Lecture 9/10: Medical and Surgical Management

Question 1

lifestyle modifications for lowered HTN

Answer 1

1kg weight loss = 1mmHg BP reduction

low sodium diet <1500mg

pharmacology to decrease fluid volume and increase vasodilation (combo of diuretics, ACE or ARB, and Ca channel blockers

Question 2

function of diuretics

Answer 2

stops sodium reabsorption by kidneys = more urine

decrease fluid levels = decrease blood volume in circulation = decreases preload (less blood returning to heart so less needs to be ejected)w

Question 3

what is a loop diuretic

Answer 3

most effective/most utilized

inhibits movement of K and Cl across membrane

not 1st line of defense; may want to first try something that doesn’t affect electrolytes so much; can be dangerous/need to replace

Question 4

function of ACE inhibitors

Answer 4

acts on RAAS to reduce intravascular fluid to reduce preload

prevent normal increase in circulating blood volume

prevents normal vasoconstriction and increased SVR that LV has to push against

can’t be used with pts with lung disease due to side effects of smooth mm contraction of all-sized airways

inhibits conversion of And I to II (occurs in lungs)

Question 5

function of Angiotensin receptor blockers (ARBs)

Answer 5

acts on RAAS to prevent normal vasoconstriction used to raise BP

Ang I gets converted to Ang II in lungs but And II is blocked from distal receptors

much safer for pts with lung disease

Question 6

function of Ca channel blockers

Answer 6

stops Ca entrance into myocardium = coronary vasodilation

decreased myocardial contraction strength and O2 demand (LV doesn’t have to work as hard to meet body O2 demand)

acts on peripheral vasculature smooth mm to vasodilate

Question 7

pharm goals for management of CAD

Answer 7

decreased myocardial O2 demand

increase myocardial O2 supply

strengthen LV contractility

Question 8

sx management goals of CAD

Answer 8

reduce/remove atherosclerotic plaque

bypass blocked coronary arteries before progression to MI

Question 9

Drugs that decrease O2 demand for those with CAD

Answer 9

BBs
CCBs
nitrates

Question 10

Drugs that increase O2 supply for those with CAD

Answer 10

thrombolytics
anti-platelets
anticoagulants

Question 11

drugs that increase LV strength

Answer 11

ionotropes

Question 12

function of beta blockers

Answer 12

stops epi and norepi from binding to B1 and B2 receptors

nonselective BBs block both B1 and B2

cardioselective BBs only block B1 receptors to prevent unwanted respiratory involvement

Question 13

methods of administration of nitrates

Answer 13

sublingual tablet
sublingual spray
sublingual powder
paste to spread on skin
transdermal patch
continuous IV drip (abbreviated gtt)

Question 14

thrombolytics function

Answer 14

accelerate clot breakdown

normal clot lysis happens naturally over period of days to weeks

Question 15

antiplatelets function

Answer 15

stops platelet adherence

doesn’t stop RBCs from sticking to one another, just prevents platelets from adding to clot formation

Question 16

anticoagulant function

Answer 16

prevent clot formation

stops normal clothing cascade from occurring

Question 17

types of inotropic meds

Answer 17

cardiac glycosides

sympathomimetics

phosphodiesterase inhibitors

arteriodilators (indirect ionotrope)

Question 18

how do cardiac glycosides work

Answer 18

decrease active transport of Na and K to increase intracellular Na

Question 19

how do sympathomimetics work

Answer 19

mimics action of epi/norepi to increase sympathetic NS drive

Question 20

how do phosphodiesterase inhibitors work

Answer 20

increase myocardial contractility without altering the Na-K pump

Question 21

how do arteriodilators (indirect ionotrope) work

Answer 21

decrease after load by decreasing arterial resistance (decreases SVR)

Question 22

what is a PCI

Answer 22

percutaneous coronary intervention

can be performed electively or emergently

ACS - door to balloon time <90 min

typically used for 1-2 vessel blockage

catheter inserted bia distal artery to access coronary arteries with goal of restoring blood flow to cardiac mm

pts generally on 2 anti-platelets post sx to prevent thrombus (aspirin + plavix)

Question 23

balloon angioplasty vs angioplasty with stent

Answer 23

balloon = Cath used to inflate balloon to open a blocked artery

stent = stent placed in place of inflated balloon to keep artery open; drug eluding stent is most common

