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Royal college > Cardiology > Flashcards

Cardiology Flashcards

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1
Q

Medications for HFrEF

A

BB+ARNI>ACE/ARB/+MRA+SGLT2+Ivabradine (SR and HR>70) + vericiguat (HF hospital in 12 mo)

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2
Q

HFpEF medications/treatment

A 
Manage HTN
Loop Diuretics to reduce congestion
Candesartan (CHARM trial)
MRA (TOPCAT)
SGTL2 (Emporer-Preserved)
For those with DM: metformin. NO Saxagliptin. NO thiazolinediones
Exercise/smoking/education/EtOH
Iron def: IV iron target Ferritin >100
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3
Q

Valve Disease:

What does A, B, C, D classification mean?

A

A: at risk
B: progressive
C: severe, asymptomatic
D: severe, symptomatic

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4
Q

Valve

Aortic stenosis: these group of medications should not be used in AS patients

A

Afterload reducers, vasodilators: eg ACEi. Can use after TAVI

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5
Q

Valve

AS: what are the numbers on echo fro severe AS?

A

AVA <1 cm2
Gradient >40 mmHg
Vmax> 4 m/s

(Very severe AS: Vmax >5; Gradient >50mmHg

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6
Q

Aortic stenosis indication for Intervention?

A

Severe AS+
Symptomatic OR LVEF <50%
OR Severe AS, asymptomatic, having CVSx
OR Symptomatic with low flow/low gradient+EF<50%
OR symptomatic low flow, low gradient, EF >50% if AS is presumed cause of symptoms

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7
Q

Indications for intervention for AR

A

Severe symptomatic AR
Severe asymptomatic but EF <55%
Severe, asymptomatic AR undergoing other CVSx

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8
Q

Mitral Stenosis - when can you do Percutaneous mitral balloon commisurotomy (PMBC)

A

severe symptomatic AS + favourable valve anatomy + can be performed at experienced centre
Contraindicated: if moderate Mitral regurgitation

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9
Q

Indications for intervention in Primary Mitral regurgitation

A

Severe, symptomatic MR

Severe MR, asymptomatic, with LVEF <60%/LVESD >40mm

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10
Q

Indications for Intervention in Secondary MR

A

GDMT for HFrEF including CRT/cath before considering for Percutaneous Mitral valve repair
Symptomatic HFrEF and severe MR

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11
Q

INR targets for AVR and MVR (no DOACS to be used for any mechanical or bioprosthetic valve replacements)

A

AVR:
- current generation INR 2.5
- Old AVR (ball in cage) 3.0
MVR: INR 3

ASA: dont need to add to mech valves unless other indication
- lifelong ASA in biosprosthetic valves
New onset AF within 3 mo of bioprosthetic valve: need to use VKA

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12
Q

Management of thoracic aortic dissection

A 
IV preferred
Control HR first <60 (to reduce shear)
Then BP target SBP <120
DO NOT CONTROL BP BEFORE HR due to risk of compensatory increased HR!
BB>CCB>Nitroprusside>ACEi

Type A: Surgery
Type B: med mgmt
DO NOT USE BB IN COCAINE INDUCED DISSECTION - because dont want pure alpha activation!

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13
Q

What is first line medication for cocaine induced aortic dissection

A

Generally IV BB (labetalol) is first line, but BB contraindicated in cocaine use due to risk of pure alpha unopposed alpha activation by cocaine

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14
Q

Etiology of pericarditis Ddx

A

V: MI
I: Infection- TB, Fungal, coxsackie, flu, parvo, adenovirus
T: toxins: Hydralazine, Procainamide, Digoxin, INH, dilantin
A: autoimmune: RA, SLE
M: metabolic: Hypothyroid, uremis, dialysis
I: iatrogenic: post radiation or CV Sx
N: neoplasm: breast, mesothelioma, lung, leukemia, lymphoma

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15
Q

Indications to admit pericarditis?

A

Fever, trop rise, pericardial effusion >20mm, tamponde, unstable
On Oral anticoags, immunocompromised, no improvement after 7d of treatment,

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16
Q

Treatment of pericarditis

A

First occurrence: NSAIDs (or ASA +/- PPI) 1-2 wks+ Colchicine 6 mo
first recurrence: NSAIDS 2weeks + Colchicine x6 mo
2nd recurrence: Glucocroticoids 2-4 wks + Colchicine
3rd recurrence Flucocorticoids+ Colchicine+ ASA
4th recurrence: other therapies like pericardiectomy, IVIG, anakinra
Pregnancy: NO COLCHICINE at all
<20 wks = ASA/NSAIDS ok
>20 wks: DO NOT USE HIGH DOSE ASA/NSAIDS
Breastfeeding: NO ASA

