Exam II: CHF, Cardiomuopathies, Pericardial Disease, Sepsis Flashcards by Linsley Lloyd

CHF: Inability of the heart to ___ and ___ blood sufficient to meet ___ ___.

fill and pump, tissue demands

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CHF Symptoms
exertional ___
d___
c___
ankle swelling
dyspnea more in the supine position
h___

fatigue
dyspnea
congestion
hypoperfusion

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CHF Causes
Cardiac valve abnormalities
Impaired ___ ___due to ischemic heart disease or cardiomyopathy
Systemic ___
Pulmonary hypertension (___ ___)
Pericardial disease

myocardial contractility, hypertension, cor pulmonale

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Cor pulmonale is defined as an alteration in the ___ and ___ of the ___ ventricle caused by a primary disorder of the respiratory system.

structure, function, right

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Pulmonary hypertension is the common link between ___ and ___.

lung dysfunction, the heart in cor pulmonale

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Right-sided ventricular disease caused by a primary abnormality of the ___side of the heart or ___ is not considered cor pulmonale, but cor pulmonale can develop secondary to a wide variety of cardiopulmonary disease processes.

left, congenital heart disease

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In chronic cor pulmonale,___ hypertrophy ___ generally predominates.

RV, (RVH)

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What condition has these causes: emphysema, pulmonary thromboembolism, interstitial lung disease, adult respiratory distress syndrome, and rheumatoid disorders are associated with what disorder

Cor Pulmonale

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Chronic obstructive pulmonary disorder is the most common cause of ___.

cor pulmonale

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decreased ___ wall motion

[Systolic heart failure ]

ventricular

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decreased ___(0.45) leads to the increased diastolic volume in the ___ ventricle

[Systolic heart failure ]

ejection fraction, left

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___ contractility

[Systolic heart failure ]

decreased

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inability to___

[Systolic heart failure ]

empty

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Causes:
CAD – ischemia – local dysfunction
Chronic___ or ___
overload
P___
Toxins (ETOH, cocaine)

[Systolic heart failure ]

pressure or volume,
Pericardial disease,
Toxins (ETOH, cocaine)

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Systolic heart failure is also called:
[Systolic heart failure ]

heart failure with reduced ejection fraction

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Chronic pressure overload – ___ and ___
[Systolic heart failure]

aortic stenosis and chronic HTN
(notes slide 5)

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Chronic volume overload – ___ and ___

[Systolic heart failure]

regurgitant valvular disease and high-output cardiac failure
(notes slide 5)

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All other causes (other than ___/___ cause global dysfunction)

[Systolic heart failure]

CAD/ischemia

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Hallmark of chronic LV systolic dysfunction is:
___ ___ ___

[Systolic heart failure]

Decreased ejection fraction

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Higher LV volume required to produce
___ ___

[Systolic heart failure]

stroke volume

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Loss of ___ ___ results
in stroke volume reduction

[Systolic heart failure]

inotropic force

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Decreased compliance of the ___and inability to ___ at normal pressures.

[Diastolic heart failure]

LV, fill

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Increased ___in a chamber of normal size.
[Diastolic heart failure]

pressures

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Impaired ___ of the LV
inability to fill.
[Diastolic heart failure]

relaxation

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Causes: CAD, HTN, aortic stenosis (___hypertrophy), ____ cardiomyopathy, pericardial disease, fibrosis, diabetes, aging [Diastolic heart failure]

concentric, hypertrophic

Seen more in ___ [Diastolic heart failure]

females

Also called:___ [Diastolic heart failure]

heart failure with preserved ejection fraction

Increased LV pressure with __ ___ [Diastolic heart failure]

diastolic filling

Decreased ___filling due to decreased compliance. [Diastolic heart failure]

Decreased stroke volume due to decreased___volume [Diastolic heart failure]

LVED

Age: [Systolic HF versus Diastolic HF]

Sys: 50-70 Dia: Frequently elderly

Gender: [Systolic HF versus Diastolic HF]

Sys: Male Dia: Female

EF: [Systolic HF versus Diastolic HF]

Sys: Depressed EF /= 40%

Left ventricle: [Systolic HF versus Diastolic HF]

Sys: Dilated LV Dia: Concentric hypertrophy-nl size

Cause: [Systolic HF versus Diastolic HF]

Sys: MI Dia: HTN, diabètes obesity, chronic lung

LV Filling [Systolic HF versus Diastolic HF]

Sys: Decreased wall motion, preserved filling Dia: Non-compliant LV, resistant to filling