Question 24

indications for a coronary artery bypass graft (CABG)

Answer 24

lesions threatening major portions of myocardium

multi-vessel disease, especially L sided blockages

ongoing ischemia following MI

Question 25

how does a CABG work

Answer 25

graft comes from internal mammary artery from internal chest wall or saphenous vein from leg veins are cauterized, flushed with heparin, and inverted for normal blood flow

Question 26

what is a sternotomy

Answer 26

most commonly used approach to access heart suprasternal notch to xiphoid process sternum is wired closed soft tissue is sutured and glued

Question 27

what is cardiopulmonary bypass (CPB)

Answer 27

heart cannot move during sx but body/brain still need perfusion CPB initiated via cannulation at aorta and IVC/SVC blood removed to oxygenator and returned straight to aorta for distribution once CPB is complete, ice slush is poured into mediastinum to stop heart

Question 28

what is an off pump CABG

Answer 28

heart is accessed from L sided thoracotomy can only operate on L sided coronary aa no CPB less expensive, no sternal precautions, faster recovery isolated portions of myocardium stopped via electrical "starfish"

Question 29

describe what typically happens post op with CABG pts

Answer 29

straight from OR to CVICU (no normal sx post op) RT and RN work to wean down ventilator support and wean off drops/sedation over the 1st 6 hours goal = be extubated within 6 hours monitoring of urine output, chest tube output, all sx sites, and external pacemaker goal = pt in chair within 8 hours of arrival and standing within 12 hours (depends on unit and pt stability)

Question 30

common CABG complications

Answer 30

pain respiratory distress (15-20%) impaired cognition/delirium (CPG "pump head") acute blood loss/cardiac tamponade (bleeding in pericardium/pressure) increased risk clot burden; difficult to balance risk of CVA with risk of hemorrhage if anti-coagulated too soon post sx dysthymia/ectopy

Question 31

when is valve repair/replacement indicated

Answer 31

for symptomatic valve dysfunction

Question 32

what is a valvuloplasty

Answer 32

minimally invasive repair (widening) using balloon Cath technology risk of replacement outweighs repair

Question 33

how does valve replacement work

Answer 33

mechanical or tissue (allograft or xenograft); mechanical required lifelong INR goal adjustment can replace multiple valves in 1 sx frequently done in conjunction with CABG open repair requires sternotomy

Question 34

what is transcatheter aortic valve replacement (TAVR)

Answer 34

minimally invasive prodecure to replace aortic valve utilizes similar process as cardiac cath via femoral or radial artery access in Cath lab valve replacement will always be mechanical sometimes used if pt has high risk of open sx replacement long term outcomes may not be as strong as open AVR

Question 35

what is an external placemaker

Answer 35

set up as backup typically 60 bpm procedure of weaning away

Question 36

what are chest tubes/JP drains used for

Answer 36

need to ensure no post op hematoma formation

Question 37

what is a pulmonary artery catheter (PAC) for invasive monitoring of heart function

Answer 37

measures R atrial pressures, pulmonary aa pressure, CO, cardiac index, and temperature inserted in RIJ or R subclavian, "floated down" the SVC, through RA, RV, and into pulmonary aa held in place my sutures and adhesive dressing at neck if dislodged, indwelling components can cause potentially fatal ectopy

Question 38

what is an arterial line

Answer 38

invasive and instant BP measurement usually in radial aa but can be femoral or brachial if pressure in the line is lost, pt can bleed out

Question 39

what is a central venous catheter

Answer 39

large IV placed in IJ, subclavian, or femoral vein allows for meds/fluids to be given directly

Question 40

line considerations

Answer 40

no mobility 2-4 hours post extubation to reduce risk of airway edema/stridor no mobility 2 hours post central line removal to reduce risk of developing hematoma (especially in neck/groin) femoral lines should not limit mobility but some facilities have restrictions

Question 41

first approach to dysrhythmias

Answer 41

pharm management; want to stabilize cell membranes during action potential by controlling movement of electrolytes

Question 42

other approaches to help dysrhythmias if pharm management doesn't work

Answer 42

pacemaker internal cardiac defibrillator (ICD) variety of other electrophysiologic procedures or sx that can be dine if less invasive measures are unsuccessful

