Cardiac

Question 1

Heart Failure Classification

Answer 1

New York Heart Association Functional Classification of Breathlessness (for heart failure patients)

Question 2

NYHA Class I

Answer 2

No symptoms and no limitation in ordinary physical activity i.e. SOB when walking, climbing stairs, etc.

Question 3

NYHA Class II

Answer 3

Mild symptoms (SOB and/or angina) and slight limitation during ordinary activity

Question 4

NYHA Class III

Answer 4

Marked limitation in activity d/t symptoms even during less-than-ordinary activity i.e. walking short distances (20-100m)
Comfortable at rest

Question 5

NYHA Class IV

Answer 5

Severe limitations
Experiences symptoms even while at rest
Mostly bedbound patients

Question 6

Heart Failure Causes

Answer 6

Volume overload
Pressure overload
Myocardial contractile impairment d/t ischemia or infarct
Restrictive filling (constrictive pericarditis, cardiac tamponade, restrictive myocarditis)
Idiopathic remodeling - cardiomyopathy
Myocardial inflammation

Question 7

Left-Sided HF Causes

Answer 7

↑LVEDP
Hypertension
CAD
Valvular disease
MI

Question 8

Right-Sided HF Causes

Answer 8

↑RVEDP
Most common cause L-sided HF
Pulmonary arterial hypertension
R ventricle MI

Question 9

Low Output HF Causes

Answer 9

Result from FILLING or EMPTYING problem
CAD
Chronic HTN
Cardiomyopathy
Valvular disease
Pericardial disease

Question 10

High Output HF Causes

Answer 10

↑ metabolic demand
Anemia
Septicemia
Hyperthyroidism

Question 11

Volume Overload

Answer 11

SHF
↓LVEF
↑LV chamber size 
S3 gallop
Compliant
ECCENTRIC remodeling

Question 12

Pressure Overload

Answer 12

DHF
Normal LVEF
↓LV chamber size
S4 gallop
↓ compliance
CONCENTRIC remodeling

Question 13

Eccentric

Answer 13

New sarcomeres in series
Hypertrophy
↑radius (chamber size)
EMPTYING problem

Question 14

Concentric

Answer 14

New sarcomeres in parallel
Hypertrophy
↓chamber radius
Cardiomyocyte thickening
FILLING problem

Question 15

Heart Failure Physiological Compensations

Answer 15

↑SNS
Arterial VSMC vasoconstriction ↑SVR ↑afterload
↑venomotor tone ↑VR
Frank-Starling mechanism engagement
SA node ↑HR
Myocardium ↑inotropy ↓catecholamine sensitivity
Adrenal gland ↑circulating catecholamines
RAAS activation d/t ↓renal blood flow
Cardiac remodeling

Question 16

Neural Compensations

Answer 16

Atrial & arterial baroreceptors trigger catecholamine release & ↑vasopressin
Catecholamines → cardiotoxicity (apoptosis & necrosis) promotes cardiac remodeling
Vasopressin ↑SVR ↑Na+/H2O retention

Question 17

Local Compensations

Answer 17

↓renal blood flow → RAAS activation promotes remodeling
Ischemic cardiomyocytes release inflammatory mediations (cytokines) that trigger cardiac remodeling
Ischemic endothelial cells release endothelin
Stretched atrial & ventricular cells release ANP/BNP (cardioprotective)
ANP promoted diuresis, natriuresis, inhibits RAAS & SNS, anti-inflammatory, inhibits remodeling

Question 18

Systolic Heart Failure

Answer 18

Emptying problem occurs in the L ventricle > R ventricle

Triggered by volume overload → eccentric remodeling

Question 19

Diastolic Heart Failure

Answer 19

Filling problem occurs in the L ventricle > R ventricle

Triggered by pressure overload → concentric remodeling

Question 20

Acute Heart Failure

Anesthetic Implications

Answer 20

Immediate goal ↑CO ↓LVEDP
End organ perfusion
Tools include inotropes, vasodilators, diuretics, Ca2+ sensitizers, BNP, NO inhibitors, & mechanical devices

Question 21

Chronic Heart Failure

Anesthetic Implications

Answer 21

Goal to prevent acute heart failure episode
Hemodynamic stability
Full preop workup
Check medications, complete cardiac history, hepatic/renal/electrolyte panels, recent EKG or Echo

Question 22

FILLING

Answer 22

DHF
Restrictive cardiomyopathy
Hypertrophic cardiomyopathy
Constrictive pericarditis
Cardiac tamponade
Hypotension
Mitral valve stenosis (L ventricle)
Tricuspid valve stenosis (R ventricle)

Question 23

EMPTYING

Answer 23

SHF
Dilated cardiomyopathy
Hypertrophic cardiomyopathy w/ LVOTO
Myocardial infarction
Aortic valve stenosis (L ventricle)
Pulmonary valve stenosis (R ventricle)

Question 24

Volume Overload

Answer 24

Aortic regurgitation (L ventricle)
Mitral regurgitation (L atrium)

Question 25

SHF or DCM Considerations

Answer 25

EMPTYING problem Heart rate - maintain NSR (atrial kick) ↓HR ↑filling time ↓CO Preload - maximize Frank-Starling & prevent fluid volume overload or pulmonary congestion Afterload - ↓SVR ↑CO (ΔP) w/o hypotension (maintain BP) ↓BP ↓CorrPP Contractility/inotropy - admin inotropes to help improve forward flow Ischemia - monitor to prevent

Question 26

DHF or RCM | Considerations

Answer 26

FILLING problem Heart rate - maintain NSR ↑HR ↓filling time SV limited Preload - maximize Frank-Starling & prevent fluid volume overload Afterload - maintain ↓SVR → SNS activation ↑HR Contractility/inotropy - maintain (not an emptying problem) ↑contractility ↑MVO2 Ischemia - avoid ↑LVEDP

Question 27

HCM w/ LVOTO | Considerations

Answer 27

FILLING & EMPTYING problem Heart rate - avoid ↑HR ↓filling time Preload - maintain w/o fluid volume overload Afterload - do NOT ↓afterload (worsens LVOTO d/t Venturi effect) Contractility/inotropy - ↑contractility worsens LVOTO Ischemia - HIGH risk

Question 28

Aortic Valve Stenosis | Considerations

Answer 28

L ventricle EMPTYING problem Heart rate - maintain NSR (atrial kick) SV limited ↑HR ↑demand ↓supply ↓HR → L ventricle overdistension Preload - maintain w/o fluid volume overload Afterload - do NOT ↓afterload (unable to compensate to maintain BP) Contractility/inotropy - maintain or ↑contractility ↑CO Ischemia - HIGH risk

Question 29

Pulmonic Valve Stenosis Considerations

Answer 29

R ventricle EMPTYING problem Heart rate - maintain NSR ↓HR → volume overload Preload - maintain w/o fluid volume overload Afterload - minimal impact ↑SVR to maintain CO Contractility/inotropy - maintain or ↑contractility Ischemia - monitor ↑MVO2 Prevent ↑PVR → worsens R ventricle congestion & cardiac demand

Question 30

Aortic & Mitral Valve Regurgitation Considerations

Answer 30

VOLUME overload Heart rate - AVOID bradycardia >80bpm ↓filling time Preload - maintain w/o fluid volume overload Afterload - avoid ↑SVR ↓SVR as tolerated (ΔP) but maintain adequate perfusion Contractility/inotropy - maintain & admin inotropes as needed to promote forward flow Ischemia - ↑LVEDP ↓CorrPP