Systolic or ___ [Forms of heart failure]

diastolic

Acute or ___ [Forms of heart failure]

chronic

___ – sudden reduction in CO, systemic hypotension, no peripheral edema. [Forms of heart failure]

Acute

Chronic – pre-existing long-term___, ___ congestion, BP maintained [Forms of heart failure]

cardiac disease, venous, maintained

___ or right-sided [Forms of heart failure]

Left-sided

___-___ (normal CI, but unable to respond to stress; caused by CAD, cardiomyopathy, HTN, valvular disease, pericardial disease) [Forms of heart failure]

Low-output

High-output (a___, pregnancy, AV fistulas, severe ___, beri-beri) [Forms of heart failure]

anemia, hyperthyroidism

Cardiac output – resting CO may be normal, but with exertion it can’t ___ or CO may be ___. [Hemodynamic effects of CHF]

increase, decreased

Frank-Starling –___ ___ is decreased so a lower ___ ___ is produced at any given LVEDP. [Hemodynamic effects of CHF]

Myocardial contractility, stroke volume

Inotropic state – ___is decreased due to depletion of ___ in the heart. [Hemodynamic effects of CHF]

contractility, catecholamines

Afterload – increased ___ – (def: tension the ___muscle must develop to open the aortic or pulmonic valve) [Hemodynamic effects of CHF]

vasoconstriction, ventricular

Heart rate – increased to raise ___because ___ ___ is fixed or decreased; tachycardia (increased sympathetic tone). [Hemodynamic effects of CHF]

CO,stroke volume

Sympathetic nervous system – activated causing ___ and ___constriction. [Hemodynamic effects of CHF]

arteriolar and venous

Myocardial hypertrophy – compensation for ___ ___ overload [Hemodynamic effects of CHF]

chronic pressure

Cardiac dilation – compensation for ___ ___to increase ___by Frank-Starling law; increases myocardial oxygen demands. [Hemodynamic effects of CHF]

volume overloads, CO

Concentric – ___ [Hemodynamic effects of CHF]

hypertrophied, thickened muscle **Pressure overload**

Eccentric – ____ [Hemodynamic effects of CHF]

dilated ventricle **Volume overload**

___ cardiac output [Pathophysiologic key elements]

Decreased

____ stroke volume [Pathophysiologic key elements]

Decreased

___ventricular end-diastolic pressures [Pathophysiologic key elements]

Increased

Ventricular ___ or ___ [Pathophysiologic key elements]

dilation or hypertrophy

___ BP [Pathophysiologic key elements]

Decreased

___tissue perfusion [Pathophysiologic key elements]

Decreased

Peripheral vaso___ [Pathophysiologic key elements]

Vasoconstriction

___ blood volume (retention of ___, ___ [Pathophysiologic key elements]

Increased, Na+, water)

Metabolic___ [Pathophysiologic key elements]

acidosis

Treatment medically: (4) [Pathophysiologic key elements]

diuretics, angiotension-converting enzyme inhibitors, vasodilators, digitalis.

Diuretics provide ___ [Pathophysiologic key elements]

relief of circulatory congestion

ACE inhibitors – (3) [Pathophysiologic key elements]

enalapril, captopril , ramipril

ACE inhibitors – enalapril, captopril , ramipril – improve ___ ___ and may prolong life [Pathophysiologic key elements]

LV function

Compensatory mechanisms to maintain CO (3)

Cardiac, autonomic nervous system, humoral

Cardiac: Frank-Starling – ___ preload to ___stroke volume (SV becomes relatively___ over time) [Compensatory mechanisms to maintain CO]

increase, increase, fixed

Cardiac: Ventricular ___ or ___ [Compensatory mechanisms to maintain CO]

dilation or hypertrophy

Cardiac: ___cardia [Compensatory mechanisms to maintain CO]

Tachy

Autonomic Nervous System Increased ____ tone – venous, arterial vasoconstriction [Compensatory mechanisms to maintain CO]

sympathetic

Autonomic Nervous System Decreased ___tone [Compensatory mechanisms to maintain CO]

parasympathetic

Humoral Renin-Angiotensin-Aldosterone system activated ___ renal perfusion – maladaptive [Compensatory mechanisms to maintain CO]

Decreased

Humoral ___ ADH [Compensatory mechanisms to maintain CO]

Increased

Humoral Increased catecholamines – ___, ___, ___ [Compensatory mechanisms to maintain CO]

myocyte necrosis, remodeling, death

Humoral ___atrial natriuretic peptide, B- type natriuretic peptide – cause diuresis, vasodilation, anti-inflammation (___over time) [Compensatory mechanisms to maintain CO]

