Anesthesia Cardiovascular Assessment
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Questions and Answers

What is the location of the SA node in the cardiac conduction system?

  • Near the IVC
  • Near the pulmonary artery
  • Near the aorta
  • Near the SVC (correct)

    • Which of the following heart sounds is normal in kids and adolescents?

  • S3 (correct)
  • S1
  • S2
  • S4

    • What is the primary cause of S3 gallop?

  • Diastolic heart failure
  • Cardiac tamponade
  • Systolic heart failure or ischemia (correct)
  • Aortic stenosis

    • Which of the following is a characteristic of S4?

    <p>Represents ventricular dysfunction and decreased compliance</p> Signup and view all the answers

    What is the best location to hear S1 splitting?

    <p>Lower left sternal border</p> Signup and view all the answers

    Which of the following conditions can cause an innocent/functional murmur?

    <p>Anemia</p> Signup and view all the answers

    What is the approximate size of the heart?

    <p>The size of a fist</p> Signup and view all the answers

    What is the main function of the mediastinum?

    <p>To connect the heart to the lungs and thoracic vertebral bodies</p> Signup and view all the answers

    What is the outermost layer of the heart?

    <p>Epicardium</p> Signup and view all the answers

    What is the formula for cardiac output?

    <p>SV x HR</p> Signup and view all the answers

    What is the term for the percentage of blood ejected from the heart during each beat?

    <p>Ejection fraction</p> Signup and view all the answers

    What is the term for the pressure the heart must work against to eject blood?

    <p>Afterload</p> Signup and view all the answers

    What is the location of the cardiac apex?

    <p>Left 5th intercostal space</p> Signup and view all the answers

    What is the primary cause of Bruit?

    <p>Atherosclerotic luminal stenosis</p> Signup and view all the answers

    Where are thrills of aortic stenosis transmitted from?

    <p>From the suprasternal notch or 2nd IC</p> Signup and view all the answers

    What is the normal location of the point of maximum impulse (PMI)?

    <p>5th ICS just medial to MCL</p> Signup and view all the answers

    What is the characteristic of the PMI in left ventricular hypertrophy (LVH)?

    <p>It is &gt;2.5 cm and shifted lateral to MCL</p> Signup and view all the answers

    What is the characteristic of the PMI in right ventricular hypertrophy (RVH)?

    <p>It is shifted downwards and to the right</p> Signup and view all the answers

    What is the timing of the murmur in aortic stenosis?

    <p>Systolic</p> Signup and view all the answers

    What is the best method for diagnosing cardiac tamponade?

    <p>Echocardiogram</p> Signup and view all the answers

    What is the treatment for cardiac tamponade?

    <p>Paracentesis and pericardial window</p> Signup and view all the answers

    What is the primary objective of preoperative evaluation in patients with ischemic heart disease?

    <p>To determine the severity, progression, and functional limitations of the disease</p> Signup and view all the answers

    What is the significance of a pulsus parvus et tardus pulse?

    <p>It represents a delayed systolic peak due to obstruction of LV ejection</p> Signup and view all the answers

    A patient with a history of heart failure presents with a preserved ejection fraction (HFpEF). What is the expected outcome?

    <p>The patient tends to do better than those with HFrEF</p> Signup and view all the answers

    What is the definition of orthostatic hypotension?

    <p>A 20mmHg drop in SBP or 10mmHg drop in DBP within 3 minutes of standing</p> Signup and view all the answers

    What is the significance of a carotid pulse in assessing cardiac function?

    <p>It is the best pulse to evaluate heart function</p> Signup and view all the answers

    A patient presents with a history of angina. What is the characteristic of stable angina?

    <p>It is brought on by exertion and relieved by rest or nitroglycerin within 30 minutes</p> Signup and view all the answers

    What is the significance of measuring JVD?

    <p>It is used to evaluate central venous pressure</p> Signup and view all the answers

    What is the primary risk factor for perioperative MI?

    <p>Unstable angina</p> Signup and view all the answers

    What is the characteristic of pulsus bisferiens?

    <p>It is a double pulse seen in AI and hypertrophic cardiomyopathy</p> Signup and view all the answers

    What is the mediastinum?

    <p>A space in the thoracic cavity between the lungs that contains the heart, trachea, esophagus, thoracic duct, and thoracic lymph nodes</p> Signup and view all the answers

    What is the most anterior structure of the mediastinum?

    <p>Right ventricle</p> Signup and view all the answers

    What is the primary purpose of the pericardium?

    <p>To anchor the heart to mediastinum and prevent friction during pumping</p> Signup and view all the answers

    What arteries lie on the epicardial surface of the heart?

    <p>Coronary arteries</p> Signup and view all the answers

    What is the correct arrangement of the heart layers from superficial to deep?

