Vascular PP1a Flashcards
(42 cards)
recent MI, preferred waiting time for surgery
percentage of vascular patients that have normal coronaries?
percentgae of vascular patients that have CAD?
preferred to wait 60 days
<10%
>50%
what is MACE
major adverse cardiac event
MI, new onset of HF, arrythmias, ST elevation, Death,
what are the take offs from the aorta
R: innominate(brachiocephalic), right common CA: internal and external CA, R subclavian
L: L common CA and L subclavian
what is the patho of Atherosclerosis
what happens when it dislodges
where are the most common areas of build up
macrophages start sticking to the endothelial lining of the vessels
they build up over time and make foam cells (fatty streaks)
more macrophages come. inside core is filled w lipids and outside has calcium build up and is (fibrous plaque)
if dislodges becomes an emboli: MI or ischemic stroke
medium and large vessels most prone or where areas of branching are
what is a simple way of testing for PVD
ankle brachial index
SBp of ankle/SBP of arm. if less than .9 this is abnormal
what are the three types of atherosclerosis morbidity
- stable plaque. remodeling of the internal lumen. decrease in supply and demand
- plaue rupture and thrombus formation - MI, Stroke, TIA, unstbale angina
- Atrophy of vessel wall and dilation created an aneurysm
what are the risk factors for atherosclerosis
smoker, obses, poor health, DM, HTN, HLD, renal insufficiency, chronic inflammation
what is the MOA of statins
what are the other medical managments of atherosclerosis
statins will decrease
LDL, VLDL, cholesterol synthesis, mevalonic acid —> decrease cholesterol
stop smoking, lose weight, healthy eating, exercise, glucose control, control HTN (BB ACEI),
what are the preoperative guidelines for vascular surgery
review preop meds
type of procedure
level of risk of procedure
is patient optimized, do we need additional evals
clinical hx
what are the effects of chronic drug therapy
aspirin, plavix, statins, ACEI, Diuretics, CCB, hypoglycemis drugs, BB
aspirin - increased bleeding, decreased GFR,
plavix - bleeding
statins - liver dysfunction and rebound inflammation
Diuretics - hypovolemia
CCB - hypotension
hypoglycemic drugs - decrease BG/ metformin —> lactic acidosis
BB: decreaesd HR, BP, bronchospasms
how long to hold
plavix
xarelto
LMWH
5000u heparin
plavix 3 days or 7 days
xarelto 5 days
LMWH 12 hr
heparin 2 hrs
what drugs should you take day of surgery and not take
Take: statins, BB,
dont take: AceI, CCB, aspirin, antiPLT
dont start new BB day of surgery
day of surgery ACEI
why not take them
how to txt
hpotension, not responding to phenyl, ephedrine
what to fluid optimise pt
pat can have refactory vasoplegia
txt: methylene blue, hydroxy cobalamin B12, Vasopressin
day of surgery anti PLT therapy
considerations
DES, BMS
should weight the benefits of surgical bleeding vs thrombotic risk
DES - 6 months
BMS - 30 days
team decision on whether to proceed
how long to hold
plavix, warfarin, fondaparinox, LMHW, dabigatran, DES, BMS, urgent surgery w DES
plavix: 3-7 days
warfarin: until INR is normal
fondaparinox: 48 hrs
LMWH: 12 hrs
dabigatran: 5-7 days
DES: 6 months or 3 months if urgent
BMS: 30 days
Day of surgery Alpha 2 agonist
considerations
clonidine: if stopped after chronic use could have profound rebound hypertension
seen: hypertension, tachycardia, diaphoreis, pulm edema
Recommendations says its not needed to prevent MACE
what type of labs do you want for a vascular patient
cbc, bmp, coags, renal , EKG, troponin, echo
when to order a repeat echo
worsening symptoms
unknown reasons for DOE
known LV dysfunction
no echo done is the past yr
what are the steps to determine if advanced cardiac testing is needed
- urgency of surgery
- ACS or othr patho present?
- will the test results change your plan
what are the 6 steps to know if additional cardiac testing is needed for vascular surgery
- urgency of surgery
- ACS present
- MACE (if <1% proceed)
- MET score >4
- if METS <4, get stress testing
- will these results change my anesthestic plan
when is it recommended get a CABG or PCI before surgery
if not getting surgery, what medications should they be on
only if the left main coronary artery is disrupted. if not, no indication
should be on statins, BB, aspirin
dicuss Ambulatory EKG
what is it, pro and cons
a tool is detect and measure arrythmias
pro: cheap, 1/3 cost of thallium testing
cons: no detection of intensity of arrythmias, cant tell if pt has pacemaker, cant tell LBBB
DTI: thallium imaging
what is it. pros and cons
the most non invasive screening
can be used during exercise or stress testing
thallium will block adenosine to the coronary arteries. now will be able to detect areas of stenosis
what can an echo tell you
bleeding, decreased preload, stenosis or regurg of valves, emboli, lesions, LVADS, EF
