Cardiology Flashcards
Give an approach to picking a non-invasive test for CAD
List the absolute contraindications to EST
Mnemonic: I DO NOT STRESS
- Inflammation (acute myocarditis, pericarditis)
- Dissection (acute aortic dissection)
- Ongoing unstable angina
- No consent
- Ongoing MI (within 2 days)
- Thrombosis (acute PE, pulmonary infarction, DVT)
- Severe AS (symptomatic)
- Technical issues (ECG changes, etc..)
- Rhythm (uncontrolled, hemodynamically significant arrythmia)
- Endocarditis (active)
- Systolic dysfunction (decompensated CHF)
- Slow (physical limitations)
What is required to achieve a maximal stress test
Should reach 85% of age-predicted maximal HR*
*max HR=220-age
What constitutes a positive EST?
- ≥1mm STE
- ≥1mm STD (horizontal or downsloping)
List high-risk features on EST?
- Duke threadmill score -11 or less
- <5 METs achieved
- Low threshold angina/ischemia
- STE
- Severe STD ≥ 2mm
- Ischemia on ≥5 leads
- Ischemia ≥3min into recovery
- Abnormal BP response
- Failure to achieve SBP>120
- Drop in BP >10
- Ventricular arrhythmia
List 2 things that can cause a false-negative result on Persantine myooview
- Drug interactions with dipyridamole
- Caffeine
- theophylline
- Severe flow limiting triple vessel or LM disease (balanced ischemia)
What are contraindications to a Persantine myoview
- Active or severe asthma or COPD
What is the reversal agent for dipyridamole
Aminophylline
What is the coronary artery calcium score and what is it used for
It is used to further risk stratify patients with intermediate risk FRS patients >40 who are not otherwise candidates for statins. Can also be considered for low-risk FRS if FMHx of premature CVD and genetic DLP
CAC>100 = start statin regardless of FRS
List contraindications to CTCA
- ACS
- Severe structural heart disease (AS or HOCM)
- Usual CT precautions
How should chronic stable CAD be managed?
- Treat symptoms with medical therapy first
- ASA + Statin
- Plavix monotherapy if ASA intolerant
- Consider revascularization if refractory symptoms, high risk structural disease (i.e LM disease), LV dysfunction, severe MR
What treatments offer a symptomatic benefit in chronic stable CAD?
- Beta blockers
- CCB
- Nitrates
What therapies help patients with chronic stable CAD live longer
- Smoking cessation, exercise, diet
- ?cardiac rehab
- Risk factor optimisation
- HTN
- DLP
- DMT2
Which patients with stable chronic CAD should be put on an ACEI?
- HTN
- DM
- EF<40
- CKD
- Reasonable for ALL patients
Which patients with chronic stable CAD should be on a BB?
EF<40 regadless of Sx
When should CABG be considered in chronic stable CAD?
- L main disease
- MV disease with DM
- Multivessel disease with LV dysfunction/CHF
What is the advantage of CABG over PCI?
Less repeat revascularisation, no clear mortality benefit
What medications should be given immediately to all patients with ACS?
- Antiplatelets
- ASA + Second agent (Ticagrelor, Clopidogrel, Prasugrel)
- Anticoagulation
- UFh, LMWH, Fonda
- Antianginal
- BB
- PRN nitrates
- (sparingly) PRN opioids
What are the contraindications to using Ticagrelor initially in ACS
- Previous intracranial hemorrhage
- Thrombolysis
- Active pathological bleeding
- moderate to severe hepatic impairment
- Combination with CYP34A inhibitors (ketonazole, clarithromycin, ritonavir…)
- Only Clopidogrel has been studied in elective PCI
- If patient is concurrently on DOAC, use clopidogrel
What antiplatelet agents shouls be used after thrombolysis
ASA + Plavix
What are the indications to perform primary PCI instead of fibrinolysis in STEMI?
