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2020 > Cardio > Flashcards

Cardio Flashcards

1
Q

Contraindications to ECG stress testing?

A
  • 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

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2
Q

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

A

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

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3
Q

In which patients should you consider CABG over PCI?

A

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

*Less repeat revascularization with CABG

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4
Q

ACS loading dosing for ASA and second anti-platelet

A

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

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5
Q

ACS maintenance dosing for ASA and second anti-platelet

A

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

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6
Q

Prasugrel contraindications

A

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

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7
Q

Ticagrelor contraindications

A

History of ICH

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8
Q

Anti-platelet combo for thrombolysis in ACS

A

ASA + Plavix

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9
Q

Anti-platelet combo for elective PCI

A

ASA + Plavix

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10
Q

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

A

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.

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11
Q

HR and SBP targets with thoracic aortic DISSECTION

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

Labetolol 1st line, CT scan is best imaging modality

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12
Q

Thoracic aortic aneurysm- guidelines for monitoring

A

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

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13
Q

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

A

TTE q6-12months

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14
Q

In what 3 situations would you prescribe Warfarin for MS?

A
  1. A.fib (ie. Vavular A fib)
  2. Embolic event
  3. Left atrial thrombus
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15
Q

Severe Aortic Stenosis Criteria on TTE

A

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

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16
Q

Severe Mitral Stenosis Criteria on TTE

A

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

17
Q

Class 1 indications for valve repair in mitral regurg?

A
  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)

18
Q

Long term mgmt of HFrEF

A
  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%.

19
Q

In which patients with HFrEf do we add ivabradine?

A

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)

20
Q

In which patients with HFrEf do we add Entrusto?

A

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

21
Q

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

A

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

  1. When switching from ACE to ARNI, 36 hour washout period important to lower risk of angioedema.
    * *No washout required for ARB/ARNI switch
22
Q

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

A

After MI–>Wait 1 month

After Revascularization—> Wait 3 months

23
Q

What are the 3 indications for ICD for secondary prevention?

A
  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
24
Q

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

A

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)

25
Q

When might you consider Spiro for HF with preserved EF?

A

If BNP elevated!

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

26
Q

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

A

Candasartan

27
Q

Iron def in HFrEF how best to treat?

A

IV iron preferred to PO

28
Q

When should you admit in pericarditis?

A
  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
29
Q

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

A

Post-MI Pericarditis

-use ASA instead of NSAIDs (High dose = ASA 650 po QID)

30
Q

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

A

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)

31
Q

Pacemaker indications after MI?

A

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)

32
Q

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

A

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)

33
Q

Risk Factors for Sudden Death in HCM?

A

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

34
Q

DDx for pulsus paradoxus?

A

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

35
Q

How do you anticoagulate a patient post mechanical valve insertion?

A

Indefinite Warfarin + ASA

36
Q

How do you anticoagulate a patient post biosynthetic valve insertion?

A

Warfarin + ASA x3-6 mos then ASA indefinite

If underwent TAVI can use: Plavix + ASA x6 mos

37
Q

Dipyridamole myocardial perfusion imaging–> contraindications and reversal agent?

A

Contraindications: Asthma or significant COPD

Reversal agent for dipyridamole is aminophylline

2020 (13 decks)

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