Cardio IE 3 : VHD and Shock TSU

valves that clinically have the most problems

aortic and mitral valves

stenosis

narrowing or tighterning of valve → obstruct forward blood flow

regurgitation

insufficiency or leaking of valve → allow backward blood flow

mitral valve stenosis

• causes

• pathophysiology

• presentation

• monitoring

• treatment

• causes

  • due to rheumatic HD

• pathophysiology

  • mitral valve narrow → increased pressure in LA → LA enlargement → high risk of AF and thromboembolic events

• presentation

  • symptomatic when 50 - 60 years old

  • pulmonary/systemic edema, fatigue

• monitoring

  • echo (every 1 - 5 years)

• treatment

  • meds (symptom control) = diuretics, BBs, non-DHP CCBs

  • mehanical intervention or valve replacement

  • balloon valvuloplasty

mitral valve regurgitation

• causes

• pathophysiology

• presentation

• monitoring

• treatment

• causes

  • mitral valve prolapse

  • dilation of LV

• pathophysiology

  • blood flow back to LA → decreased CO → LV enlarges to increase CO → HF

• presentation

  • asymptomatic

  • mild → pulmonary congestation

  • severe → pulmonary HTN, HF symptoms

• monitoring

  • echo annually

• treatment

  • reduce preload → diuretics

  • LV dysfunction → HF therapy

  • valve replacement

aortic valve stenosis

• causes

• pathophysiology

• presentation

• monitoring

• treatment

• causes

  • most common valvular disorder

  • calcification of aortic valve

• pathophysiology

  • narrowed aortic valve → LV pumps against higher pressure → LV hypertrophy

• presentation

  • present at 60 - 90 years

  • mild → chest pain during exertion

  • severe → chest pain, SOB, syncope, HF

• monitoring

  • echo (every 1 - 5 years)

• treatment

  • valve replacement

  • balloon valvuloplasty

aortic valve regurgitation

• causes

• pathophysiology

• presentation

• monitoring

• treatment

• causes

  • abnormal valve leaflets, dilated aortic root

• pathophysiology

  • aorta dilated → LV enlarges and thickens

• presentation

  • asymptomatic due to cardiac compensation

  • pulmonary congestion, peripheral edema, chest pain

• monitoring

  • echo (every 0.5 - 3 years)

• treatment

  • afterload-reducing agents

  • valve replacement

valve repair

• fix and preserves patient’s valve

• preferred over replacement

• no anticoagulation needed

valve replacement

• open heart surgery

• transcatheter aortic valve implantation (TAVI)

  • less invasive

mechanical valves vs bioprosthetic valves

• mechanical

  • high durability

  • highly thrombogenic → lifelong anticoagulation

  • preferred if risk factors for bleeding, refuses/CI to anticoagulation

• bioprosthetic

  • porcine or bovine

  • less thrombogenic

  • low durability

  • preferred if pt is young

antithrombotic therapy for valve replacement: bioprosthetic

• aortic

• mitral

• aortic

  • aspirin 50 - 100 mg/day indefinitely

  • opt. add clopidogrel 75 mg daily for 3 - 6months if TAVI

• mitral

  • warfarin w/ INR 2 - 3 for 3 months, then aspirin 50 - 100 mg/day indefinitely

antithrombotic therapy for valve replacement: mechanical

• aortic

• mitral

• bridging

• additional aspirin

• aortic

  • warfarin w/ INR 2 - 3 indefinitely

• mitral

  • warfarin w/ INR 2.5 - 3.5 indefinitely

• bridging

  • w/ IV UFH or SC LMWH if INR subtherapeutic

• additional aspirin

  • add 50 - 100 mg/day if add. risk factors for thromboembolism

    • Afib, low EF, older age, history of TE)