- Timely
- PCI cabable hospital: FMC to baloon time <90min
- non-PCI capable hospital: FMC to balloon time <120 min
- Later presentation (12-24hrs)
- Cardiogenic shock
How quickly should fibrinolysis be administered following FMC?
30 mins
How quickly should a patient recieve PCI following fibrinolysis for a STEMI
24hrs
What is the window to give TNK in the case of a STEMI?
- can be given up to 24hrs
What risk scores can be used to risk stratify patients with NSTE-ACS
GRACE, TIMI
How should patients with NSTE-ACS and a moderate to high TIMI risk be managed once they are on all the ACS meds
PCI within 48hrs
*Reduces risk of rehospitalization but no mortality benefit
How should patients with NSTE-ACS and a low TIMI risk be managed once they are on all the ACS meds
- Non-invasive testing is reasonable first to determine the benefit of invasive strategy
What is the advantage and disadvantage of a BMS?
- Endothelialize quickly: Lower risk of stent thrombosis after 4 weeks
- Higher risk of restenosis
What is the advantage and disadvantage of a DES?
- Lower risk of restenosis
- Can be used in smaller vessels and CABG grafts
- Take longer to endothelialize=higher risk of in stent thrombosis
For how long should DAPT be continued after ACS?
minium of 12 months for all DAPT
For urgent procedures, can consider less
Can consider for up to 3 years if the patient is not at high risk for bleeding and tolerated the first year well
If DAPT is considered beyond the first year after ACS, what agents should be used?
- Clopidogrel
- Ticagrelor (60mg BID)
For how long should patients be on DAPT after an elective PCI?
- Aim for 6-12 months
- If that is impossible due to bleeding or surgery, minimum times are
- BMS: DAPT x 1 month then ASA indefinitely
- DES: DAPT x 3 months then ASA indefinitely
- If that is impossible due to bleeding or surgery, minimum times are
List high risk clinical features for thrombotic events post DES
- DM
- CKD
- Previous stent thrombosis
- Current smoker
- Hx MI
- Troponin + ACS
List high risk angiographic features for in stent thrombosis following PCI
- Multiple stents ore use of a biodegradable vascular scaffold
- ≥3 stents implanted
- ≥ 3 lesions stentes
- Long lesion length (>60mm total stent length)
- Complex lesions
- Bifurcation treated with 2 stents
- Stenting of chronic occlusion
- LM or proximal LAD stenting
- Multivessel PCI
What factors are associated with an increased bleeding risk in patients on DAPT?
- Need for OAC in addition to antiplatelets
- Advanced age (>75)
- Frailty
- Anemia (hb<110)
- Chronic renal failure (CrCl<40)
- Low body weight (<60 kg)
- Hospitalization for bleeding in the past year
- Previous stroke or IC bleed
- Regular need for NSAIDS or prednisone
For how long should elective, non-cardiac surgery be delayed following PCI
- BMS: 1 month
- DES: 3 months
For how long should semi-urgent, non-cardiac surgery be delayed following PCI
- BMS: 1 month
- DES: 1 month
* Individualize, not all patients can wait 1 month
How should DAPT be managed perioperatively in patients who are on such medications following PCI?
- Hold clopidogrel and ticagrelor 5-7 days pre-op
- Hold prasugrel 7-10 days pre-op
- Continue ASA perioperatively “whenever possible”
- Restart DAPT post-op as soon as deemed safe by surgical team
List post-MI complications
- Heart failure
- Arrythmias
- Tachy: Atrial, ventricular
- Brady: heart block
- Mechanical complications
- Papillary muscle dysfunction and acute MR
- Ventricular septal rupture
- Free wall rupture
- RV infarct
- Pericarditis
- Post-MI Pericarditis
- Early (5d)
- Delayed (2-8 weeks) (Dressler syndrome)
- Post-MI Pericarditis
Which type of MI predisposes to heart block and RV infarction
Inferior
How are post-MI pericarditis treated?
- High dose ASA + colchicine
List the medications that should be started/optimised on all patients after an MI before they leave the hospital
- High potency statin
- BB
- ACEI
- +/-MRA
What non-pharmacological interventions should be offered after a patient leaves the hospital following ACS?
