Cardio only Flashcards
1
Q
How do the cardiovascular physiologic changes of pregnancy impact cardiac function?
A
Increased stroke volume and HR, leading to increased Cardiac output
2
Q
Which cardiac conditions are considered WHO Pregnancy Class I
A
(a) Uncomplicated, small or mild:
-PDA
-MV prolapse
-Pulmonary stenosis
(B) Successfully repaired simple lesions:
-ASD
-VSD
-PDA
-anomalous pulmonary venous drainage
(c) Isolated atral or ventricular ectopic beats
3
Q
What are the risks and recommendations for patients with WHO Pregnancy Class I conditions?
A
No / mild increase in morbidity
2-5% maternal cardiac event rate
Cardiology eval once or twice
4
Q
Which cardiac conditions are considered WHO Pregnancy Class II
A
Unoperated ASD or VSD Repaired tetralogy of fallot Repaired aortic coarctation Supraventricular arrhythmia Turner syndrom without cardiac disease
5
Q
What are the risks and recommendations for patients with WHO Pregnancy Class II conditions?
A
Small increased risk of maternal mortality or moderate increase in morbidity
6-10% maternal cardiac event rate
Cardiology follow up q trimester
6
Q
Which cardiac conditions are considered WHO Pregnancy Class IV
A
Pulmonary arterial hypertension
Systemic right ventricle with mod/severe ventricular dysfunction
Severe systemic ventricular dysfunction (LVEF <30%, NYHA 3-4)
Hx of PPCM w/ any residual LV dysfunction
Severe mitral stenosis
Severe symptomatic aortic stenosis
Aortic dilation >45mm in Marfan
Aortic Dilation >50mm in aortic disease w/ bicuspid aortic valve
Vascular Ehlers-Danlos
Fontan circulation with any complication
7
Q
What are the risks and recommendations for patients with WHO Pregnancy Class IV conditions?
A
Extremely high risk of maternal mortality or severe morbidity; Pregnancy is contraindicated
Discuss termination
Monthly cardiology followup
>27% maternal cardiac event rate
8
Q
What are the most common complications you see with cardiac conditions?
A
Pulmonary edema
Arrhytmia (A fib most common)
9
Q
What is rheumatic heart disease?
A
Untreated / incomplete treatment of group A strep leading to valve vegetations
10
Q
What baseline evaluation do you perform on a patient who has a history of cardiac disease?
A
History and physical exam
Echocardiogram
Cardiology consultation
11
Q
What is the inheritance of Marfan syndrome?
A
Autosomal dominant
12
Q
What is the pathology in Marfan syndrome?
A
Defective fibrillin gene leading to weak connective tissues
13
Q
Classic findings for Marfan?
A
Large fingers, long arms span, joint hypermobility, dilation/dissection of aorta.
14
Q
How would you approach a patient with Marfan that presents to the ED at 18 weeks with chest pain?
A
I would be concerned for aortic dissection
Vital signs, H&P
I would order an echo, ECG, CXR
Cardiology consultation
15
Q
How common is aortic root dilation in Marfan syndrome?
A
60-80% of adults with Marfan syndrome will have it
16
Q
What is the typical presentation for an aortic dissection?
A
Radiating pain to shoulder and back
17
Q
How would you manage a patient with Marfan that presents to ED with chest pain at 18 weeks and is found to have an aortic root of 5cm?
A
Counsel regarding pregnancy termination
Contol BP
CT surgery consultation
18
Q
How would you counsel a patient with Marfans with an aortic root of 2.5cm regarding TOLAC?
A
Same risks of TOLAC
Discuss avoiding valsalva
and Epidural to control BP
19
Q
What are the goals for BP, HR and delivery considerations in Marfan?
Marfan indications for c/s?
A
SBP <130
HR <70
Avoiding valsalva (second stage assist, + epidural)
Cesarean may be helpful in patients with aortic root >4, dissection or heart failure
20
Q
What are the key concerns postpartum in patients with Marfan?
A
Acute aortic dissection / rupture
HTN
Rupture
21
Q
At what aortic root diameter is preconception repair recommended if patient desires pregnancy?
