Exam 1
You are preparing to induce anesthesia IV in a morbidly obese pediatric pt. The initial dose of which of the following agents should be based upon ideal body weight? a) rocuronium b) fentanyl c) succinylcholine d) propofol
a) rocuronium In obese peds pt; initial dose of rocuronium & morphine should be based on IBW; propofol & remifentanil should be based on LBW; succinylcholine & sugammadex, and fentanyl should be based on TBW
Select two classic symptoms of aortic stenosis (select 2) a) syncope b) angina c) a-fib d) bradycardia
a, b The classic triad of symptoms that accompany severe aortic stenosis are angina, syncope, and CHF
Which of the following interventions would be appropriate in the mgt of a pt with symptomatic cardiac tamponade until a pericardiocentesis can be performed? (select 4) a) adminster colloid soln IV b) admin crystalloid soln IV c) admin a BB to prevent tachycardia d) admin isoproteronol to prevent bradycardia e) admin atropine to prevent vagal reflexes f) hypoventilate the pt to creatte mild to moderate acidosis
a, b, d, e Primary goals are expand intravascular volume w/ crystalloids or colloids, maintain HR and contractility, administer dopamine to increase SVR prn, give atropine to prevent vagal rxn to increased intrapericardial pressure, correct acidosis
A pt w/ mitral stenosis has a left atrial pressure of 27 mmHg. You would presume that the pt likely a) is asymptomatic b) has pulmonary htn c) has decreased preload d) would benefit from a balloon aortic valvotomy
b) has pulmonary hen a mean left atrial pressure of 25 mmHg is required when the mitral area is less than 1 cm. If this pressure is sustained, the pt will likely develop pulm htn
Which of the following are characteristics of unstable angina? (select four) a) transient T wave changes b) transient ST segment changes c) chest pain that began less than 6 months ago d) chest pain that lasts longer than 30 min e) chest pain that is caused by exertion and relieved by rest f) chest pain that has progressively increased in severity g) third degree block h) sinus tachycardia
a, b, d, f unstable angina is characterized by substernal chest pain that began less than 2 months ago, has progressively increased in severity, duration, or frequency, is less responsive to pharmacologic therapy, occurs at rest, lasts longer than half an hour, or exhibits transient T-wave or ST segment changes
Select two classic clinical presentations associated w/ pericardial tamponade. a) jugular venous distension b) hypertension c) pulsus paradoxus d) anemia
a, c Pts w/ pericardial tamponade present w/ tachycardia, hypotension, distended neck veins, distant heart tones, pulsus alternans, or pulsus paradoxus
Which two hemodynamic changes would increase the severity of aortic regurgitation? (select two) a) a decrease in HR b) an increase in HR c) an increase in the DBP d) a decrease in the DBP
a, c the decrease in HR increases the diastolic time which adversly affects the pts condition by increasing the proportion of the SV that reguritates backward thru the aortic vavle. An increasase in the DBP increases the backward pressure gradient which results in an increase in the proportion of SV that regurgitates back into the ventricle
What is the most potent stimulus for pulmonary vasoconstriction? a) hypotension b) hypoxia c) acidosis d) hypocapnia
b) hypoxia generalized alveolar hypoxia is the most potent stimulus for pulmonary vasoconstriction; when it occurs locally, it serves to shunt blood to areas that are better oxygenated. Systemic acidosis also promotes pulmonary vasoconstriction but is not as strong a stimulus as hypoxia.
Factors that decrease the amount of prolapse in pts w/ mitral valve prolapse include (select four) a) drug-induced myocardial depression b) pulmonary HTN c) increased preload d) HTN e) decreased systemic vascular resistance f) tachycardia g) a-fib h) vasoconstritction
a, c, d, h Any factor that maintains a larger ventricular volume will decrease the degree of prolapse. HTN, vasoconstriction, drug-induced myocardial depression, and increased preload will decrease the degreee of prolapse
How does an increase in the diastolic BP affect the severity of aortic regurgitation? (select two) a) it results in an increase in the backward pressure gradient across the valve b) It results in a decrease in the backward pressure gradient across the valve c) it decreases the left ventricular regurgitant volume d) it increases the left ventricular regurgitant volume
a, d An increase in the diastolic BP increases the backward pressure the backward pressure gradient which results in an increase in the proportion of SV that regurgitaates back into the left ventricle
What changes in heart sounds are associated w/ mitral valve prolapse? (select two) a) midsystolic click b) late diastolic murmur c) opening snap d) late systolic murmur
a, d mitral valve prolapse is associated w/ a midsystolic click and a late systolic murmur. An opening snap is associated w/ mitral stenosis
What aspects of the induction of GA would have detrimental effects on the pt w/ cardiac tamonade? (select 2) a) peripheral vasodilation from administration of an inhaled anesthetic b) hypertension d/t laryngoscopy c) increased HR during laryngoscopy d) positive pressure ventilation
a, d the combo of peripheral vasodilation & myocardial depression from the anesthetic and decreased venous return from PPV can produce severe, life-threatening hypotension in the pt w/ cardiac tamponade
Which CCB can be titrated IV as an antihypertensive agent? a) nifedipine b) nimodipine c) amlodipine d) nicardipine
d) nicardipine nicardipine is a CCB that can be titrated IV for use as an antihypertensive medication
Cardiac tamponade
pluses paradoxus
constrictive pericarditis
prominent y-descent on the CVP tracing
Which of the following would you expect to see with a myocardial contusion? a) decreased serum LDH levels b) increased serum troponin levels c) normal to decreased creatine kinase levels d) hyponatremia
b) increased serum troponin levels Chest pain, palpitations, dysrhythmias, ST and T wave abnormalities, and elevated LDH, creatine kinase, and troponin levels are all consistent with myocardial contusion
What is the initial compensatory mechanism as aortic stenosis develops? a) an increase in afterload b) an increase in right ventricular pressure c) an increase in left ventricular pressure d) a decrease in pulmonary vascular resistance
c The initial compensatory mechanism for aortic stenosis is an increase in left ventricular pressure to maintain flow thru the narrowed aortic valve. This results in a pressure gradient across the valve.
