1. Left main disease >50% occulusion 2. Multisystem disease + LV dysfunction/HF

- high risk features on non invasive test - refractory to medical tx

- HF - Arrythmias o Tachy ( atrial/vent) o Brady ( Heart block especially if inf MI) - Mechanical complications o Pap msc dysfunction & acute MR o Ventricular septal rupture o Free wall rupture o RV infarction ( esp inferior) - Pericarditis o Post MI pericarditis = early (±5d) vs delayed ( dressler ; 2-8weeks) o Fever, pl CP, rub, effusion tx = high dose ASA + colchicine

CAD + HF Flashcards by Ikram Abow Mohamed

Ischemia 2018 study regarding conservative vs invasive strategy

no difference in all cause mortality but CV death was lower

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CAPRIE trial study regarding clopidogrel

as SAPT :
- showed reduced MAJOR ADVERSE CARDIOVASCULAR EVENTS (MACE) with clopidogrel over ASA in patients with
* CAD/
* Stroke/
* PAD

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HOST EXAM STUDY ( CIRCULATION 2023)

Showed lower rates of cardiovascular death, MI, stroke and bleeding with long term clopidogrel compared to ASA after 1 year of DAPT post PCI (12.8% vs 16.9%)

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CCB when to avoid as an antianginal and which subtype reduces preload

if EF <40%
dihydropyridine

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WHich antianginal reduces LVEDP?

nitrate

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name the disease modifying therapies in CAD

BB
AceI
SGLT2/GLP1

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in what context does BB not reduce MACE ?

*If no previous MI and LVEF >50 = use of BB therapy does not ↓ MACE, in absence of other indication for BB (eg for control of HTN or rapid afib

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compass trial results implies what ?

low dose ASA + rivaroxaban 2.5 mg BID
- Another option for secondary prevention in patients with chronic stable CAD
- another alternative to patient with CAD + AF at low risk stroke ( CHads65=0)

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Post PCI trial rsults says what about routine stress test

don’t need to do routine stress testing after a year : no differences in all cause death, MI or hospitalization for angina with surveillance strategy on routine stress testing

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Indication for CABG

Left main disease >50% occulusion
Multisystem disease + LV dysfunction/HF

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benefiits of CABG

less repeat revascularisation
Better survivial
unknown stroke

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invasive angio for?

high risk features on non invasive test
refractory to medical tx

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post MI complication

HF
Arrythmias
o Tachy ( atrial/vent)
o Brady ( Heart block especially if inf MI)
Mechanical complications
o Pap msc dysfunction & acute MR
o Ventricular septal rupture
o Free wall rupture
o RV infarction ( esp inferior)
Pericarditis
o Post MI pericarditis = early (±5d) vs delayed ( dressler ; 2-8weeks)
o Fever, pl CP, rub, effusion tx = high dose ASA + colchicine

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ticagrelor contraindicaiton

o IC hmrg
o Active patho bleeding
o Hepatic impairment
o Combinations with CYP34A inhibitors ( ketoconazole, clarithromycin, ritonavir)
o Avoid if evidence of brady/ Heart block

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prasugrel CI

o Active bleeding
o Prior TIA/stroke ( even if ischemic stroke)
o Hypersensitivity rxn

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in fibrinolysis/thrombolysis, what’s your antiplatelet cocktail and why

ASA and clopidogel, because not studied (tica & prasu)

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tica vs prasu, which one would you not give if have bradycardia/heart blog

tica

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tica vs prasu, which one would not give if hepatic impairment

tica

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tica vs prasu, which one would not give if prior stroke ( regardless s

prasu

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prefered antiplatelet

ticagrelor

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right atrial 2023 study said what about anticoagulation post PCI

48H post PCI anticoagulation in STEMI showed no difference in death, MI , stroke ,r evascularization, stent thrombosis

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how long do you continue anticoagulation and when do you stop

for at least 48 hours or until discharge or max 8 days or stop once revascularized

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when do you start beta blockers in CAD

within 24 hours in stable patients

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why tica prefered vs clopidogrel

