Podcast
Questions and Answers
What is the primary concern regarding perioperative ACE inhibition?
What is the primary concern regarding perioperative ACE inhibition?
- Potential for severe intraoperative hypotension, especially in hypovolemic patients. (correct)
- Elevated risk of bradycardia and heart block during anesthesia.
- Increased risk of postoperative hypertension due to rebound effect.
- Reduced effectiveness of vasopressors in maintaining blood pressure.
Angiotensin receptor (AT) blockers primarily function by which mechanism?
Angiotensin receptor (AT) blockers primarily function by which mechanism?
- Increasing the production of angiotensin II.
- Inhibiting the conversion of angiotensin I to angiotensin II.
- Competitively inhibiting the action of angiotensin II at the AT1 receptor. (correct)
- Directly stimulating AT1 receptors to increase blood pressure.
Which surgical procedures are classified as intermediate risk according to the ACC/AHA guidelines?
Which surgical procedures are classified as intermediate risk according to the ACC/AHA guidelines?
- Aortic and other major vascular surgeries.
- Superficial skin biopsies and cataract removals.
- Peripheral vascular surgeries.
- Intraperitoneal and intrathoracic surgeries. (correct)
How should hypotension related to ACE inhibitors or AT blockers typically be managed during anesthesia?
How should hypotension related to ACE inhibitors or AT blockers typically be managed during anesthesia?
In which clinical scenario is blood pressure most likely to become angiotensin-dependent?
In which clinical scenario is blood pressure most likely to become angiotensin-dependent?
Which of the following best describes the underlying mechanisms of ventricular dysfunction in heart failure?
Which of the following best describes the underlying mechanisms of ventricular dysfunction in heart failure?
How does the Frank-Starling law initially compensate for decreased myocardial contractility in heart failure?
How does the Frank-Starling law initially compensate for decreased myocardial contractility in heart failure?
What is the long-term consequence of sustained volume increase in the context of the Frank-Starling mechanism in heart failure?
What is the long-term consequence of sustained volume increase in the context of the Frank-Starling mechanism in heart failure?
Which of the following ECG findings would be LEAST likely in a patient with heart failure?
Which of the following ECG findings would be LEAST likely in a patient with heart failure?
Why is heart failure the only major cardiovascular condition increasing in prevalence?
Why is heart failure the only major cardiovascular condition increasing in prevalence?
In the context of heart failure, what is the significance of sympathetic nervous system activation?
In the context of heart failure, what is the significance of sympathetic nervous system activation?
A patient with an LVEF of 30% is undergoing surgery. Based on the information, they are at an increased risk of what?
A patient with an LVEF of 30% is undergoing surgery. Based on the information, they are at an increased risk of what?
What is the relationship between the severity of a patient's heart failure, surgical risk, and perioperative risk?
What is the relationship between the severity of a patient's heart failure, surgical risk, and perioperative risk?
Why is echocardiography considered a key investigation in heart failure?
Why is echocardiography considered a key investigation in heart failure?
A 60-year-old patient with a history of hypertension and coronary artery disease is scheduled for elective hip replacement surgery. Pre-operative assessment reveals an ejection fraction of 35% and mild dyspnea on exertion. Which of the following is the MOST important consideration regarding their perioperative risk?
A 60-year-old patient with a history of hypertension and coronary artery disease is scheduled for elective hip replacement surgery. Pre-operative assessment reveals an ejection fraction of 35% and mild dyspnea on exertion. Which of the following is the MOST important consideration regarding their perioperative risk?
In the long-term treatment of heart failure, what is the primary target of medical management?
In the long-term treatment of heart failure, what is the primary target of medical management?
A clinician is considering using transoesophageal echocardiography (TOE) on a patient with suspected heart failure. According to the information, what is a limitation of TOE in this context?
A clinician is considering using transoesophageal echocardiography (TOE) on a patient with suspected heart failure. According to the information, what is a limitation of TOE in this context?
A patient with long-standing heart failure develops increased shortness of breath and leg swelling. Which physiological adaptation is MOST likely contributing to these symptoms?