Which of the following would decrease the magnitude of a left-to-right shunt? a) high inspired oxygen concentration b) positive-pressure ventilation c) intravenous administration of neosynephrine d) intravenous administration of epinephrine
b) positive-pressure ventilation PPV increases pulmonary vascular resistance (PVR), which results in a decrease in the left-to-right shunt. A high FiO2 will decrease PVR and increase the shunt; IV admin of neo or epi will increase SVR which will increase the magnitude of the shunt
An increase in BP d/t coarctation of the aorta would be an example of: a) essential HTN b) secondary HTN c) pre-hypertension d) hypertensive emergency
b) secondary HTN
What is the most common congenital heart defect in infants and children? a) atrial septal defect b) ventricular septal defect c) patent ductus arteriosus d) ebstein's anomaly
b) ventricular septal defect
Which of the following statements regarding mitral valve stenosis is false? a) it is associated w/ a decreased left ventricular volume b) it is associated w/ a decreased left atrial pressure & increased right atrial pressure c) it can cause right ventricular failure d) it can result in pulmonary edema
b) it is associated w/ a decreased left atrial pressure & increased right atrial pressure As flow thru the mitral valve opening into the L ventricle is decreased (decreasing the L ventricular volume) left atrial pressure increases resulting in L atrial hypertrophy and distention.
Which of the following statements regarding aortic stenosis is true? a) aortic stenosis is assocaited w/ an increase in left ventricular complieance b) myocardial oxygen demands is not altered in aortic stenosis c) aortic stenosis is associated w/ diastolic dysfunction d) aortic stenosis does not alter arterial flow to the myocardium
c)
What is the normal aortic valve area? a) 1.5 - 2 cm b) 2 - 2.5 cm c) 2.5 - 3.5 cm d) 4.5 - 5.5 cm
c) 2.5 - 3.5 cm
When inducing GA for a pt w/ chronic HTN, you should strive to maintain the mean arterial BP within what percent of normal? a) 10 b) 15 c) 20 d) 30
c) 20 When inducing GA for a pt w/ chronic HTN, you should strive to maintain the mean arterial blood pressure within 20% of normal
Patent ductus arteriosus
*Can be treated w/ cyclooxygenase inhibitors *Communication between the descending aorta and the left pulmonary artery; it normally closes within 48 hours of birth. Prostaglandin inhibition by nonselective COX receptor antagonists such as indomethacin can help promote closure of the defect
Eisenmenger's syndrome
*Reversal of a left-to-right shunt *Defined by the reversal of a left-to-right shunt when pulmonary vascular resistance increases above that of systemic vascular resistance
Aortic stenosis
*Systolic murmur over the 2nd right interspace *associated w/ a systolic murmur over the aortic area (2nd right interspace)
Coarctation of the aorta
*widened pulse pressure in the arms *consists of a ridge that extends into the lumen of the aorta either proximal to the left subclavian artery (pre-ductal coarctation) or distal to the left subclavian artery (postductal coarctation); characterized by a SBP that is higher in the upper extremities than in the legs. The DBP is typically the same, which explains the widened pulse pressure in the arms.
Compared to pure beta-adrenergic blockers, labetalol produces (select two) a) less bradycardia b) an increased incidence of bronchospasm c) an increased risk for hypoglycemia d) an increased incidence of orthostatic hypotension
A, D Because of its alpha-adrenergic blocking capability, labetalol produces less bradycardia than pure beta-adrenergic blockers but has an increased incidence of orthostatic hypotension
Which of the following statements regarding mitral valve stenosis is false? a) it is associated w/ a decreased left ventricular volume b) it is associated w/ a decreased left atrial pressure and increased right atrial pressure c) it can cause right ventricular failure d) it can result in pulmonary edema
b)
What is the overall risk for preoperative MI in the general population undergoing general anesthesia? a) 0.03% b) 0.3% c) 3% d) 10%
b) 0.3%
What is the most common risk factor for the development of aortic dissection in older pts? a) aortic stenosis b) HTN c) cadiomyopathy d) mitral regurgitation
b) HTN
Which of the following statements does not correspond w/ an accurate understanding of the appropriate anesthetic management goals for the pt w/ aortic stenosis? a) normal NSR should be maintained b) Myocardial depression reduces the severity of the lesion c) hypotension should be treated aggressively d) both bradycardia and tachycardia should be avoided
b) Myocardial depression reduces the severity of the lesion
What substance is synthesized & released by the adrenal cortex when stimulated by angiotensin II? a) angiotensin-converting enzyme b) aldosterone c) cortisol d) vasopressin
b) aldosterone The angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II then triggers the adrenal cortex to produce aldosterone
What hormone is released from the cardiac atria in response to increased atrial stretch and increases the renal excretion of sodium and water?
