Ischemic Heart Disease

Question 1

Treatment for Prinzmetal angina?

Answer 1

CCB -> Verapamil

Question 2

2 most important risk factors for IHD (ischemic heart disease)?

Answer 2

Male and age

Question 3

what percentage of surgical patients have IHD?

Answer 3

30%

Question 4

How much of an occlusion does stable angina indicate?

Answer 4

70%

Question 5

What condition is the most common cause of impaired coronary flow resulting in angina pectoris?

Answer 5

Atherosclerosis

Question 6

Angina can radiate through what dermatomes?

Answer 6

C8-T4

Question 7

Stable vs unstable angina?

Answer 7

S - CP that does not change over 2 months
U - angina at rest lasting longer than 10 minutes

Question 8

Describe the acute and long term trends of a troponin level

Answer 8

Acute: remains elevated for 3-4 hours
Long term: elevated ~2 weeks

Question 9

What is the relationship between ST depression and angina?

Answer 9

ST depression is usually indicative of subendocardial ischemia. The larger the ST depression the greater the likelihood of significant CAD.

Question 10

Is a stress test or nuclear stress imaging more sensitive for detection of IHD?

Answer 10

Nuclear stress imaging

Question 11

What tracers and chemicals are used in nuclear stress imaging?

Answer 11

Tracers: Thallium and technetium
Chemical stressors: atropine, dobutamine, pacing, adenosine and dipyridamole

Question 12

What does coronary angiography NOT tell us about IHD? What could provide a hint?

Answer 12

The stability of the plaque (old vs new). Presence of collateral circulation

Question 13

What are Thienopyridines (P2Y inhibitors)

Answer 13

Examples: clopidogrel (Plavix) and prasugrel (Effient)

These inhibit ADP receptor P2Y inhibiting platelet aggregation

Effient is more potent than Plavix and has a higher risk of bleeding

Question 14

What anti-platelet is a prodrug?

Answer 14

Plavix (clopidogrel)

Question 15

What affects do platelet glycoprotein IIb/IIIa antagonists do? Name a few…

Answer 15

these inhibit platelet activation, adhesion and aggregation. Abciximab, eptifibatide, tirofiban.

Question 16

What drugs are nitrates synergistic?

Answer 16

BBs and CCBs

Question 17

What is a core measure for anesthesia providers r/t to beta blockers? Why?

Answer 17

All patients previously on BB should receive a BB during the case.

BBs are the only drugs that prolong the lifespan of patients with CAD.

Question 18

What conditions are nitrates contraindicated?

Answer 18

Aortic stenosis and hypertrophic cardiomyopathy

Question 19

Only drug that prolongs life in CAD?

Answer 19

BBs

Question 20

Which BBs have bronchospasm concerns?

Answer 20

Propranolol and Nadolol

Question 21

Advantage of being on an ACE? Cons?

Answer 21

A = prevent remodeling and stabilize electrical activity, reduce myocardial workload/oxygen demand
C = loss of RAAS means they don’t handle hypotension as well

Question 22

When is revascularization indicated in L main, all other coronaries and EF changes?

Answer 22

L main = 50% occlusion
Other coronaries = 70% occlusion
EF: less than 40%

Question 23

What are the two interventions we have for coronary revascularization?

Answer 23

PCI and CABG.

Question 24

What coronary occlusions is a CABG generally preferred over PCI?

Answer 24

L main disease, triple vessel disease or a patient with DM with 2 or more vessel disease

Question 25

How would you differentiate unstable angina vs a NSTEMI?

Answer 25

12-lead and troponins. 12-lead is +/- with + troponin = NSTEMI negative 12-lead with negative troponin = unstable angina

Question 26

What is the criteria to diagnose an MI?

Answer 26

+ troponin, s/sx of ischemia, ECG changes, pathologic Q waves, imaging evidence (wall motion abnormality) or direct identification via angiography

Question 27

What is the relationship of depth of ST changes to likelihood of ACS?

Answer 27

The greater the degree of depression = the higher chance of significant coronary disease

Question 28

If an EKG suggests an MI, is an echo required?

Answer 28

No. It can be helpful if they have a BBB or if AMI is uncertain such as suspected aortic dissection.

Question 29

Contraindications to starting a BB?

Answer 29

Heart failure, low CO state and not at risk of cardiogenic shock

Question 30

When should thrombolytics be given? Cutoff time?

Answer 30

Within 30 - 60 minutes, and no later than 12 hours

Question 31

Timeframe to start angioplasty?

Answer 31

Within 90 minutes and within 12 hours of symptom onset

Question 32

When is PCI preferred over thrombolytics?

Answer 32

Heart failure, pulmonary edema, symptoms present for at least 2-3 hours or when the clot becomes more mature. Also if patient cannot receive systemic thrombolytics.

Question 33

Treatment for unstable angina?

Answer 33

Bed rest, oxygen, analgesia and BBs. Nitro and CCBs can help if ischemia persists. Other helpful agents: ASA, plavix, heparin Thrombolytics = contraindicated

Question 34

How long is a patient at risk for thrombosis after balloon angioplasty, bare metal/drug eluding stent placement?

Answer 34

Balloon = 2-3 weeks Bare stent = 12 weeks minimum (longer preferred) Drug eluding stent = a full year

Question 35

What are our 2 major concerns with a stent placement?

Answer 35

Thrombosis and increased risk of bleeding

Question 36

Downside of ASA/Plavix relative to heparin?

Answer 36

No reversal agent, all you can do is give platelets

Question 37

How long should a patient wait for surgery after angioplasty, bare metal stent, CABG and drug eluding stent placement?

Answer 37

Angio = 2 -4 weeks Bare = 4 - 12 weeks CABG = 6 - 12 weeks Drug = 6 - 12 months

Question 38

When do you stop an ACE?

Answer 38

24 hours

Question 39

What is the preferred agent to treat bradycardia in the OR?

Answer 39

Glycopyrrolate > atropine

Question 40

What other drug do we give with glycopyrrolate?

Answer 40

Neostigmine--> the effects balance each other out

Question 41

What tool do we use to quantify risk stratification of surgery? What's considered low risk? Elevated risk?

Answer 41

revised cardiac risk index (RCRI). Low risk: RCRI 2

Question 42

Goal for METs?

Answer 42

Greater than 4, which is climbing a flight of stairs or better

Question 43

Ideal time to wait for surgery after an MI?

Answer 43

Generally greater than 60 days

Question 44

Hard cardiac stops to the administration of anesthesia?

Answer 44

Unstable angina, decompensated HF, severe valve disease, significant dysrhythmias

Question 45

Most important goal to achieve if a patient has heart disease when going to the OR? Other factors to try and control?

Answer 45

Must avoid tachycardia. Other goals = prevent HTN, SNS stimulation, arterial hypoxemia and hypotension. Go slow.

Question 46

What anesthetics are good to use to prevent tachycardia?

Answer 46

Sux, Vec, Roc, cisatracurium, lidocaine, esmolol, fentanyl, remifentanil and Dex

Question 47

With severely impaired LV function, what would be a good choice of anesthesia for induction?

Answer 47

High dose opioid only

Question 48

Assuming appropriate anesthetic depth, good drug of choice to treat tachycardia? Brady?

Answer 48

T = esmolol B = Glyco > atropine

Question 49

II, III and AVF changes indicate what kind of occlusion?

Answer 49

RCA occlusion

Question 50

I, AVL indicate changes indicate what kind of occlusion?

Answer 50

Circumflex occlusion

Question 51

V3-5 indicate changes indicate what kind of occlusion?

Answer 51

LAD occlusion