Increased, blunted

Increased atrial natriuretic peptide, B- type natriuretic peptide – released in response to stretching of the ___ and ___ – helps blunt ___ for a while [Compensatory mechanisms to maintain CO]

atria and ventricle, remodeling

Heart failure results in the release of biologically active signaling molecules, the so-called “___ ___” that is initially compensatory in maintaining cardiac output and blood pressure but that, over time, results in progressive ___ ___ dysfunction [Compensatory mechanisms to maintain CO]

neurohumoral response, left ventricular

This paradigm of progressive heart failure has led to studies showing that treatment with drugs that block the activity of these biologic mediators (___ ___) ___ mortality [Compensatory mechanisms to maintain CO]

beta blockers, reduces

This concept is further supported by extensive data showing that mortality is ___ in heart failure patients treated with ____ [Compensatory mechanisms to maintain CO]

reduced, angiotensin-converting enzyme inhibitors

Pulmonary congestion: Pulmonary edema [LV HF VS RV HF]

LVHF

Jugular venous distention, edema, hepatomegaly, ascites, weight gain, ankle swelling, abdominal distention [LV HF VS RV HF]

RVHF

Tachypnea, moist rales, resting tachycardia, S3 gallop, hypotension, diaphoresis [LV HF VS RV HF]

LVHF

Hypoxia, fatigue, cough, rales [LV HF VS RV HF]

LVHF

Systemic congestion Peripheral venous HTN, peripheral edema [LV HF VS RV HF]

RVHF

Class I: Ordinary physical activity ___ ___ cause symptoms [NY Heart Association Classification – Based on Functional Status of Patient]

does not

Class II: Symptoms occur with ___ exertion [NY Heart Association Classification – Based on Functional Status of Patient]

ordinary

Class III: Symptoms occur with___exertion [NY Heart Association Classification – Based on Functional Status of Patient]

less than ordinary

Class IV: Symptoms occur___ [NY Heart Association Classification – Based on Functional Status of Patient]

at rest

Severity of___symptoms has an excellent correlation with ___ and ___. [NY Heart Association Classification – Based on Functional Status of Patient]

HF, quality of life and survival.

Stage A: ___ [AHA classification]

High risk with no symptoms

Stage A: Risk factor reduction, ___ and ___education [AHA classification]

patient and family

Stage A: Treat HTN, DM, dyslipidemia; ___ or ___in some patients [AHA classification]

ACE inhibitors or ARBs

Stage B: ___heart disease, no symptoms [AHA classification]

Structural

Stage B: Ace inhibitors or ARBs in all patients, ___ ___in selected patients [AHA classification]

Beta blockers

Stage C: Structural disease, ___ or ___ symptoms [AHA classification]

previous or current

Stage C: ___ and ____ in all patients [AHA classification]

ACE inhibitors and Beta blockers

Stage C: Dietary sodium restriction, ___ and ____ [AHA classification]

diuretics and digoxin

Stage C: Cardiac resynchronization if ___ ___ ___present [AHA classification]

bundle branch block

Stage C: ____, mitral valve surgery [AHA classification]

Revascularization

Stage C: Consider ___ team [AHA classification]

multidisciplinary

Stage C: Aldosterone antagonist,___ [AHA classification]

nesiritide

Stage D: ____symptoms requiring special intervention [AHA classification]

Refractory

Stage D: Iso___ [AHA classification]

topes

Stage D: ___, transplantation [AHA classification]

VAD

Stage D: H___ [AHA classification]

Hospice

Reversing pathophysiology of ___ ___ and stop the cycle of ___ ___ mechanisms [CHF Treatment goals]

heart failure, poor compensatory

Short term goals: Relieve ___ Improve___ ___ Improve quality ___ ___ [CHF Treatment goals]

congestion tissue perfusion of life

Long term goals: Slowing or reversing the progression of ___ ___ [CHF Treatment goals]

ventricular remodeling

Two drug classes that have shown to decrease ventricular remodeling are ___ and ___ [CHF Treatment goals]

beta-blockers and ACE inhibitors.

ACE inhibitors: ___, ___, ___, ___. [Treatment Systolic HF]

enalapril, captopril, lisinopril, quinapril

Beta-blockers: ___, ___, ___ [Treatment Systolic HF]

Metoprolol (Lopressor), bisopropolol (Zebeta), carvedilol (Coreg)

Aldosterone antagonist: ___, ___ [Treatment Systolic HF]

spironolactone, eplerenone

Angiotensin II receptor blockers – (all of the above can slow progression of___, reduce M &M) [Treatment Systolic HF]

vent remodeling

Class III antiarrhythmics: ___ [Treatment Systolic HF]

amiodarone

Diuretics: ___ and ___ [Treatment Systolic HF]

thiazide and loop

Digitalis: ___ [Treatment Systolic HF]

digoxin

Vasodilators: ___, ___ [Treatment Systolic HF]

hydralazine, isorbide dinitrate

Statins – ___ and ____ [Treatment Systolic HF]

lipid lowering and anti-inflammatory effects

Di___ Vasodilators (___, ___) Inotropic support [Treatment of ACUTE HF]

