Cardiac Assessment Part 2 Flashcards by Cooper Hewett

What valve issue?

May be asymptomatic until severe

Symptoms

angina, syncope, CHF
Exercise testing for CAD has poor diagnostic accuracy
should not be performed in symptomatic patients

Aortic stenosis

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HR where ischemia occurs

Ischemic threshold

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(T/F) LBBB is always indicative of abnormal pathology

True

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With aortic stenosis avoid drugs that increase ___, decrease ____ and _________

HR
SVR
Preload

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What valve disease?

Often no symptoms until severe dz
Symptoms

pulmonary edema, dyspnea, PND
chest pain, palpitations, AF
hemoptysis, hoarseness (Ortner’s syndrome)

Mitral stenosis

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Classification of valve stenosis (aortic & mitral)

Valve area = >1.5 cm^2

Mild

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Classification of valve stenosis (aortic & mitral)

Valve area = 1-1.5 cm^2

Moderate

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Classification of valve stenosis (aortic & mitral)

Valve area = <1 cm^2

Severe

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Understand Pressure-volume loops

Research it

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What valve disease?

Chronic versus Acute
Graded from 1+ to 4+
Hemodynamic goals
maintain preload
increase HR>/= 80 pm
what about ASCVD
maintain contractility
decrease afterload

Aortic Regurg

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Is frank-starling mechanism intrinsic or extrinsic?

Intrinsic

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What valve disease?

Acute:

papillary muscle dysfunction- chest trauma or MI, myxomatous disease
Sudden increase in LAP – pulmonary circuit
Presents as bivent failure

Acute mitral regurg

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What valve disease?

Chronic:

LV dilation, RHD, chordae thickening
Eccentric hypertrophy and LAE
Compensated vs. decompensated

Chronic mitral regurg

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With mitral regurg, avoid anything that increases _____!

PVR

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Review classifications of heart failure. NYHA classification scale is very common, but know both NYHA & ACC/AHA. Seen on slide 61 on PP.

Slide 61

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With MR, maintain preload, but be careful not to ________

overload

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What type of heart dysfunction?

Chronic increased afterload
Increased wall thickness with no change in chamber size
Diminished compliance

Concentric Hypertrophy

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Pt in HF are much more depend on _____ kick than the normal pt. Therefore, watch out for what arrhythmia?

Atria kick
Afib

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IF possible, use nerve _____ for pain management for cardiac pts to help alleviate pain.

Nerve blocks

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What type of heart dysfunction?

Dilated LV
chronic increase in volume
Increased wall thickness with an increase in chamber size

Eccentric Hypertrophy

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What type of heart dysfunction? (take your time and read the symptoms/presentations)

Dynamic stenosis with varying degrees of obstruction
nonobstructive, labile, or obstructive
Sudden death may be the first manifestation of the disease
Potential mechanisms include atrial arrhythmias with sudden hypotension. LVOT obstruction exacerbated by brady or tachy arrhythmias, or myocardial ischemia
May have total obstruction to Ao outflow
asymm hypertrophy of intraventricular septum
anterior displacement of papillary m and MV leaflets (SAM)
Mitral Regurgitation

Hypertrophic Subaortic Stenosis (HOCM)

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New or worsened HF within ___ weeks of non-cardiac surgery leads to a 2x increase of 30-day mortality

4 weeks

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Who decides if a cardiac pt is cleared for surgery?

YOU (bring up convo w/ surgeon)

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HOCM Preoperative Considerations? (List at least 3)

-continue all meds incl. antiarrhythmics
-avoid hypovolemia
-avoid tachycardia & sympathetic stimulation
-all types of anesthesia are acceptable
-Ca++ / BB?

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Serotonin causes ______ stenosis

Tricuspid

Your biggest job to identify w/ aortic stenosis pts.?

Symptomatic or non symptomatic

With AS, the after load comes from the ______

aortic valve

With increase SVR, the after load comes from the _____

vascular system

Give vasodilators with AS?

Nooo Problem is not the vasculature (SVR) Will bottom out BP and cardiac perfusion

AS can pull volume out of the ______ arteries via the venturi effect

coronary

With AS, monitor BP with ____ ____

A line

Induction should be ______ and steady with AS and cardiac pts

Slow

Narcotics are ______ stable

Cardiac stable

What drug for SVR increase in cardiac pt.?