Atrial natriuretic peptide ANP is released from the cardiac atria d/t increased atrial stretch. It exhibits vasodilatory effects and increases the renal excretion of sodium and H2O
An increase in blood pressure due to coarctation of the aorta would be an example of a) essential HTN b) secondary HTN c) Pre-hypertension d) hypertensive emergency
B) secondary HTN is an increase in BP d/t a cause that can be ID'd and cured; essential HTN has no identifiable cause and is dx based on the exclusion of causes; 95% of pts have essential HTN
How does chronic HTN affect the L ventricle? (select 2) a) It can produce eccentric hypertrophy b) It can reduce left ventricular subendocardial perfusion c) It increases the L ventricular ejection fraction d) it increases left ventricular oxygen demand
B, D Faced w/ increased afterload associated w/ chronic HTN, the left ventricle increases its myocardial mass (concentric hypertrophy). As the L ventricle undergoes compensatory concentric hypertrophy, the increased myocardial mass has a higher O2 demand while contraction of the hypertrophied muscle can reduce subendocardial O2 supply, placing the myocardium at greater risk for ischemia
You would expect serum troponin levels to become elevated within how many hours following the onset of an acute myocardial infarction? a) 1 hour b) 2 hours c) 3 hours d) 8 hours
c) 3 hours Troponin is a cardiac-specific marker for myocardial infarction that becomes elevated within 3 hours of myocardial injury and remains elevated for several days following the event
What is the compensatory mechanism that maintains SV in pts w/ mild mitral stenosis? a) a decrease in systemic vascular resistance b) an increase in left atrial pressure c) an increase in pulmonary artery pressures d) concentric ventricular hypertrophy
b) an increase in left atrial pressure left atrial pressure increases, which increases the blood flow thru the mildly narrowed mitral valve opening. the increase in atrial pressure will fail to maintain SV during tachycardia or a-fib
What is the compensatory mechanism that maintains stroke volume in pts w/ mild mitral stenosis? a) a decrease in systemic vascular resistance b) an increase in left atrial pressure c) an increase in pulmonary artery pressures d) concentric centricular hypertrophy
b) an increase in left partial pressure, which increases the blood flow through the mildly narrowed mitral valve opening. The increase in atrial pressure will fail to maintain SV during tachycrdia or artial fibrillation
Which of the following valvular lesions is most likely to result in eccentric left ventricular hypertrophy? a) aortic stenosis b) aortic regurgitation c) mitral stenosis d) tricuspid stenosis
b) aortic regurgitation
Which substance is released from the ventricles in response to increased wall stress? a) atrial natriuretic peptide b) b-type natriuretic peptide c) somatostatin d) vasopressin
b) b-type natriuretic peptide. This substance produces diuresis, increased sodium excretion, and vasodilation
Which of the following chest radiograph findings are consistent with advanced tuberculosis? a) unilateral basilar infiltrates b) bilateral apical infiltrates c) pneumothorax d) productive cough
b) bilateral apical infiltrates In addition to positive Mantous skin tests, chest pain, night sweats, and nonproductive cough, tuberculosis is associated w/ chest x-ray findings such as bilateral upper lobe infiltrates, apical and subapical infiltrates, and vertebral osteomyelitis (Pott's dz) which is common in advance extrapulmonary TB
Which of the following decreases in mitral stenosis? a) left atrial pressure b) left ventricular volume c) pulmonary artery pressure d) aortic vavle surfac area
b) left ventricular volume as the mitral valve orifice narrows, a pressure gradient develops across the valve as a compensatory mechanism to maintain flow thru the valve. as the valve opening deceases and the pressure gradient increases, the flow of blood thru the opening decreases and left ventricular volume decreases
What do pts with HTN urgency present with?
HTN & symptoms such as HA, epistaxis, or anxiety; the exception to this rule is parturients. A parturient w/ a diastolic BP > 109 mmHg is defined as being in a state of htn emergency even if no other symptoms are present.
HTN emergency is defined as:
HTN w/ evidence of end-organ damage such as MI, dissecting aortic aneurysm, renal insufficiency, pulm edema, encephalopathy, eclampsia, or intracerebral hemorrhage. HTN w/o signs of end-organ damage is termed 'htn urgency'
What is the most common cause of sudden cardiac death in young athletes?
Hypertrophic cardiomyopathy
Which of the following radiographic changes are consistent with cor pulmonale? (select two) a) narrowing of the pulmonary arteries b) decreased vascular marking in the peripheral fields c) decreased retrosternal space on the lateral film d) decreased right ventricular size
b) decreased vascular marking in the peripheral fields c) decreased retrosternal space on the lateral film The chest x-ray often reveals increased width of the right pulm artery & decreased pulm vascular markings in the lung periphery. A late sign of cor pulmonale may be a decrease in the retrosternal space on the lateral film as right ventricular enlargement becomes evident
What is the normal area of the mitral valve? a) 1.5 - 2.5 square centimeters b) 2.5 - 3.5 square centimeters c) 4 - 6 square centimeters d) 6.5 - 8 square centimeters
c) 4 - 6 square centimeters
What is the most common cause of right ventricular heart failure?