Diuretics, NTG, SNP

Catecholamines (___, ___) [Treatment of ACUTE HF]

dobutamine, dopamine

Phosphodiesterase-3 inhibitor (____) [Treatment of ACUTE HF]

milrinone

Exogenous B-Type natriuretic peptide* once response to endogenous BNP, is blunted over time, exogenous BNP causes diuresis, ___, vasodilation, ____ effect and ___ and the sympathetic nervous system. [Treatment of ACUTE HF]

natriuresis, anti-inflammatory, inhibition of RAAS

“the presence of CHF has been described as the ___ ___ ___ risk factor for predicting perioperative cardiac morbidity and mortality”

single most important

Goal: [CHF Anesthetic management]

optimize cardiac output

If surgery is elective, ___ to maximize patient’s condition – precipitating factors. [CHF Anesthetic management]

postpone

Ketamine supports ___ ___ [CHF Anesthetic management]

cardiac output

Volatile agent used cautiously due to ___ effects (greater) [CHF Anesthetic management]

depressant

Opioids as only drug is justified – depress ___ ___ [CHF Anesthetic management]

sympathetic stimulation *Cahoon doesn't agree with this

Consider positive pressure ventilation and ___ [CHF Anesthetic management]

PEEP

Avoid sympathetic stimulation which might cause ___ [CHF Anesthetic management]

arrhythmias

Avoid _____ if on digoxin [CHF Anesthetic management]

hyperventilation

Careful fluid titration (____) – advanced monitoring [CHF Anesthetic management]

euvolemic

Continue medications to day of surgery, except: ____ [CHF Anesthetic management]

Diuretics

2014 ACC/AHA Guidelines on Perioperative Cardiovascular Eval and Management of Patients undergoing Noncardiac Surgery – “continuation is reasonable” ____ ____ [CHF Anesthetic management]

ACE inhibitors Angiotensin receptor blockers

Check lytes (prone to ___ due to excess ADH), EKG, ___ [CHF Anesthetic management]

hyponatremia, Echo

Regional anesthesia ____SVR by blocking peripheral sympathetic stimulation ____ cardiac output continuous epidurals with their___onset is the best. [CHF Anesthetic management]

decreases, increases, slow

Acute heart failure during surgery – take to ICU for __ and __ [CHF Anesthetic management]

invasive monitoring and treatment

Post-op pain – can cause ___ which can worsen heart failure [CHF Anesthetic management]

sympathetic stimulation

Cardiomyopathies: Progressive, life-threatening ___ ___ ___

congestive heart failure

Cardiomyopathies: Classified as ___ and ___

primary, secondary

Cardiomyopathies: Classified as ___, ___, and ___ cardiomyopathy with restrictive physiology

dilated, hypertrophic, and secondary

Cardiomyopathies: Primary – confined to heart muscle mostly – ___, ___, ___.

genetic, acquired, mixed

Cardiomyopathies: Secondary – heart involved in relationship to___ disorder

multiorgan

Most ___ type [Dilated Cardiomyopathy]

common

Characteristics: left or bilateral ventricular ___ (___) [Dilated Cardiomyopathy]

dilation, (eccentric)

Characteristics: impaired myocardial contractility –___dysfunction [Dilated Cardiomyopathy]

systolic

Characteristics: ___cardiac output [Dilated Cardiomyopathy]

decreased

Characteristics: ___ ventricular filling pressures [Dilated Cardiomyopathy]

increased

Characteristics: Ventricular ___ and ___ are common (ICD placement) [Dilated Cardiomyopathy]

dysrhythmias, sudden death

Characteristics: Principle indication for cardiac ____ [Dilated Cardiomyopathy]

transplantation

Etiology is unknown, may be___, or associated with ___. [Dilated Cardiomyopathy]

genetic, infection

Many secondary cardiomyopathies are ___. [Dilated Cardiomyopathy]

dilated

___ __ men at increased risk [Dilated Cardiomyopathy]

African American

Initial presentation – ___ ___ – chest pain on exertion mimics ___. [Dilated Cardiomyopathy]

heart failure, angina

Ventricular dilation may cause ____and ___ ___. [Dilated Cardiomyopathy]

mitral, tricuspid regurg

Thrombosis formation in floppy ventricle – needs ____. [Dilated Cardiomyopathy]

anticoagulation

Placement of ___ for arrhythmias. [Dilated Cardiomyopathy]