A patient with long-standing heart failure develops increased shortness of breath and leg swelling. Which physiological adaptation is MOST likely contributing to these symptoms?
Which factor most significantly affects the accuracy of LVEF calculation?
Which factor most significantly affects the accuracy of LVEF calculation?
A patient presents with oedema but denies dyspnoea or fatigue. How might this presentation influence the approach to their diagnosis?
A patient presents with oedema but denies dyspnoea or fatigue. How might this presentation influence the approach to their diagnosis?
In which situation might transoesophageal echocardiography (TOE) be considered over transthoracic echocardiography (TTE) for a patient with suspected heart failure?
In which situation might transoesophageal echocardiography (TOE) be considered over transthoracic echocardiography (TTE) for a patient with suspected heart failure?
Why is regular monitoring of renal function recommended for patients on ACE inhibitors?
Why is regular monitoring of renal function recommended for patients on ACE inhibitors?
Which of the following is the primary concern with perioperative use of ACE inhibitors related to renal function?
Which of the following is the primary concern with perioperative use of ACE inhibitors related to renal function?
Why might intravenous beta-blockers be considered for patients who are NPO?
Why might intravenous beta-blockers be considered for patients who are NPO?
In the context of heart failure management, what is the established consensus regarding long-term beta-blocker treatment during the perioperative period?
In the context of heart failure management, what is the established consensus regarding long-term beta-blocker treatment during the perioperative period?
What is a potential consequence of a blood pressure-dependent GFR in a patient treated with ACE inhibitors?
What is a potential consequence of a blood pressure-dependent GFR in a patient treated with ACE inhibitors?
Which of the following scenarios would warrant considering the cessation of ACE inhibitor therapy?
Which of the following scenarios would warrant considering the cessation of ACE inhibitor therapy?
In addition to metoprolol and bisoprolol, which other beta-blocker is recommended for use in chronic heart failure?
In addition to metoprolol and bisoprolol, which other beta-blocker is recommended for use in chronic heart failure?
What is the rationale for considering nitrate and hydralazine therapy as a substitute for ACE inhibitors?
What is the rationale for considering nitrate and hydralazine therapy as a substitute for ACE inhibitors?
Which of the following is the MOST significant risk factor for myocardial infarction following major vascular surgery, based on the information available?
Which of the following is the MOST significant risk factor for myocardial infarction following major vascular surgery, based on the information available?
What is the primary focus of the ACC/AHA 2005 guideline update?
What is the primary focus of the ACC/AHA 2005 guideline update?
According to the European Society of Cardiology, what is the main subject of their expert consensus document?
According to the European Society of Cardiology, what is the main subject of their expert consensus document?
In the study by Metra et al. (2002), what aspect of heart failure treatment was investigated?
In the study by Metra et al. (2002), what aspect of heart failure treatment was investigated?
How does chronic treatment with metoprolol or carvedilol affect the hemodynamic response to inotropic agents like dobutamine?
How does chronic treatment with metoprolol or carvedilol affect the hemodynamic response to inotropic agents like dobutamine?
A patient with severe heart failure is undergoing a non-cardiac surgery. Which of the following strategies would be LEAST appropriate for maintaining hemodynamic stability during the perioperative period?
A patient with severe heart failure is undergoing a non-cardiac surgery. Which of the following strategies would be LEAST appropriate for maintaining hemodynamic stability during the perioperative period?
A patient on chronic digoxin therapy is scheduled for emergency surgery. Which of the following is the MOST important consideration regarding their digoxin management?
A patient on chronic digoxin therapy is scheduled for emergency surgery. Which of the following is the MOST important consideration regarding their digoxin management?
A patient with Stage D heart failure experiences severe hypotension following induction of general anesthesia. What is the MOST likely underlying cause related to their heart failure?
A patient with Stage D heart failure experiences severe hypotension following induction of general anesthesia. What is the MOST likely underlying cause related to their heart failure?
When considering regional anesthesia for a patient with heart failure, which factor is MOST crucial to address to prevent hemodynamic instability?