Left ventricular heart failure Causes of isolated right ventricular failure include pulmonary hytertension or right ventricular myocardial infarction
A young, otherwise healthy athlete has long OT syndrome. During anesthesia, he exhibits torsades de pointes. What is the tx of choice for this?
Magnesium
Which drugs are selective beta-1 adrenergic blockers?
Metoprolol, atenolol, and esmolol
Manifestations of cor pulmonate include: a) systolic murmur b) elevated pulmonary artery pressures c) respiratory alkalosis d) Prominent V wave on the central venous pressure tracing
b) elevated pulmonary artery pressures Cor pulmonale is a sequence of symptoms that originate with hypoxia d/t pulm pathology, often COPD. The hypoxia results in HPV & elevated pulm artery pressures. In the face of pulm HTN, the right ventricle can begin to fail resulting in prominent A waves on the CVP, jugular venous distention, hepatosplenomegaly, peripheral edema and often a diastolic murmur d/t incompetence of the pulmonary valve.
Which beta-blocker is metabolized rapidly in the blood by an esterase located in the red blood cell cytoplasm? a) atenolol b) esmolol c) metoprolol d) labetalol
b) esmolol
Myocardial contusion
ST-T wave abnormalities
ECG changes seen in acute pericarditis occur in four stages:
Stage 1: there is diffuse ST segment elevation and depression of the PR segment Stage 2: the ST and PR changes normalize Stage 3: T wave inverts Stage 4: T waves normalize
Tricuspid atresia is characterized by (select four) a) arterial hypoxemia b) enlarged right ventricle c) enlarged left ventricle d) increased pulmonary blood flow e) atrial septal defect f) left-to-right shunt g) pulm blood flow that can occur via a ventricular septal defect h) left ventricular hypolasia
Tricuspid atresia a) arterial hypoxemia c) enlarged left ventricle e) atrial septal defect g) pulmonary blood flow that can occur via a ventricular septal defect
You are preparing to induce GA in a pt taking propranolol for HTN. Which drug would you anticipate to have substantially higher than normal plasma concentrations after administration? a) isoflurane b) fentanyl c) chloroprocaine d) propofol
b) fentanyl Propranolol decreases the clearance of amide local anesthetics, but not ester anesthetics such as chloroprocaine. The pulm uptake of fentanyl, however, is substantially decreased in pts taking propranolol. As a result, plasma concentrations shortly after injection can be 2-4 times higher than normal.
What is tricuspid atresia?
a congenital heart defect that is characterized by a small right ventricle, enlarged left ventricle, decreased pulmonary blood flow (that occurs via a ventricular septal defect, patent ductus arteriosus, or bronchial vessels), and arterial hypoxemia. Blood passes from the right atrium to the left atrium (right-to-left shunt) via an atrial septal defect prior to ejection into the systemic circulation causing a cyanotic defect
Myocardial infarction, papillary muscle dysfunction, chordae tendinae rupture, trauma to the chest, and infectious endocarditis are the most common causes of a) acture mitral regurgitation b) pulm HTN c) chronic aortic stenosis d) ebstein's anomaly
a)
Which alteration would be most likely to produce CHF or hypotension in the pt w/ aortic stenosis? a) new onset of a-fib b) decrease in HR from 70 bpm to 50 bpm c) PVCs at a rate of 6-8 per minute d) new onset right bundle branch block
a)
Which of the following interventions would be appropriate for a pt with mitral regurgitation, but NOT for a pt w/ mitral stenosis? a) an increase HR b) increase the afterload substantially c) avoid an increase in pulmonary vascular resistance d) increase preload slightly
a)
What is the most common cause of heart failure? a) CAD b) valvular dz c) arrhythmias d) pericardial dz
a) impaired contractility d/t ischemis heart dz or cardionmyopathy are the most common culprits, but valvular dz, htn, pericardial dz, and pulm htn are also causes of heart failure
Which of the following statements regarding pericarditis is not true? a) it produces myocardial depression b) it is often releived by sitting forward c) it initially produces diffuse ST segment elevation d) it is commonly preceded by a viral infection
a) pericarditis is often d/t a viral illness, but may often occure 1-3 days after a MI. Deep insiration worsens the pain. often releived by sitting forward. If not other assocaited pericardial dz is present, acute pericardiits does not alter ca
The abrupt DC of a beta blocker can result in a) MI b) hyperglycemia c) bradycardia d) hypotension
a) MI The abrupt DC of a beta blocker can produce angina pectoris or even myocardial infarction
Which of the following ECG changes is an indication of subendocardial ischemia? a) ST depression b) ST elevation c) inverted T waves d) widened QRS wave
a) ST depression Depression of the ST segment is typically associated w/ subendocardial ischemia. ST segment elevation is typically associated w/ transmural ischemia
What BP is designated as a hypertensive emergency in the parturient? a) a diastolic greater than 109 mmHg b) a diastolic greater than 129 mmHg c) a systolic pressure greater than 149 mmHg d) a systolic pressure greater than 179 mmHg
a) a diastolic greater than 109 mmHg Encephalopathy usually does not present until the diastolic BP reaches 150 mmHg. The exception is parturients who may exhibit signs of encephalopathy w/ diastolic pressures at 100 mmHg. Even if no overt signs of end-organ damage are noted, a diastolic pressure higher than 109mmHg in a parturient is designated as a hypertensive emergency & immediate tx is warranted.