ICD

___ transplant [Dilated Cardiomyopathy]

Cardiac

Goals – avoid ___ ___, maintain ___, prevention of increased ventricular ___. [Management of Anesthesia: DC]

cardiac depression, normovolemia, afterload

Expect slow ___times. [Management of Anesthesia: DC]

circulation

Treat hypotension with ____ (beta); the ___stimulation with ____ could cause adverse increased afterload due to increase SVR. [Management of Anesthesia: DC]

ephedrine, alpha, phenylephrine

Regional – acceptable due to decreases in ___ and ___; slow onset of ___ is best. May be anticoagulated – limits ___anesthesia [Management of Anesthesia: DC]

preload and afterload, sympathetic blockade, regional

Most commonly seen with ___ Also ____, sarcoidosis, carcinoid [Secondary Cardiomyopathy with restrictive physiology]

amyloidosis, hemochromatosis

Characteristics Systemic diseases that cause ___ ___ that result in increased stiffness of the myocardium. [Secondary Cardiomyopathy with restrictive physiology]

myocardial infiltrates

Severe ___dysfunction. [Secondary Cardiomyopathy with restrictive physiology]

diastolic

NO cardiomegaly or ___dysfunction [Secondary Cardiomyopathy with restrictive physiology]

systolic

Atrial fibrillation is common; can have conduction system involvement (can lead to___ ___ or ___ ___) [Secondary Cardiomyopathy with restrictive physiology]

heart block, vent dysrhythmias

Cardiac___ is NOT a treatment option – myocardial infiltrates would recur. [Secondary Cardiomyopathy with restrictive physiology]

transplant

Prognosis is ___. [Secondary Cardiomyopathy with restrictive physiology]

very poor

Management of anesthesia: Maintain sinus rhythm, avoid abrupt ___ (stroke volume is ___). [Secondary Cardiomyopathy with restrictive physiology]

bradycardia, fixed

Management of anesthesia: Loss of ___ ___ is detrimental to ventricular filling. [Secondary Cardiomyopathy with restrictive physiology]

atrial kick

Management of anesthesia: Maintain venous return and___. [Secondary Cardiomyopathy with restrictive physiology]

normovolemia

Management of anesthesia: If anticoagulated, ____ is avoided. [Secondary Cardiomyopathy with restrictive physiology]

regional

Characteristics: Left ventricular outflow obstruction; due to ___interventricular septum that can lead to obstruction of outflow if the ventricle is empty or ___. [Hypertrophic Cardiomyopathy]

hypertrophied, hypercontractile

Characteristics: Mitral regurgitation – systolic ___movement ___ without any perceived reason (no HTN or AS). [Hypertrophic Cardiomyopathy]

anterior, LVH

Characteristics: Dynamic LV ___. [Hypertrophic Cardiomyopathy]

outflow tract obstruction

Characteristics: Diastolic _____ [Hypertrophic Cardiomyopathy]

dysfunction

Characteristics: Myocardial ____ [Hypertrophic Cardiomyopathy]

ischemia

Characteristics: ___rhythmias [Hypertrophic Cardiomyopathy]

Dysrhythmias

Made worse by ___therapy, diuresis, and ___(treat CHF) [Hypertrophic Cardiomyopathy]

inotropic, nitrates

Affects 1 in ___ adults – genetic ___ ___trait – most common cardiac [Hypertrophic Cardiomyopathy]

500, autosomal dominant

___ ___ is first presentation in patients less than 30 years [Hypertrophic Cardiomyopathy]

Sudden death

___ of patients with HCM (during exercise) have an abnormal response – systolic BP fails to increase ___ mm Hg or a fall in systolic BP – poorer prognosis. Either due to dynamic___obstruction or systemic ___ during exercise [Hypertrophic Cardiomyopathy]

25%, > 20, LVOT, vasodilation

Pathphysiology: Diastolic dysfunction Loss of diastolic compliance and inability of the ventricle to ___. [Hypertrophic Cardiomyopathy]

relax

Pathophysiology: Diastolic dysfunction Elevated___ despite hyperdynamic ventricular function. [Hypertrophic Cardiomyopathy]

LVEDP

Pathphysiology: Diastolic Dysfunction ___ heart sound [Hypertrophic Cardiomyopathy]

Fourth

Obstructed LV outflow in ___of patients [Hypertrophic Cardiomyopathy]

75%

Pathophysiology: Obstructed LV outflow Loud mid to late ___murmur. [Hypertrophic Cardiomyopathy]

systolic

Pathophysiology: Obstructed LV outflow Obstruction worsened by enhanced contractility (low ___ ___, decreased___ ___ - stimulates the SNS). [Hypertrophic Cardiomyopathy]

ventricular volume, LV afterload

Pathophysiology: Mitral regurgitation in ___patients [Hypertrophic Cardiomyopathy]

most

Pathophysiology: Mitral Regurgitation Movement of mitral valve leaflets restricted by ___ ___. [Hypertrophic Cardiomyopathy]

hypertrophied septum

Pathophysiology: EKG - LV hypertrophy, ___, supraventricular and ventricular arrhythmias, ___ ___. [Hypertrophic Cardiomyopathy]

deep Q waves, myocardial ischemia

Factors influencing LVOT Events that increase outflow obstruction (3): [Hypertrophic Cardiomyopathy]