A
> 4.5cm
22
Q
What is the risk of rupture in patients with aortic root >4cm?
A
10%
23
Q
How often do you follow up aortic root size during pregnancy?
A
If normal, every trimester
If Dilated but <40mm, q 4-6 weeks
If 40-45mm, q 4 weeks
If >45mm, Prophylactic surgery preconception, or during pregnancy if rapid growth
24
Q
G2P1 at 12 weeks with a history of PPCM after her last delivery. She was started on digoxin and BP meds which she self discontinued 6 months ago. She has not seen her cardiologist in a year.
BP 140/82, P 89, O2 sat 99% on RA, Lungs CTAB, CV: RRR, No pedal edema. What is your initial evaluation?
A
ECG, echocardiogram, CBC
25
G2P1 at 12 weeks with a history of PPCM after her last delivery. She was started on digoxin and BP meds which she self discontinued 6 months ago. She has not seen her cardiologist in a year.
BP 140/82, P 89, O2 sat 99% on RA, Lungs CTAB, CV: RRR, No pedal edema.
Echo shows EF 45%, ECG normal, Hb 11.2 and Creatinine 0.6.
Is the patient at risk for recurrent cardiomyopathy? How do you counsel her?
Yes, even if LV function appears to have recovered, patients may deteriorate during the pregnancy.
Counsel her that she is at increased risk of worsening LV function, pulmonary edema, arrhythmias.
Her risk of death is lower if function recovered before pregnancy, however deterioration may be permanent.
26
G2P1 at 12 weeks with a history of PPCM after her last delivery. She was started on digoxin and BP meds which she self discontinued 6 months ago. She has not seen her cardiologist in a year.
BP 140/82, P 89, O2 sat 99% on RA, Lungs CTAB, CV: RRR, No pedal edema.
Echo shows EF 45%, ECG normal, Hb 11.2 and Creatinine 0.6.
How do you follow her cardiac function during pregnancy?
Echos q trimester or with symptoms suggestive of worsening function.
27
G2P1 at 12 weeks with a history of PPCM after her last delivery. She was started on digoxin and BP meds which she self discontinued 6 months ago. She has not seen her cardiologist in a year.
BP 140/82, P 89, O2 sat 99% on RA, Lungs CTAB, CV: RRR, No pedal edema.
Echo shows EF 45%, ECG normal, Hb 11.2 and Creatinine 0.6.
At 32 weeks she presents with elevated BP (158/94), P110, O2 sat 94%. An echo is performed and shows EF of 30%.
What is your differential diagnosis?
Recurrent cardiomyopathy
Pulmonary embolism
Preeclampsia
Pulmonary edema
28
G2P1 at 12 weeks with a history of PPCM after her last delivery. She was started on digoxin and BP meds which she self discontinued 6 months ago. She has not seen her cardiologist in a year.
BP 140/82, P 89, O2 sat 99% on RA, Lungs CTAB, CV: RRR, No pedal edema.
Echo shows EF 45%, ECG normal, Hb 11.2 and Creatinine 0.6.
At 32 weeks she presents with elevated BP (158/94), P110, O2 sat 94%. An echo is performed and shows EF of 30%.
How do you treat her?
```
Diuresis for preload reduction
BP control for afterload reduction
Digoxin to improve contractility
Supplemental O2
Cardio consult
```
29
What will prompt delivery in peripartum cardiomyopathy?
Worsening cardiac function despite therapy
30
What are the diagnostic criteria for peripartum cardiomyopathy?
HF developed in the last month of gestation or 5 months postpartum
Absence of an indentifiable cause for heart failure
Absence of recognizable cardiac disease before pregnancy
LVEF <45%
Shortening fraction <30%
LVEDV >2.5 cm/m^2
31
What are the key things to avoid in peripartum cardiomyopathy?
Hypertension
Fluid overload
Increasing cardiac demand
32
Goals of management in PPCM?
