Cardiology (10-20%) Complete Flashcards
Principles of Non-Invasive Testing for
stable CAD
Absolute Contraindications to EST (Exercise Stress Test)
EST Results (Exercise Stress Test)
• Maximal vs. submaximal test
– Patient should reach ______% of age-predicted maximum heart rate
– (Max HR = ____________)
EST Results (Exercise Stress Test)
• Maximal vs. submaximal test
– Patient should reach 85% of age-predicted maximum heart rate
– (Max HR = 220 – age)
EST (Exercise Stress Test) Results:
Positive test:
________________
________________
High-risk features?
Myocardial Perfusion Imaging
Coronary CT Angiography (CCTA)
Treatment of Chronic Stable CAD
• Treat symptoms with ____________ first
• Consider _________ if refractory symptoms, high-risk structural disease (e.g. LM disease), LV dysfunction, severe MR
Optimal Medical Therapy (OMT) is ________ to revascularization (PCI/CABG) for patients with Stable CAD
ISCHEMIA TRIAL:
The bottom line is all-cause mortality was ________ by an invasive strategy.
• Treat symptoms with medical therapy first
• Consider revascularization if refractory symptoms, high-risk structural disease (e.g. LM disease), LV dysfunction, severe MR
Optimal Medical Therapy (OMT) is non-inferior to revascularization (PCI/CABG) for patients with Stable CAD
ISCHEMIA TRIAL:
The bottom line is that all-cause mortality was not reduced by an invasive strategy.
Treatment of Chronic Stable CAD
ALL patients with CAD:
– Commence __________ for CAD
– __________ + __________ for evidence of coronary atherosclerosis regardless of the modality of diagnosis
– __________ can be used as __________ if __________ intolerant
Treatment of Chronic Stable CAD
ALL patients with CAD:
– Commence medical treatment for CAD
– Aspirin + statin for evidence of coronary atherosclerosis regardless of the modality of diagnosis
– Plavix can be used as SAPT if ASA intolerant
Treatment of Chronic Stable CAD
Antianginal ( ____________ benefit)?
Disease-modifying therapies?
Adjunctive therapies?
Treatment of Chronic Stable CAD
Revascularization - PCI vs. CABG
Acute Coronary Syndromes:
Immediate Medical Management
Reperfusion Therapy – STEMI
• Primary PCI > fibrinolysis:
– ___________
• PCI capable hospital -> FMC-to-balloon
time < ____ min
• Non-PCI capable hospital -> FMC-to-
balloon time < ____ min
– if later presentation (______h of symptom onset)
– if ________ shock
• Fibrinolysis indicated if _________ ( ___ mins)
• __________ strategy superior to rescue PCI: Drip (give lysis) then ship (send immediately to PCI center for angiogram/PCI within ____ hours)
– If fibrinolysis -> should be administered
within ___ minutes of FMC
– If Fibrinolysis -> PCI should occur within
___ hours
– Timing of fibrinolysis -> the earlier, the
better, but can be given up to ____h after
onset of chest pain w STE
Contraindications to thrombolysis
for STEMI?
The Second Antiplatelet:
• ________/_______ are more potent than _______, with ______ efficacy but more ______ risk
• Ticagrelor is contraindicated if there is a history of: __________, __________, __________, __________
– Should consider avoiding in patients with
evidence of __________ or __________
• Prasugrel is contraindicated if __________, __________ or __________ while on prasugrel, __________ reaction
– If elective PCI, only __________ has been studied
– If a patient has AFIB on OAC, _________ is recommended [CCS AFib 2020]
• __________ have NOT been adequately evaluated in the setting of fibrinolysis in STEMI -> Use __________ only
Reperfusion Therapy - NSTE-ACS
Int/high-risk patients:
- _________ strategy (angiogram within ____hr) and it reduces the risk of _________ but NO _________
PCI
• Bare metal stent (BMS) – rarely used
– Endothelialize quickly = ______ risk of stent thrombosis after 4+ weeks
– But…higher risk of ______
• Drug-eluting stent (DES) – standard of care
– Elute anti-proliferative agents
– Lower rates of ______ vs. BMS = can be used in smaller vessels, CABG grafts
– But…take longer to endothelialize
• Drug-coated balloon (DCB)
– Expand a blood vessel and deliver antiproliferative agents (e.g. Paclitaxel) without delivering a stent
– Useful for ______, ______, ______
Stents and DAPT Durations (without AF)
POST ACS (STEMI or NSTEMI/UA): Aim for ______ months of DAPT
– ACS DAPT= _____ + _____ (dose) or _______ (dose) (preferred over ____ + _____)
• Reassess bleeding at _______ (time)
– If HIGH-RISK bleed: ________
– If LOW-RISK bleed: ________ - Good evidence for up to _______ years (DAPT trial)
DAPT After 12 months: Suggest ____ + one of:
• _________ (dose)
• _________ (dose)
Stents and DAPT Durations (without AF)
Non-ACS situations (ELECTIVE PCI)
• High Risk of Bleeding: Elective PCI DAPT = ________ + ________
– BMS = DAPT for ____ months then ____
with ____ or ____ indefinitely
– DES = DAPT for ____ months then ____
with ____ or ____ indefinitely
• Not at high risk of bleeding: DAPT for ________ months, then reassess
– If High-Risk thrombotic events: extend
DAPT up to ______ yrs
