Cardiac Assessment Flashcards
(90 cards)
1
Q
Nearly __ of 2 adults have hypertension
A
1
2
Q
Chronic increase in BP leads to _______ and _______ dysfunction
A
LV hypertrophy
diastolic
3
Q
Hypertension has a greater impact on _____ risk than MI risk
A
CVA
4
Q
Increased perioperative risk with DBP >____
A
110
5
Q
Risk MI ⬆ -% for every _ mmHg ⬆ diastolic BP
A
2-3%
1mmHg
6
Q
_________ increases risk of ischemic heart disease (IHD)
A
Hypertension
7
Q
Risk factors for primary hypertension
A
Increased Age Excessive Dietary Intake of Sodium African American Race Tobacco Use** Alcohol Consumption of >2 drinks/day Genetic/Family History Obesity Stress
8
Q
Medication noncompliance Medication withdrawal Accelerated hypertension in a patient with preexisting hypertension Reno-vascular hypertension Acute glomerulonephritis
Which type of HTN?
A
Acute HTN
9
Q
SBP>180 or DBP>130 mmHg Requires immediate reduction Persistent diastolic pressure > 130 mmHg associated with acute vascular damage Evidence of end-organ damage Brain Heart Kidneys Retina
Which type of HTN?
A
Hypertensive crisis
10
Q
Unable to achieve BP <140/90 despite treatment with >3 different anti-hypertensives at maximally tolerated dose
Increased interest in endothelin A antagonists; aldosterone antagonists and SNS targeted antagonists (including devices)
Focus on the renal system’s role in resistant hypertension
Which type of HTN?
A
Resistant HTN
11
Q
Normal BP range
A
<120
<80
12
Q
Pre-HTN range
A
120-139
80-89
13
Q
Stage 1 HTN
A
140-159
90-99
14
Q
Stage II HTN
A
160-179
100-109
15
Q
Stage III HTN
A
180-209
110-119
16
Q
Stage IV HTN
A
> 210
>120
17
Q
Recommendation for Stage I & II for surgery
A
Proceed with anesthesia and surgery
18
Q
Recommendation for Stage III for surgery
A
Consider postponing anesthesia and surgery, especially in patients with other cv risk factors and end-organ damage
19
Q
Recommendation for Stage IV for surgery
A
Defer anesthesia and surgery whenever possible, begin appropriate anti-hypertensive therapy, and arrange for outpatient follow up or inpatient BP control
20
Q
30% of adults in the United States have a plasma cholesterol level above _____ mg/dl
A
240
21
Q
Plasma cholesterol concentration below _____ mg/dl would decrease the incidence of IHD 30% to 50%
A
200
22
Q
Increase of ____-density lipoproteins worse than _____-density lipoproteins
A
Low
High
23
Q
Cholesterol Goals: Total <\_\_\_\_ LDL <\_\_\_\_ HDL >\_\_\_ TG<\_\_\_
A
total <200
LDL <100
HDL >60
TG <150
24
Q
Atherosclerosis fixed lesions > 75% causes what symptoms
A
exercise/stress induced symptoms (compensatory vasodilation can no longer meet metabolic needs)
25
Atherosclerosis fixed lesions > 90% causes what symptoms
symptoms at rest
26
Atherosclerosis plaque disruption physiology (acute coronary syndrome, ACS, anesthesia stress test)
Sympathetic surge causes shear forces on coronary plaque
Endothelial and systemic inflammation
Hypercoagulable state induced by surgical stress→ risk of thrombosis
27
Pt presents with ACS (any type) pre-op. Ok for surgery?
NO
28
Type of cardiac necrosis involves full or nearly full thickness of the ventricular wall along a single vessel distribution
Transmural
29
What type of anesthetics preferred for HTN pt?
Regional if possible
30
Type of cardiac necrosis
Necrosis limited to the inner 1/3 to _ of the ventricular wall
May extend beyond the distribution of one vessel
Usually due to plaque disruption then lysis of the thrombosis before transmural injury occurs
Or may be due to prolonged and severe reductions in SBP
Subendocardial
31
Type of MI due to plaque rupture, erosion, or dissection
| Can be either a STEMI or NSTEMI
Type I
32
Type of MI due to imbalance of supply and demand
Usually an NSTEMI
Most common in the post operative phase
Type II
33
Which type of cholesterol attracts macrophages
LDL
34
Which type of cholesterol repels macrophages
HDL
35
Two types of stents
Drug-eluting
| Bare metal
36
In pt with stents, caution on premature discontinuation of ___ _______ therapy
anti platelet
37
What type of stent
Mechanism of action: the implanted medication prevents neointimal proliferation but also stent endothelization = risk of thrombosis
Drug eluting stents
38
____ LAD dominate pts have poorer prognosis's with MI
Left dominate
39
Duration of no surgery with DE stents
365 days
40
Duration of no surgery with bare metal stents
30 days
41
With BM stents, delay surgery optimally to __ months
3 months
42
Timing post CABG for surgery, ok after ___ months
1 month
43
Patients with a CABG within the previous 5 years and are clinically stable – is there a need for additional workup?
NO
44
With CP originating from vasospasms, which drug is used to treat them and do you keep them on it perioperatively?