-greater efficiency
-no increased bleedidng risk

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hold p2yi pre CABG how long

2-7 days per op

stable CAD with AF - what does the AFIRE trial say

rivaroxaban +ASA had more bleeding with nor eduction on ischemic events compared to rivaroxaban alone. thus OAC monotherapy is prefered

high bleeding risk patients, name the major bleeding risk

1. advanced ckd 2. cirrhosis + portal htn 3. active malignancy ( except melanoma) in last 12 month and underoging tx 4. spontaenous bleeding with hospit or transfusion in last 6 month or anytime if recurrent;chronic bleeding diathesis 5. hgb <110, thrombocytopenia w/ plt <100 6. prior spontaneous/traumatic ICH <12 month 7. brain avm/stroke <6month 8. anticipated use of longterm anticoag ( exclusiding compass riva trial ) 9. non deferable major surgery on DAPT 10. Recent major surgery/trauma <30days before PCI

minor bleeding risk patient

2 minor - moderate CKD - spontaenous bleeding wtih hospitalization or transfusion <12month not meeting major criterion - hgb 110-129 for men / 110-119 women. - any ishcemic stroke not meeting major criterion - long term NSAID/steroids - age >75

complex pci - name what could it be

1. left main 2. 3 vx 3. 3 lesions 4. 3 stents 5. >60 mm stent 6. bifurcation stents 7. bypass graft PCI 8. atherectomy/CTO procedure

what does the combinatiton of ASA-statin-ramipril do per the SECURE trial

reudces MACE and imrpoves adherence

PCI in what case if person has diabetes with LM

in the case of low intermediate complexity CAD , could consider it as an alternative to CABG

if thrombolysis in ACS - what P2Y12 do you avoid

Prasu & tica

do you stop anticoag if revasc ?

yes !

per right trial, point of extending anticoag 48H post PCI ?

none !

if fibrinolysis, how quickly does it need to happen

30 min

if fibrinolysis, pci should occur when ?

within 24H

max timing for fibrinolysis

24H

CI to fibrinolysis for stemi

HABITS - hmrg ( IC, ever) - aortic dissection - bleeding ( diathesis, active) - IC (lesion/malignancy) - T ( trauma, closed headed) - STROKE ( ischemic w/in 3 months)

what do load a patient with when doing lysis ?

clopidogrel

can you give tica or prasu post lysis

yes

early invasive strategy within 48H in NSTEMI improves what ? any mortality benefit ?

reduces risk of rehospit for ACS no mortality benefit

post ACS DAPT

-DAPT 12 months : ASA + tica/prasu - after 1 year; if high risk --> sapt, if low risk --> ad 3 years

post ACS DAPT in high bleeding risk ?

DAPT or 3 months and descalate to SAPT after 1-3 months or to a less potentent 2nd antiplt ( change to asa + clopido)

post elective PCI stent ? what do you do - high risk bleed - low risk bleed

high risk. bleed *DES : 3 months DAPT --> SAPT 4eva *BMS : 1 month DAPT --> SAPT 4 eva low risk bleed DAPT x 6M --> if high risk thromobotic risk --> 3 years

medically managed ACS, which p2y1?

- Tica >clopido > prasu

whend o you give second antiplatelet in ACS acutely ?

STEMI

postop CABG - off pump tx - onb pump tx - afib

- DAPT : ASA+tica/prasu - SAP - OAC

sglt2 inhib reduce what in CAD?

MACE

empact mi and dapa mi : sglt2 post mi ...... what did they say

post mi without db w/ lv dysfunction or hf - did not reduce death or mace . so no routine sglt2 post MI

influenza vaccination post MI ?

Influenza vaccine administered within 72 hours post STEMI/NSTEMI reduced all cause mortality, MI, stent thrombosis at 12 months compared to placebo

allergens causing coro vasospasms in context of minoca

kounis syndrome

who do you want to consider for invasive coro in hf

1. HF + sx 2. EF <35% + risk factors CAD 3. Systolic HF + evidence on non invasive coro perfusion testing

how quickly to establish diagnosis of acute HF in ED ?

<2hrs

timing of echo in acute HF ?

