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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
Q

What is the retrograde transfemoral approach?

A

Delivery system introduced through fem artery allowing positioning of prosthetic valve within native stenotic aortic valve

26
Q

What is the antegrade transvenous approach?

A

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
Q

What is the transapical approach?

A

LV apex is reached by anterolateral minithoacotomy. Valve delivery system introduced through LV apex and subsequently positioned in stenotic aortic valve.

28
Q

What is part of the pre-Ex assessment?

A
  • clinical Hx
  • physical Ax (including sternal stability)
  • Ex Ax ( contraindications, aerobic Ex/muscle strength/other functional Ax)
  • risk stratification
29
Q

What does the pre-ex Ax involve?

A

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
Q

What is Clinical Hx? What should it include?

A

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
Q

What are Ex specific factors during the clinical Hx?

A
  • 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
Q

What does the physical Ax include?

A

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
Q

What are the phases of Korotkoff sounds?

A

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
Q

What to do for first BP measurements?

A
  • 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
Q

What should be considered before a subjective sternal Ax?

A

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
Q

What is the prevalence of sternal pain?

A
  • ~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
Q

What can sternal instability mean?

A
  • 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
Q

What is the frequency of the physical sternal Ax?

A

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
Q

What are the pros of using an Ex Ax?

A
  • 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
Q

What is part of the aerobic Ex Ax?

A

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
Q

What are the pros of a submaximal Ex test?

A
  • 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
Q

What is risk stratification?

A

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
Q

What are some risk stratification considerations for different patients?

A

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
Q

What factors make up a high-risk patient? Based on the AACVPR Stratification Algorithm.

A

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
*

EXMD4742 (9 decks)

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