- Identify +/- optimize DM
- Smoking cessation
- CV rehab
- Driving restrictions
What are the driving restrictions following a STEMI
- Private driving: 1 month post-D/C
- Commercial driving: 3 months post-D/C
What are the driving restrictions following an NSTEMI with wall motion abnormalities?
- Private driving: 1 month post-D/C
- Commercial driving: 3 months post-D/C
What are the driving restrictions following UA or an NSTEMI with no LV damage
- Private driving: 48hrs with PCI, 7days without PCI
- Commercial driving: 7 days with PCI, 30 days without PCI
What are the driving restrictions following CABG
- Private driving: 1 month post-D/C
- Commercial driving: 3 months post-D/C
What are the driving restrictions following an elective PCI
- Private driving: 48hrs
- Commercial driving: 7 days
How are non-ischemic cardiomyopathies classified and what are the possible etiologies for each group?
What is the most common HOCM phenotype?
Asymetric septal hypertrophy
List symptoms of HOCM
- Chest pain
- Dyspnea
- Syncope
- Arrythmia
- Stroke
- CHF
- SCD
Other than hypertrophy, what is most often seen on ECHO in HOCM
- Dynamic LV outflow tract obstruction
- Systolic anterior motion MV → excentric MR
- Papillary muscle abnormalities
Who should be screened for HOCM
- 1st degree relatives of a case
What Rx can be used to manage chest pain syndromes, LVOT obstruction and SAM in HOCM?
- BB
- Second line : CCB, Dipyridamole
What interventions can be offered to patients with HOCM?
- Septal myomectomy
- ETOH ablation
*Not in all patients
What should be avoided in HOCM with regards to a patient’s volume status?
Avoid hypovolemia, low preload states
Who should be on a DOAC in the presence of HOCM and AFIB
Everyone (CHADS65 does not apply)
Which patients with HOCM should be considered for an ICD?
- Sustained VA or prior cardiac arrest
- FMHx of SCD, LV wall thickness>30mm, unexplained syncope
- NSVT or abnormal BP response on treadmill with other RF
What will reduce the murmur in HOCM
- Bradycardia
- passive leg raise
- handgrip
What increases a HOCM murmur?
- Valsalva or standing up
- Reduced afterload (ACEi)
What medications should be avoided in HOCM
- Afterload reducing agents (ACEi)
- Preload reducing agents (nitrate, diuretics)
List cardiac manifestations of cardiac amyloidosis
- Presyncope/syncope
- Atrial arrythmias (AF, sometimes ventricular arrythmias)
- bradyarrythmias
List extracardiac manifestations of cardiac amyloidosis
- Autonomic dysfunction
- Orthostatic hypotension
- Gastroparesis
- Sexual dysfunction
- Sweating abnormalities
- Neuropathy
- Carpal tunnel
- Renal insufficiency, nephrotic syndrome
What evaluations should be performed in suspected cardiac amyloidosis?
- ECG
- Echo
- +/- CMRI
- SPEP UPEP serum FLC
- Tc-99m-PYP scan : ATTR
- Genetic testing (genetic ATTR)
- +/- cardiac biopsy
What are possible ECG findings in cardiac amyloidosis
- Low voltages
- Pseudoinfarct pattern
How is cardiac AL-amyloidosis treated
- +++ diuretics
- AVOID:
- BB
- CCB
- ACE/ARB
- dig
- OACs for afib regardless of CHADS65 score
- Consider ICD, Get EP involved
- Chemo +/- ASCT
How is cardiac ATTR-amyloidosis treated
- +++ diuretics
- AVOID:
- BB
- CCB
- ACE/ARB
- dig
- OACs for afib regardless of CHADS65 score
- Consider ICD, Get EP involved
- Tafamidis or inotersen or patisiran +/- liver transplant
What investigations should be sent in AF?
