Ischemia Heart Disease (Exam 2) Flashcards
(125 cards)
1
Q
What percent of surgical patients have a risk factor for Ischemic Heart Disease?
A
30%
2
Q
What are the 2 most common important risk factors for developing artherosclerosis?
A
- Males
- Age
3
Q
What are the modifiable risk for Ischemic Heart Disease?
A
- Hypercholesterolemia
- Hypeternsion
- Cigarette smoking
- Diabetes Mellitus
- Obesity
- Sedentary Lifestyle
4
Q
What are the non-modifiable risk factors for Ischemica Heart Disease?
A
- Males
- Age
- Genetic/Family History
5
Q
Define Angina Pectoris
A
- Imbalance between coronary blood flow (supply) and myocardial oxygen consumption (demand)
6
Q
Stable Angina, indicates they have a what percentage occlussion?
A
70%
7
Q
What does the release of adenosine and bradykinin do to improve the balance between myocardial oxygen supply and demand?
A
- Slow atrioventicular conduction
- Decrease cardiac contractility.
8
Q
What is the most common cause of impaired coronary blood flow resulting in angina pectoris?
A
- Artherosclerosis
9
Q
What is the one medication that is proven to be beneficial for cardiac patients?
A
Beta blockers
10
Q
What are the most common signs and symptoms of Iscemic Heart Disease?
A
- Retrosternal chest pain
- Pressure
- Heaviness
11
Q
What 2 types of patient might have abnormal or no cardiac symptoms for IHD?
A
- Women
- Diabetes
12
Q
What 3 non-medical factors induce angina?
A
- Physical exertion
- emotional tension
- cold weather
13
Q
What is Chronic Stable Angina?
A
- Chest pain does not change in frequency or severity in 2- month period.
14
Q
What is unstable angina?
A
*Chest pain that lasts longer than 10 minutes
* Chest pain increasing in frequency and/or severity without increase in cardiac biomarkers
15
Q
What degree occlussion does someone have with chest pain that does not go away with rest or nitro?
A
- 90-100%
16
Q
Cardiac conditions that cause chest pain
A
- Angina
- Rest or unstable angina
- Acute MI
- Pericarditis
17
Q
Vascular conditions that can cause chest pain
A
- Aortic dissection
- Pulmonary embolism
- pulmonary hypertension
18
Q
Pulmonary Conditions that can cause chest pain
A
- pleuritis and/or pneumonia
- tracheobronchitis
- spontaneous pneumothorax
19
Q
Gastrointestinal Conditions that can cause Chest Pain
A
- Esophageal reflux
- peptic ulcer
- gallbladder disease
- pancreatitis
20
Q
Musculoskeletal disorders that can cause chest pain.
A
- costochondritis
- Cervical disk disease
- trauma or strain
21
Q
Infectious conditions that can cause chest pain
A
- herpes zoster
22
Q
Psychological conditions that can cause chest pain.
A
- Panic disorder
23
Q
What does an EKG show for IHD?
A
- ST segment depression
- Associated T wave inversion
- ST elevation
24
Q
How can you diagnosis IHD?
A
- 12 lead EKG
- Exercise Stress Test
25
What medications can you give for an Amniotic Fluid embolism?
* Toradol
* Zofran
26
What labs should you order for ISD?
* Serial Troponins
27
The ____ the degree of ST- segment depression, the ____ the likelihood of significant coronary artery disease.
* greater
* greater
28
What has a greater sensitivity than exercise testing for detection of ischemic heart disease
Nuclear Stress Test
29
Why do we use Nuclear Stress tests to diagnose ISH?
* Greater sensitivity
* Assesses coronary perfusion
* determines size of perfusion abnomality
* Estimates LV systolic size and function
* differentiates old vs new MI
30
What tracers are used during Stress Tests?
* Thallium
* Atropine, doBUTamine, pacing
* adenosine, dipyridamole
31
What does an Echocardiography show?
* Wall motion abnomalities
* Valvular function
32
What does a Coronary angiography show?
* determines location of occlusive disease
* diagnose Prinzmetal angina
* Assess results of angioplasty/stenting
* DOES NOT measure stability of plaque
33
What is variant angina?
