CV Disease Pt 1

Question 1

Coronary Perfusion Pressure = ?

Answer 1

Arterial diastolic pressure - LVEDP (is 5% of CO or 250ml/min)

Question 2

Maximum coronary flow occurs during _____

Answer 2

Diastole

Question 3

Auto regulation is between ______ mmHg

Answer 3

50-120

Question 4

Concentric hypertrophy is d/t?

Answer 4

Chronically elevated afterload (pressure overload)

Question 5

Eccentric hypertrophy is d/t?

Answer 5

Chronically elevated preload (volume overload)

Question 6

Beginning of contraction, heart is as big as it gets.
Shows EDPVR & LVEDV where pressure is fairly low.
Indicates compliance

Answer 6

Point B

Question 7

Ventricle starts relaxing. Ca is releasing from troponin and going back to SR. Shows ESPVR/ regurgitation

Answer 7

Point D

Question 8

NYHA Classification of heart disease

Answer 8

I. Asymptomatic;
II. Symptoms with ordinary activity, no symptom at rest;
III. Symptoms with minimal activity, no symptoms as rest;
IV. Symptoms at rest

Question 9

LA pressure in mitral stenosis

Answer 9

25/14

Question 10

PE mitral stenosis

Answer 10

Opening snap, diastolic murmur, LA&raquo_space; LV pressure during diastole, RV lift, completely normal LV

Question 11

Mitral stenosis diagnosis:

Answer 11

ECG signs of LA enlargement, RVH;
A fib;
CXR shows straightening of the L heart border;
Dilation of pulmonary veins;
Echo shows narrowed “fish mouth” shaped orifice

Question 12

Medical therapy for mitral stenosis

Answer 12

Diuretics for pulm congestion, Digoxin, anticoagulant

Question 13

Anesthetic concerns for Mitral Stenosis

Answer 13

1. Slow (low HR to allow time for blood to fill ventricle);
2. Regular (sinus rhythm);
3. Not too full (maintain preload);
4. Not too tight (maintain afterload-SVR);
5. Not too strong (maintain contractility)

Question 14

Pressure-volume loop for mitral stenosis

Answer 14

1. Decreased preload;
2. Decreased LVEDV;
3. Decreased LVEDP;
4. Decreased SV;
5. Decreased EF

Question 15

Pressure-volume loop for Mitral Regurgitation

Answer 15

1. Increased LVEDV (compensation by LV chronic);
2. Increased LVESV;
3. Shortening of Isovolumetric contraction phase

Question 16

How does Mitral Regurgitation cause eccentric LV hypertrophy?

Answer 16

As LV SV is pumped backward into the LA (increasing LAP), the LV compensates by dilating & increasing LVEDV (to maintain CO despite decreased SV). This eventually leads to increased LVESV

Question 17

PE for Mitral Regurgitation

Answer 17

Diffuse and hyper dynamic ventricular impulse;

Systolic murmur best heard at apex, radiating to axilla, wide splitting S2; S3 d/t volume overload in LA

Question 18

Large V wave in MR shows?

Answer 18

Decreased atrial and pulmonary compliance and increased pulmonary blood flow & regurgitant volume

Question 19

Anesthetic concerns for MR

Answer 19

1. Fast (high HR 80-100 bc brady worsens regurg);
2. Forward (decrease afterload-SVR);
3. Regular (maintain SR);
4. Not too strong (maintain contractility)

Question 20

Valve leaflets balloon upwards as the ventricle contracts

Answer 20

Prolapse

Question 21

Abnormal closure of mitral valve produces what murmur of mitral regurgitation

Answer 21

Holosystolic

Question 22

Sudden tension in mitral valve prolapse produces?

Answer 22

Mid-systolic click

Question 23

Anesthetic concerns for mitral valve prolapse:

Answer 23

Avoid agents that increase HR or release histamines.

Select NDNMB that does not have circulatory effect

Question 24

Pressure-volume loop for aortic stenosis

Answer 24

1. Increased afterload;
2. Increased LVESP (=200mmHg);
3. Increased LVESV;
4. Increased LVEDV;
5. Decreased SV

Question 25

What moves the loop to the right in AS?

Answer 25

Increased LVESV is added to incoming venous blood and increases LVEDV (preload). The increase in preload increases the force of contraction (Starling’s law)

Question 26

What moves the loop upward in AS?

Answer 26

Concentric LVH limits overexpansion of LVEDV but increases LVEDP.

Question 27

3 clinical symptoms associated with aortic stenosis that indicate poor prognosis:

Answer 27

1. Angina w/o CAD d/t decreased O2 supply to the sub-endocardium by decreased ventricular diastolic compliance; 2. Syncope and faintness; 3. DOE

Question 28

PE for Aortic stenosis

Answer 28

Paradoxical splitting of S2, very narrow pulse pressure d/t low SBP, S4(bc hypertrophic LV), systolic ejection murmur w/ LV pressure >> aortic pressure during diastole

Question 29

Anesthetic concerns for AS

Answer 29

1. Slow (HR); 2. Full (maintain or increase preload); 3. Tight (maintain or increase afterload to maintain coronary perfusion pressure); 4. Regular (maintain SR); 5. Not too strong (maintain contractility)

Question 30

Pressure-volume loop for Aortic regurgitation

Answer 30

1. No Isovolumetric relaxation; 2. No Isovolumetric contraction as blood still coming during systole; 3. Increased LVEDV; 4. Increased LVESP; 5. Increased SV; 6. Increased pulse pressure; 7. Blood pours down both in systole & diastole causing increased volume & pressure

Question 31

Regurgitant flow from aorta to ventricle during diastole results in?