17
Q

pulses paradoxus

A

drop in BP >10mmHg on inspiration

18
Q

Kussmaul sign

A

JVP goes up with inspiration! This is because there is cardiac tamponade or constrictive pericarditis leading to increased pressure around the heart on inspiration, and blood gets pushed back up into the JVP

19
Q

Name and complete the triad associated with Aspirin/NSAIDs sensitivity + Nasal polyps AND ______

A

Samster’s triad

1) ASA/NSAID sensitivity: exacerbates respiratory disease
2) Asthma
3) Nasal polyps

20
Q

AF etiology

A 
P: PE, COPD, OSA
I: infarct, infection, idiopathic
R: rheumatic mitral valve disease
A: anemia
T: toxins: Cocaine, EtOH, caffeine, thyrotoxicosis
E: electrolytes, endocarditis, Ethanol
S: stress, stimulants, post -op stress
21
Q

When are VKA preferred for AF? associated conditions

A

mod-severe mitral stenosis
Rheumatic mitral valve stenosis
mechanical heart valves
New onset AF within 3 months of valve replacement

22
Q

What is the only medication that has mortality benefit in AF?

A

OAC

23
Q

OAC in CKD for AF? What are the cutoffs

A

eGFR >15: OAC okay

eGFR <15 or on HD: no OAC

24
Q

Factors that increase risk of bleeding when considering OAC/DAPT for CAD and AFIB

A

Age >65, frail, wt <60 kg, HTN, prior stroke/ICH, excess EtOH, Hb <110, CKD, liver disease

25
Q

Factors that increase risk of thrombosis in AF/CAD

A

DM, smoker, CKD, prior ACS, prior stent thrombosis

MVD; LAD or L. Main disease, bifurcation stent, >2 stents, stent length >60mm, CTO intervention

26
Q

Special populations OAC in AFIB

A

Liver disease: do not use OAC in Child Pugh C or coagulopathy
Cancer: LMWH is king. Doacs preferred over warfarin. Apixaban can now be used in GI cancers (CARVAGGIO)
HCM: AF and HCM give OAC regardless of CHADS65
Thyroid: OAC during acute thyrotoxicosis until euthyroid state restored due to hyper coagulability!
Pregnancy: NO DOACS!. Consider LMWH. warfarin only in trimester 2-3

27
Q

Patient with AF and child Pugh B cirrhosis. What is choice of DOAC?

A

Can not use rivaroxaban, significant hepatic metabolism
Use apixaban
If OAC is prescribed for CHILD Pugh C (it should generally not be prescribed) then use VKA, DOACs not evaluated in CP C

28
Q

what is the antidote for dabigatran?

A

idaricizumab

29
Q

what is a single reversal agent for rivaroxaban, apixaban, edoxaban?

A

Andexanet alpha: inhibitor of factor Xa inhibitors. It bind to the drugs and sequesters them rendering them useless. Use in patients who present with uncontrollable or potentially life-threatening bleeding

Use if any of these drugs were used in the past 18 hours

30
Q

Timing of OAC after ischemic stroke?

A

TIA: within 24 hours
Mild stroke (NIHSS<8): 3 days
Moderate stroke (NIHSS 8- 15): 6 days
Severe/Large stroke (NIHSS >16): 12-14 days

31
Q

What can you do for patients with AF who can not take OAC for some reason?

A

Left atrial appendage occlusion! LAAO

32
Q

Define Unstable atrial fibrillation?

A

Hypotension (SBP <90), pulmonary edema, or ACS

33
Q

PE related changes on ECG

A

sinus tach, RBBB, RAD, TWI in V1-4, S1Q3T3

34
Q

signs that a WCT is VT?

A

fusion or captured beats, QRS axis shift, morphology of QRS complex especially in leads V1-V6

35
Q

what sign predicts the severity of Aortic Regurgitation!

A

Hill sign: more frequent when the murmur is more severe
- a popliteal arterial pressure that was >20 mmHg higher than the brachial arterial pressure
As the regurgitation becomes more severe, the murmur extends through more of diastole, may become holodiastolic, and is often rougher in quality. Patients with a longer diastolic murmur, a displaced LV impulse, a wide pulse pressure, and the peripheral findings of a wide pulse pressure cited in the previous section are considered to have severe AR.

36
Q

Signs of increased ICP on ECG?

A

o Cerebral T waves, sometimes you get these T wave inversions, QT prolongation, and bradycardia with cushing reflex

37
Q

physical exam findings of VT

A

Cannon A waves: indicate AV dissociation

Variable S1: indicates AV dissociation

38
Q

Helpful clues on ECG for VT

A

capture and fusion beats
Northwest axis (extreme axis deviation)
Wide QRS
Concordance of QRS in precordial leads

Royal college (2 decks)

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