Palpate for temperature, edema- is it pitting, texture, grade pulses
Assess is there Arterial vs Venous Insufficiency
_________ Murmurs are associated with forward flow through the valves and have a crescendo- decrescendo pattern ie Aortic Stenosis
______ Murmurs occur when the blood is forced backward in to the atrium and have a pansystolic pattern ie Mitral Regrugitation
_____ Murmurs – Occur between S1 and S2 – think contracting phase. They are either ejection or regurgitant murmurs
____ murmurs occur between S2 and S 1- think filling phase & are almost always indicative of heart
When taking a cardiac history, what do you include?
Risk factors for coronary artery disease (CAD)
Family history of CAD
Functional, Psychologic, Social and Economic Status
Clinical manifestations of heart disease
What are some clinical manifestations of cardiac disease?
Fatigue and decreased exercise tolerance
What causes chest pain and what are the types?
¨Non‐ischemic chest pain
What is classic angina pectoris?
¤Oppressive feeling, pressure, tightness, burning in precordium
¤Triggered by exercise or excitement
¤Relieved with rest or nitroglycerin (NTG)
What is atypical angina?
¨Atypical angina‐2/3 classic components
What is non-ischemic chest pain?
¤Fleeting¤Localized (1 finger localization)
What is unstable angina?
What do we need to know about dyspnea?
¨On exertion (DOE)
¨Orthopnea (worse lying flat)
¨Paroxysmal nocturnal dyspnea (PND)
¨Angina Equivalent (symptoms of CV disease is SOB)
¨Differentiate from noncardiac dyspnea
What do we need to know about palpitations?
¨Awareness of heart beat
¤Neurologic symptoms (syncope)
¨Provocation (coffee brings it on..etc)
Tell me about edema
¨Neck vein distention?(JVD)
¨Evidence for other volume overload states?
What kind of things do you ask about regarding the patients functional status?
¨Nature and requirements of job
¨“How far can you walk on level ground?”
¨“How many flights of stairs can you climb?”
What are you looking for BEFORE the cardiac exam?
¨Maybe clues to presence of cardiac disease
¨Abnormal heart rate or rhythm
How do you take VS "by the book"
¨VS in each arm
¨Supine and erect
¨Timing and amplitude of arterial pulses
¤Parvus and tardus
--On palpation, pulse is weak/small (parvus)
& late (tardus)
¤Compare upper & lower extremity
Getting a BP:
¨Cuff should fit snugly around the arm, with its
lower edge at least __ inch above the antecubital space
¨Width of the cuff ‐ at least __% of the
circumference of the limb to be used
¨Rubber bag long enough to extend at least ___ around the limb
halfway (10" in adults)
How do you get a BP in a lower extremity?
¨With the patient lying on the abdomen, an 8‐inch wide cuff should be applied with the compression bag over the posterior aspect of the mid‐thigh and should be rolled diagonally around the thigh to keep the edges snug against the skin
¨Auscultation should be carried out in the popliteal fossa
A thrusting apex exceeding 2 cm in diameter suggests ________
left ventricular enlargement
Systolic retraction of the apex may be visible in cases of __________
Normally, cardiac pulsations are not visible lateral to the __________
How do you do the palpation portion of your cardiac exam?
¨Use the fingertips or the area just proximal to them
¨Timed with the simultaneously palpated carotid pulse or auscultated heart sounds
¨Chest completely exposed and elevated to 30 degrees
¨Both supine and in the partial left lateral decubitus positions
Rotating the patient into the left lateral decubitus position with the left arm elevated over the head causes the heart to move laterally and increases the palpability of both normal and pathological thrusts of the_____
The subxiphoid region, which allows palpation of the _______, should be examined with the
tip of the index finger during held inspiration
What is normally produced by left ventricular contraction and is the lowest and most lateral
point on the chest at which the cardiac impulse can be appreciated?
How (where) can you normally palpate the PMI or LV impulse?
medial and superior to the intersection of the
left midclavicular line and the fifth intercostal space
and is palpable as a single, brief outward motion
TRUE OR FALSE. PMI is not palpable
in 50% of adults > 50 yo
TRUE or FALSE. In the left lateral decubitus position, a PMI diameter of more than 2 cm is an accurate sign of left ventricular enlargement
FALSE. More than 3cm is a sign of LV enlargement
What is LV heave or lift and when do you see it?
