Cardio

Question 1

Contraindications to ECG stress testing?

Answer 1

• Recent MI (<4 days)
• Unstable Angina
• Severe symptomatic LV dysfunction
• Life-threatening arrhythmia
• Acute pericarditis
• PE
• Severe (or symptomatic) aortic stenosis

Uninterpretable (consider alternate test)
• Resting ST depression > 1 mm, Digoxin use, Pre-excitation (WPW), Paced rhythm, LBBB

Question 2

Stress Treadmill test results for positive test and high risk features.

Answer 2

Positive Test
– >1 mm horizontal or down-sloping (NOT UPSLOPING) ST depression over multiple leads
• Duke Treadmill Score also provides prognostic significance (DO NOT NEED TO MEMORIZE).

High Risk Features*
– ≥2mm ST-segment depression, ST depression with <5 METs activity, or persisting greater than 3 minutes into recovery
– Exercise-induced ST elevation
– Exercise-induced VT/VF
– Exercise-induced sBP decrease of >10mmHg
– Inability to increase sBP to >120mmHg with exercise

Question 3

In which patients should you consider CABG over PCI?

Answer 3

Consider CABG if:
– L main disease (>50% occlusion)
– Multivessel disease with diabetes
– Multivessel disease with LV dysfunction/CHF

*Less repeat revascularization with CABG

Question 4

ACS loading dosing for ASA and second anti-platelet

Answer 4

ASA 160 mg CHEWED
Ticagrelor 180 mg
Prasugrel 60 mg
Clopidogrel 300-600 mg

Question 5

ACS maintenance dosing for ASA and second anti-platelet

Answer 5

ASA 81 mg OD
Ticagrelor 90 mg q12h
Prasugrel 10 mg OD
Clopidogrel 75 mg OD

Question 6

Prasugrel contraindications

Answer 6

Age>75
Body weight <60kg
Hx of TIA/ stroke.

Question 7

Ticagrelor contraindications

Answer 7

History of ICH

Question 8

Anti-platelet combo for thrombolysis in ACS

Answer 8

ASA + Plavix

Question 9

Anti-platelet combo for elective PCI

Answer 9

ASA + Plavix

Question 10

What is the difference between BMS vs DES in terms of re-stenosis and thrombosis?

Answer 10

BMS- endothelialize quickly but can re-stenosis.
DES- Slower to endothelialize but secrete drugs to prevent re-stenosis, can be used in small vessels. Higher rates of thrombosis.

Question 11

HR and SBP targets with thoracic aortic DISSECTION

Answer 11

• Target HR 60-65 bpm
• Target BP <120 systolic

Labetolol 1st line, CT scan is best imaging modality

Question 12

Thoracic aortic aneurysm- guidelines for monitoring

Answer 12

CT or MR q6-12 months (MR if <50 to limit rad exposure)

Question 13

If severe asymptomatic valve disease, how frequently should you follow with imaging?

Answer 13

TTE q6-12months

Question 14

In what 3 situations would you prescribe Warfarin for MS?

Answer 14

1. A.fib (ie. Vavular A fib)
2. Embolic event
3. Left atrial thrombus

Question 15

Severe Aortic Stenosis Criteria on TTE

Answer 15

Severe AS Criteria (mostly diagnosed on echo):
– Mean Gradient ≥40 mmHg
– Max jet velocity ≥4 m/s
– (AVA <1.0 cm2)

Question 16

Severe Mitral Stenosis Criteria on TTE

Answer 16

– MV area ≤1.5 cm2 (very severe = ≤1 cm2)
– Mean Gradient >10 mmHg
– Diastolic pressure half time (PHT) >150 ms

Question 17

Class 1 indications for valve repair in mitral regurg?

Answer 17

1. Severe primary MR with symptoms and EF >30%
   – *Surgery contraindicated if EF <30% as LV using MR to relieve pressure

2.Severe asymptomatic primary MR with LV dysfunction (LVEF between 30-60%) or dilatation (LV end systolic dimension >40mm)

Question 18

Long term mgmt of HFrEF

Answer 18

1. Work up
   - TTE
   - BNP (yes! for prognostic purposes)
   - Coronary angio (r/o ischemic cause)
2. Mgmt
   - Non pharm- smoking, fluid and salt restrict, multi D team
   - ACEi, BB, Spiro when EF <40%,
   - ARB+Neprilysin inhibitors (LCZ696/Entresto®)
   - SDN+hydralazine (in black patients and other ethnic groups intolerant of ACEi/ARB)

Avoid most CCBs when LVEF <40%.

Question 19

In which patients with HFrEf do we add ivabradine?

Answer 19

Already on ACE/ARB, BB, Spiro and after 3 mos max doses
AND
NYHA II-IV and HR with NSR >70 (if hospitalized in past 12 months) and switch ACE/ARB to Sacubitril/Valsartan

*Acts on SINUS NODE to reduces heart rate in patients without reducing BP or contractility (need to be in SR)

Question 20

In which patients with HFrEf do we add Entrusto?