    <p>Epicardium, myocardium, endocardium</p> Signup and view all the answers

    What is the typical allowable MAP range for healthy surgical patients?

    <p>20% from baseline</p> Signup and view all the answers

    What are the three components of Beck's triad?

    <p>Hypotension, Muffled heart sounds, and Distended neck veins</p> Signup and view all the answers

    What type of pulse is seen in cardiac tamponade?

    <p>Pulsus paradoxus</p> Signup and view all the answers

    What is pulsus paradoxus?

    <p>A decrease in systolic blood pressure during inspiration</p> Signup and view all the answers

    Increased intrapericardial pressure causes impaired ___ filling in cardiac tamponade

    <p>Diastolic</p> Signup and view all the answers

    Electrical alterans and decreased voltage can be seen in cardiac tamponade

    <p>True</p> Signup and view all the answers

    Which ventricle forms the cardiac apex?

    <p>Left ventricle</p> Signup and view all the answers

    What is the normal diameter of the PMI?

    <p>1-2.5 cm</p> Signup and view all the answers

    Great vessels enter in the cardiac apex

    <p>False</p> Signup and view all the answers

    S1 heart sounds correspond with which action of the cardiac cycle?

    <p>Atrioventricular valve closure</p> Signup and view all the answers

    S2 heart sounds correspond with closure of what valves?

    <p>Pulmonary and aortic</p> Signup and view all the answers

    What sound occurs immediately after S4 sounds?

    <p>S1</p> Signup and view all the answers

    S4 heart sounds indicate which of the following?

    <p>LVED stiffness, ventricular dysfunction, and decreased compliance</p> Signup and view all the answers

    Split S1 sound is an abnormal finding

    <p>False</p> Signup and view all the answers

    S2 splitting on inspiration indicates which of the following?

    <p>Increased right heart filling time, delayed closure of the pulmonic valve</p> Signup and view all the answers

    S2 splitting on expiration indicates which of the following?

    <p>Fast right ventricular ejection</p> Signup and view all the answers

    Which valve closure sound is loudest in S1 splitting?

    <p>Mitral valve</p> Signup and view all the answers

    Which valve closure sound is loudest in S2 splitting?

    <p>Aortic valve</p> Signup and view all the answers

    Where is S2 splitting best auscultated?

    <p>2nd-3rd ICS to the left sternum</p> Signup and view all the answers

    What are the normal values for the aortic valve?

    <p>2.5-3.5 cm^2</p> Signup and view all the answers

    What is Pectus excavatum?

    <p>A congenital deformity of the chest wall characterized by a sunken in chest</p> Signup and view all the answers

    What is pectus carinatum?

    <p>A congenital deformity of the chest wall characterized by a prominent sternum</p> Signup and view all the answers

    Functional murmurs require rapid intervention

    <p>False</p> Signup and view all the answers

    Unstable angina is associated with the highest risk of perioperative MI

    <p>True</p> Signup and view all the answers

    ST changes are present in stable angina

    <p>False</p> Signup and view all the answers

    Distal pulses are best to evaluate vessels

    <p>True</p> Signup and view all the answers

    As pulse travels from aorta to peripheral arteries, the MAP and SBP decrease

    <p>False</p> Signup and view all the answers

    What type of pulse variation is seen in aortic insufficiency?

    <p>Bisferiens pulse</p> Signup and view all the answers

    What is pulsus alterans?

    <p>An abnormal arterial pulse characterized by alternating strong and weak beats seen in severe LV failure and cardiac tamponade</p> Signup and view all the answers

    What type of pulse is seen in aortic stenosis?

    <p>Pulsus parvus et tardus</p> Signup and view all the answers

    What is pulsus paradoxus?

    <p>A fall of systolic blood pressure of &gt;10 mmHg during the inspiratory phase</p> Signup and view all the answers

    A patient has deep pitting where indentation briefly remains. What grade of pitting edema does this patient have?

    <p>3+</p> Signup and view all the answers

    A patient has moderate pitting where indentation resolves rapidly. What grade of pitting edema does this patient have?

    <p>2+</p> Signup and view all the answers

    Mild pitting with only slight indentation and no appreciable extremity edema indicates what level of edema

    <p>+1 edema</p> Signup and view all the answers

    Patients with baseline HTN are more likely to develop intraop HYPOTENSION

    <p>True</p> Signup and view all the answers

    How does cardiomegaly affect the point of maximal impulse (PMI)?

    <p>It shifts laterally</p> Signup and view all the answers

    Ascites, pregnancy, and abdominal distention shift the PMI to which direction?

    <p>Upwards and to the left</p> Signup and view all the answers

    What is typically described in a murmur of aortic stenosis?

    <p>Crescendo-decrescendo, radiating to the carotids and with/without S3 or S4</p> Signup and view all the answers

    The intensity of aortic stenosis murmurs can be decreased by which of the following?