Neo (not levo, will increase HR)

Cardiac murmurs overview. Looks at slide 81 on PP

Review slide 81 on PP

Stretch of the left recurrent laryngeal nerve

Ortners syndrome

You can see _______ syndrome with MS pts

Ortners syndrome

Have big left _____ chamber with MS pts

left atrium

Normal aortic valve size

3-4 cm^2

Critical aortic stenosis valve size?

<0.7

Mean AV gradient gives you reflection of ___ dysfunction

LV dysfunction

Sever AV area paired w/ moderate AV mean gradient. What does pt. probably need?

Needs inotrope Prob have cardiomegaly d/t LV dysfunction

What is mean gradient (when referencing valves)?

Difference in pressure between LV and Post-aortic valve

Which is worse valvular regurg? 1+ or 4+

Decrease _______ with aortic regurg

Afterload

Dont give ____ ______ with aortic regurg

Beta Blockers

Dont give ____ ______ with aortic regurg

Beta Blockers

Sudden increase in LA pressure? What valve disease?

Mitral regurg

Main difference in acute vs chronic MR?

Acute - increase LA pressure chronic - LA enlargement See slide 73 on PP

HTN, AS, IHSS, LVH can all lead to what?

Concentric hypertrophy

With concentric hypertrophy, what 2 things lead to decreased supply?

-arteries in endocardium are compressed -decrease CO

2 ways to increase supply w/ concentric hypertrophy?

-decrease HR -maintain volume

If you decrease SVR with concentric hypertrophy, you can decrease filling of ______ arteries

coronary arteries

Eccentric hypertrophy = _______ LV

dilated

Give ______ drugs w/ eccentric hypertrophy Which one? Why?

inotropic drugs Milronone Doesn't increase HR (and vasodilates)

Should you increase or decrease SVR w/ eccentric hypertrophy?

decrease

HOCM pts commonly die of __________

Arrhymias (Vfib/Vtach)

Hypertrophic sub aortic stenosis is a _______ stenosis

dynamic

Should decrease _______ with HOCM

contractility

What 2 drugs are our friends with HOCM?

Beta blockers Ca+ channel blockers

What is common with athletes? (increased contractility)

HOCM

What primary causes HOCM? (aside from contractility)

Hypertrophy of intraventricular septum

Tx. for HOCM?

Septal ablations

Need volume w/ HOCM?

Yes

With decreased BP w/ HOCM, dont use _______ drugs. Use _____ and _______

Inotropic drugs Neo & fluids

Where is the aortic area?

2nd right intercostal space

Where is the pulmonic area?

2nd left intercostal space

Where is Erb's point?

3rd left intercostal space, left sternal border

Where is tricuspid area?

4th left intercostal space, left lower sternal border

Where is mitral area?

5th left intercostal space, midclavicular line

What murmur? Second parasternal interspaces Midsystolic

Aortic stenosis

What murmur? Third and fourth parasternal interspaces Holodiastolic

Aortic insufficiency

What murmur? Apex Mid-diastolic

Mitral stenosis

What murmur? Apex Holosystolic

Mitral regurgitation

What murmur? Apex Late systolic

Mitral valve prolapse

Pneumonic for Valve area locations (from left to right, top to bottom)

All People Enjoy Time Magazine

The _____ maneuver will decrease intensity of AS murmur

valsalva

W/ Class I ACC/AHA valvular disease, symptomatic and no prior ______, then they need an _____

ECHO ECHO

Class IIa ACC/AHA valve disease - if ______ ok to go with surgery

non-symptomatic

Dont do _______ ______ ________ __________ w/ class IIb ACC/AHA valve disease

percutaneous mitral balloon commissurotomy

SA node bpm

60-100

SA conduction speed through atrium

1.5

AV node delay time

.15 second delay

Speed of conduction at AV node

.05 m/sec

Bundles speed of conduction

2 m/sec

V escape rhythm bpm

20-40

Av node bpm

40-60

What is a bundle branch block?

Ventricles are depolarized at different times

Pacemaker cell resting Vm

-70 mV

Ventricular myocyte resting Vm

-90 mV

What 4 ions responsible for action potential?

Na, K, Cl, Ca

PVC is an _________ arrhythmia

ventricular

Increased sympathetic activity usually causes what arrhythmia?