Answer 20

Already on ACE/ARB, BB, Spiro and after 3 mos max doses
AND
SR with HR <70 or Afib or pacemaker–>Switch ACE/ARB to Sacubitril/Valsartan

Question 21

What are two important considerations when considering switching from ACE to Entrusto for a patient? Hint: allergy history and bridging

Answer 21

1.ARNI contraindicated if history of hereditary (familial) or idiopathic angioedema

2. When switching from ACE to ARNI, 36 hour washout period important to lower risk of angioedema.
   * *No washout required for ARB/ARNI switch

Question 22

How soon should you measure EF to determine need for ICD after MI? after revascularization?

Answer 22

After MI–>Wait 1 month

After Revascularization—> Wait 3 months

Question 23

What are the 3 indications for ICD for secondary prevention?

Answer 23

1. Cardiac arrest VT of VF
2. Sustained VT/VF/Cardiac syncope with known structural heart disease
3. Sustained VT >48hrs from MI or revascularization

Question 24

What is Cardiac Resynchronization Therapy (CRT) and what are the indications?

Answer 24

Pacing of the RV and LV

Indications:

1. EF <35%
2. Sinus Rhythm
3. LBBB or QRS >130

*Can still consider if: QRS >150 ms (and not LBBB), presence of Afib, elderly age or frailty, chronic RV pacing with reduced EF (THIS DECISION WILL BE MADE BY THE ELECTROPHYSIOLOGY TEAM)

Question 25

When might you consider Spiro for HF with preserved EF?

Answer 25

If BNP elevated! If K<5 and eGFR >30 ml/min, MRA (e.g. spironolactone) should be considered

Question 26

What is the preferred agent of choice for HTN treatment in HFrEF?

Answer 26

Candasartan

Question 27

Iron def in HFrEF how best to treat?

Answer 27

IV iron preferred to PO

Question 28

When should you admit in pericarditis?

Answer 28

1. Immunocompromised host 2. Trauma 3. Oral anticoagulation therapy 4. Myopericarditis (Troponin elevation) 5. Fever T>38C 6. Subacute onset 7. Severe effusion (>20mm) or cardiac tamponade 8. Hemodynamic instability

Question 29

What is Dressler's syndrome and what is the treatment?

Answer 29

Post-MI Pericarditis | -use ASA instead of NSAIDs (High dose = ASA 650 po QID)

Question 30

Indications for PPM insertion? Two major categories: Sinus Node Dysfunction and Acquired AV block.

Answer 30

Sinus Node Dysfunction • Symptoms clearly attributed to bradycardia (spontaneous or from required drug therapy) • Symptomatic tachy-brady, chronotropic incompetence • Symptoms are likely due to bradycardia Acquired AV Block • 3rd degree block or 2nd degree type 2 • Alternating RBBB/LBBB • Permanent AF and symptomatic bradycardia • Symptomatic AVB (spontaneous or from required drug therapy)

Question 31

Pacemaker indications after MI?

Answer 31

Pacemaker reasonable if: – Persistent 3rd degree AV block – Persistent Advanced/infranodal 2nd degree AV Block (Mobitz II) or 2nd degree AV block with alternating BBB – Transient advanced 2nd degree AV block (Mobitz II) or 3rd degree AV block with associated BBB – Symptomatic 2nd or 3rd degree AV block (i.e. symptomatic bradycardia)

Question 32

3 features that rule in Aortic Stenosis and 1 that rules out?

Answer 32

Rule in AS • slow rate of rise of carotid pulse (+LR 2.8-130) • mid to late peak murmur (+LR 8-101) • soft S2 (+LR 3.1-50) Rule out AS • Absence of radiation to right carotid (LR 0.05 – 0.10)

Question 33

Risk Factors for Sudden Death in HCM?

Answer 33

MAJOR: -Family history of SCD - Spontaneous sustained VT Cardiac arrest (Vfib) -UNEXPLAINED syncope -LV thickness >= 30mm Abnormal exercise blood pressure, NSVT (on Holter)

Question 34

DDx for pulsus paradoxus?

Answer 34

– Cardiac Tamponade – Severe asthma/COPD –PE – Has also been described in RV infarction and severe pectus excavatum,

Question 35

How do you anticoagulate a patient post mechanical valve insertion?

Answer 35

Indefinite Warfarin + ASA

Question 36

How do you anticoagulate a patient post biosynthetic valve insertion?

Answer 36

Warfarin + ASA x3-6 mos then ASA indefinite | If underwent TAVI can use: Plavix + ASA x6 mos

Question 37

Dipyridamole myocardial perfusion imaging--> contraindications and reversal agent?

Answer 37

Contraindications: Asthma or significant COPD | Reversal agent for dipyridamole is aminophylline