When considering regional anesthesia for a patient with heart failure, which factor is MOST crucial to address to prevent hemodynamic instability?
In a patient with heart failure undergoing general anesthesia, what is the primary rationale for using invasive arterial and central venous monitoring, despite the lack of strong evidence showing improved outcomes?
In a patient with heart failure undergoing general anesthesia, what is the primary rationale for using invasive arterial and central venous monitoring, despite the lack of strong evidence showing improved outcomes?
A patient with severe heart failure requires an inotrope during the perioperative period. Which of the following considerations is MOST important when selecting and administering inotropic support?
A patient with severe heart failure requires an inotrope during the perioperative period. Which of the following considerations is MOST important when selecting and administering inotropic support?
A patient with heart failure and reduced ejection fraction (HFrEF) is undergoing a surgical procedure. Which anesthetic approach is MOST likely to be beneficial in terms of afterload management?
A patient with heart failure and reduced ejection fraction (HFrEF) is undergoing a surgical procedure. Which anesthetic approach is MOST likely to be beneficial in terms of afterload management?
Which statement BEST reflects the consensus on the use of digoxin in the perioperative management of heart failure patients?
Which statement BEST reflects the consensus on the use of digoxin in the perioperative management of heart failure patients?
Flashcards
Heart Failure
Heart Failure
A complex clinical syndrome resulting from impaired ventricular performance.
Causes of Ventricular Dysfunction
Causes of Ventricular Dysfunction
Death/dysfunction of myocytes; Pressure/volume overload.
Effects of Decreased Myocardial Contractility
Effects of Decreased Myocardial Contractility
Stroke volume drops; End-diastolic volume and pressure increase.
Frank-Starling Law in Heart Failure
Frank-Starling Law in Heart Failure
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Cardiac Remodelling
Cardiac Remodelling
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Heart Failure Prevalence
Heart Failure Prevalence
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Compensatory Mechanism in Heart Failure
Compensatory Mechanism in Heart Failure
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Perioperative Risk
Perioperative Risk
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Left Ventricular Ejection Fraction (LVEF)
Left Ventricular Ejection Fraction (LVEF)
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Decreased LVEF Significance
Decreased LVEF Significance
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LVEF Calculation Accuracy
LVEF Calculation Accuracy
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Normal ECG in Heart Failure
Normal ECG in Heart Failure
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Echocardiography in Heart Failure
Echocardiography in Heart Failure
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Echocardiography Challenges
Echocardiography Challenges
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Target of Heart Failure Treatment
Target of Heart Failure Treatment
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Vicious Neurohumoral Cycle
Vicious Neurohumoral Cycle
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Sympathomimetics
Sympathomimetics
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ACE Inhibitor
ACE Inhibitor
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Angiotensin Receptor Blockers (ARBs)
Angiotensin Receptor Blockers (ARBs)
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Angiotensin-Dependent Blood Pressure
Angiotensin-Dependent Blood Pressure
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Hypovolemia
Hypovolemia
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Beta-blockers in HF
Beta-blockers in HF
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Beta-blockers & Inotropes
Beta-blockers & Inotropes
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ACC/AHA Guidelines
ACC/AHA Guidelines
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Post-Vascular Surgery Risks
Post-Vascular Surgery Risks
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Beta-Adrenoreceptor Antagonists (Beta-Blockers)
Beta-Adrenoreceptor Antagonists (Beta-Blockers)
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Perioperative Hypotension
Perioperative Hypotension
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Phenylephrine, Norepinephrine, or Epinephrine Infusion
Phenylephrine, Norepinephrine, or Epinephrine Infusion
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ACE-Inhibitor-Induced Acute Renal Failure
ACE-Inhibitor-Induced Acute Renal Failure
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Glomerular Afferent Arteriolar Blood Flow
Glomerular Afferent Arteriolar Blood Flow