48hrs

3 ddx of acute pulmonary edema

- htn - mr - arrythmia

if hypertensive or MR and have acute pulmo edema, what to give ?

short acting VD ( nitro spray/infusion/patch)

if soft bp, acute hf, atrial arrythmia, what meds can you use to help control rate ?

digoxin

the use of validated score to see if admission or outpatient management was associated with what ?

decreased overall death and decreases hospit

why do we use BNP in HF ?

1. if dx uncertain 2. prognosis

per sodium hf trial 2022, strict salt restriction improves HF related hospit visit or cv death ?

between CABG and PCI in ischemic cardiomyopathy options for revascularization, which one would lead to improvced outcomes ? what remains paramount regardless

CABG !!! optimizing medical therapy

BB in hfref , in what case ?

euvolemic and hmd stable

if ef <40%, what meds to avoid ( except which one in that category)

ccb. amlodipine in HTN

NYHA 4 patients - candidate for BB ?

ARNI post acei wash out period time ? why ?

36 hours avoid bradykinin--> angioedema

when do you start considering device therpay options - NYHA - EF - amb/hospit ?

NYHA 1-4 EF <35% ambulatory

when do you start considering HF advanced therapy , advanced care plan, palliation

NYHA 3-4 high risk Advanced HF

requirement to start ivabradine

- being in sinus rhythm - if hospit in last year for CHF + HR > 70

ARNI CI

1. familial/idiopathic angioeedema

Victoria trial looked at what ?

the vericiguat initiation in EF < 45 % with recent hospitalisation which showed a 10% decrease in CV deaht & HF hospit

primary prevention devices after how long ? ( considerd appropriate)

3M OMT 3M post revasc 40D after MI

CCS HF guideline in terms of who should get an ICD

ICM, NYHA 2-4 , EF <35% ICM , NYHA 1 , EF <30% NICM, NYHA 2-3, EF <35%

ICD 2nd prevention for who ( ischemic and non ischemic populatiobn)

1. Cardiac arrest ( VT/VF) 2. Sust VT in prescence of significant SHD 3. sust VT >48H post MI/revasc

which ICD for 2nd prevention is able to pace : trasV or subcut

transv

CRT has been shown to reduce what ?

HF sx, hospit and death

what does CRT do .. ?

Paces RV and LV to resynchronize

CRT indication - strong recommendation

1. SR 2. Sx ( NYHA II- III, ambulatory IV ) 3. on GDMT 4. EF < 35% 5. typical LBBB 6. QRS > 130s

HFpEF management driven by what ?

- sx driven - rely on risk factor modification

SGLT2i for HfpEF ? - if so helps in what ?

yes all, even if not diabetic

Candesartan helps in what for HFpEF ? per which trial.

- decreases HF hospit per CHARM preserved trial ( not MACE)

MRA decrease what in HFpEF in topcat trial ?

HF hospit

Firearts HF trial HfPEF states what ?

Finerenone, a novel non steroid MRSA, decrease the composite of worsening HF events and CV death compared to placebo

GLP-1 agonist , new role in hfpef? in gudeline ?

- sx control - weight loss - CV death and hospit not yet in guideline

it is based on which trial to state that sglt2i can be used in hfpef patients ? ( 2 trials)

based on emperor preseved and deliver trials. no reduction in mortality. only reduction in HF hospit

can you use MRA, ARB or ARNI ?

yes could be considered to reduce HF hospitalisation especially if EF on the lower end spectrum ( 40-50%)

are tehre any benefit to use ARNI in hfpef patients ? based on what study ?

no benefit ( although maybe a subgroup with ef 45-49%) . based on the paragon hf group

up to how low of egfr can you use sglt2i to reduce hhf ?

when do you give iron in HF population

consider if ferritin <100 or if ferritin 100-299 + tsat <20%

gdmt for patients on chronic dialysis ?

yes !

canaglifolozin ok for egfr 20 ? if not which one

no. empa

trials for canagliflozin in non diabetics ?

what can you add to help wth alkalosis when giving diuretics ?

acetazolamide

do you have orthostatic hypoTA in POTS ?

no. only orthostatic tachycarddia increase by 30 bpm within 10 mins of standing with no drop in bp 20/10)