Quiz 1 - The Cardiovascular Patient Flashcards
With anesthesia, will you typically have increased or decreased SVR?
Decreased
With anesthesia will you typically have increased or decreased stroke volume?
Decreased
During induction, how much can anesthesia lower your systemic blood pressure?
20-30% decrease BUT tracheal intubation can increase systemic BP by 20-30 mmHg.
How much can anesthetic agents lower cardiac output?
15%
In addition to identifying potentially serious cardiac disorders during an initial history, what else should you know about the cardiac disorder?
disease severity, stability, and prior therapy
What factors can place a patient at higher cardiac risk during surgery?
- Functional capacity
- age
- co-morbid conditions (i.e. DM, PVD,…)
- type of surgery
- ANEMIA
- presence of CAD and CHF
- Hx of CVA
- Creatinine greater than 2 mg
- IDDM
- High risk surgery
What 4 things should you assess on every pt before anesthesia?
- history
- physical exam
- diagnostic tests
- knowledge of planned surgical procedure
in a pt with valvular heart disease, what should you know from their history?
Whether it is stenotic or regurgitant.
Also, whether they have dyspnea, orthopnea, PND, embolic events, hemoptysis, heart failure or palpitations
During the physical exam, what items should you pay attention to?
cyanosis, pallor, dyspnea during the conversation or with minimal activity, nutritional status, obesity, skeletal deformities, tremor and anxiousness.
During a detailed cardiac assessment, what items should you assess?
- JVD or pedal edema
- cap refill
- displaced apical pulse (cardiomegaly)
- S3 gallop (increased LVEDP)
- S4 (decreased compliance)
- presence of murmur
- pulmonary edema
What does 1 metabolic equivalent or 1 MET represent?
Oygen consumption of a resting adult (3.5 ml/kg/min). Can be measured by persons ability to do normal ADL’s including walking around inside of house or 1 block on level ground.
What does 4 MET’s represent?
ability to climb stairs or walk up a hill. Run for short distances. Walk on level ground at 4mph.
What does 10 MET’s represent?
Ability to participate in strenuous sports like swimming, tennis, and football.
If patients reduce exertion because of cardiac symptoms but still meet a 4-MET threshold, will clinicians over or under estimate their risk?
Underestimate their risk
If a person in not able to meet a 4-MET activity level due to non-cardiac reasons, will a clinician tend to over or under estimate their cardiac risk?
Overestimate their risk.
How is Functional Capacity defined in terms of numbers of MET’s one can accomplish?
- Poor (<4 METS)
- Moderate (4-7 METS)
- Good (7-10 METS)
What is the number 1 determinant of myocardial workload?
Heart Rate
T/F: Conduction disturbances such as right bundle branch block or first degree AV block, may lead to concern but usually do not justify further workup.
True
What is the risk indicies that assess the patient’s overall physical status and to predict morbidity and mortality?
ASA
What is the risk indicies that risk stratification of medical patients with angina, but they have been adapted for use in surgical patients.
NYHA/CCS
what is the risk indicies that identify 9 independent variables that correlated with advers perioperative events?
Cardiac Risk Index (CRI)
what is the risk indicies identified risk factors for cardiac morbidity bet were very cumbersome to apply?
-Modified Cardiac Risk Index
What are major perioperative cardiovascular risk?
- Unstable coronary syndromes
- Decompensated heart failure
- Significant arrhythmias
- Severe Valvular disease
What are moderate perioperative cardiovascular risk factors?
- mild angina
- History of MI, Pathologic Q’s
- Compensated or Prior CHF
- Diabetes Mellitus
- Renal Insufficiency (CKD)
What are minor perioperative cardiovascular risk factors?
- Advanced age
- Abnormal ECG (LVG, LBBB, ST-T abnormalities)
- Rhythm other than sinus
- Low functional capacity
- History of stroke
- Uncontrolled systemic hypertension
High risk surgeries have a greater than ___% of perioperative death or MI.
5
Moderate risk surgeries have a _____ % risk of perioperative death or MI.
1-5
Low risk surgeries have a less than _____% risk of perioperative death of MI.
1
What are six noninvasive cardiac tests?
- Transthoracic ECHO
- Exercise tests and pharmacologic tests
- Exercise stress test
- Dobutamine stress Echo
- Adenosine stress test
- ambulatory ECG monitoring
What are the risk reduction strategies for perioperative management for cardio?
a. Anesthetic “maneuvers”
* anesthesia, temperature regulation, invasive monitoring.
b. Surgical technique
* Laparoscopic vs. open, endovascular
What are risk reduction strategies for medical management of cardio?
- Medical management
- beta blocker, antiischemic medication, lipid lowering agents
- Preoperative coronary revascularization/valvuloplasty
Evidence base practice parameters of class 1 are _________?
-benefits outweigh the risks
Evidence base practice parameters of class 2a are _______?
-reasonable to consider
Evidence base practice parameters of class 2b are ______?
-may be reasonable to consider
Evidence base practice parameters of class 3 are -____?
-not indicated
Evidence base practice parameters of level A are ______?
highest level of evidence
Evidence base practice parameters of level C are _______?
lowest level of evidence.
What patient will you see for coronary angiogram/coronary intervention for class 1.
- stable angina with significant LMCA stenosis
- stable angina who have 3 vessel disease
- stable angina who have 2 vessel disease with significant proximal LAD stenosis
- unstable angina or non-ST segment elevation MI
- Coronary revascularization before noncardiac surgery is recommended in patients with acute ST elevation MI.
BONUS: What would be a thorough and detailed assessment of a cardiac patient?
- Thorough Hx
- Detailed physical examination
- Judicious use of tests
- Categorize patients into low, intermediate & high risk categories
- Combine preop assessment with periop risk reduction strategies to optimize medical treatment in order to improve outcome
What is the risk indicies that Indentify 6 independent predictors of adverse cardiac outcomes in patients undergoing noncardiac surgery
Revised Cardiac risk Index (RCRI)
What is the risk indicies the provied a framework for screening and identifying patietns who are at high risk for perioperative cardiac events (PCE)
ACC/AHA guidelines