SVT

BiV pacemaker may not have ____ mode

Async mode

Dont order pre-op ______ if pacer depend. No point

EKG

Detsky Modified Cardiac risk index 2 worst things

-Critical AS -Class 4 Angina

With DM pts, always check _____

Hbg A1C

Most detailed cardiac assessment tool

NSQIP MI/Cardiac Arrest Risk Calculator (MICA)

Functional capacity = ______ ________

cardiac reserve

You want MET > ____ before surgery

MET > 4

MET = ______ _________

Metabolic equivalents

Highest surgical risk procedures (list a few)

Emergency surgery Aortic Vascular Prolonged Procedures with fluid shifts Total hip replacements

Emergency neurohormone resembling atrial natriuretic peptide but synthesized primarily in the ventricles Secreted in response to increased ventricular volume, pressure overload, or increased wall tension Can be used in diagnosis of CHF; values rise and fall in response to exacerbation and resolution of CHF Recommended according to the ACC/AHA Guidelines for Mgmt of HF

B-type Natriuretic Peptide (BNP)

BNP <100

Normal

BNP 100-300

HF present

BNP 300-600

Mild HF

BNP 600-900

Moderate HF

BNP >900

Severe HF

Marker for inflammation produced in the liver and smooth muscle cells risk of atherothrombosis May predict MI, CVA, PVD, sudden cardiac death Information independent of other risk factors Acute care predict early and late mortality in acute ischemia useful in chest pain mgmt with negative troponin levels

C-reactive protein

Very sensitive and specific indicators of damage to the myocardium Differentiate between unstable angina or MI in patients with chest pain or ACS. can also occur in patients with coronary vasospasm Marker of all heart muscle damage, not just MI

Troponin

ACC/AHA 2014 Recommendations for MI surveillance and Mgmt - Class I - Troponin and cardiac workup needed?

Yes

ACC/AHA 2014 Recommendations for MI surveillance and Mgmt - Class III - Troponin and cardiac workup needed?

No No benefit

BNP currently 500. You see they have been 1000s in the past. You worried?

Nope

ACC/AHA classes (this is true for all types). Class I = tx or testing needed? Class III = tx or testing needed?

Class I = needed Class III = not indicated *this is true for all classification types under ACC/AHA

ST depression and t wave inversion – abnormality of ___________

repolarization

Least invasive, most cost-effective method of detecting ischemia

Exercise electrocardiography

With the evaluation of LV fx, increased number of abnormal segments = _______ risk

increased risk

You MUST inform patients of their _____

risks/informed consent

You MUST document that you informed patients of their ______

risks/informed consent

Cardiac patients must be _______ treated for hemodynamic changes

aggressively treated

Assess ejection fraction and valvular function Limited predictive value - failure to detect all IHD

Resting ECHO

If heart is taking up more than ____ of the chest on an x-ray then there is concern

1/2

Kerley-B lines (pulmonary vascular markings) = _______ ______

pulmonary edema

Type of ECHO: Can assess static function and/or dynamic function Hibernating or stunned myocardium High sensitivity and specificity for perioperative cardiac death and MI Should not be used for patients with severe arrhythmias, significant hypertension, large thrombus-laden aortic aneurysms, or hypotension

Dobutamine stress ECHO

A new _BB block does not go to OR

LBB block Must be evaluated

_____ pattern on EKG doesn't not go to OR

Strain pattern

EKG for low risk surgery?

Low positive predictive value but high negative predictive value. What does this mean? What is an example of this with cardiac workup?

Won't tell us that they have a certain problem but will tell us that they dont ex. exercise electrocardiography

Dyskinesia

when the ventricle muscle contracts it "flops opposite ways"

Hypokinesia

Ventricle doesn't contract much

Akinesia

Ventricle doesn't contract at all

_______ ECHO is not useful to predict abnormalities under OR stress

resting

this type ECHO has high sensitivity and specificity for perioperative cardiac death and MI

Dobutamine stress echo

Dont do ________ _____ ECHO for AS pts

Dobutamine stress echo

Thalium-201 or cardiolyte are the ______ for exercise nuclear imaging

markers

Agents to use to increase demand during Pharmacologic Stress Thallium Imaging?

Coronary vasodilators - Adenosine and Persantine (dipridamole) Inotropes (increase demand)

Would you rather have a fixed or reversible cardiac defect?

Fixed

Gold Standard for defining coronary anatomy

Cardiac Angiography

Know PP slide 129 normal PA cath values

Know slide 129 on PP

Best monitor for looking at the heart on the spot in the Or

TEE

Look at PP slide 135 for a few considerations w/ anesthetic techniques regarding different surgeries

PP slide 135

Cardiac Assessment Part 2 Flashcards

(141 cards)