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EXMD4742 > WK2 - CVD > Flashcards

WK2 - CVD Flashcards

1
Q

What clinical investigations for CAD are used for asymptomatic/low risk?

A

CT Coronary Calcium Score

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2
Q

What clinical investigations for CAD are used for symptomatic/>low risk?

A

Non-invasive functional tests: stress echo or cardiac MRI

Non-invasive anatomical tests:
Ct coronary angiogram - use for stable chest pain

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3
Q

What is coronary angiography?

A
  • single most effect test to Dx CAD
  • dynamic x-ray imaging of coronary arteries to detect prescence/severity of CAD
  • invasive
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4
Q

Provide some definitions of invasive procedures.

A

Coronary Angiogram / Angiography -identify specific site/severity of CAD (lesion/stenosis/blockage)

Percutaneous Transluminal Coronary Angioplasty (PTCA)
* Open a diseased coronary artery via catheterised balloon inflation - often combined with stent (PCI) - 25% re-stenosis rate (1st 6M)

Percutaneous Coronary Intervention (PCI)
* Deploy a metal stent to a diseased section of coronary artery

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5
Q

What are the aims of revascularisation?

A

*Increase blood flow/O2 delivery to ischaemic myocardium beyond obstructive arterial lesion
*Decrease chance of MI; ST-segment depression, angina pectoris, ventricular arrhythmias
* Potentially reduce cardiovascular-related morbidity/mortality

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6
Q

What are the fundamental principles of CAD interventions?

A

Does intervention relieve Sx and prolong life?

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7
Q

Explain PTCA.

A

Percutaneous (access through skin)
Transluminal (within blod vessel)
Coronary (heart vessel artery)
Angioplasty (reshaping)

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8
Q

What is the difference between PTCA and PCI?

A

PTCA = inserting balloon into narrowed area of coronary artery before expanding, pushing plaque to sides of artery and restoring normal artery diameter

PCI = Preserve patency of vessel, reduce risk of acute closure/re-stenosis
* Stainless steel mesh
* Drug eluting
* ~95% cases following PTCA
* Lower re-stenosis rates:
* 25-40% bare metal
* <10% drug eluting

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9
Q

What are some pCI contraindications?

A
  • anti-platelet therapy (e.g. bleeding disorders)
  • Allergy, or hypersensitivity to anti-platelet/anticoagulation therapy
  • Hypersensitivity to stent metal or alloy (e.g. cobalt, nickel, chromium)
  • Lesion prevents proper placement of stent.
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10
Q

What is coronary artery bypass graft surgery? What are some considerations for rehab?

A
  • Median Sternotomy
  • Cardiopulmonary bypass
  • Revascularisation using venous/arterial graft from arm/leg (vein harvesting)
  • 1y occlusion rate of graft ~15%

Considerations for Rehab
* Incisional healing
* Sternal stability
* Hypovolemia
* Low haemoglobin

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11
Q

What happens in cardiac surgery via median sternotomy?

A

Involves surgical division of sternumto gain access to heart
*doctor separates two halves of breastbone and spread apart to expose heart.
* procedure commonly used for CABG surgery and valve repairs/replacements.

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12
Q

What are some post-operative complications of median sternotomy?

A
  • sternal instability
  • restricted ROM and pain
  • wound and scar problems
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13
Q

Which veins are harvest for CABG surgery?

A
  • Internal mammary or Internal Thoracic Artery (ITA)
  • Saphenous or radial veins
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14
Q

What is a cardiopulmonary bypass?

A
  • Heart-lung machine to pump blood through the body during CABG
    surgery
  • necessary to stop heart while surgery performed – injected with cold solution
  • Allows for delicate sewing of small grafts to the coronary arteries
  • Once completed – tubes removed, heart may be temporarily paced
    during recovery
  • Off pump procedure ?
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15
Q

What happens when a CABG surgery is completed?

A
  • sternum pushed/sewn together with small wires
  • skin over sternum sewn back together
  • Tubes inserted into chest to drain blood and other fluids from heart
  • tubes connected to suction device keep fluids
    away from heart
  • tube inserted through mouth or nose into stomach to drain stomach fluids
  • sterile bandage or dressing is applied
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16
Q

What are the risks of CABG?

A
  • Bleeding during/after the surgery
  • Blood clots can cause heart attack, stroke/ lung problems
  • Infection at incision site
  • Cardiac inflammation (e.g. pericarditis)
  • Pneumonia
  • Breathing problems
  • Cardiac dsrhythmias/arrhythmias (e.g. atrial fibrillation)
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17
Q

Compare PCI and CABG.