```
Decrease preload (lasix)
Decrease afterload (antihypertensive)
Improve contractility (digoxin)
```
33
What meds should you be careful of in treatment of BP in PPCM?
Alternative meds?
Avoid Beta blockers, they will decrease HR, which will further decrease cardiac output
Use hydralazine, amlodipine, or nitroglycerin
*though you can use them if maxed preload/afterload and contractility first
34
What are the most common cardiac complications in PPCM?
Pulmonary edema
Arrhythmia
Thromboembolism
Cardiac arrest
35
What is the difference between Systolic and Diastolic dysfunction?
Systolic dysfunction: Pump problem, thin weakened muscle,enlarged ventricle
Diastolic dysfunction: Filling problem, problems with overflow into lung
36
How do you treat A-fib in pregnancy?
Treat as if nonpregnant
| Consult cardiologist
37
What is the most common sustained arrhythmia in pregnancy? Tx?
SVT, responds well to medications
38
What factors are the determinants of Cardiac output? How are they measured?
```
CO = SV x HR
SV determined by:
Preload (left: PCOP, right: CVP)
Afterload (Left: SVR, right PVR)
Contractility (LVSWI)
```
39
32 yo G3P2 at 18 weeks w/ history of a VSD repaired at age 8, presents with palpitations. 2 prior uncomplicated full term NSVDs 3 and 5 years ago.
What initial evaluation do you perform?
```
H&P
OB ultrasound
Maternal Echo
ECG
CBC
```
40
32 yo G3P2 at 18 weeks w/ history of a VSD repaired at age 8, presents with palpitations. 2 prior uncomplicated full term NSVDs 3 and 5 years ago.
What are you main concerns?
If the VSD is closed, and what the flow across it is like (If it is Right to left could be a sign of Pulmonary hypertension)
41
32 yo G3P2 at 18 weeks w/ history of a VSD repaired at age 8, presents with palpitations. 2 prior uncomplicated full term NSVDs 3 and 5 years ago.
Vitals and labs are normal, Echo shows PASP 70mmHg and Tricuspid regurgitant velocity (TRV) 3.4m/s w/ evidence of left to right flow across the VSD.
How do you interpret these results?
Findings are suspicious (but not diagnostic) for Pulmonary hypertension d/t
(1) increased PASP
(2) increased tricuspid regurgitant velocity (TRV)
42
TRV cutoffs suggestive of Pulmonary HTN?
```
<2.8m/s = Low likelihood
>3.4m/s = high likelihood
2.8-3.4 = intermediate likelihood
```
43
What is the diagnostic criteria for pulmonary hypertension?
Pulmonary artery systolic pressure >=25mmHg
| Normally 8-20mmHg
44
How reliable is Echo in diagnosing pulmonary HTN in pregnancy?
Reliable of normal / low.
Not very reliable if elevated
IVC diameter is increased in pregnancy, and less compressible
This causes a false estimate of right atrial pressure.
Right heart catheterization is required to confirm diagnosis (which is why using TRV to help stratify risk is helpful)
45
What is eisenmenger syndrome?
Shunt resulting in Pulmonary hypertension with reversal of left to right to right to left
46
How do you counsel a patient about pregnancy risks with Eisenmenger syndrome?
Very high rate of maternal death (>50%)
Termination of pregnancy is RECOMMENDED but there is even an increased risk of mortality during termination procedure (though lower risk than continuing pregnancy)
High rate of pregnancy loss
47
What physiologic changes in pregnancy lead to high mortality rates in eisenmenger syndrome?
(1) Decreased systemic vascular resistance (Worsens the hypoxemia because the resistance for the Right to Left shunt is now lower and allows more deoxygenated blood to move to the systemic vasculature)
(2) Increased cardiac output
(3) Increased volume
(4) Hypercoagulability
48
18 yo G1 at 39 weeks with shortness of breath in active labor.
BP 155/96, P: 122, RR: 24 O2 sat 91% T37.4
Pt is sitting up in bed and appears short of breath
CV: Irregular rate with Systolic ejection murmur 2/6
Lungs bibasilar crackles
2+ Pedal edema
What is your differential diagnosis?