Increased myocardial contractility Decreased preload Decreased after load

Factors influencing LVOT Increased myocardial contractility: ___-Adrenergic stimulation (catecholamines) ___ [Hypertrophic Cardiomyopathy]

Beta Digitalis

Factors influencing LVOT Decreased preload: Hypo___ Vaso___ ___cardia Positive pressure ventilation [Hypertrophic Cardiomyopathy]

volemia dilators Tachy

Factors influencing LVOT Decreased afterload: ___tension ___dilators [Hypertrophic Cardiomyopathy]

Hypo Vaso

Factors influencing LVOT Events that decrease Outflow obstruction (3): [Hypertrophic Cardiomyopathy]

Decreased myocardial contractility Increased preload Increased after load

Factors influencing LVOT Decreased myocardial contractility: Beta-Adrenergic ___ ___ anesthetics Calcium ___ [Hypertrophic Cardiomyopathy]

blockade Volatile Entry Blockers

Factors influencing LVOT Increased Preload: ___volemia ___cardia [Hypertrophic Cardiomyopathy]

Hyper Brady

Factors influencing LVOT Increased afterload: ___tension Alpha___ [Hypertrophic Cardiomyopathy]

Hyper -adrenergic Stimulation

HC – ___ Contractility [Anesthetic management: Hypertrophic Cardiomyopathy]

Halt

Decrease myocardial contractility (avoid ___) [Anesthetic management: Hypertrophic Cardiomyopathy]-Drug

ketamine

Increase ___ (avoid PEEP) and ___ [Anesthetic management: Hypertrophic Cardiomyopathy]

preload, afterload

Avoid ___ (? anticholinergics) [Anesthetic management: Hypertrophic Cardiomyopathy]

tachycardia

Treat with esmolol, ____ Anxiolytics [Anesthetic management: Hypertrophic Cardiomyopathy]

metoprolol [Avoid Tachycardia]

Minimize ____stimulation [Anesthetic management: Hypertrophic Cardiomyopathy]

sympathetic

If hypotensive, use ____ [Anesthetic management: Hypertrophic Cardiomyopathy]

phenylephrine

If hypertensive, don’t use ___ or ___ [Anesthetic management: Hypertrophic Cardiomyopathy]

Nipride or NTG

Maintain __ ___ (NSR) [Anesthetic management: Hypertrophic Cardiomyopathy]

atrial kick

If present, turn off ___ and have defib available [Anesthetic management: Hypertrophic Cardiomyopathy]

AICD

Minimize ___ obstruction [Anesthetic management: Hypertrophic Cardiomyopathy]

outflow

Monitoring: CVP and PA pressure monitoring will not reflect ___ ___ in these patients. [Anesthetic management: Hypertrophic Cardiomyopathy]

LV filling

Treat hypovolemia cautiously – poor ___ compliance [Anesthetic management: Hypertrophic Cardiomyopathy]

Acute pericarditis Most common cause – ___infection [Pericardial Disease Acute pericarditis]

viral

Also seen r/t post MI ___, postcardiotomy, metastatic disease, ___, TB, rheumatoid arthritis [Pericardial Disease Acute pericarditis]

syndrome, irradiation

Pathophysiology ___ ___reaction – small effusion [Pericardial Disease Acute pericarditis]

Serofibrinous inflammatory

Pathophysiology Usually ___-___ – rarely can lead to chronic constrictive [Pericardial Disease Acute pericarditis]

self-limiting

Sudden onset chest pain – differentiated from ischemia-type pain by worsening with ___ and relief with postural changes, sitting or ___ ___. [Pericardial Disease Acute pericarditis]

inspiration, leaning forward

Characteristics: fever, ___ ___ rub, ___ elevation in cardiac enzymes, diffuse ST changes in most ___ leads and two or three limb leads [Pericardial Disease Acute pericarditis]

pericardial friction, no, precordial

Anesthetic management – unchanged – may be treating ___ illness (NSAIDs) [Pericardial Disease Acute pericarditis]

underlying

MI Syndrome – occurs ___days following a transmural MI – interaction between the healing necrotic myocardium and the ____. [Pericardial Disease Acute pericarditis]