Answer 31

Eccentric hypertrophy (dilatation and volume overload)

Question 32

High pitch “blowing” diastolic murmur

Answer 32

Aortic regurgitation

Question 33

“Dancing carotid”- rapid rise followed by a rapid fall of carotid pulse a/w AR

Answer 33

Corrigan pulse

Question 34

“Bounding” femoral pulse a/w AR

Answer 34

Pistol-shot

Question 35

Diastolic bruit over femoral artery a/w AR

Answer 35

Duroziez sign

Question 36

Bobbing motion of head a/w AR

Answer 36

De Musset’s sign

Question 37

Systolic blushing & then diastolic blanching of the fingernail bed a/w AR

Answer 37

Quincke’s pulse

Question 38

Anesthetic concerns with aortic regurg:

Answer 38

1. Fast (sinus tach will give less time for regurg); 2. Full (slight increase in preload); 3. Forward (low TPR/afterload to improve forward flow)

Question 39

Decreases compliance of arterial tree, thus leading to increase in pulse pressure

Answer 39

Arteriosclerosis

Question 40

Associated with low diastolic pressure and high systolic pressure, net result is very high pulse pressure

Answer 40

Patent ductus arteriosus

Question 41

Low diastolic and high systolic pressure leads to high pulse pressure

Answer 41

Aortic regurgitation

Question 42

Tx for malignant hypertension

Answer 42

IV nitroprusside and diuretics

Question 43

Antihypertensive for African American men

Answer 43

Diuretics (beta blockers not effective)

Question 44

Antihypertensive for diabetic pt with renal insufficiency, CHF

Answer 44

ACE inhibitors

Question 45

Antihypertensive for pt with exertional angina

Answer 45

Beta blockers

Question 46

Avoid which antihypertensives in elderly?

Answer 46

Clonidine (a2 agonist), prazosin (a1 antagonist) (causes orthostatic hypotension)

Question 47

Avoid which antihypertensives in smokers and COPD?

Answer 47

Beta blockers

Question 48

Avoid which antihypertensives in renal insufficiency?

Answer 48

Beta blockers and diuretics

Question 49

Avoid which antihypertensives in diabetes and gout?

Answer 49

Thiazide diuretics

Question 50

Most common cause of chronic cor pulmonale

Answer 50

COPD

Question 51

Clinical features of Cor Pulmonale

Answer 51

``` Peripheral edema, liver enlargement, distended neck veins; Loud P2 (normally A2 is louder)suggest pulmonary HTN; low sat, right axis deviation, increased mean pulmonary artery pressure ```

Question 52

Mean PA pressure a/w primary pulmonary HTN

Answer 52

> 25 mmHg (normal 12-16)

Question 53

Immune reaction against necrotic myocardium post MI a/w acute pericarditis

Answer 53

Dressler’s syndrome

Question 54

What does CXR show with pericardial effusion?

Answer 54

Globular shaped heart

Question 55

Cardiac tamponade leads to ______ of pressures

Answer 55

Equalization

Question 56

Dissension of JVP during inspiration a/w cardiac tamponade

Answer 56

Kussmaul’s sign

Question 57

Decrease in SBP > 10 mmHg during inspiration (normal drop =6) a/w cardiac tamponade

Answer 57

Pulses paradoxus

Question 58

PE with cardiac tamponade

Answer 58

Quiet heart sounds, increased JVP, & hypotension

Question 59

XR findings for cardiac tamponade

Answer 59

“Water bottle heart”

Question 60

Anesthetic considerations with cardiac tamponade

Answer 60

Ketamine induction, increase IV fluids, avoid vasodilation & cardiac depression

Question 61

Occurs when the heart becomes encased in a rigid, chronically inflamed, calcified pericardium

Answer 61

Constrictive pericarditis

Question 62

Pericardial knock

Answer 62

As the ventricles fill, the descending ventricles “knock” against the pericardium in constrictive pericarditis

Question 63

Tx for constrictive pericarditis

Answer 63

Surgical stripping of pericardial shell

Question 64

Type ___ aneurysm involves the ascending aorta while type ___ does not

Answer 64

A; B

Question 65

MCC of abdominal aortic aneurysm

Answer 65

Atherosclerosis

Question 66

PE with abdominal aortic aneurysm

Answer 66

Pulsatile abdominal mass, bruits, hypotension (if rupture)

Question 67

Signs of AAA rupture

Answer 67

Grey Turner’s sign, Cullen’s sign, CV collapse

Question 68

Location of atherosclerosis (greatest to least):

Answer 68

Abdominal aorta > coronary artery > popliteal artery > carotid artery