- CXR
- ECG
- CBC
- lytes
- Cr
- Glucose
- TSH
- Echo
- BNP
Give a classification for causes of CHF
When should you suspect Cardiogenic shock in CHF
- Clinical + biochemical manifestations of tissue hypoperfusion
- SHOCK trial definition:
- Clinical
- hypotension (a systolic blood pressure of<90 mm Hg for at least 30 minutes or the need for supportive measures to maintain a systolic blood pressure of >90 mm Hg)
- end-organ hypoperfusion (cool extremities or a urine output of <30 ml per hour, and a heart rate of >60 beats per minute).
- hemodynamic criteria
- cardiac index of no more than 2.2 liters per minute per square meter of body-surface area
- pulmonary-capillary wedge pressure of at least 15 mm Hg
- Clinical
How is cardiogenic shock managed?
- Stop beta blockers and other antihypertensives
- Vasopressors and ionotropes
- May need mechanical support
How is acute pulmonary edema managed in the context of CHF?
- Identify underlying etiology
- Aggressive diuresis
- If congested, lasix
- If hypertensive or MR
- Short acting vasodilators
- May need inotropes
- NIPPV
- May require invasive ventilation
How are atrial arrythmias managed in the context of CHF?
- Determine chicken or egg (difficult)
- If overloaded achieve euvolemia
- If on BB, continue unless they are in shock
- If they are not on beta blockers, do not start them if they are overloaded or in shock
- Use short acting medications
- Dig can be helpfull
- If unstable, use ACLS algorythm
Regurgitate the shock grid
What investigations should be sent to determine the etiology of chronic CHF
- Echo + BNP
- BNP if unclear diagnosis and prognosis
- Assess for CAD (often cath)
- CMRI if non-ischemic
How is chronic HFrEF managed?
- Risk factor modifications and lifestyle interventions
- Exercise
- Salt restriction (2-3g)
- +/- fluid restriction (<2L/day)
- Smoking cessation
- EtOH avoidance
- Treat comorbidities
- Multidisciplinary care model
- Early ACP discussions
- Pharmacotherapy
- Consider interventional therapy
- ICD, CRT
- Surgery, Percutaneous MR repair
- Revascularisation if ischemic
- Reassess annually once stabilised
What is the pharmacotherapy for HFrEF?
- Quadruple therapy
- BB
- ARNI
- MRA
- SGLT2
In what timeframe should patients be on optimal doses of HFrEF pharmacotherapy
3-6 months
*can titrate q2-4 weeks
When should beta-blockers not be started on chronic CHF patients
NYHA IV
How long after stopping an ace inhibitor can you start an ARNI?
36 hours
List indications for SGLT2is in cardiology
- T2DM + established ASCVD
- T2DM, Age > 50 and risk factors for ASCVD
- T2DM, age >30, microalbuminuria
- LVEF<40 +/- T2DM
- HFpEF not yet in guidelines but trial based
What should you council your patients on if you are starting them on an SGLT2i?
- Genital mycotic infections, UTIs
- Do not start if they have an active genital/urinary infection
- Temporary reduction in GFR up to 15%, generally resolves in 1-3 months
- Hypoglycemia: Usually not seen unless they are also on insulin or a secretagogue
- HOLD SGLT2 when sick
- Risk of euglycemic DKA
- DO not start in decompensated DM
- Very rarely causes hypotension
What beta blockers are prefered in HFrEF?
- Bisoprolol
- Carvedilol
- Metoprolol succinate
When should Ivabradine be used in HFrEF
If on max Beta blockade, still having symptoms, hospitalized in last 12 months for CHF and HR >70
Is a washout period required when swiching from ARB to ARNI?
No
Are ARNIs contraindicated in the case of a history of angioedema?
Yes
What are the indications for ICDs in primary prevention?