1-3, pericardium

Dressler syndrome – delayed form of acute pericarditis following acute MI – can occur ___ to ___ after initial MI – thought to be an ___ initiated by the entry of bits of necrotic myocardium into the circulation (acting as antigens). [Pericardial Disease Acute pericarditis]

weeks to months, autoimmune process

Pericardial thickening and ___ [Pericardial Disease Chronic Constrictive pericarditis]

fibrosis

__ – most common in past [Pericardial Disease Chronic Constrictive pericarditis]

Pathophysiology Abnormal diastolic___ of both ventricles [Pericardial Disease Chronic Constrictive pericarditis]

filling

Patho: Filling pressures increase – ___ and ___congestion [Pericardial Disease Chronic Constrictive pericarditis]

pulmonary and peripheral

Patho: ___ and CO may decrease [Pericardial Disease Chronic Constrictive pericarditis]

Patho: Equilibration of ___, PCWP, ___ [Pericardial Disease Chronic Constrictive pericarditis]

PAD, RAP

___systolic function is good initially, but may atrophy over time [Pericardial Disease Chronic Constrictive pericarditis]

Diffuse low-voltage QRS, T-wave ___, ___ P-waves [Pericardial Disease Chronic Constrictive pericarditis]

inversion, notched

Treatment – ___ – risk of dysrhythmias, bleeding (high m & m of 6-19%) [Pericardial Disease Chronic Constrictive pericarditis]

pericardiotomy

Anesthetic Management Plan for hemorrhage, need to go on ___. [Pericardial Disease Chronic Constrictive pericarditis]

CPB

Anesthetic Management Large gauge IVs, ___ line [Pericardial Disease Chronic Constrictive pericarditis]

arterial

Anesthetic Management Preserve myocardial contractility SV is ___ – preserve HR – ___ needs to be avoided. [Pericardial Disease Chronic Constrictive pericarditis]

fixed, bradycardia

Anesthetic Management Use agents like ___, ketamine. [Pericardial Disease Chronic Constrictive pericarditis]

pancuronium

Anesthetic Management ___ preload [Pericardial Disease Chronic Constrictive pericarditis]

Preserve

Anesthetic Management Be careful with positive pressure ventilation – decreased ___ ___ [Pericardial Disease Chronic Constrictive pericarditis]

venous return

Anesthetic Management ___ afterload [Pericardial Disease Chronic Constrictive pericarditis]

Preserve

Anesthetic Management Postop low CO may persist due to ___ of myocardium – may require ___support [Pericardial Disease Chronic Constrictive pericarditis]

atrophy, inotropic

Medical history Constrictive Pericarditis: Previous pericarditis, cardiac ___, trauma, radiotherapy, ___ ___disease Restrictive Cardiomyopathy: ___ ___ history [Constrictive Pericarditis v. Restrictive Cardiomyopathy]

surgery, connective tissue No such

Mitral or tricuspid regurgitation Constrictive Pericarditis: Usually ___ Restrictive Cardiomyopathy: Often ___ [Constrictive Pericarditis v. Restrictive Cardiomyopathy]

absent present

Ventricular septal movement with respiration Constrictive Pericarditis: Movement towards left ventricle ___ Restrictive Cardiomyopathy: ___movement toward left ventricle [Constrictive Pericarditis v. Restrictive Cardiomyopathy]

on inspiration Little

Respiratory variation in mitral and tricuspid flow velocity Constrictive Pericarditis: ___% in most cases Restrictive Cardiomyopathy: ___% in most cases [Constrictive Pericarditis v. Restrictive Cardiomyopathy]

>25 <15

Equilibrium of diastolic pressures in all cardiac chambers Constrictive Pericarditis: Within ___ in nearly all cases Restrictive Cardiomyopathy: ___ in only a small proportion of cases [Constrictive Pericarditis v. Restrictive Cardiomyopathy]

5mm Hg Present

Respiratory variation of ventricular peak systolic pressures Constrictive Pericarditis: Right and Left ventricular peak systolic pressures are ___ Restrictive Cardiomyopathy: Right and Left ventricular peak systolic pressures are ___ [Constrictive Pericarditis v. Restrictive Cardiomyopathy]

out of phase (discordant) in phase

MRI/CT Constrictive Pericarditis: ___pericardial thickening in most cases Restrictive Cardiomyopathy: ___ pericardial thickening [Constrictive Pericarditis v. Restrictive Cardiomyopathy]

Show Rarely show

Endomyocardial Biopsy Constrictive Pericarditis: ___ or ___findings Restrictive Cardiomyopathy: ___ in some cases [Constrictive Pericarditis v. Restrictive Cardiomyopathy]

Normal or nonspecific Amyloid present

Angina pectoris-lying down ___-due to change in outflow obstruction when ventricle has greater___ [Hypertrophic Cardiomyopathy Symptoms]

relieves, preload

F___ [Hypertrophic Cardiomyopathy Symptoms]

Fatigue

S___ [Hypertrophic Cardiomyopathy Symptoms]