* coronary vasospasm
34
How do we treat variant angina?
* Calcium Channel Blockers
* Verapomil
35
Treatment of IHD (nonmedications)?
* Cessation of smoking
* Ideal body weight
* diet
* exercise
* treatment of hypertension
36
Mortality differences between young people and old people with MIs?
* Collateral Circulation, old people will survive
37
Medication to treat IHD?
* ASA
* platelet glycoproteinIIb/IIIa receptor antagonist
* Thienopyridines (P2Y12 inhibitor)
* Nitrates
* BB
* CCB
* ACE-i
* Statins
38
ASA
* inhibits COX-1... thromboxane A2
* **Irreversible, platelet life span**(7-14 days)
* 75 -325 mg/day
39
Thienopyridines (P2Y-12 inhibitors)
* clopidogrel
* Prasugrel (effient)
40
Clopidogrel
* Inhibits ADP receptor P2Y-12 and platelet aggregation
* Irreversible, platelet life span
* D/C ~ 80% of platelets recover to normal function
* PRODRUG --- 10-20% of people hypo/hyper response; PPI
41
Prasugrel (Effient)
* Inhibits ADP receptor P2Y12 and platelet aggregation
* Higher risk of bleeding
* MORE POTENT and PREDICTABLE THAN PLAVIX
42
Nitrates
* Dilate coronary arteries and collaterals
* Decrease peripheral vascular resistance
* Decreases preload
* Potential anti-thrombotic effects
43
Nitrates drug interactions
* Synergistic with beta-blockers/calcium channel blockers
* Contraindicated with aortic stenosis and hypertrophic cardiomyopathy
44
Beta Blockers
* Only drug to prolong life in CAD pts
* Anti-ischemic, anti-hypertensive, anti-dysrhythmic
* Decreases risk of death and reinfarction in MI pts
45
What does blocking B1 do?
*decreases Heart rate
* increases diastolic time
* decreases myocardial contractility
* decreases myocardial oxygen demand
46
Name 4 B-1 blockers
* atenolol
* metoprolol
* acebutolol
* bisprolol
47
Name (2) B-2 adrenergic blockers? And what do you need to be concerned about?
* propanolol
* nadolol
* **Pulmonary complications**
48
Calcium Channel Blockers
* Uniquely effective for decreasing frequency/severity of spasm
* Dilate coronary arteries
* Decrease
1. Vascular smooth muscle tone
2. Contractility
3. Oxygen consumption
4. Systemic BP
49
ACE inhibitors
* stops the angiotensin convering enzyme from converting angiotensin 1 to angiotensin 2
* Treats:
1. HTN
2. Heart Failure
3. Cardioprotective
50
What does Angiotensin increase?
* Myocardial hypertrophy
* intestinal myocardial fibrosis
* coronary vascoconstriction
* inflammatory responses
51
Statins
* Coronary Plaque Stabalization
* Decreases
1. Lipid oxidation
2. Inflammation
3. Matric malloproteinase
4. Cell death
**REDUCES OVERALL MORTALITY IN SURGICAL PATIENTS**
52
When does Revascularization happen?
* Failure of medical therapy
* 50% L main coronary artery
* 70% epicardial coronary artery
* Impaired EF <40%
CABG > PCI
53
Can OMI/STEMI have ST elevation?
* Yes
* Just might not be present on the left side of the heart.
54
Define Acute Coronary Syndrome?
* Acute or worsening imbalance of myocardial oxygen supply to demand.
55
Name 4 causes of ACS
* Atheromatous plaque
* coagulation cascade
* thrombin generation
* arterial occlusion
56
How do we diagnosis a STEMI?
* ST Elevation on EKG
* Rise in cardiac markers -- Troponin
* Some evidence of myocardia ischemia. ---LBB,Q wave
57
What is more specific CKMB or Troponin?
Troponin
58
When will you see an increase in Troponin for an MI patient?
* Within 3 hours after MI
59
What abnormalities will you see on imaging studies for an MI?
* LLB or abnormal EKG
* regional wall motion abnormalities
60
What does CKMB lab test tell us?
* There has been some type of muscle death has occured
* Not specific to cardiac muscle.