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Glomerular Filtration Rate (GFR)
Glomerular Filtration Rate (GFR)
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Efferent Arteriolar Vasoconstriction
Efferent Arteriolar Vasoconstriction
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Recommended Beta-Blockers for Chronic Heart Failure
Recommended Beta-Blockers for Chronic Heart Failure
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Inotropes in Heart Failure
Inotropes in Heart Failure
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Preload Dependence
Preload Dependence
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Perioperative Fluid Shifts
Perioperative Fluid Shifts
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Invasive Monitoring
Invasive Monitoring
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Neuraxial Blockade and Hypotension
Neuraxial Blockade and Hypotension
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Digoxin Management
Digoxin Management
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Sympatholysis Hypotension
Sympatholysis Hypotension
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Afterload Reduction Benefit
Afterload Reduction Benefit
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Study Notes
- Heart failure (HF) is a complex clinical syndrome resulting from impaired ventricular performance
- HF is a common condition, affecting 1% of the population aged 50-59 and 10% of those over 80
- HF prevalence is increasing due to an aging population and improved survival from other cardiovascular diseases
- HF carries a high mortality rate, with a 50% 4-year mortality and a 50% 1-year mortality for severe cases
Pathophysiology
- Ischemic heart disease and hypertension are major causes of HF
- Other causes include diabetes, valvular disease, cardiomyopathies, infections, and nutritional factors
- Mechanisms of ventricular dysfunction involve myocyte death or dysfunction and pressure or volume overload
- Cardiac remodeling includes myocardial hypertrophy, chamber enlargement, and increased ventricular wall stress
- Sympathetic activation and the renin-angiotensin-aldosterone system (RAAS) contribute to a vicious cycle, exacerbating heart injury
Diagnosis and Staging
- HF diagnosis requires clinical signs and symptoms along with objective evidence of ventricular dysfunction
- ECG findings may include chamber hypertrophy, ventricular strain, signs of ischemia, atrial fibrillation
- Echocardiography assesses myocardial dysfunction severity and may diagnose the underlying cause
- The American College of Cardiology and American Heart Association (ACC/AHA) have a four-stage classification for HF management
Risk Assessment
- Surgery is classified based on perioperative hemodynamic changes, fluid shifts, and stress response severity
- High-risk surgeries include open aortic and peripheral vascular procedures
- Functional capacity is a key indicator of cardiovascular reserve, with limited exercise tolerance being a risk marker
- LVEF is used as a measure of systolic function, with lower values indicating more severe dysfunction
Medical management
- Aims to counter the vicious cycle of RAAS activation, decrease cardiac output, and cardiac remodeling
- Angiotensin-converting enzyme (ACE) inhibitors are a first-line treatment to decrease the risk of myocardial infarction and death
- ACE should be stopped 10 hours before surgery and may cause hypotension
- Angiotensin receptor antagonists are alternatives for patients intolerant to ACE inhibitors, but pose hypotension risks during anesthesia
- Beta-blockers reduce hospital admissions, prevent disease progression, and improve long-term survival
- Diuretics control symptoms but can lead to electrolyte abnormalities, hypovolemia, and arrhythmias
Other Considerations
- Digoxin controls symptoms and ventricular rate in AF, but has a narrow therapeutic index and can cause toxicity
- Beta-agonists or phosphodiesterase inhibitors are reserved for severe HF due to association with worse survival
- Elective non-cardiac surgery should be timed to decrease patient risk
- Decompensated or untreated HF is a major risk predictor, requiring postponement of surgery if possible
Anesthetic management
- Management depends on the degree of heart failure, cause/nature of cardiomyopathy, and surgical procedure
- Stages A and B focus on avoiding drug interactions and maintaining therapy benefits
- Stable anesthesia, with minimal myocardial depression or afterload change, is favored for heart failure patients
- Regional techniques can be an alternative but pose a risk of hypotension
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Description
Explore key considerations for managing patients on ACE inhibitors/AT blockers during anesthesia, including hypotension management and risk stratification. Review heart failure mechanisms, Frank-Starling law implications, and ECG findings. Learn about the increasing prevalence and management of heart failure in cardiovascular care.