    <p>Valsalva maneuver and hand grip exercise</p> Signup and view all the answers

    Where are aortic stenosis murmurs best heard?

    <p>In the second parasternal interspace</p> Signup and view all the answers

    In dextrocardia, where is the PMI shifted?

    <p>To the right</p> Signup and view all the answers

    Thrills of aortic stenosis are transmitted to the carotid arteries from the suprasternal notch or 2nd ICS

    <p>True</p> Signup and view all the answers

    <1 cm^2 is indicative of severe aortic stenosis

    <p>True</p> Signup and view all the answers

    0.5-0.7 cm^2 is indicative of critical aortic stenosis

    <p>True</p> Signup and view all the answers

    A minimum 4 METs are recommended for surgical optimization

    <p>True</p> Signup and view all the answers

    What is a MET (Metabolic Equivalent)?

    <p>A unit of measurement for oxygen consumption used to express the energy cost of physical activities</p> Signup and view all the answers

    What is functional capacity as it relates to METs?

    <p>A measure of the energy cost of various physical activities</p> Signup and view all the answers

    What medications are part of cardioprotective pharmacotherapy?

    <p>All of the above</p> Signup and view all the answers

    What considerations should an anesthesiologist take into account when treating patients with implanted cardiac devices?

    <p>All of the above</p> Signup and view all the answers

    An alternate form of pacing and a magnet should be available when caring for patients with implanted cardiac devices

    <p>True</p> Signup and view all the answers

    Monopolar cautery is preferred for patients with implanted cardiac devices

    <p>False</p> Signup and view all the answers

    What causes S3 heart sounds?

    <p>Rapid deceleration of blood against ventricular wall</p> Signup and view all the answers

    At what systolic blood pressure (SBP) and diastolic blood pressure (DBP) is stage 1 hypertension diagnosed?

    <p>130-139 mmHg SBP and 80-89 mmHg DBP</p> Signup and view all the answers

    At what systolic blood pressure (SBP) and diastolic blood pressure (DBP) is uncontrolled hypertension typically defined?

    <p>180/110 mmHg or higher</p> Signup and view all the answers

    What are the elements of a pulse assessment?

    <p>All of the above</p> Signup and view all the answers

    What characteristic of a pulse does the contour describe?

    <p>Shape</p> Signup and view all the answers

    A normal carotid pulse can be described as smooth, relatively rapid upstroke, more gradual downstroke, interrupted briefly at the pulse peak

    <p>True</p> Signup and view all the answers

    A normal radial pulse can be described as weak, irregular, and asymmetrical

    <p>False</p> Signup and view all the answers

    Bruit are diastolic sounds

    <p>False</p> Signup and view all the answers

    In which patient condition should prophylactic antibiotics be considered before undergoing dental procedures?

    <p>Ineffective endocarditis</p> Signup and view all the answers

    What are the current recommendations for use of perioperative β-blockade and statins for cardiovascular risk reduction?

    <p>Beta blockers are not indicated for routine use in low-risk patients having non-cardiac surgery</p> Signup and view all the answers

    Does delaying elective surgery for patients with mild to moderate hypertension for the purpose of optimizing blood pressure reduce perioperative risk?

    <p>No</p> Signup and view all the answers

    Should statins be continued intraoperatively for patients who have been on statins for 1 week-30 days preoperatively?

    <p>Yes, continue statins</p> Signup and view all the answers

    What is the primary cause of acute aortic insufficiency (AI)?

    <p>Infective Endocarditis</p> Signup and view all the answers

    What pulse abnormalities can be seen in cardiac tamponade?

    <p>A and B</p> Signup and view all the answers

    In which cardiac phase do S1 sounds typically occur?

    <p>Systole</p> Signup and view all the answers

    In which cardiac phase do S2 sounds occur?

    <p>Early Diastole</p> Signup and view all the answers

    Study Notes

    Anesthesia and Surgery

    • Anesthesia is a stress test that requires patients to be optimized prior to procedures to identify potential cardiac events.
    • Surgical types:
      • Emergent surgery: risk of life or limb in 6 hours
      • Elective surgery: non-emergency surgery
      • Urgent surgery: risk of life or limb in 24 hours

    Cardiovascular Anatomy

    • Heart size: roughly the size of a fist
    • Heart differences between males and females: female hearts are smaller than male hearts
    • Mediastinum: connective tissue lined compartment bordered by the lungs, sternum, and thoracic vertebral bodies
      • Contains: heart, aorta, PA, SVC, IVC, trachea, esophagus, thoracic duct, and thoracic lymph nodes
      • RV is the most anterior structure
    • Pericardium: fibrous outer layer and inner serous layer
      • Fibrous layer: affixes heart to mediastinum
      • Serous layer: consists of parietal and visceral layers
    • Epicardium: outermost layer where right and left coronary arteries lie
    • Myocardium: muscle middle layer of the heart
    • Endocardium: innermost layer that lines the heart

