Cardiovascular pathophysiology

Question 1

Which surgical procedure presents the HIGHEST risk of cardiovascular morbidity and mortality for the patient with coronary artery disease?
a. open reduction and internal fixation of a femur fracture
b. video-assisted lung thoracoscopy
c. open abdominal aortic aneurysm repair
d. carotid endarterectomy

Answer 1

c. open abdominal aortic aneurysm repair

Question 2

You can stratify cardiac risk with the patient’s

Answer 2

history & type of surgery

Question 3

Surgical procedures associated with the highest cardiac risk include

Answer 3

emergency surgery
open aortic surgery
peripheral vascular surgery
long surgical procedures with significant volume shifts and blood loss

Question 4

Patient-related conditions that increase cardiac risk include

Answer 4

a history of ischemic heart disease
CHF
cerebrovascular disease
DM
serum creatinine >2 mg/dL

Question 5

If a patient had a recent MI, then the risk of reinfarction is greatest within

Answer 5

30 days of the event

Question 6

After a recent MI, elective surgery should be delayed for

Answer 6

4-6 weeks

Question 7

Cardiac risk is defined as

Answer 7

perioperative MI, CHF, and death

Question 8

A patient with ____________ should be optimized before elective non-cardiac surgery.

Answer 8

unstable angina

Question 9

The following surgeries put the patient at intermediate cardiac risk:

Answer 9

carotid endarterectomy
head & neck surgery
intrathoracic or intraperitoneal surgery
orthopedic surgery
prostate surgery

Question 10

What is the NYHA classification of heart failure?

Answer 10

four classes that help to classify the extent of heart failure symptoms during activity

Question 11

NYHA class 1 is

Answer 11

no symptoms with physical activity

Question 12

NYHA class 2 is

Answer 12

symptoms appear during normal activity but no symptoms at rest

Question 13

NYHA class 3 is

Answer 13

symptoms appear with less than normal activity but no symptoms at rest

Question 14

NYHA class 4 is

Answer 14

symptoms appear with minimal activity or even at rest

Question 15

What is the risk of perioperative MI if the patient had an MI <3 months ago?

Answer 15

30%

Question 16

What is the risk of perioperative MI in the general population?

Answer 16

0.3%

Question 17

Use the data set to calculate the coronary perfusion pressure.
HR= 50 bpm
Systolic BP= 100 mmHg
diastolic BP= 55 mmHg
pulmonary artery occlusion pressure= 15 mmHg
central venous pressure= 10 mmHg

Answer 17

40
CPP= Aortic diastolic pressure- LVEDP or in this case DBP- PAOP

Question 18

Most MIs occur within ________ after surgery

Answer 18

48 hours

Question 19

Which lead is best for monitoring dysrhythmias?

Answer 19

II

Question 20

The treatment for intraoperative myocardial ischemia should focus on

Answer 20

interventions that make the heart slower, smaller, and better perfused

Question 21

Myocardial oxygen balance is determined by the ratio of

Answer 21

oxygen supply relative to demand

Question 22

The myocardium is at risk when the

Answer 22

supply is less than the demand

Question 23

Factors that reduce myocardial oxygen supply include, but are not limited to,

Answer 23

tachycardia, hypoxemia, anemia, and a left shift of the oxyhemoglobin curve

Question 24

Factors that increase myocardial oxygen demand include

Answer 24

tachycardia
hypertension
SNS stimulation
increased wall tension
increased preload
increased afterload
increased contracitlity

Question 25

Myocardial injury and infarction injure the ___________, and disruption of this structure allows ______________

Answer 25

sarcolemma; intracellular proteins (CK-MB, Troponin-I, troponin-T) to enter the systemic circulation

Question 26

Infarcted myocardium releases which three important biomarkers?

Answer 26

CK-MB, troponin I, troponin T

Question 27

________________ are more sensitive than _________ for the diagnosis of myocardial infarction

Answer 27

Cardiac troponins; CK-MB

Question 28

Lead II aids in the identification of ____________ ischemia

Answer 28

inferior wall

Question 29

Which leads are best for detecting LV ischemia?

Answer 29

V3, V4, & V5

Question 30

What is the intervention for increased O2 demand?

Answer 30

beta blocker to a HR < 80 bpm increased depth of anesthesia, vasodilator nitroglycerin

Question 31

What is the intervention for decreased O2 supply?

Answer 31

anticholinergic, pacing vasoconstrictor, reduce depth of anesthesia nitroglycerin, inotrope

Question 32

We can assess ventricular compliance by evaluating

Answer 32

ventricular pressure at a given ventricular volume

Question 33

Co-existing condition that lead to diastolic dysfunction include

Answer 33

age >60 years myocardial ischemia hypertension aortic stenosis

Question 34

If the patient has diastolic dysfunction, _____________ are required to prime the ventricle

Answer 34

higher filling pressure

Question 35

In the case of diastolic dysfunction, _____________ & ______________ will overestimate ventricular filling pressures

Answer 35

CVP & PAOP

Question 36

Compliance is decreased by conditions that make the heart

Answer 36

"stiffer"

Question 37

Elevated filling pressures put patients at higher risk of

Answer 37

pulmonary edema

Question 38

_______________ & ______________ are critically important to maintain the priming function.

Answer 38

Preservation of NSR and atrial kick

Question 39

Compliance is increased by conditions that

Answer 39

dilate the heart

Question 40

Clinical examples of conditions that increase compliance include

Answer 40

chronic aortic insufficiency dilated cardiomyopathy

Question 41

Identify a compensatory mechanism in the patient with congestive heart failure. a. decreased brain natriuretic peptide b. decreased left ventricular end-diastolic pressure c. increased renal blood flow d. increased sympathetic tone

Answer 41

d. increased sympathetic tone

Question 42

Heart failure occurs when the myocardium is

Answer 42

unable to pump enough blood to satisfy the body's metabolic demand

Question 43

Heart failure with reduced ejection fraction represents

Answer 43

a pump problem

Question 44

Examples of heart failure with reduced ejection fraction include

Answer 44

myocardial ischemia valve insufficiency dilated cardiomyopathy

Question 45

Anesthetic management of the patient with heart failure with reduced EF includes

Answer 45

lowering afterload increasing contractility

Question 46

_____________ is the most common cause of right heart failure.

Answer 46

Left heart failure

Question 47

Conditions that increase PVR include

Answer 47

hypoxia, hypercarbia, acidosis, hypothermia, high PEEP, and nitrous oxide

Question 48

Heart failure with preserved ejection fraction (HFpEF or diastolic failure) represents a

Answer 48

filling problem

Question 49

The patient with HFpEF experiences

Answer 49

s/sx of HF but has a normal ejection fraction

Question 50

Examples of HFpEF include

Answer 50

myocardial ischemia valve stenosis hypertrophic cardiomyopathy hypertension cor pulmonale obesity

Question 51

Anesthetic management for heart failure includes

Answer 51

maintaining a higher afterload and slowing the heart rate

Question 52

Compensatory mechanisms for heart failure include

Answer 52

chronic SNS activation down-regulation of beta receptors cardiac remodeling

Question 53

Treatment of right ventricular failure includes

Answer 53

inotropes- milrinone, dobutamine pulmonary vasodilators- inhaled nitric oxide or sildenafil (PDE-5 inhibitor) reversing causes of increased PVR

Question 54

List 4 physiologic adaptations to heart failure.

Answer 54

sns activation excessive vasoconstriction fluid retention myocardial remodeling

Question 55

List 3 physiologic functions of BNP.

Answer 55

natriuresis diuresis vasodilation