Question 43

class I dysrhythmia meds

Answer 43

Na channel blockers limits myocardial excitation and contraction

Question 44

class II dysrhythmia meds

Answer 44

beta blockers inhibits sympathetic NS

Question 45

Class III dysrhythmia meds

Answer 45

K channel blockers prolongs refractory period and makes it more difficult for myocytes to respond to stimulation from one another

Question 46

class IV dysrhythmia meds

Answer 46

Ca Channel blockers slows conduction through AV nodes

Question 47

what is a permanent pacemaker (PPM) and how does it work

Answer 47

creates action potential in necessary areas in L chest with leads inserted via cephalic vein through the SVC into R atrium, R ventricle, or L ventricle can be single chamber, dual chamber, or biventricular subcutaneous generator functions at a fixed rate, mode, with variety of settings and backup settings

Question 48

indications for pacemaker

Answer 48

bradycardia type II-III heart blocks other uncontrolled arrhythmias

Question 49

things to keep in mind about placement of permanent pacemaker

Answer 49

generator may need to be replaced if batteries run out can interrogate PPM via external device to change settings, charge battery, turn off, etc PPM post op precautions

Question 50

complications of PPM

Answer 50

infection lead movement/migration bleeding, clots no MRI, TENS, NMES caution near magnets

Question 51

what is a leadless pacemaker

Answer 51

new does not require leads or L upper chest generator inserted via femoral vein and IVC into RV can influence RV or LV electrical activity based on location

Question 52

what is an internal cardiac defibrillator

Answer 52

similar to PPM and fires in event of arrhythmia leads inserted into AV node and ventricles pts with EF <35% have higher chance of fatal ventricular fibrillation so sometimes ICD placed prophylactically combination PPM-ICD devices if pt meets indications for both

Question 53

indications for internal cardiac defibrillator

Answer 53

VFib VTach cardiac arrest HF/CM with EF <35% hypertrophic CM combo heart block with ventricular arrhythmia

Question 54

what is cardiac ablation

Answer 54

minimally invasive procedure that controls arrhythmia by creating scar tissue in myocardium targets ectopic foci might not permanently fix problem

Question 55

what is a maze procedure

Answer 55

type of cryo ablation specifically used for persistent AFib creates maze of scar tissue to block abnormal signals but allows normal impulse conduction requires partially open or laparoscopic approach and frequently done in conjunction with other CTS

Question 56

what is an atrial appendage and the clinical indication

Answer 56

both atria have extra tissue that can expand if needed L atrial appendage is larger and can be more problematic higher pressures on the L can case the LAA to expand and be a reservoir for blood >90% of clots that cause CVA originate in LAA

Question 57

what is watchman's procedure

Answer 57

presence of R or L atrial appendage increases risk of clot development in AFib minimally invasive procedure via femoral or radial artery that "plugs" appendage to prevent clot formation higher pressures in L side of heart create enlarged LAA

Question 58

what is LAA or RAA surgical closure/when is it indicated

Answer 58

if watchman's wasn't successful or contraindicated, the atrial bulge can be surgically closed can be done laparoscopically but also in conjunction with other open heart sx

Question 59

what is cardioversion

Answer 59

electrophysiological procedure that restores normal rhythm needs to be done in a highly monitored environment can be done electively or emergently if pt is in fatal rhythm during MI or cardiac arrest situation conscious sedation used for procedure used frequently for AFib with RVR if meds aren't controlling adequately

Question 60

goals of pharm management for heart failure

Answer 60

maintain CO fluid reduction to reduce preload augment LV contractility and decrease after load limit sympathetic nervous system action

Question 61

HF medication types

Answer 61

diuretics ACE/ARB BBs antiarrhythmics Ionotropes

Question 62

what is mechanical circulatory support

Answer 62

if LV isn't functioning well enough to perfuse tissues, MCS can be used to supplement CO various devices can be surgically inserted to improve heart function

Question 63

what is an intra-aortic balloon pump

Answer 63

MCS device placed into proximal descending aorta via femoral, axillary, or subclavian artery balloon attached to helium tank that inflates during diastole and deflates before systole inflation = pushes blood into coronary aa while aortic valve is closed to provide optimal coronary cardiac output deflation = suction of deflation assists with dropping after load and reducing work load on failing LV