    Heart Chambers and Valves

    • Right atrium (RA) and right ventricle (RV):
      • Receive deoxygenated blood from the SVC, IVC, and coronary sinus
      • Coronary sinus receives blood from cardiac veins and drains the myocardium
    • Left atrium (LA) and left ventricle (LV):
      • Receive oxygenated blood from the lungs
    • Heart valves:
      • Atrioventricular (AV) valves: tricuspid and bicuspid/mitral valves
      • Semilunar valves: pulmonic and aortic valves
      • Valve sounds:
        • S1: AV valve closure
        • S2: semilunar valve closure

    Cardiac Output and Function

    • Cardiac output: volume of blood ejected from the heart each minute (SV x HR)
    • Stroke volume (SV): volume of blood ejected from the heart each beat
    • Ejection fraction: percentage of blood ejected during each beat
    • Preload: volume of blood remaining in the ventricles at the end of diastole
    • Contractility: ability of the muscle cells to stretch and recoil
    • Afterload: pressure the heart has to work against to eject blood

    Cardiac Base and Apex

    • Cardiac base: formed by the posterior surface of the heart, located at the right and left 2nd intercostal space (ICS)
    • Cardiac apex: formed by the tip of the LV, located at the 5th ICS, just medial to the left midclavicular line (MCL)

    Cardiac Conduction

    • SA node: located near the superior vena cava (SVC)
    • AV node: located between the atria and ventricles
    • Bundle of His: only direct connection for electrical impulses to move from atria to ventricles
    • Bundle branches: extend from the Bundle of His to the ventricles

    Heart Sounds

    • S1 and S2 sounds: normal heart sounds
    • S3 sound: normal in kids and adolescents, but pathologic in adults
    • S4 sound: pathologic, indicating ventricular dysfunction and decreased compliance
    • Heart sound splitting: defined by the time difference between the closure of the mitral and tricuspid valves

    Heart Murmurs

    • Heart murmur: distinct heart sounds attributed to turbulent blood flow
    • Graded by intensity (1-6) and can be indicative of valvular disease
    • Innocent/functional murmur: due to increased blood flow through the heart (e.g., anemia, fever, pregnancy, hyperthyroidism)

    Pre-Operative Cardiac Assessment

    • Pre-operative EKG: guidelines vary between facilities
    • Risk of MI increases with proximity to MI
    • Patient history: pre-existing heart disease, disease severity, stability, comorbidities, functional capacity, surgical procedure

    Hypertension

    • Definition: SBP > 140 or DBP > 90
    • Uncontrolled hypertension: SBP > 180 or DBP > 110
    • Complications: MI, end-organ damage, AKI, etc.

    Ischemic Heart Disease and MI

    • Risk factors: advanced age, smoking, DM, HTN, pulmonary disease, previous MI, LV dysfunction, PVD
    • Signs and symptoms: fatigue, angina, palpitations, syncope, dyspnea
    • Pre-operative evaluation: determining severity, progression, and functional limitations

    Angina and Heart Failure

    • Angina: substernal discomfort
    • Stable angina: brought on by exertion, relieved by rest or nitroglycerin in <30 minutes
    • Unstable angina: newly developed or progressively worsening
    • Heart failure: symptoms = CHF, pulmonary edema, paroxysmal nocturnal dyspnea; clinical findings = S3 gallop, rales, tachypnea, resting tachycardia, JVD, peripheral edema

    Assessment of Pulses

    • Rate, rhythm, contour, amplitude
    • Pulse wave amplification: arterial pulse changes as it travels from the aorta to peripheral arteries
    • Normal findings: carotid pulse is smooth, rapid upstroke with a gradual downstroke, briefly interrupted by the pulse peak; radial pulse is strong, regular, and asymmetrical

    Pulse Abnormalities

    • Pulsus bisferiens: double pulse
    • Pulsus bigeminus: alteration in pulse amplitude that follows a ventricular premature beat
    • Pulsus alterans: regular alternating pulse amplitude due to alternating LV contractile force
    • Pulsus parvus et tardus: small and slow-rising pulse, representing a delayed systolic peak due to obstruction of LV ejection

    Orthostatic Hypotension

    • Definition: BP falls when standing up or stretching
    • Criteria: 20mmHg drop in SBP or 10mmHg drop in DBP within 3 minutes of standing
    • Causes: blood pooling in the lower extremities

    Measuring JVD

    • Find highest point of oscillation in the internal jugular vein and measure the distance above the sternal angle
    • JVP > 3 cm is indicative of elevated CVP

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