¤left ventricular dilatation without volume overload
Sustained outward movement of area larger than 2 to 3 cm in diameter
What is RV heave or lift and when do you see it?
¨Palpable anterior systolic movement (replacing
systolic retraction) in the left parasternal region
¤felt by the proximal palm or fingertips
¨Right ventricular enlargement
¨Pulmonary HTN & increased pulmonary blood flow frequently produce a prominent systolic pulsation of the pulmonary trunk in the second intercostal space just to the left of the sternum
What are thrills and how do you assess them?
¨The flat of the hand or the fingertips usually best appreciate thrills, which are vibratory sensations that are palpable manifestations of loud, harsh murmurs having low‐ to medium‐frequency components
The topographical areas for auscultation:
¤Left and right sternal borders interspace by interspace
cardiac apex when the apex is occupied by the left ventricle
¨The second component, if present, is normally
confined to the lower left sternal edge, is less
commonly heard at the apex, and is seldom heard at the base
What is the 1st component of S1 associated with?
The first major component is associated with closure of the mitral valve and coincides with abrupt arrest of leaflet motion when the cusps, especially the larger and more mobile anterior mitral cusp, reach their fully closed positions
What is the 2nd component of S2 associated with?
The origin of the second component of S1 has been debated but is generally assigned to closure of the tricuspid valve based on an analogous line of reasoning
What causes a loud S1
Short PR interval (<160 msec)
Tachycardia or hyperkinetic states
"Stiff" left ventricle
Left atrial myxoma
Holosystolic mitral valve prolapse
What causes a soft S1
Long PR interval (>200 msec)
Depressed left ventricular contractility
Premature closure of mitral valve ( e.g., acute aortic regurgiation)
Mid‐diastolic sounds are, for all practical purposes, either normal or abnormal ___ sounds
Most, if not all, late diastolic or presystolic sounds are __ sounds
When is S3 generated?
during the rapid filling phase of the ventricle
When is S3 normal?
Frequent in normal children and in patients with high cardiac output
When is S3 abnormal?
In older patients an S3 is abnormal
¤Impairment of ventricular function
¤AV valve regurgitation
Other conditions that increase the rate or
volume of ventricular filling
What is the different between a L sided S3 and a R sided S3?
Left sided S3
¤Bell piece of the stethoscope
¤Left ventricular apex during expiration
¤Left lateral position
¤Left sternal border or just beneath the xiphoid
¤Louder with inspiration
Describe the 2nd and 3rd phases of ventricular filling (after the rapid filling phase)
Second filling phase‐diastasis
¤Variable in duration
¤Usually < 5 % of ventricular filling
Third phase of diastolic filling
¤In response to atrial contraction
¤15 % of normal ventricular filling
When is S4 generated?
S4 is generated during the atrial filling phase
Describe the S4 and the situation in which it is found.
Low‐pitched, presystolic sound
¤Associated with an effective atrial contraction
¤Best heard with the bell piece of the stethoscope
¤Loudest at apex
¤Left lateral decubitus position
Diminished ventricular compliance
Frequently accompanied by visible and palpable presystolic distention of the left ventricle
What are some cardiac conditions in which you would hear S4?
Ischemic heart disease
Acute mitral regurgitation
Most patients with an acute myocardial infarction and sinus rhythm have an audible S4
What are you hearing when you auscultate a murmur?
Turbulent blood flow
How is the intensity (loudness) of a murmur graded?
What characteristics (general categories) of the murmur do you define?
¤Location and radiation
¤Timing in cardiac cycle
What is some basic information we can obtain from an EKG?
¨Heart rate and rhythm
¨Risk for lethal arrhythmias (prolonged QT)
what kind of information can we obtain by getting a CXR?
¨Interstitial or alveolar edema
¨Non cardiac causes of dyspnea
What kind of information can we obtain my getting an ECHO?
¨L & R ventricular function
¤Valvular regurgitation or stenosis
What will stress testing show us?
¨Coronary blood flow reserve
¤Ischemic ECG changes
¤Wall motion abnormality by echocardiography
¤Perfusion defect with nuclear imaging
What will a cardiac catheterization show us?