Question 64

what is an impella

Answer 64

MCS device placed into LV via femoral, axillary, or subclavian aa mechanically pimps blood from LV into the aorta at a set rate unloads the LV work and decreases myocardial O2 demand

Question 65

what is a left ventricular assist device (LVAD)

Answer 65

implanted MCS device that replaces the workload of the LV and has a motor that controls blood flow at a set rate to maintain cardiac output can be used as a bridge to transplant, temporary ventricular rest, or as destination therapy longest living pt with LVAD = died after 15 years

Question 66

components of LVAD

Answer 66

pump drive line controller external power batteries machine weighs between 4-6 lbs must have power source no pulse

Question 67

LVAD medications (in addition to typical meds for HF)

Answer 67

lifelong anti-coagulant (Life of the LVAD) aspirin or plavix or both pulmonary HTN meds to reduce R heart workload supplements

Question 68

LVAD complications

Answer 68

bleeding; LVAD cant function correctly if pt isn't anticoagulated bloot clots; device mechanism can case clots; prevalence is decreasing R sided heart failure; device placement on L side can alter normal RV movement/function drive line infections; soft tissues infections can migrate to heart

Question 69

describe a heart transplant/important statistics

Answer 69

more pts on waitlist than will ever receive a heart extensive medical, physiological, educational, and financial screening process estimated 1st 5 year expense = $1.6 million 80-90% have 1 year survival rate 60% have 5 year survival rate average survival is 12 years

Question 70

what does it mean that pts who are candidates for heart transplants are on max medical management protocols

Answer 70

severe functional deficits limited life expectancy some must remain hospitalized until transplant becomes available

Question 71

indications for OHT

Answer 71

end stage heart failure congenital heart disorder cardiomyopathy

Question 72

Contraindications for OHT

Answer 72

age >75 severe mental/psychological instability drug, tabacco, ETOH use w/I 6 mo BMI >35 malnourishment uncontrolled DM PVD severe lung disease autoimmune disease with multi system involvement AIDS current/recent malignant cancer other systemic illness with shortened life expectancy

Question 73

J

Question 74

process of heart transplant

Answer 74

1. pt placed on waitlist after being deemed candidate 2. geographic waitlist maintained by United Network of Organ Sharing (UNOS) 3. when an organ becomes available, is matched to a pt based on various characteristics (age, blood type, size, etc) 4. oran is preserved and transported to recipient

Question 75

OHT medications

Answer 75

immunosuppressants: prevent organ rejection corticosteroids: reduce inflammation/risk of rejection antibiotics/antivirals: prevent illness in setting of immunosuppression insulin: counteracts side effects of OHT meds that cause hyperglycemia statins: improve long term outcomes, reduce risk of CAD in donor heart Anticoagulants/anti-platelets: reduce risk of CAD in donor heart

Question 76

OHT complications

Answer 76

infection - highest risk 12 months post op - opportunistic infections in setting of immunosuppression rejection - 50-80% in first 12 months - symptoms of rejection = fever, fatigue, myalgias very challenging to balance risk of rejection with infection

Question 77

what is carotid endarterectomy

Answer 77

sx procedure to remove plaque build up frequently at CCA-ICA bifurcation reduces CVA risk drastically

Question 78

what is carotid stenting

Answer 78

implanted stent to open artery in area of atherosclerotic block

Question 79

indications for AAA surgical repair/replacement

Answer 79

>5cm or high rate of growth rupture or + S&S risk of dissection

Question 80

describe the open sx approach for aortic repair/replacement

Answer 80

aorta repaired/replaced via open laparotomy incision higher blood loss and open complications with open repair

Question 81

describe endovascular aortic repair (EVAR)

Answer 81

can be done it pt is too high risk for open repair vasculature accessed via B femoral aa faster recovery and lower mortality/morbidity in short term worse long term outcomes, higher rates of needing re-do sx

Question 82

what is embolectomy/thrombectomy/atherectomy

Answer 82

removal of blood clot or atherosclerotic plaque can be achieved in a variety of ways

Question 83

what is balloon angioplasty and stenting

Answer 83

peripheral revascularization very similar to cardiac PCI