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52 Cards in this Set

  • Front
  • Back
Normal Coronary Blood Flow Parameters:
225-250mL/min, 4-7% of CO
Coronary Autoregulation Parameters:
50-120mmHg (MAP)
Coronary Perfusion Pressure (CPP):
Normal range 50-80mmHg
Main determinent of CPP is DBP
Coronary Flow Reserve:
Resting Coronary Blood Flow
(-) Maximal Coronary Blood Flow; the smaller the difference = smaller the reserve
Factors that Increase Myocardial Supply:
-Coronary blood flow (autoregulation)
-Increased DBP
-Decreased HR
-Increased Oxygenated Hgb
Myocardial ischemic threshold:
The point in which development of ischemia occurs, most significant cause is increased HR
Preload Desired with Cardiovascular Disease:
Decreased, yet adequate to maintain CPP & adequate Stroke Volume
Afterload Desired with Cardiovascular Disease:
Maintain or slightly decrease to "unload" heart, not a dramatic decrease that would trigger barorecpetor = increased HR (bad)
Contractility Desired with Cardiovascular Disease:
If LV good then slight depression; if LV bad then depression could cause CHF
Factors that increase myocardial rate of O2 consumption to the greatest:
(Most to least):
-Increased HR
-Increased contractility
-Increased wall tension
Energy Starvation Hypothesis
With decreased amounts of substrate and decreased amounts of O2 there is decreased energy production & decreased pumping efficiency = potential for ischemia
Normal B/P:
<120 systolic <80 diastolic
120-139 systolic
80-89 diastolic
Hypertension Stage 1:
140-159 systolic
90-99 diastolic
Hypertension Stage 2:
>160 systolic
>100 diastolic
Idiopathic HTN:
Essential or idiopathic HTN accounts for 90% of HTN, unknown etiology, thought d/t ANS dysfunction = chronic vasoconstriction, hyperactive renin-aldosterone system, or increased amounts of Ca+ stores
Changes in CO & SVR with HTN:
Initially have increased cardiac output with normal SVR, over time CO returns to normal but SVR increases
Left Ventricular Hypertrophy:
Concentric/wall thickens, increased muscle from pushing against increased SVR
Composition of Plaque:
-Inflammatory cells
Stable Angina:
-Occurs when coronary artery occlusion ~50-70%
-With increased demand cannot meet supply needs develop s/s of ischemia
-Relieved with rest, O2, NTG
-Usually <15min
-No increased morbidity/mortality associated with stable angina in cardiac patients presenting for noncardiac surgery
Unstable angina:
abrupt or new onset increase in severity, frquency, duration of anginal attacks (>3/day), angina at rest, no precipitating factors, usually lasts >30min, associated with MI and plaque disruption & micro-emboli
Myocardial Ischemia/Infarction Time Periods:
-<40 minutes reperfusion minimal damage
-40min-4hrs = necrosis
->6hrs = infarcted tissue
Myocardial stunning & Ischemic preconditiong:
even within infarcted tissue there are viable myocytes, stunning occurs as a r/o brief period of ischemia followed by reperfusion, resolves in 42-78hrs.
-Myocytes become ineffective which decreases metabolic rate, decreases MVO2, & protects cells in low O2 environment
Reperfusion of ischemic tissue:
Ischemic tissue exposed to O2 then O2 free radicals (substrate, acid, free Ca+, mediators of inflammation) are created and released that destroy cell membranes, myocardium, mitochondria
Coronary Artery Spasm:
"Prinzmetal's angina," unknown etiology, thought d/t stress, hyperventilation, exertion, females>males, no CAD, trt: Nitrates, Ca+ channel blockers, spasm can lead to infarction!
Top 3 objective factors that increase the intraoperative risk of myocardial ischemia/infarct:
History MI, CHF, S3 gallop
Revised Cardiac Risk Index:
6 Factors:
-high risk surgery
-hx ischemic heart dx
-hx CVA
-hx CHF
-preop use insulin
-preop serum creatinine >2.0

*>3 factors significant
Low Risk Surgical Procedures:
-Endoscopic procedures
-Superficial procedures
Intermediate Risk Surgical Procedures:
-Carotid endarterectomy
-Head & Neck
High Risk Surgical Procedures:
-Emergent major in elderly
-Aortic/Major Vascular
-Peripheral vascular
-Prolonged with large fluid shifts
Major Clinical Predictors:
-Unstable Coronary syndromes
-Decompensated CHF
-Significant arrhythmias
-Severe valvular disease
Intermediate Clinical Predictors:
-Mild angina pectoris
-Prior MI
-Compensated or prior CHF
-Diabetes Mellitus
Minor Clinical Predictors:
-Advanced age
-Abnormal ECG
-Rhythm other than sinus
-Low functional capacity
-Uncontrolled systemic HTN
Functional Capacity:
-Low: 1-3 METS: eating, dressing, walking around house
-Moderate: 4 METS: walk one flight stairs, walk at 4mph
-Excellent: >10 METS: swimming, tennis

*Less than 4 METS is a minor clinical predictor
Ejection Fraction:
-Normal: 60% or >
-Mild dysfunction: 59-40%
-Moderate dysfunction: 39-20%
-Severe dysfunction: 19% or less
-picture @ one moment in time
-detects acute changes
-old MI's
-conduction abnormalities
2-D Echo:
-assesses wall motion
-estimates EF
-estimates chamber size
-measures wall thickness
-can be inaccurate-depend on technician-when EF low can be <15%->28% inaccurate
Exercise electrocardiography (Treadmill):
-Increase demand to see if supply can keep up
-ischemia, arrhythmias, hypotension, syncope, MI, sudden deateh
-normal test does not exclude CAD
Holter monitor:
-Measures silent ischemia
-Records arrhythmias
Exercise thallium:
Give thallium, pt. exercises fluroscopy for infarcted areas
Pharmacological Stress thallium:
Pt. doesn't exercise, given adenosine and dipyridamole-dilate coronary's (produce coronary steal without direct negative inotropic stess testing)
Coronary angiography:
gold standard for evaluating CAD
Significant ventricular dysfunction indicators:
-EF <40%
-CI <2.2L/min
-LVEDP >18mmHg
Beta Blocker Hemodynamic Effects:
-Decrease contractility
-Decrease SA automaticity
-Decrease AV conduction
Most sensitive leads for ECG:
V4 & V5 90% sensitive
II & III 80% sensitive
-Peaked T Waves
-Inverted T Waves
-ST segment depression
-20-40 minutes
-ST segment elevation
->1-2 hours
-Abnormal Q waves
->25% height of R wave in that lead
->2mm wide
LAD occlusion on ECG:
Circumflex occlusion on ECG:
I, aVL, possibly V5, V6
RCA occlusion on ECG:
Highest sensitivity for ischemia for intraoperative monitoring, only use intraoperative, expensive, analysis difficult