¨Presence and degree of coronary artery disease
¨Left ventricular systolic and diastolic function
¨Presence and hemodynamic consequences of valvular disease
What are the Pros of an exercise EKG
¤Can assess functional capacity
¤Safe and widely available
¤Long history of data in varying populations
¤No radiation exposure
What are the Cons of an exercise EKG?
¤Sensitivity lower than with imaging (70%)
¤Specificity poor if abnormal baseline ECG
Doesn’t localize or quantify ischemia
What are the pros of nuclear imaging?
¤Good sensitivity and specificity (85%)
¤Well validated studies to detect CAD and assess prognosis
¤Can determine the extent and location of ischemia
What are the Cons of nuclear imaging?
¤Intermediate radiation exposure
¤Inaccurate in the presence of left bundle branch block
What are the pros of a stress ECHO?
¤Good sensitivity and specificity
¤Quick, readily available
¤Less expensive than nuclear imaging
¤Localization of ischemia
What are the Cons of a stress ECHO?
¤Obese or very thin may not image well
¤Less accurate in setting of baseline abnormalities
¤Interpretation is subjective and nonstandardized
What are the pros of coronary calcium scoring?
¤Readily available and inexpensive
¤Not limited by conduction system abnormalities
¤No need to exercise
What are the cons of coronary calcium scoring?
¤No functional information
¤Very low specificity, esp. in pts >60yo
¤No good reproducible data on outcomes
What are the Pros of CT angiography?
¤Very good at identifying native coronary disease
What are the Cons of CT angiography?
¤High radiation dose
¤Inability to intervene
¤No functional information, only anatomic
What are the pros of a coronary angiogram?
¤Direct visualization of the coronary lumen
¤Good prospective therapeutic data based on
coronary angiographic results
¤Ability to intervene
What are the cons of a coronary angiogram?
¤Does not assess functional significance of lesion
Limitation of All Stress Testing Modalities
Inability to identify plaques that are vulnerable to rupture and thus development of acute coronary syndrome.
What are some things we assess for intraop?
What area of ischemia/infarction will show in leads II, III & aVF?
the inferior wall
What area of ischemia/infarction will show in leads I, aVL, V4-V6?
What area of ischemia/infarction will show in leads V1-V3?
What area of ischemia/infarction will show in leads V1-V6?
Patient-related complications associated with using NIBP devices
¤Most common complication: skin & tissue compression which can lead to skin irritation and bruising
¤Prolonged use and frequent blood pressure determinations → venous pooling and congestion
¤Excessive venous pressures →tissue ischemia and nerve damage.
Factors that can interfere with obtaining accurate NIBP measurements
¤Highly irregular or rapid cardiac rhythms because of great beat to beat variability (most NIBP devices employ oscillometric technology that is dependent on fairly regular cardiac rhythms to determine blood pressure)
¤Excessive patient movement such as shivering, restlessness, or external movement such as that from a helicopter, ambulance transport, or a rapid-cycling ventilator can interfere with detection of cardiac oscillations by the NIBP monitor→ erroneous blood pressure measurements
¤Surgical team leaning on cuff!!*
Causes of hypotension: Differential diagnosis (DDD VITAMINS)
D Developmental (valvular heart disease)
D Drugs (Anesthetics & other drugs)
D Degenerative (Neurologic)
V Vascular (CV instability)
I Infectious/Iatrogenic (Adverse reactions, surgical)
T Toxic/Traumatic (Hemorrhage, sepsis)
A Autoimmune/Anoxic (Anoxic brain injury)
M Metabolic/Medical (Medical causes)
I Endocrine (Pregnancy)
N Neoplastic (Cancers)
S Special (Postoperative, deliberate)
What are some causes of hypotension in the OR?
Antihypertensive agents (ACEI and ARBs)
IV contrast agents
What is deliberate hypotension and how do we achieve this
Technique in general anesthesia in which a short-acting hypotensive agent is administered to reduce blood pressure and thus bleeding during surgery. The procedure facilitates surgery by making vessels and tissues more visible and reducing blood loss.
Sodium nitroprusside commonly used
¤Afterload reducer w/ rapid onset & short half-life
¤Easy to titrate
Can also use NTG & esmolol or Inhalational agents!!