```
Preeclampsia
Pulmonary Edema
PPCM
Hypertensive CM
Pulmonary embolism
```
49
18 yo G1 at 39 weeks with shortness of breath in active labor.
BP 155/96, P: 122, RR: 24 O2 sat 91% T37.4
Pt is sitting up in bed and appears short of breath
CV: Irregular rate with Systolic ejection murmur 2/6
Lungs bibasilar crackles
2+ Pedal edema
How will you work this patient up?
```
O2 to get SaO2 >=95%
Labs: preeclamptic and BNP
EKG
Echo
Consider diuretic
```
50
18 yo G1 at 39 weeks with shortness of breath in active labor.
BP 155/96, P: 122, RR: 24 O2 sat 91% T37.4
Pt is sitting up in bed and appears short of breath
CV: Irregular rate with Systolic ejection murmur 2/6
Lungs bibasilar crackles
2+ Pedal edema
CXR: shows Pulmonary edema + cardiomegaly, PEC Labs are normal
ECG shows: Atrial fibrillation
Echo: moderate Mitral stenosis, Mild TR, Mild AR, enlarged Left Atrium
How does this change our differential / workup?
Less concern for preeclampsia or pulmonary pathology
The main issue is likely mitral stenosis leading to pulmonary edema
and leading to left atrial enlargement which causes atrial fibrillation.
51
18 yo G1 at 39 weeks with shortness of breath in active labor.
BP 155/96, P: 122, RR: 24 O2 sat 91% T37.4
Pt is sitting up in bed and appears short of breath
CV: Irregular rate with Systolic ejection murmur 2/6
Lungs bibasilar crackles
2+ Pedal edema
CXR: shows Pulmonary edema + cardiomegaly, PEC Labs are normal
ECG shows: Atrial fibrillation
Echo: moderate Mitral stenosis, Mild TR, Mild AR, enlarged Left Atrium
What are the next steps in management?
```
Manage pulmonary edema:
-sit patient upright
-give O2 for sat>=95%
-give diuretic
Maximize cardiac output:
-reduce preload: furosemide, epidural
-decrease HR: beta blocker, pain management, epidural
```
52
Exceptions to vaginal delivery in cardiac diseases?
Dilated aorta with Marfans
Severe aortic stenosis
Eisenmenger syndrome
Decompensated cardiomyopathy thats not improving
53
What does an elevated BNP suggest?
Heart failure / cardiogenic pulmonary edema
54
What is rheumatic fevers effect on valves?
Untreated group A strep that leads to scarring of the valves
55
Is mitral stenosis a low risk or high risk condition in pregnancy?
If Class 1 or 2: Low risk
If accompanied with Atrial fibrillation: Moderate risk
If Associated with Pulmonary HTN: High risk
56
What is the problem in mitral stenosis?
Stenotic mitral valve leads to increased Left Atrial pressure due to obstruction, Less LV filling
Eventually can lead to pulmonary hypertension because so much of a backflow getting to the left heart
57
What are the fetal risks in a pregnancy complicated by mitral stenosis?
Increased risk of PTB/IUFD in moderate / severe
58
What are the valve areas to know for Mitral stenosis?
<2cm -> can become symptomatic
| <1.5cm -> severe
59
What are the goals of therapy for a patient with mitral stenosis in pregnancy?
```
Avoid tachycardia (as you dont have enough time to get blood across the stenotic mitral valve)
Avoid hypovolemia - need volume to get flow over mitral valves
Avoid hypervolemia - if too much volume -> pulmonary edema
Treat Atrial fibrillation if present (digoxin-chronic, verapamil-acute, Anticoagulate with heparin)
```
60
What are the most common cardiac complications occuring during pregnancy in a patient with mitral stenosis?
Cardiogenic pulmonary edema
| Arrhythmias
61
How do you follow a patient with a history of mitral stenosis during pregnancy?
Echo at least in 1st and 3rd trimester (More if patient becomes symptomatic)
Regular follow up with cardio
62
How do we monitor patients in labor with mitral stenosis?