A

PCI
* CAD with suitable anatomy
* Predominantly done on
discrete single vessel
lesions
* 2 and 3 vessel
disease possible
* Patients usually younger

CABG
* L Main Disease
* 2 and 3 vessel
disease
* Diffuse disease not
amenable to PCI
* More likely if stenting not
appropriate or likely to be
complicated
* Patients usually older

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18
Q

Compare PCI and CABG over long-term events.

A

PCI results lasting longer than CABG

PCI potential cause for ruptre and thrombolic occlusion over long-term

CABG provides protection against vessel occlusion through surgical collateralisation

19
Q

Compare the benefits of CABG vs PCI.

A
  • improved long-term survival rates
  • protects against future coronary vessel occlusion (surgical collateralisation) = reduction in future MI
  • fewer procedural complications
  • faster Rx
  • shorter hospital stays
  • patients able to return to ADLs quickly
  • PCI performed via cardiac catheter through small perforation of radial or femoral artery
  • stents mechanically open artery
20
Q

Are valves affected by CVD?

A
  • damaged due to infection, RHD or congential defects
  • affected cusps may grow thick and brittle from scar tissue or Ca2+ deposits
  • become thin/weak resulting in inefficient valve
21
Q

Give a cool fact on heart valve disease.

A

It is either stenotic or regurgitant with aortic and mitral valves most commonly affected.

Stenotic = valve is narrowed and blood flow is restricted

Regurgitant = valve does not closed properly and allowes blood to flow backwards/forwards

22
Q

List mechanism of valve procedures

A

Type of procedure dependent on extent of disease, stenosis/regurgitation, patient/surgery risk

Types:
* bioprosthetic/mechanical
* durabiltiy/anticoagulation

23
Q

What are some types of valve procedures?

A

repair/replacement/open heart/ percutaneous

Percutaneous replacements delivered via catheter for commonly aortic valves (aortic stenosis)
- can also be done of pulmonary and mitral valves

AORTIC VALVE
transcathetic aortic valve implantation (TAVI) for patients with aortic valve stenosis (for those unsuited for open heart surgery
- involves inserting new artificial heart valve inside old tight valve using balloon catheter.

24
Q

What are the access methods for TAVI?

A
  • transfemoral,
  • transapical (through anterolateral mini-thoracotomy)
  • subclavian or transaortic (through minimally invasive surgical incision into the aorta)