Which of the following would best exemplify a dx of HTN emergency? a) parturient w/ a BP of 179/110 s/ any symptoms b) a pt w/ a BP of 185/118 and epistaxis c) a pt w/ a BP of 192/105 & HA d) a pt w/ a BP of 179/100 & anxiety
a) a parturient w/ a BP of 179/110 w/o any symptoms
What congenital heart disorders create mechanical obstruction to the trachea? (select three) a) absent pulmonic valve b) ebstein's anomaly c) truncus arteriosus d) double aortic arch e) aberrant left pulmonary venous return f) partial anomalous pulmonary venous return g) transposition of the great arteries h) coartication of the aorta
a) absent pulmonic valve d) double aortic arch e) aberrant left pulmonary venous return
MI, papillary muscle dysfunction, chord tendine rupture, trauma to the chest, and infectious endocarditis are the most common cuases of a) acute mitral regurgitation b) pulmonary hypertension c) chronic aortic stenosis d) ebstein's anomaly
a) acute mitral regurgitation
The normal response of the juxtaglomerular apparatus to chronic vasoconstriction is a) an increase in the release of renin b) a decrease in the release of renin c) an increase in the release of aldosterone d) a decrease in the release of aldosterone
a) an increase in the release of renin in the face of chronic vasoconstriction, the juxtaglomerular apparatus release renin. The end result of renin release is the conversion of angiotensin I to angiotensin II. Angiotensin II is the primary stimulus for the release of aldosterone by the adrenal cortex. Aldosterone results in increased Na & H2O retention.
Which of the following would be appropriate in the anesthetic mgt of a pt w/ hypertrophic cardiomyopathy? a) avoid an increase in myocardial contractility b) maintain a slightly increased HR c) Restrict IV fluids to decrease the preload d) administer nitrates to decrease the afterload
a) avoid an increase in myocardial contractility
Which antihypertensive agent has the shortest plasma half-life? a) fenoldopam b) hydralazine c) metoprolol d) nicardipine
a) fenoldopam has a half-life of about 5 minutes & requires administration as an infusion. Metoprolol has a have life of 3-7 hours. Hydralazine has a half-life of 2-8 hours. Nicardipine has a half-life of 2-4 hours
Which of the following interventions would be appropriate for a pt w/ mitral regurgitation, but NOT for a pt w/ mitral stenosis? a) increase the HR b) increase the afterload substantially c) avoid an increase in pulmonary vascular resistance d) increase preload slightly
a) increase the HR in mitral regurgitation, your goal is to amintain an inceased HR & decreased afterload while the goal in mitral stenosis is to maintain a normal or decreased HR and normal afterload. In both disorders, you should maintain NSR, avoid increases in pulmonary vascular resistance, and maintain preload at normal to incrased levels
What type of shunt is associated w/ acyanotic congenital heart disease? a) left-to-right intracardiac shunt b) left-to-right intrapulmonary shunt c) right-to-left intracardiac shunt d) right-to-left intrapulmonary shunt
a) left-to-right intracardiac shunt The result of this shunt is pulmonary HTN, right ventricular hypertrophy, and congestive heart failure
Which disorder exhibits a higher incidence of mitral valve prolapse? a) marfan syndrome b) COPD c) myasthenia gravis d) stevens-Johnson syndrome
a) marfan syndrome MVP has a higher occurence in pts w/ Marfan syndrome, systemic lupus erythematosus, rheumatic carditis, thyrotoxicosis, and myocarditis
The classic triad of symptoms associated w/ severe aortic stenosis include all of the following except a) midsystolic click on ausculatation b) angina c) syncope d) congestive heart failure
a) mid systolic click on auscultation
Which of the following Rx txs may result in increased intracranial pressure when treating hypertensive emergencies associated w/ encephalopathy? a) nitroprusside b) esmolol c) labetalol d) hydralazine
a) nitroprusside May increase ICP & therefore must be used cautiously in the tx of hypertensive crises associated w/ encephalopathy
Diastolic dysfunction is associated w/ a) normal EF b) eccentric left ventricular hypertrophy c) volume overload of the left ventricle d) increased myocardial compliance
a) normal EF Symptoms of pulmonary congestion can occur in the presence of a normal EF. another name for diastolic heart failure is heart failure with presenrved EF. because the left ventricle becomes fibrosed, thickeded and nondistensible, the ventricles fail to fill adequatley despite normal systolic fn, Systolic heart failure wil often follow diastolic heart failure
How long after a myocardial infarction is the risk for reinfarction the greatest? a) one month b) two months c) four months d) six months
a) one month the first 30 days after an MI is associated w/ the highest risk for reinfarction. The mortality rate with reinfarction is 50%. Because of these statistics, it is recommended that no pt undergo elective surgery until at least 60 after the MI.