Continuous pulsox
Arterial line (bp evaluation) - means in a critical unit
Can also estimate cardiac output with pulse contour monitor
Strict I/Os
63
What are indications for cesarean delivery in a patient with mitral stenosis?
Usual obstetric indications
64
Delivery considerations in mitral stenosis?
Consider assisted second stage
65
Can a patient with mitral stenosis have neuraxial or epidural anesthesia?
Yes, ideally slow to minimized hypotension
| But important to prevent tachycardia
66
What are your options for controlling heart rate during labor in a patient with mitral stenosis?
Epidural (slow)
| B-blockers (esmolol drip)
67
What is your target heart rate for a patient with mitral stenosis
<90-100bpm
68
What medications should you not use in mitral stenosis patients?
Terbutaline (will increase HR)
| Caution with albuterol
69
What are the potential complications that may occur if a patient with mitral stenosis develops tachycardia?
Pulmonary edema
| Arrhythmias
70
What are the causes of aortic stenosis?
Idiopathic hypertrophic subaortic stenosis
Bicuspid aortic Valve
Rheumatic Valve disease
Lupus
71
What are the maternal risks in a pregnancy complicated by aortic stenosis?
Underperfusion (worse outcome than pulm edema)-> angina, syncope
Arrhythmia (leads to sudden death)
Pulmonary edema caused by hypervolemia
72
What are the fetal risks in a pregnancy complicated by aortic stenosis?
Hypoxia
Preterm delivery
Fetal growth restriction
Fetal death
73
What are the goals of therapy for a patient with aortic stenosis in pregnancy?
Avoid hypotension
Avoid hypovolemia
Avoid tachycardia
74
What are the most common cardiac complications occuring in pregnancy in a patient who has a history of aortic stenosis?
Pulmonary edema
| Arrhythmia
75
What initial evaluation will you perform on a patient with aortic stenosis with new onset SOB / fatigue and normal vitals?
Echo, ECG, CBC
76
How do you manage a patient with severe aortic stenosis in pregnancy?
Limit activity
Consult CT surgery (candidate for repair?)
Consult cardiology
77
How do you follow a patient with a history of aortic stenosis during pregnancy?
```
Baseline echocardiogram to evaluate:
-size of aortic valve opening
-gradient flow across the Valve
-ejection fraction
Baseline EKG (which can show left heart hypertrophy)
Consult to CT surgery
Consult to cardiology
Anesthesia consult
```
78
Critical valve area in aortic stenosis?
Genereally good outcome if valve area >1cm^2 (normal 3-4cm^2)
79
What are indications for cesarean delivery in a patient with aortic stenosis?
Usual obstetric indications
80
Can a patient with aortic stenosis have neuraxial or epidural anesthesia?
No (except in advanced center with experience anesthesiologists)
Important to avoid the decrease in preload caused by decreased systemic vascular resistance
Decreased SVR -> decreased pressure to push blood across a stenotic valve.
This can lead to drop in flow to coronary circulation.
81
What complications may develop in a patient with aortic stenosis and increasing preload?
Obstruction impedes flow across the valve -> pulmonary edema
82
What complications may develop in a patient with aortic stenosis and decreasing preload?
Underperfusion/inadequate cardiac output
- -> Angina due to decreasd coronary perfusion
- -> Syncope due to poor cerebral perfusion
- -> Sudden death due to arrhythmias
83
Key things to avoid in Aortic stenosis?
Avoid hypotension
Avoid hypovolemia
Avoid tachycardia
84
What are the maternal risks in a pregnancy complicated by mechanical valve replacement?
Thrombosis
Death
Risks of anticoagulation
85
What are the fetal risks in a pregnancy complicated by mechanical valve replacement?
Increased rate of pregnancy loss in the setting of warfarin use
Warfarin embryopathy - nasal hypoplasia, stippled epiphysis, optic atrophy, ACC, Dandy-Walker, MR
86
How do you manage anticoagulation in a patient in pregnancy with a history of mechanical valve replacement?