– If not at high risk of thrombosis or if now
at high-risk bleeding: _______
Periop Mgmt - Stents and DAPT
Elective Non-Cardiac Surgery
• BMS – Delay surgery for at least _____ months
post-PCI
• DES – Delay surgery for at least _____ months
post-PCI
Semi-Urgent Non-Cardiac Surgery
• BMS – Delay surgery for at least _____ months
post-PCI
• DES – Delay surgery for at least _____ months
post-PCI
Post-MI Complications
• Arrhythmias
– Brady: Heart block (esp. _______ MI)
• Mechanical complications
– RV infarction (esp. _______ MI)
• Pericarditis
– Post MI pericarditis = Early (___d) vs. delayed [_____ syndrome] (_____ wks)
– Rx is ______ + ______
ACS: Chronic Management/Risk factors
Initiate BEFORE Discharge
• __________________
• __________________
• ________ vaccine administered within 72 hours post-STEMI/NSTEMI reduced all-cause mortality, MI, and stent thrombosis at 12 months compared to placebo
Driving Restrictions - CAD
STEMI:
Private Car: ______ months post-discharge, Commercial Driver (Truck, Bus) ______ months post-discharge
NSTEMI with wall motion abnormalities
Private Car: ______ months post-discharge, Commercial Driver (Truck, Bus) ______ months post-discharge
UA or NSTEMI with no LV damage
With PCI: Private Car: ______ post-discharge, Commercial Driver (Truck, Bus) ______ post-discharge
Without PCI: Private Car: ______ post-discharge, Commercial Driver (Truck, Bus) ______ post-discharge
CABG: Private Car: ______ months post-discharge, Commercial Driver (Truck, Bus) ______ months post-discharge
Elective PCI: Private Car: ______ post-discharge, Commercial Driver (Truck, Bus) ______ post-discharge
Hypertrophic Cardiomyopathy
• Broad management principles:
– Family screening/genetics for ________
– Avoid ______/______
– ______: chest pain syndromes, LVOT Obstruction, SAM
• Second line – ______, ______
– Interventions for some – ______/______
– ______ for ANYONE with AF (______ does not apply)
– Consideration for ICD if:
• Sustained ______ or prior ______ (Class I)
• FMHx of ______, LV wall thickness >______ mm, ______ syncope (Class IIa)
• NSVT or abN BP response on treadmill w/ other risk factors (Class IIa)
HCM. What happens to murmur with these?
Bradycardia?
A Passive leg raise?
Handgrip?
Valsalva?
Standing up?
ACEI?
• Treatment involves?
• Avoid?
Cardiac Amyloidosis
Cardiac Amyloidosis treatment
Long-term Management of HFrEF
• BNP: 2017 CCS recommends BNP if ________ and for ________
• BNP: 2017 CCS recommends BNP if diagnosis unclear and for prognosis
Revascularization and ischemic
cardiomyopathy
STITCH Trial vs REVIVED-BCIS trial
- Comparison of CABG vs PCI in heart failure
HFrEF Pharmacotherapy
Long-term Management of HFrEF
Other Important HF Medication Considerations
________ contraindicated if history of hereditary (familial) or idiopathic angioedema
ARNI is contraindicated if history of hereditary (familial) or idiopathic angioedema
ICDs in HF
ICDs for 2o prevention
Cardiac Resynchronization Therapy (CRT)
Slam dunk (strong recommendation) for CRT:
___________________
___________________
___________________
___________________
___________________
___________________
When Should We Worry About HFrEF Patients?
HF with Preserved EF (HFpEF)
GDMT in HFpEF
SGTL2: Mortality and Hospitalizations?
Special HF Populations and conditions
SGLT2i Doses and eGFR Cutoffs in HF and CKD
Diuretics in Heart Failure
Valve Disease - Guiding Principles
Aortic Stenosis
Aortic Stenosis - Intervention
Aortic Regurgitation causes?
Chronic Regurgitation causes?
Aortic Regurgitation - Intervention
Mitral Stenosis:
• Severe MS?
– MV area _____ cm2 (very severe = ____ cm2)
Mitral Stenosis - Intervention
Percutaneous mitral balloon commissurotomy (PMBC)
– CONTRAINDICATED if:
i) ______________
ii) ______________
Mitral Regurgitation - Intervention
Functional Mitral Regurgitation - Intervention and management
Antithrombotic Therapy After
Valve Replacement
Thoracic Aortic Dissection
Thoracic Aortic Dissection Management
Thoracic Aortopathy/Aortic Aneurysm
Aortic aneurysm pearls
Acute Pericarditis
When to Admit Pericarditis
Treatment of Acute Pericarditis
Constriction vs. Tamponade vs. Restriction
Atrial fibrillation algorithm
Anticoagulation in AF/AFL
Anticoagulation in CKD/ESRD
AF with Vascular Disease
Situation 1:
(1) AFib + STABLE* CAD/PAD
AF with Vascular Disease
Situation 2:
(2a) AFIB + PCI (elective or ACS)
AF with Vascular Disease
Situation 3:
(2a) AFIB + ACS – NO PCI /stent
Cardioversion of AF
CCS 2020: Long-Term Rhythm Control Choices
Other Highlights of AF Guidelines
Pacemakers after Myocardial Infarction – R.C. Classic
Ventricular Arrhythmias
CCS 2022 Peripheral Arterial Disease Guidelines
CCS 2022 Peripheral Arterial Disease Guidelines
Management:
CMA Fitness to Drive
CCS 2020: POTS Guideline
Tips for Tackling Murmurs
Murmur review part 1
Murmur review part 2
Heart Sounds
Aortic Stenosis: Rule in and Rule out
Risk Factors for Sudden Death in HCM
AS vs HCM
Septal Defects
Pulsus Paradoxus
Peripheral Vascular Disease