Which of the following ECG changes are associated w/ cor pulmonale? a) peak P waves in leads II, III, and aVF b) left axis deviation c) left bundle branch block d) inverted T wave in leads I and aVL
a) peak P waves in leads II, III, and aVF The ECG changes associated w/ cor pulmonale are d/t the increase in mass of the right side of the heart. Right atrial hypertrophy can also manifest as right axis deviation, right bundle branch block and are often present as a result of right ventricular hypertrophy.
Which of the following electrocardiographic changes are consistent with cor pulmonale? a) peaked P waves in leads II, III, and aVF b) ventricular bigeminy c) deep S waves in lead V1 and tall R waves in lead V5 d) Biphasic P waves in lead V1
a) peaked P waves in leads II, III, and aVF these findings are consistent with right atrial hypertrophy and right axis deviation and right bundle branch block which are consistent with right ventricular hypertrophy
What clinical signs would you expect to see in a pt w/ constricitve pericarditis? (select 4) a) pulsus paradoxus b) severe bradycardia c) prominent y-descent on a CVP tracing d) a-fib e) kussmaul's sign f) ventricular discordance g) hypovolemia h) symptom improvement w/ beta-blocker administration
a) pulses paradoxus c) prominent y-descent on a CVP tracing e) kussmaul's sign f) ventricular discordance
Which statements concerning myocardial ischemia and cheanges in the ST segment on the ECG are correct? (select two) a) ST segment elevation is typically assocaited w/ subendocarial ischemia b) ST segment depression is typically associated with subendocardial ischemia c) ST segment elecation is typicaly assocaited with transmural ischemia d) ST segment depression is typicaly associated with transmural ischemia
b, c Depression of the ST segment is typically associated w/ subendocardial ischemia. ST segment elecation is typicaly associated w/ transmural ischemia
What drugs are components of the triple therapy that is the mainstay Rx tx of CHF? (select 2) a) digoxin b) beta blockers c) diuretics d) IV calcium
b, c Triple therapy consists of an ACE inhibitor, a beta-blocker, and a diuretic (which is often an aldosterone antagonsit)
Which classes of patients are most at risk for intracranial hemorrhage if thrombolytic therapy is adminiistered in the seeting of acute myocardial infarction? (select two) a) pts w/ hydrocephalus b) pts w/ uncontrolled hypertension c) pts w/ a first-degree relative diagnosed w/ a cerebral aneurysm d) pts over the the age of 75
b, d
Which of the following symptoms of cardiac tamponade are indications of ventricular discordance? (select 2) a) beck's triad b) kussmaul's sign c) decreased voltage on the electorcardiogram d) pulsus paradoxus
b, d Kussmaul's sign & pulsus paradocus are both indicative of ventricular discordance (also known as ventricular dyssynchrony) that occurs d/t the opposing response of the ventricles to filling during the resp cycle
Which of the following are compensatory mechanisms that occur d/t congestive heart failure? (select 2) a) preload decreases b) circulating NE levels increase c) concentric hypertrophy occurs d) adrenergic receptors are down-regulated
b, d increase preload and sympathetic tone, activation of the renin-angiotensin system, and ventricular hypertrophy are the compensatory mechanisms that occur in the presence of heart failure
Which of the following symptoms of cardiac tamponade are indications of ventricular discordance? (select 2) a) beck's triad b) kussmaul's sign c) decreased voltage on the ECG d) pulsus paradoxus
b, d kussmaul's sign and pulsus paradoxus are both indicative of ventricular descordance (also known as ventricular dyssynchrony) that occurs d/t the opposing response of the ventricles to filling during the resp cycle
What is the most effective means of preventing the post-induction hypotension commonly seen in HTN pts? a) administration of ephedrine prior to induction b) administration of neo-synephrine after induction c) administration of crystalloids prior to induction d) administration of dopamine during induction
c) administration of crystalloids prior to induction Because the chronically HTN pt is volume contracted, adequate hydration prior to induction will usually attenuate the drop in blood pressure seen after induction of anesthesia
Which of the following statements regarding aortic stenosis is true? a) aortic stenosis is associated w/ an increase in L ventriucular compliance b) Myocardial oxygen demand is not altered in aortic stenosis c) Aortic stenosis is associated w/ diastolic dysfunction d) Aortic stenosis does not alter arterial flow to the myocardium
c) aortic stenosis is associated w/ diastolic dysfunction left ventricular compliance deceases as the left ventricle hypertrophies, resulting in diastolic dysfunction. The myocardial demand is increased d/t ventricular hypertrophy and the supply is decreased as the exraordinary compression of intramyocardial vessels during systole restricts arterial flow to the myocardium
A reversal of left-to-right intracardiac shunt d/t an increase in the pulmonary vascular resistance is associated w/ a) ebstein's anomaly b) truncus arteriosus c) eisenmenger's syndrome d) tricuspid atresia
c) eisenmenger's syndrome is a reversal of a left-to-right intracardiac shunt d/t an increase in the pulmonary vascular resistance. Once the pulmonary vascular resistance reaches a level that is equal to or exceeds systemic vascular resistance, the shunt reverses to a right-to-left shunt
Which of the following symptoms are consistent w/ a dx of cardiac tamponade? a) hypertension b) loud S2 heart sound over the apex c) electrical alternans d) bradycardia
c) electrical alternans Beck's triad, the classic triplet of signs associated w/ cardiac tamponade, includes hypotension, distant heart sounds, and distended neck veins. Because of the obstruction of right atrial filling, CVP increase r/in destended neck veins unless severe hypovolemia is also present. Hypotension evelops as cardiac output drops and tachycardia often ensues as a compensatory mechanism. Electircal alternans is a variation in the ECG caused by the shifting of the heart within the distended pericardium as it beats.