Syncope

Tachydysrhythmias-dysrhythmias are cause of ___ ___ in young adults [Hypertrophic Cardiomyopathy Symptoms]

sudden death

Heart ___ [Hypertrophic Cardiomyopathy Symptoms]

failure

Treatment goals Improve diastolic ___ [Hypertrophic Cardiomyopathy Symptoms]

filling

Treatment goals Reduce ___ ___obstruction [Hypertrophic Cardiomyopathy Symptoms]

LV outflow

Treatment goals Decrease myocardial ___ [Hypertrophic Cardiomyopathy Symptoms]

ischemia

___-the reduction of arterial blood pressure more than 10 mm Hg from exhalation to inhalation

Pulsus paradoxus

Kussmaul sign –

distention of jugular veins during inspiration

Ventricular discordance – opposing responses of the right and left ___ to filling during the ___ cycle

ventricles, respiratory

Continual increases in the ___ pressure resulting in impaired diastolic filling [Cardiac Tamponade]

intrapericardial

Slow accumulation allows the ___ to stretch [Cardiac Tamponade]

pericardium

Rapid accumulation can cause ___ ___ [Cardiac Tamponade]

cardiovascular collapse

Causes: Trauma Cardiac ___ Malignancy within ___ Expansion of ___ after pericarditis [Cardiac Tamponade]

surgery mediastinum effusion

Normal intrapericardial pressure – ___ [Cardiac Tamponade]

subatmospheric

Any accumulation changes ____ Poor diastolic ___ ___ in SV and CO Peripheral ___ Poor tissue perfusion Catecholamine ___ [Cardiac Tamponade]

pressure filling Decrease congestion release

Catecholamine release: ___cardia Vaso___ Increased venous pressure to maintain ___ [Cardiac Tamponade]

Tachy constriction CO

Beck’s triad: [Cardiac Tamponade]

hypotension, jugular venous distention, distant muffled heart sounds

Equilibration of LA, RA, and RVEDP at ___ [Cardiac Tamponade]

20 mm Hg

___ and ___ in the presence of a hemodynamically significant cardiac tamponade can result in life-threatening hypotension. [Cardiac Tamponade-Anesthetic management]

GA and pos press ventilation

___is your drug of choice – increases contractility, SVR, and HR. [Cardiac Tamponade-Anesthetic management]

Ketamine

In a hemodynamically unstable patient to undergo general anesthesia, some recommend prepping and draping prior to___to allow for quicker relief of tamponade. [[Cardiac Tamponade-Anesthetic management]

induction

Often seen after release of severe tamponade, a swing from ___ to marked ___. Be prepared! [Cardiac Tamponade-Anesthetic management]

hypotension, hypertension

Conditions in which there are pathogenic microorganisms in the ___. [Sepsis]

bloodstream

___ from localized effect to severe generalized inflammation with ___ ___ [Sepsis]

Continuum, multi-organ failure

___plus systemic inflammatory response syndrome (SIRS) Estimated mortality: ___% [Sepsis]

Infection 10-25

Infection: ___ detected in blood or tissue Estimated mortality: ___% [Sepsis]

Pathogens 0-10

Severe sepsis: Sepsis plus ___ ___: Lactic acidosis, Oliguria, Confusion, Hepatic dysfunction Estimated mortality: ___% [Sepsis]

organ dysfunction 25-50

Severe sepsis plus hypotension (systolic BP ___mmHg despite adequate fluid resuscitation) Estimated mortality: [Sepsis]

<90 50-80

Sepsis: F___ ___glycemia Altered mental status (___)

Fever Hyper encephalopathy

SIRS WBC ___ or ___ or more than ___% bands Heart rate > ___beats/min Temp >38 or <36o C Resp rate >20 breathes/min or PaCO2 <___ mm Hg

>12,000 or <4000 10% 90 32

Septic Shock Perfusion ___ Lactic acidosis Oliguria Hemodynamic instability High output cardiac ___(hypotension, bounding pulse, wide pulse pressure)

abnormalities failure

Anesthesia management ___ until treatment of sepsis with antibiotics

Postpone

Anesthesia Management May not be able to delay as cause of sepsis is the reason for urgent surgery – “___ ___surgery” - abscess, bowel perforation, infected device

source control

Preop goals – optimize patient’s condition MAP ___mm Hg CVP* of____ mm Hg ___ urine output Normal pH without lactic acidosis MvO2 ___ Antibiotics – within ___ hour of sepsis recognition [Sepsis-Anesthetic management]

MAP > 65 CVP 8 – 12 Adequate UOP MvO2 > 65% one

Intraop goals Invasive monitoring – ___ ___ IV access – volume and blood products Inotropic/___ [Sepsis-Anesthetic management]

poor reserve vasopressors

Exam II: CHF, Cardiomuopathies, Pericardial Disease, Sepsis Flashcards

(285 cards)