61
Drug therapy for an MI
* MONA
* P2Y -12 inhibitors
* Platelet glycoprotein IIa/IIIb
* Unfractionated heparin
* BB
* RAAS
62
What is the primary goal in management of STEMI?
* To re-establish blood flow in the obstructed coronary artery ASAP
63
What medication do we use for Reperfusion Therapy?
* **Steptokinase**
* Reteplase
* TPA
* **tenecteplase**
64
When do we administer Thromboltics to MI patients?
* within 30-60 minutes
* no longer than 12 hours after symptoms begin.
65
What is better for MI patients, PCI or thrombolytics?
PCI
66
Indications for a PCI
* Contraindications to thrombolytic therapy
* Severe HF and/or pulmonary edema
* Symptoms present for 2-3 hours
* Mature Clot
67
How does Dr Cornellius differentiate between major and minor surgery for counterindication to thrombolytic therapy?
* Can the surgery site be compressed.
68
What are counterindations for thrombolytic therapy?
* Surgery: major vs minor
* Uncontrolled HTN
* aneurysm
* Inracranial bleeds
* Received thrombolyitics in the past 3 - 6 months.
* Active bleeding
69
What are you at a risk for when given multiple dose of thrombolytics?
* Anaphylatic Reaction
70
Indications for a CABG
* Abnormal Coronary Anatomy
* Failed angioplasty
* Evidence of infarction- related ventricular septal repture
* Mitral Regurg
71
Does reperfusion occur faster in PCI or CABG?
PCI
72
Name 5 causes of Angina/NSTEMI
* Rupture or erosion of coronary plaque
* Dynamic obstruction due to vasoconstriction
* Worsening coronary luminal narrowing
* inflammation
* myocardial ischemia
73
Presentation of Angina at rest
* chest pain lasting > 10 minutes
74
Presentation of Chronic angina
* After interventions
* 2 month mark
* more frequent and easily provoked
75
Presentation of New-onset angina
* Diagnosis of exclusion
* severe, prolonged or disabling
* they feel like they are going to die.
76
What are the treatments for Angina/NSTEMI?
* Bedrest, oxygen, analgesia, BB
* Nitro
* CCB
* ASA/Clopidogrel/ticarelor/heparin
77
What therapy is NOT indicated for Angina/NSTEMI
* Thrombolytics
* Can increase mortality
78
What is Percutaneous Coronary Intervention (PCI)?
* Alternative to CAGB
* Balloon angioplasty, bare-metal stent, drug eluding stent
* Destruction of endothelium
79
What are the 2 main Risks with a PCI?
* thrombosis
* increased risk of bleeding
80
What is the most significant independent predictor of stent thrombosis in patient's who have had a PCI?
* P2Y-12 inhibitors discontinuation.
81
What are the 2 most common medications in Dual Antiplatlet Therapy (DAPT)?
* ASA
* P2Y-12 inhibitors
81
When should you D/C DAPT meds for surgical bleeding risk? And who should you always consult?
* 5 days- clopidogrel or ticagrelor
* 7 days - prasugrel
* continue ASA is possible
*** ALWAYS CONSULT THE PTS CARDIOLOGIST**
82
How do you reverse ASA or Plavix?
* Give platelets
83
When can you have surgery done after having an angiolasty without stenting?
2 - 4 weeks
84
How long do you have to wait to have surgery after a bare metal stent placement?
* 30 days - 12 weeks
85
How long do you have to wait to have surgery after a CABG
* 6 - 12 weeks
86
How long do you have to wait to have surgery after a drug-eluting stent placement?
* 6-12 months
87
What is the purpose of a Pre-Op assessment?
* Determine presence of risk factors
* Evaluate METs
* Co-existing non-cardiac disease
* physical exam
* Specialized testings
88
What 2 non-cardiac disease are we most concerned about?
* diabetes
* HTN
89
During pre-op assessment, what co-existing disease are we concerned about with Coronary Syndrome?
90
Do we stop B-blockers before surgery?
No
91
If someone is on a Beta Blocker and are bradycardic, what medication works better? Glycopyrrolate or Atropine?
* Glycopyrrolate
92
Why would we give an alpha-2 agonist to a patient with Angina/NSTEMI?