Calcium Channel Blockers
| Yes
45
Class of recommendation for revascularization:
evidence or general agreement that the procedure is useful, beneficial, and effective
Class I
46
Class of recommendation for revascularization:
conflicting evidence – weight is in favor of intervention
Class IIa
47
Class of recommendation for revascularization:
conflicting evidence but the weight is NOT in favor of intervention
Class IIb
48
Class of recommendation for revascularization:
evidence that the treatment is not useful, beneficial or effective
Class II
49
Class of recommendation for revascularization:
Risk of harm is high
Class III
50
medication that should be continued preoperatively and:
Decrease oxygen consumption by reducing heart rate resulting in a lengthen time in diastole
Decrease myocardial contractility
Redistribution of blood flow to the subendocardium
Plaque stabilization
Beta-blockers
51
Are you going to take pt off plavix periop?
NOOOO
52
If pt comes in on anticoagulants what are the 2 things you should do
Communicate with cardiologist
| Know WHY they are on it
53
What type of drug?
```
HMG-CoA reductase inhibitors
Potential to decrease risk of MI in high-risk patients
0-30 days reduced risk of MI
1year – trend for decreased risk
Decrease cholesterol synthesis
Anti-inflammatory properties
Reduced CRP
Vasodilatory effects
Anti-thrombogenic
Timing: 1-2 months before surgery vs. shorter time before surgery
```
Statins
54
What two risks with statins should you be aware of?
statin induced myopathy
| rhabdomyolysis
55
Which Glycoprotein IIb/IIIa inhibitor?
Long acting. Reversed only with platelet transfusion
Bleeding time returns to 75% of normal in 24 hours; risk of excessive bleeding 3-5%
Abciximab (ReoPro)
56
Which Glycoprotein IIb/IIIa inhibitor?
Effects can not be reversed with plt transfusion
Bleeding time returns to 1.5 times normal within 6 hours
Eptifibatide (Integrilin)
57
Which Glycoprotein IIb/IIIa inhibitor?
Plasma half-life of 2 hours; plt function returns to 90% of normal with 4-8 hours
Tirofiban (Aggrastat)
58
With Glycoprotein IIb/IIIa inhibitors it is prudent to delay elective cases __-__ hours
24-48 hours
59
Should you ideally hold antihypertensives before surgery?
Yes due to refractory hypotension
60
This type of med has positive interactions between β-antagonists and CCBs
antihypertensives
61
Warfarin: d/c __ days prior to surgery
5 days
62
ASA: d/c __-__ days prior to surgery
7-10 days
63
Thienopyridines: d/c __-__ days prior to surgery
5-7 days
64
It can be reasonable to continue ___ and ___ if they are on it for heart failure (not necessarily just HTN)
ACEI
| ARB
65
What cardiac sound? closure of AV valves
S1
66
What cardiac sound? closure of semilunar valves
S2
67
What cardiac sound? signifies LV failure and/or volume overload lub-dub-ta or Kentucky
S3
68
What cardiac sound? usually indicative of hypertrophic LV, AS, HOCM ta-lub-dub or Tennessee
S4
69
Myocardial ischemia occurs most frequently in the ____ period
postop
70
Equation for pressure
Tension/radius
71
Presence of inflammatory markers (c-reactive protein) can indicate risk for
heart failure
72
LVEDP
>___ usually indicates some degree of ventricular dysfunction
>15
73
stroke volume/end diastolic volume = ________
Ejection fraction
74
Normal EF = ___%
75%
75
Heart failure EF < ___%
<40%
76
RV or LV failure?
```
Systemic Congestion
Peripheral edema/anasarca
Ascites/hepatomegaly
Coagulopathy
Hepatojugular reflex
Precordial lift
Parasternal heave
```
RV failure
77
RV or LV failure?
```
Pulmonary Congestion
Dyspnea /orthopnea
PND
Poor peripheral perfusion
Dizziness, confusion, cool extremities
Fatigue
```
LV failure
78
Dont start _____ on the day of surgery
Beta blockers
79
Systolic or diastolic dysfunction?
Prevalent in elderly patients with hypertensive heart disease
Present in most patients with symptomatic heart failure but can occur in isolation
Better prognosis with DHF but the complication rate is the same
Very few RCTs regarding best medication regimen
Preserved EF with increased left ventricular filling pressure
Impaired relaxation and passive stiffness
THINK COMPLIANCE
Diastolic
80
With diastolic failure,
Avoid _______
Avoid ______
Avoid _______
tachycardia
ischemia
hypertension
81
Know what the frank-starling curve is
Intravascular volume curve reflecting the frank-starling mechanism (actin-myosin sheath in the sarcomere of myocardium that is elastic and contracts more forcefully with added intravascular volume until a certain point where they overstretch and cardiac performance is significantly decreased)
82
If needed, check platelet count and ________ with anticoagulated pts
function
83
What vasopressor for ACE/ARB induced hypotension?
Vasopressin
84
Is pre op nitroglycerin still a thing?
NOOO
85
Is pre op clonidine useful if the pt isn't already on it?
Nope
86
What is the worst thing (and try to prevent) for cardiac pts?
Tachycardia
87
For both pain and anxiety you could use what drug?
Precedex
88
Be cautious with these two meds (anxiety and pain)
Benzos & opioids
89
Be cautious with these two meds (anxiety and pain)
Benzos & opioids
90
Non cardiac surgery with new or worsened HF within __ weeks of surgery had a 2x greater risk of 30-day mortality and significantly increased risk of prolonged mechanical ventilation, sepsis, pneumonia , ARF, and cardiac arrest compared with a matched cohort of stable HF
4 weeks
