  9. BB = prevent increased O2 demand
27
Q

intraoperative management goals in those w/ ischemic heart disease

A
  1. optimize myocardial O2 supply & keep O2 demand low

2. monitor for ischemia, & tx it if it develops

28
Q

factors that decrease myocardial O2 supply

A
  1. decreased coronary blood flow (patency)
  2. tachycardia
  3. diastolic hypotension
  4. hypocapnia (= coronary artery vasoconstriction)
  5. coronary artery spasm
  6. decreased PaO2
  7. anemia
  8. arterial hypoxemia
  9. L shift of oxyhemoglobin dissociation curve
  10. increased blood viscosity
29
Q

factors that increase myocardial O2 demand

A
  1. SNS stimulation
  2. tachycardia
  3. HTN
  4. increased myocardial contractility
  5. increased afterload
  6. increased preload
  7. shivering
  8. hyperglycemia
30
Q

induction of anesthesia in pts w/ ischemic heart disease

A
  1. anxiolysis pre-operatively
  2. no ketamine, preferably etomidate or high opioids
  3. use NDNMB w/out HR/BP implications (vec, roc, cis)
  4. be quick w/ DL
  5. minimize SNS response = lidocaine, esmolol, fentanyl
31
Q

anesthesia maintenance w/ ischemic heart disease

A
  • AVOID TACHYCARDIA
  • NO HYPOTENSION
  • keep vitals w/in 20% of pre-op value
  • normal preload & afterload
  • decrease contractility if LVF is normal (demand)
  • maintain NSR

Options

  • volatile agent = controlled myocardial depression to avoid increased demand
  • opioids for those w/ LVF = avoid myocardial depression w/ volatiles
  • regional = avoid hypotension >20% of initial BP –> phenylephrine or ephedrine if bradycaria
32
Q

EKG monitoring for ischemia perioperatively

A
  • evaluate for ST depression
  • II (RCA)
  • V5 (LAD)
33
Q

lead/vessel relationship

A 
RCA = II, III, aVF
LCx = I, aVL
LAD = V3, V4, V5
34
Q

perioperative ischemia monitoring options

A
  1. EKG (ALWAYS)
  2. PA cath (not shown to be associated w/ improved outcomes)
  3. transesophageal echocardiography (evaluate regional wall motions)
    - abnormalities occur before EKG changes occur
    - abnormalities can be attributed to events other than myocardial ischemia
35
Q

intraoperative management of MI

A
  • when ST segment changes >1mm on EKG

tx changes in HR/BP

  • IV BB
  • nitroglycerin if BP elevated
  • sympathomimetic to tx hypotension
  • inotropes if hemodynamically unstable
  • intra-aortic balloon pump may be necessary
  • plan for early postop cardiac catheterization if applicable
36
Q

causes of ischemic heart disease

A
  • atherosclerosis (most common)
  • severe HTN or tachycardia
  • coronary artery vasospasm
  • hypoxia
  • anemia
  • severe AI or AS
37
Q

perioperative MI incidence

A

risk of perioperative death 2/2 cardiac causes = <1% in general population
- most perioperative MIs occur w/in the first 24-48hrs postoperatively

COEXISTING (10 decks)

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