Transfemoral approach is preferred

25
What is the retrograde transfemoral approach?
Delivery system introduced through fem artery allowing positioning of prosthetic valve within native stenotic aortic valve
26
What is the antegrade transvenous approach?
Delivery system is advanced through Fem vein to RA and mitral valve to be subsequently positioned in stenotic aortic valve *this approach is rarely used
27
What is the transapical approach?
LV apex is reached by anterolateral minithoacotomy. Valve delivery system introduced through LV apex and subsequently positioned in stenotic aortic valve.
28
What is part of the pre-Ex assessment?
* clinical Hx * physical Ax (including sternal stability) * Ex Ax ( contraindications, aerobic Ex/muscle strength/other functional Ax) * risk stratification
29
What does the pre-ex Ax involve?
Thorough evaluation ensures prescribed Ex program is tailored to individual. * screening for physiological, subjective and adverse responses to Ex * serves as baseline reference to compare follow-up Ax
30
What is Clinical Hx? What should it include?
Comprehensive review of patients med Hx is paramount to safe/effective Ex prescription. Includes: * principle diagnosis * past/current Sx * relevant investigations * modifiable CV risk factors prescribed meds * co-morbidities and other med Hx * family med Hx * cognitive function
31
What are Ex specific factors during the clinical Hx?
* Ex habits past/present, including lifestyle PA * personal Ex preferences * barriers (time, anxiety, depression, orthopaedic limitations, safety, financial and geography) * enablers to Ex ( things that make Ex easier/ overcome barriers * social issues (family support, socioeconmic, transport)
32
What does the physical Ax include?
Ax of general physical wellbeing, considers acute condition and long-ter risks. Includes: * RHR and rhythm * BP (sitting/standing) * BGL (if required) * O2 saturation * weight/height * waist circumference * signs of fluid retention - orthopnoea, exertional dysponea, ankle oedem, bloating) * sternal stabiltiy, wound integrity and sensitivity in post-surgical patients * mobility status, safety with ambulation, falls risk * further Ax (if required): balance, neurological factors, ROM
33
What are the phases of Korotkoff sounds?
Phase I (SBP) - consecutive faint, clear tapping sounds with gradual increase in intensity Phase II - sounds change to swishing/blowing Phase III - sond becomes clearer/crisper, creating soft thuds that become louder Phase IV - sound becomes suddenly muffled and assume a soft, blowing character that diminishes Phase V - sound disappears
34
What to do for first BP measurements?
* measure both arms, if there is evidence of peripheral arterial disease * with variation of >5mmHg between arms, use arm with higher reading for all subsequent measures * when there is suspected postural hypotension (e.g. older patients and/or those with diabetes), measure both sitting/standing BP. Repeat after patient stands for at least 2mins
35
What should be considered before a subjective sternal Ax?
Pain - intermittent/constant, dull/sharp, hot/cold, deep/superificial Feeling of instability/excessive motion - e.g. patient rep chest " feels like it is going ot fall open" Sounds - clicking/clunking activities that provoke unstable feeling/pain/clicking/crepitus State of wound/scar - colour, sensitivity to temp, discharge ( serous/coloured), hypersensitive, presence of keloid scarring or adhesions)
36
What is the prevalence of sternal pain?
* ~30% post-cardiac surgery patients develop MSK complications involving shoulders, chest, UB * post sternotomy pain may interfere with comfort, function and sleep * harvesting internal mammary artery contribute to 29% patients - shotting intermittent pain of ANT chest wall on harvest side * tenderness observed on palpation of manubrium, sternocostal joints, ANT rib cage and numbness +/- allodynia of ANT intercostal nerves T1-2 and T5-6
37
What can sternal instability mean?
* excessive movement due to disruption of wires connecting surgically divided sternum * often rep "clicking/clunking" sensation = pain/discomfort with ADLS (e.g.reaching, STS, rolling over bed) * can lead to non-union, infection and delayed healing * prevalence is 1-8% of patients with median sternotomy * minimal motion of 2 sternal halves should be present in early weeks following median sternotomy * finding of subjective and physical exam rep to cardiac surgeon/GP
38
What is the frequency of the physical sternal Ax?
day 5-7 post-cardiac surgery - document in med record and notify treating cardiac surgeon is sternum unstable wk3-6 post surgery Prior to Ex - esp. involving UB advanced stretches, weight or pulleys (unilateral) - record as outcome measure on Ex chart On an ongoing basis - when instability detected following wound/infection/breakdown at Wk3-4 intervals
39
What are the pros of using an Ex Ax?
* valuable info to develop and guide Ex prescription * include subjective observations of individuals Ex tolerance * objective Ex test results * used to calculate Ex intensity based on equation/algorithm
40
What is part of the aerobic Ex Ax?
Ex performance can be Ax by: * maximal (cardiopulmonary Ex test) * maximal or submaximal (graded Ex stress test) * submaximal test (6MWT, incremental shuttle walk test) Type of test depends on facility and level of med support.
41
What are the pros of a submaximal Ex test?
* used more than maximal testing *easily administered * less likely to cause adverse events * does not require med supervision and ECG monitoring Defined by: <80-85% predicted HRmax // <15 RPE on Borg Scale of 6-20 * RPE important for beta blocker patients * record BP, HR, O2 saturation, RPE and Sx * terminate test if HR exceeds pre-determined limit or if Sx develop
42
What is risk stratification?
Ensuring benefits of regular Ex clearly outweigh risk of advrse events during Ex. Authorities: ACSM and AACVPR Risk of Ex-related cardiac event divided into: low, mod, high Clinical risk may change quickly and should be reviewed each supervised Ex session
43
What are some risk stratification considerations for different patients?
High-risk criteria patients should commence Ex in hospital-based program. Patient unable/unwilling can join conservative Ex prescription in community environment Necessary info not always available for comprehensive risk strat - default approach = to treat as high risk, prescribe conservatively at first. Already known high-risk patients, delay Ex prescription until necessary further info obtained
44
What factors make up a high-risk patient? Based on the AACVPR Stratification Algorithm.
High risk = one or more * LV ejection fraction <40% * survivor of cardiac arrest or sudden death * complex ventricular dysrhythmias (ventricular tachy, frequent >6/min) * MI surgery complicated by cardiogenic shock, CHF or post-procedure ischemia * abnormal hemodynamics with Ex, esp. flat/decreasing SBP/chronotropic incompetence with increasing workload *

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