In normal patients, perfusion preserved at MAP > 50mm Hg
What are some causes of hypertension?
¨Systolic HTN with wide pulse pressure (older people)
What are some examples of HTN related to pre-existing disease?
Early acute MI
What are some examples of HTN related to surgery?
¤Prolonged tourniquet time
What are some causes of HTN related to anesthesia?
¤Inadequate depth of anesthesia
¤Improperly sized BP cuff (too small)
¤Transducer artifact-increased resonance
(improperly low position of transducer)
Causes of HTN related to medication? What about other causes of HTN?
¤Rebound HTN (if clonidine, BB, or
¤Systemic absorption of vasoconstrictors
¤IV indigo carmine dye
¤Hypothermia & vasoconstriction
What are frequent causes of HTN?
What are other causes to consider?
What about rare causes?
Some causes of hypotension are that warming patient & controlling pain in PACU reduces sympathetic tone & redistributes blood volume to periphery.
Effects of surgical blood loss, 3rd spacing, ongoing hemorrhage, & inadequate volume replacement→hypotension. How do you treat???
¨Must be treated swiftly & aggressively
¨Then if necessary, vasopressors or inotropes
What is the purpose of a cardiac evaluation?
¨Determine preexisting cardiac disease
¨Disease severity, stability, prior treatment
¨Type of surgery planned
Name 4 active cardiac conditions
¨Unstable Coronary Syndrome
¨Decompensated Heart Failure
¨Severe Valvular disease
What are some clinical risk factors for cardiac disease?
¨Family History of premature CAD
What four major questions are you going to ask regarding your patient with CAD?
¨How much of myocardium is at risk?
¨How much stress can myocardium handle before it becomes ischemic?
¨What is patient’s LV function?
¨Is the patient medically optimized?
What is the definition of hypertension?
¨Definition SBP >140 or DBP >90mmHg
¨Stage 3 HTN
Why should we optimize someone w/HTN?
¤Reduces perioperative hemodynamic instability.
¤Reduces instances of myocardial ischemia & CVA
What you do you need to consider for your patient with AS?
¤Symptomatic = delay or cancel
¤Severe AS = Need study less than 12 months old
¤What if patient is not a candidate or refuses AVR?---Don’t give a spinal!!!
What is the definition criteria for aortic stenosis?
<1cm is severe
<0.6cm is critical
1.5-1cm is moderate AS
Tell me about severe Mitral stenosis
¤At increased risk for heart failure
¤Only surgically repair valve prior to non-cardiac surgery if there is a need that is not related to proposed surgery
What do you need to do if someone is on an oral anticoagulant
--Normalize INR then restart post-op
--Heparin bridge to surgery
What are the levels of evidence
Benefit> or = to Risk
Risk> or = to Benefit
Why do we do pre-op testing?
¨Provide a framework to consider cardiac risk for non-cardiac surgery
¨Use this knowledge to individualize care
Non-invasive eval of LV function (when would you do this?)
¨Class IIa: Patients with dyspnea of unknown origin,
¨Class IIa: Patients with current or prior heart failure. (if not been evaluated in past 12 months)
¨Class IIb: Reassessment of LV function in previously documented cardiomyopathy in clinically stable patient is not well established.
¨Class III Routine perioperative evaluation of LV function is not recommended.
Resting EKG (When would we do this?)
•Class I: Patients with at least 1 clinical risk factor undergoing vascular procedures. (diabetes, CHF, etc) *not for bunuectomy
•Class I: Patients with known CAD, PVD, cerebrovascular disease undergoing intermediate risk surgical procedure (thyroidectomy).
•Class IIa: No risk factors but having vascular procedure (healthy person getting carotid surgery, get EKG)
•Class IIb: Patients with at least 1 risk factor
having intermediate risk operation.
(HTN & thyroidectomy-get EKG?)
•Class III Pre-op and post-op resting 12
lead ECG is not indicated for asymptomatic patients having low risk surgery.
Non invasive stress test (when would we do this?)
•Class I: Active cardiac conditions in which non-cardiac surgery is planned should be evaluated and treated before surgery.
•Class IIa: Patient’s with 3 or more clinical risk factors and poor functional capacity who require vascular surgery.