* sedation - precedex
* decreases sympathetic outflow
* decrease BP
* Decrease HR
93
Per Cornelius, what is the enemy of any angina/NSTEMI patient?
* Tachycardia
94
What medication do you need to hold 24 hours before surgery?
ACE-i
95
What are the Inflammatory responses to surgery?
* Hypercoagulable state
* Plaque rupture
96
What medication do you give to stop the inflammatory response from surgery?
Statins
97
What medications do you give to stop the neuroendocrine response from surgery?
* Alpha-2 analgesics
98
What is the most common tool stratifiy cardiac patients and determine if they are healthy enough for surgery?
* Revised Cardiac Risk Index (RCRI)
99
What does the RCRI do?
* Prediction tool recommended by ACC/AHA
* Estimates risk of cardiac complications
* Low risk: <1%: < or = 1 RCRI
* high risk : > 1%: > or = 2 RCRI
100
What are the 6 components of RCRI?
1. High-risk surgery
2. Ischemic Heart Disease
3. Congestive Heart Failure
4. Cerebrovascular disease
5. Insulin-dependent diabetes mellitus
6. Preoperative serum creatine components > 2 mg/dL
101
How do we measure Functional Capacity?
* METs
* 1 MET = 3.5mL/kg/min
102
What METs do you need to have before qualifying for surgery?
> or = 4 METs
103
Urgency of Surgery: Emergency
* Life or limb would be threatened if surgery did not proceed within 6 hours or less
* can do surgery w/out pre-op cardiac assessment
* focus on surveillance and early treatment
104
Urgency of Surgery: Urgent
* life or limb would be threatened if surgery did not proceed within 6 to 24 hours
105
Urgency of Surgery: Time-sensitive
* delays exceeding 1 to 6 weeks would adversely affect patient outcomes.
106
What 6 conditions can significantly increase the risk of perioperative adverse cardiac events?
1. Unstable Coronary Syndromes
2. Unstable or severe angina
3. Decompensated heart failure
4. Severe valvular heart disease
5. Significant dysrhythmias
6. Age
107
What are our anesthesia goals for cardiac patients?
* Prevent Myocardial ischemia
* Monitor for ischemia
* Treat ischemia
108
What 5 things do we want to prevent during anesthesia?
* Persistent tachycardia
* Systolic HTN
* SNS stimulation
* Arterial hypoxemia
* Hypotension
109
During anesthesia we want to maintain HR abd BP within what % of baseline?
20%
110
Name 9 conditions that can decrease oxygen delivery
1. Decreased coronary blood flow
2. Tachycardia
3. Hypotension
4. Hypocapnia
5. Coronary artery spams
6. Decreased oxygen content
7. anemia
8. arterial hypoxemia
9. shift oxyhemoglobin dissociation curve to the left.
111
Name 6 things that can increase oxygen requirements
1. SNS stimulation
2. Tachycardia
3. Hypertension
4. Increased Myocardial contractility
5. increased afterload
6. increased preload
112
Anesthetic considerations for Cardiac patients to prevent SNS response.
* parolytic agent
* DL < 15 seconds
* volatile anesthetics
* nitrous oxide
* opioids
* neuraxial anasthetics
113
What medication do you give a tachycardic cardiac patient?
esmolol
114
What medication do you give to a bradycardic cardiac patient?
* Glycopyrolate
* Gradual increase in HR
115
What medications do you give a hypotensive cardiac patient?
* Ephedrine
* Phenylephrine
* Fluids
* blood
116
What are our most common used telemetry Leads to monitor patient?
* II
* IV
117
What does lead 2 show us?
* Inferior part of the heart
118
What part of the heart does lead 5 show us?
* Anterior, lateral
119
What leads show the Right Coronary Artery?
* 2
* 3
* avF
120
What leads show the Circumflex Artery?
* 1
* aVL
121
What leads show the left anterior descending artery?
* V3-V5
122
Where does the RCA supply blood?
* Rt Atrium
* Rt Ventricle
* SA node
* inferior aspect of left ventricle
* AV node
123
Where does the Circumflex supply blood?
* Lateral aspect of left ventricle
124
Where does the Left Anterior Descending Artery supply blood?
* Anteriolateral descending coronary artery