A pt w/ a hx of TB is currently taking isoniazid. What diagnostic tests may be seriously altered d/t this drug? a) electrocardiogram b) motor evoked potentials c) liver function tests d) urine protein
c) liver function tests isoniazid is toxic and can result in damage to the liver and cause elevated transaminases
Dressler's syndrome is a) blindness r/t hypotension in the prone position b) ST segment deression during myocardial ischemia c) pericarditis following a myocardial infarction d) low serum cortisol levels following chrinic exogenous steroid administration
c) pericarditis following a myocardial infarction
What is the most common cause of secondary HTN? a) obesity b) hyperlipidemia c) renal artery stenosis d) hyperaldosteronism
c) renal artery stenosis secondary HTN is an increase in blood pressure d/t a cause that can be ID'd and cured such pheochromocytoma, renal artery stenosis, coarctation of the aorta, Conn's syndrome, or Cushing's disease.
What of the following would decrease the amount of prolapse in pts w/ mitral valve prolapse? (select 2) a) increased EF b) vasodilation c) increased intravascular volume d) hypertension
c, d Any factor that maintains a larger ventricular volume will decrease the degree of prolapse. Hypertension, vasoconstriction, drug-induced myocardial depression, and increased preload will decrease the degree of prolapse
What of the following would decrease the amount of prolapse in pts w/ mitral vavle prolapse? (select 2) a) increase EF b) vasodilation c) increased intravascular volume d) HTN
c, d Any fator that maintains a larger ventricular volume will decrease the degree of prolapse. HTN, vasoconstriction, drug-induced myocardial depression, and increased preload will decrease the degree of prolapse
Which anesthetic management goals are common for pts w/ mitral regurgitation and pts w/ mitral stenosis? a) you should maintain a decreased cardiac contractility in both disorders b) you should maintain a normal to increased HR in both disorders c) you should avoid increases in pulmonary vascular resistance in both disorders d) preload should be maintained at a normal level for both disorders
c, d In mitral regurgitation, your goal is to maintain an increased HR and decreased afterload, while the goal in mitral stenosis is to maintain a normal or decreased HR and normal afterload. In both disorders, you should maintain NSR, avoid increases in pulmonary vascular resistance, and maintain preload at normal to increased levels
What two factors determine the regurgitant volume in mitral regurgitation? a) pulm vascular resistance b) right atrial pressure c) size of the mitral valve opening d) the pressure gradient across the mitral valv
c, d The size of the mitral valve opening, the hr, and the pressure gradient across the valve determine the regurgitant volume in mitral regurgitation
What are the anesthetic mangaement goals for the pt w/ aortic regurgitation? (select two) a) maintain a normal to low heart rate b) maintain a moderately decreased cardiac contractility c) maintain a normal to high preload d) maintain normal sinus rhythm
c, d in aortic regurgitation, the heart rate should be maintained normal to high, the afterload should be decreased, myocardial depression should be avoided, normal sinus rhythm should be maintained, and preload should be normal to high
In a pt w/ mitral valve regurgitation, corrective surgery is preferred to be performed whtn the EF is a) 30% b) 40% c) 50% d) > 60%
d) >60% Corrective surgery for mitral regurgitation should be done when the EF is greater than 60%. If the pt is symptomatic, it should be performed even if the EF is normal. Otherwise, significant cardiac modeling occurs that prevents any effective improvement in performance
Which of the following is NOT one of the requirements for the dx of a new myocardial infarction? a) Q waves on the ECG b) ischemic symptoms c) changes in serum cardiac enzyme markers d) EF < 40%
d) EF < 40% The dx of an acute MI requires that any one of the following criteria be met: 1) the rise and fall of cardiac markers (especially troponin), symptoms of ischemia, ECG changes indicative of ischemia, q waves on the ECG, or imaging evidence of myocardial damage or wall motion abnormalities
The presence of a bicuspid aortic valve predisposes the pt to the development of a) tricuspid regurgitation b) mitral regurgitation c) eccentric left ventricular hypertrophy d) aortic stenosis
d) aortic stenosis Aortic stenosis is the narrowing of the aortic valve which results in obstruction of blood flow into the aorta. It is the results of degeneration and calcification of the leaflets of the aortic valve or the presence of a bicuspid rather tahn a normal tricuspid valve
Pulsus paradoxes would most likely be seen with which pathology? a) bradycardia b) complete heart blcok c) peripheral vascular dz d) cardiac tamponade
d) cardiac tamponade
Which of the following echocardiographic findings would be consistent w/ aortic stenosis? a) Eccentric hypertrophy of the right ventricle b) Concentric hypertrophy of the right ventricles c) eccentric hypertrophy of the ventricles d) concentric hypertrophy of the left ventricle
d) concentric hypertrophy of the left ventricle the exposure of the left ventricle to the increased pressure grdients associated w/ aortic stenosis result in concentric hypertrophy of the left ventricle (thickening of the ventricle wall). Eccentric hypertrophy is associated w/ the increased volume load associated w/ regurgitant lesions.