•Class IIb: May consider for patients with 1-2 clinical risk factors and poor functional capacity who require intermediate risk surgery.
•Class IIb: May consider for patients with 1-2 clinical risk factors and good functional capacity having vascular surgery.
•Class III: No clinical risk factors having intermediate risk or low risk surgery.
Coronary Revascularization (CABG or PCI), who would be Class I for this?
Class I: Patients with stable angina who have significant LM disease.
Class I: Patients with stable angina who have 3 vessel disease.
Class I: Patients with stable angina who have 2 vessel disease with significant proximal LAD stenosis and EF less than 50% or demonstrable ischemia on non-invasive stress testing
Class I: Patients with high risk unstable angina or non ST segment elevated MI.
Class I: Patients with acute ST-elevation MI.
Coronary revascularization (CABG or PCI), who would be class IIa for this?
Class IIa: PCI to mitigate cardiac symptoms in patients who need elective surgery in next 12M.
Class IIa: Patients who have received drug- eluting stents needing urgent surgery that mandate discontinuing thienopyridine therapy.
Coronary revascularization (CABG or PCI), who would be class IIb?
Class IIb: Not well established for patients with
high risk ischemia or low risk ischemia. (dobutamine echo with 5 segements of wall motion abnormalities or 1 to 4 segements)
Coronary revascularization (CABG or PCI) who would be Class III for this?
Class III: Routine prophylactic revascularization is not recommended in patients with stable CAD.
Class III: Elective surgery is not recommended for 4-6 weeks after bare metal stents, 12 months for drug eluting if dual antiplaelet therapy needs to be discontinued perioperatively.
Class III: Surgery is not recommended for 4 weeks after PTCA.
Who is class I for Beta blocker therapy?
¨Class I: Continue beta blockers for those taking beta blockers for angina, symptomatic arrhythmia’s, HTN.
¨Class I: Give to patients undergoing vascular surgery who are at high cardiac risk according to preoperative testing.
Who is Class IIa for betablocker therapy?
Class IIa: Recommended for patients who pre-op assessment testing identifies CAD.
Class IIa: Probably recommended for patients
having vascular surgery with 1 clinical risk factor. (HTN, taking diuretic for control)
Class IIa: Probably recommended for patients
identified as having CAD or high cardiac risk by the presence of 1 more than 1 clinical risk factors.
Who is class III for beta blocker therapy?
Class III: Avoid use in those with absolute contraindications for beta blocker therapy.
What are the different classes for Statin therapy?
¨Class I: If on a statin, continue.
¨Class IIa: Reasonable use for those with or
without clinical risk factors having vascular surgery.
¨Class IIb: Consider for those with at least 1
clinical risk factor having intermediate risk procedure.
What are the different classes for Alpha 2 agonist?
¨Class IIb: May consider for pre-op control of HTN
in those with CAD or at least 1 clinical risk factor.
¨Class III: Avoid in those patients with absolute contraindication for these medications.
Who should be admitted to the ICU PRE-OP?! (What class?)
ICU monitoring with Swan Ganz catheter in order to optimize hemodynamic status should be used only in highly select patients who are unstable and have multiple comorbid conditions
Who can benefit from volatile anesthetic agents?
Class IIb: Can be beneficial to maintain anesthesia in hemodynamically stable patients at risk for ischemia
Who (what class) of patients need prophylatic intraop NTG?
Class IIb: Unclear if intraop use for patients at high risk for myocardial ischemia is warrented
What about intraop TEE, what class is that?
Class IIb: Reasonable to use in emergent case to determne cause of acute persistent hemodynamic abnormality.
What class is maintenance of body temperature
Class I: Recommended for most procedures other than in ones where hypothermia is intended to provide organ protection
What are the classes for glycemic control?
Class IIa: Reasonable to control glucose in DM
patients and those at risk for myocardial ischemia having vascular and high risk surgery with planned ICU admission.
Class IIb: Strict glucose control appears uncertain in DM patients or acute hyperglycemia patietns having surgery without planned ICU admission.
What are the classes for pulmonary artery catheters?
Class IIb: May be reasonable in patients at risk
for hemodynamic disturbances easily detected by PA catheter.
Class III: Routine use is not recommended
What are the classes for ST segment monitoring?