Stop warfarin before 6 weeks, switch to LMWH
When on LMWH follow anti-Xa weekly
pre-dose goal 0.6-0.7U/mL (trough)
4 hours post dose goal 1.0U/mL (peak)
Switch to UFH at 35 weeks and stop when delivery is expected in 6 hours
87
What are indications for cesarean delivery in a patient with mechanical valve replacement?
Usual obstetric indications
| Unless patient is on warfarin at the time, in which case a C/s is recommended to avoid fetal cerebral hemorrhage
88
How do you counsel a patient about the importance of anticoagulation in pregnancy with a mechanical valve replacement?
Anticoagulation needed to decrease risk of mechanical thrombosis which can cause embolic disease such as embolic stroke and death
Medications have many side effects and risks to you and fetus, but that the benefits outweigh those risks
89
What are the risks and benefits of warfarin therapy for anticoagulation in a pregnancy with a mechanical valve replacement?
Benefits:Effective anticoagulation, decrease risk of clots / death
Risks: Warfarin embryopathy in 1st trimester
Fetal hemorrhage after 1st trimester
90
What are the risks and benefits of unfractionated heparin in the first trimester and again after 35 weeks for anticoagulation in a pregnancy with a mechanical valve replacement?
Risks: Increased risk of valve thrombosis with benefit of decreased fetal risk
91
What are the risks and benefits of low molecular weight heparin therapy for anticoagulation in a pregnancy with a mechanical valve replacement?
Risks of underdosing
Less fetal risk
Less frequent dosing the UFH
92
When does warfarin embryopathy risk increase?
Dose > 5mg daily
| Continuation after 6 weeks of gestation
93
Fetal risks of warfarin?
```
Warfarin embryopathy:
Nasal bone hypoplasia
IUGR
Stippled epiphyses
Agenesis of corpus callosum
Mental retardation
```
94
For a pregnant woman with a mechanical valve, and therapeutic anticoagulation, describe how you will manage her anticoagulation during pregnancy?
Continue coumadin until pregnant
Change to therapeutic (adjusted dose) LMWH by 6 weeks
Monitor Anti Xa levels (goal 0.7-1.2U/mL) 4 hours post dose
95
For a pregnant woman with a mechanical valve, and therapeutic anticoagulation, describe how you will manage her anticoagulation around the time of delivery?
Change to IV UFH in labor (Target PTT >2)
Suspend 4-6 hours predelivery
Resume LMWH and coumadin 4-6h postpartum (d/t paradoxical protein c decrease when starting coumadin) (target Anti-xa 0.35-0.7U/mL)
96
What are the maternal risks of pregnancy in patients with mechanical valves?
```
Valve thrombosis
Arrhythmias
Anticoagulation complications
Heart failure
Endocarditis
```
97
How is chronic hypertension defined?
stage 1 hypertension: SBP 130-139, DBP 80-89
| stage 2 hypertension: SBP >140 , DBP >90
98
How do you counsel the patient regarding maternal risks of chronic hypertension in pregnancy?
```
Increased risk of maternal mortality from CVA, pulmonary edema, MI or renal failure (absolute risk low, but increased relative risk)
Increased risk of GDM
Increased c/s risk
Increased PPH
Preeclampsia
```
99
How do you counsel the patient regarding the fetal risks of chronic hypertension in pregnancy?
Preterm delivery (indicated)
Fetal growth restriction
Fetal death
Congenital anomalies
100
What baseline assessment do you perform in patients with chronic hypertension?
H&P
EKG or Echo
24 hour urine protein
Baseline labs (CBC, CMP)
101
What medications can you use for antepartum chronic hypertension management?
Labetalol
| Procardia
102
What are your goals of therapy for antihypertensive management?
SBP 120-159
DBP 80-109
*consider more aggressive goals if evidence of end organ damage
103
How do you manage apatient with chronic hypertension in pregnancy?
Baseline evaluation
Home BP monitoring
Serial growth ultrasounds starting at 28 weeks
Weekly antenatal testing if on medical management
Timing of delivery (37-39 weeks if on medications, 38-39 weeks if controlled without medications)