Pts with CHF often exhibit a) hypermagnesemia b) hyperkalemia c) hypernatremia d) hyponatremia
d) hyponatremia d/t activation of the vasopressin system. tx w/ diuretics to reduce vascular fluid volume may also lead to hypokalemia and hypomagnesemia
A pt experiencing a myocardial infarction also takes the drug vardenafil. What side effect could occur if he is administered nitroglycerine? a) anaphylaxis b) hemorrhagic stroke c) pruritus d) hypotension
d) hypotension Severe hypotension may ensue if nitrates are administered to a pt taking sildenafil, tadalafil, or vardenafil
A child w/ tetralogy of Fallot squats during a hyper cyanotic spell. This helps relieve symptoms by: a) increasing HR b) increasing pulmonary vascular resistance c) decreasing cardiac contractility d) increasing peripheral vascular resistance
d) increasing peripheral vascular resistance squatting increases peripheral vascular resistance and relieves the right-to-left shunt
Which of the following is not a characteristic of hypertrophic cardiomyopathy? a) occurs frequently in pts under the age of 30 b) is associated w/ diastolic dysfunction c) pts are typically asymptomatic at rest d) is associated w/ a fixed aortic obstruction
d) is associated w/ a fixed aortic obstruction pts w/ aortic valve stenosis have a fixed obstruction
What induction agent is most useful for the pt w/ cardiac tamponade undergoing GA? a) etomidate b) propofol c) thiopental d) ketamine
d) ketamine
A pt at risk for endocarditis is not required to receive prophylactic abx for which of the following procedures? a) dental procedures b) empyema drainage c) bronchoscopy for biopsy d) lower GI procedures
d) lower GI procedures Prophylaxis is now recomened for at-risk pts undergoing urinary procedures with a concurrent bacterial urinary infection. It is not recommended for upper or lower GI endoscopic procedures.
A pt in post-anesthesia recovery is exhibiting signs of an acute MI w/ cardiac failure. Which of the following agents is contraindicated? a) morphine b) nitroglycerin c) aspirin d) metoprolol
d) metoprolol Beta-blockers reduce the risk of reinfarction by decreasing myocardial oxygen demand. They should only be administered in a hemodynamically stable pt and should not be administered if the pt exhibits low cardiac output or heart failure
What organism is responsible for causing tuberculosis? a) actinomycetes pneumoniae b) streptococcus tuberculosis c) staphylococcus pneumoniae d) mycobacterium tuberculosis
d) mycobacterium tuberculosis
Which of the following hormone changes is consistent w/ congestive heart failure? a) aldosterone levels are decreased b) NE levels are decreased c) vasopressin levels are decreased d) natriuretic peptide levels are increased
d) natriuretic peptide levels are increased in CHF, sympathetic activation is increased, which results in increased secretion of NE. Circulating vasopressin levels are nearly twice the normal value in pts w/ CHF. Natriuretic peptide levels increase as the ventricles become the principal source of the hormones's release.
Pericardial effusion and pericardial tamponade are associated w/ all of the following disorders except a) dressler's syndrome b) systemic lupus erythematosus c) scleroderma d) patent ductus arteriosus
d) patent ductus arteriosus dressler's syndrome is a form of pericarditis seen following MI. Systemic lupus erythematosus, scleroderma, rheumatoid arthritis, metastatic dz, mediastinal radiation, and various infections are all associated with an increased incidence of pericardtis. Patent ductus arteriosus is not associated with an abnormally high risk for pericarditis.
Which beta-blocker is available in IV form? a) atenolol b) verapamil c) nadolol d) propranolol
d) propranolol In the US, propranolol, metoprolol, and esmolol; verapamil is a CCB
Which of the following congenital disorders would result in obtruction of right ventricular outflow? a) aortic stenosis b) mitral stenosis c) tricuspid stenosis d) pulmonic stenosis
d) pulmonic stenosis
What is the most common cause of mitral stenosis? a) congestive heart failure b) pulmonary HTN c) Ebstein's anomaly d) rheumatic heart dz
d) rheumatic heart dz incidence of mitral stenosis is higher in females. Over a period of 20-30 years, rheumatic fever causes the mitral valve leaflets to become thickened, the commissure may fuse, and the leaflets and annulus may become calcified
The most common for of hypertension is:
essential HTN essential HTN is an increased BP for which there is no identifiable cause; aprox 95% of pts w/ HTN are dx w/ essential HTN. Pre-HTN is defined as a SBP between 120-139 or a DBP between 80-89. A diastolic pressure higher than 109 mmHg w/ signs of end-organ damage is designated as a htn emergency. A diastolic pressure higher than 109 mmHg is the parturient is designated as htn emergecy even if no signs of end-organ damage are present.
Acute pericarditis
friction rub