Class IIa: Intra and post-op monitoring can be
useful in monitoring those with known CAD and those having vascular surgery.
Class IIb: May consider use in those with 1 or
multiple risk factors for CAD.
What are the classes for surveillance for perioperative MI?
Class I: Measure troponin on patients with ECG changes or with chest pain typical for acute coronary syndromes.
¨Class IIb: Not well established for stable patients having had vascular or intermediate risk surgery.
¨Class III: Not recommended for asymptomatic patients having had low risk surgery
¨Class IIb: Uncertain for patients with only 1
clinical risk factor having intermediate risk procedure or vascular procedure.
¨Class IIb: Uncertain for those having vascular
surgery and not currently on beta blocker.
What do we do if a patient has a pacemaker?
Evaluate pacemaker 3-6 months prior to surgery
Evaluate pacemaker after surgery
Set to asynchronous if pacer dependant or use magnet
ICD set tachyarrhythmia settings to off
What does the QT interval represent?
Duration of ventricular systole
___ limb leads form the frontal plane
___ chest leads form the horizontal plane
What are the lateral leads?
What are the lateral leads?
What are the anterior chest leads?
What are the RIGHT chest leads?
What are the LEFT chest leads
What are the septal leads?
Name the 5 things we determine from an EKG
Wolfe-Parkinson White Syndrome
•Abnormal accessory pathway, bundle of Kent
•Short circuits usual delay through AV node
•Delta wave on EKG, has illusion of shortened PR interval and lengthened QRS.
What are the types of block?
•Sick sinus syndrome
•1st degree AV block
•2nd degree AV block
Wenckeback (formerly type 1)
Mobitz (formerly type 2)
•3rd degree block
Describe a bundle branch block
•QRS is 0.12 seconds or greater
•Check V1 and V2 for RBBB
•Check V5 and V6 for LBBB
Tell me about the axis
•Measure the Vector of electrical stimulus
•Follows the general direction of the depolarization of the heart (uppper R to lower L)
•Mean RS vector
•Normal vector is downward and to the patient’s left
----Between 0 degrees and +90 degrees is normal
* 0 degrees is due left
* +90 degrees is due south
•Vector will point toward area of ___________
•Vector will point away from area of _______
For the axis, in Lead I and Lead aVF, both QRS are mainly positive, is this a normal axis?
YES! (two thumbs up rule)
For the axis, Lead I QRS is normally positive. If not then it's ________
right axis deviation
For the axis, Lead aVF QRS is normally positive. If not then it's _______
left axis deviation
For the axis, lead I and AVF both mainly negative then it's _________
•Then extreme right axis deviation
(# is extremely +)
Tell me about axis rotation
•QRS normally begins more negative in V1 and becomes more positive in V6
•V3 and V4 are generally isoelectric
•QRS is about equal above and below
•Rightward rotation occurs when V1 or V2 are isoelectric
•Leftward rotation occurs when V5 or V6 are isoelectric
Which lead (on a 12 lead EKG) do you check for atrial hypertrophy or enlargement?
•Check Lead V1
•Usually see a diphasic P wave
-If initial component is larger then Right atrial enlargement
-If terminal component is larger then Left atrial enlargement
Where do you look for RV hypertrophy on an EKG?
- Large R wave, small S wave
- R wave gets progressively smaller from V2-V6
- Right Axis Deviation
-More vectors directed towards the hypertrophied Right ventricle
- Rightward rotation in horizontal plane
Where do you look for LV hypertophy on an EKG?
•Usually deep S wave but with LVH even deeper
•Also Left axis deviation and left rotation of vector
•V5 see Tall R wave
•So, measure depth of S wave in V1 and Height of R wave in V5
(If total is greater than 35mm the LVH)
Tell me about infarction and what you'll see on an EKG
•Q wave is diagnostic for infarction
•Significant Q waves are absent in normal EKG’s
•Tiny q waves are insignificant
•Q wave >.04 seconds or 1/3 of QRS
amplitude is significant
In what leads would you see signs of anterior infarction?
In what leads woould you see signs of inferior infarction?
In what leads would you see signs of a lateral infarction?
In what leads would you see signs of a posterior infarction?
•But….QRS is upside down relative to Anterior MI
True or False. It can be difficult to see Q waves in LBBB.