ODACs in valvular disease

• dabigatran, rivaroxaban, apixaban, edoxaban

• CI in mechanical heart valves

• increased risk of thromboembolism and bleeding compared to waefarin

which valve preferred if women wish to have children in future

bioprosthetic

which drug increases risk of congenital fetus abnormalities, fetal loss, hemorrhagic complications

warfarin

if willing, warfarin can be continued in —- trimester if daily dose —-

1st trimester; < 5 mg

which med is chosen instead of warfarin due to congenital effects

LMWH

• which is last line option

• which is added for high risk pts

• UFH IV

• low dose aspirin

shock

• acute, generalized state of inadequate perfusion of critical organs

• SBP < 90 mmHg OR reduction of at least 40 mmHg from bseline

perfusion triangle

• inadequate perfusion due to problems w. heart, blood vessels, blood

goal and monitoring of shock

• achieve/maintain MAP > 65 mmHg

• assess perfusion and oxygenation of body

• assess organ specific O2 delivery and utilization

cardiogenic shock

• description

• etiologies

• treatment

• description

  • heart fails to pump out blood

• etiologies

  • HF

  • valve dysfunction

• treatment

  • increase CO

  • inotropes

obstructive shock

• description

• etiologies

• treatment

• description

  • heart pumps well

  • outflow obstructed

• etiologies

  • PE

  • tamponade

• treatment

  • treat obstruction

hypovolemic shock

• description

• etiologies

• treatment

• description

  • heart pumps well

  • not enough blood volume to pump

• etiologies

  • blood loss

  • fluid loss

• treatment

  • IV fluids

distributive shock

• description

• etiologies

• treatment

• description

  • heart pumps well

  • peripheral vasodilation

• etiologies

  • anaphylaxis

  • sepsis

• treatment

  • IV fluids

  • vasopressors

receptor actions

• alpha 1

• beta 1

• beta 2

• D

• V

• alpha 1

  • vasoconstriction, increased chronotropy

• beta 1

  • increased ionotropy, chronotropy

• beta 2

  • vasodilation (blood vessels), bronvhodilatioin, vasodilation (kidneys)

• D

  • vasodilation in kidneys

• V

  • v1 = vasoconstriciton

  • v2 = reabsorption of water in kidneys

vasopressor agents

• epinephrine

• norepinephrine

• dopamine

• phenylephrine

• vasopressin

epinephrine

• dose

• receptors

• effects

• use

• dose

  • IV push or titratable infusion

• receptors

  • alpha 1, beta 1, beta 2

• effects

  • vasoconstriction, increased inotropic/chronotropic activity

• use

  • most common in life-threatening situations (cardiac arrest)

  • 3rd or 4th line vasopressor in shock

Norepinhrine (Levophed)

• dose

• receptors

• effects

• use

• dose

  • IV as titratable infusion

• receptors

  • alpha 1 > > beta 1

• effects

  • vasoconstriction

  • increased inotropic/chronotropic activity

• use

  • preffered in sepsis

  • most common in ICU

dopamine

• dose

• receptors

• effects

• use

• dose

  • IV as titratable infusion

• receptors

  • dopamine, beta 1, alpha 1 - dose dependent

• effects

  • low dose = increased renal blood flow (D)

  • medium dose = increased inotropic/chronotropic activity (beta 1)

  • high dose = vasoconstriction (alpha 1

• use

  • cardiogenic shock

phenylephrine (Neo-synephrine)

• dose

• receptors

• effects

• use

• dose

  • IV as titratable infusion

• receptors

  • alpha 1

• effects

  • vasoconstriction

• use

  • alt if tachyarrhythmias from NE or D are concern

vasopressin

• dose

• receptors

• effects

• use

• dose

  • IV as titratable infusion

• receptors

  • V1 and V2

• effects

  • vasoconstriction (V1)

  • reabsorption of water in kidneys (V2)

• use

  • adjunct to NE in sepsis

  • used for diabetes insipidus

  • not affected by acidosis

general ADE of vasopressors

• arrhythmias

• tachcardia

• tissue ischemia