- LVEF <30 (or 31-35 weak recomendation)
- as per HF guidelines:
- if ICM NYHA II-IV: EF ≤35
- if ICM, NYHA I: EF≤30
- If NICM, NYHA II-IV: EF ≤ 35
- as per HF guidelines:
- After:
- 3 months optimal medical therapy AND
- 3 months post revascularization AND
- 40 days post-MI
*Caution in NYHA IV not expected to improve
What are the indications for ICDs in secondary prevention?
- Presence of 1 of these conditions with no reversible cause
- Cardiac arrest VT-VF (strong recommendation)
- Sustained VT in the presence of significant structural heart disease (strong recommendation)
- Sustained VT > 48hrs post-revascularisation. (weak recommendation)
What is the 1/3 rule for CRT?
- In non-carefully selected patients
- 1/3 improve
- 1/3 stay the same
- 1/3 worsten
List the slam dunk, may respond, and marginal recommendations for CRT
- Slam dunk
- In SR
- NYHA II-IV
- On GDMT
- EF <35%
- Typical LBBB
- QRS ≥130
- May respond
- In SR
- NYHA II-IV
- On GDMT
- EF<35%
- Non-LBBB
- QRS ≥150
- Marginal candidate
- Permanent AF
- Patients who require chronic RV pacing and have symptomatic HFrEF
When should a patient get a CRT-D as opposed to a CRT-P?
If they independently meet the criteria for an ICD
When should you worry about HFrEF patients and working them up for advanced therapy?
- ≥1 of these crit. met while on GDMT
- LVEF <25%
- Poor CPET results (Peak exercise VO2 <14 ML/kg/min)
- Progressive end-organ dysfunction
- recurrent HF hospitalizations
- Need to reduce or stop HF therapies
- Diuretic refractorieness
- Need for ionotropic support
- Worsening RHF or group 2 PH
- 6MWT <300m
- Increased 1 year mortality predicted by HF risk scores
- Persistant hyponatremia
- Cardiac cachexia
- Inability to perform ADLs
How should HFpEF be treated
- Largely based on symptom management and risk factor modification
- BP control as per HTN Canada guidelines
- Loop diuretics for coongestion
- Consider candesartan and MRAs
- No recommendations for ARNI
- Non-guideline based therapy
- Sx HF, EF>40, elevated BNP and either echo findings of diastology or HF hospitalisation
- empagliflozin 10
- Sx HF, EF>40, elevated BNP and either echo findings of diastology or HF hospitalisation
How should DM be managed in CHF patients
- Metformin 1st line agent
- Use SGLT2
Which oral hypoglycemiants should be avoided in CHF?
- Saxagliptin (other DPP4s ok)
- Thiazolinediones
How Should IDA be managed in CHF
- If ferritin < 100 or if <300 and TSat <20%, give IV iron
How is CKD managed in CHF?
- Continue GDMT for patients on chronic HD
- Best data for ACEI/ARB/BB
- MRAs safe
How is OSA managed in CHF patients
- CPAP as per other guidelines
- No vent recommendations in central sleep apnea
How is exercise, smoking/ETOH managed in CHF patients
- Regular exercise
- Stop smoking
- stop drinking
What is the medical therapy for AS?
- Treat HTN as per standard guidelines
- Treat lipids as per guidelines
- ACEi/ARBs post TAVI
What is the pharmacological therapy for AR?
- Treat HTN (preferably with ACE/ARB)
- If prohibitive surgical risk and LV systolic dysfunction or symptomatic: ACE/ARB or ARNI
What is the pharmacological therapy for MS?
- VKA if prior embolic event or LA thrombus or AF
- Control of tachycardia can help symptoms
What is the pharmacological management of MR and TR?
- Treat HF as per standard guidelines
- Vasodilator therapy not recommended in asymptomatic primary MR and normal LV function
What are the 3 etiologies of AS?
- Bicuspid (young)
- Rheumatic (developing countries)
- Calcific (old)
What are the symptoms of AS
- Angina
- Syncope
- HF
What are the criteria to define severe AS?
- Mean gradient > 40
- Max gradient > 4
- AVA<1
What is low flow-low gradient AS
If the ventricle is weak, (HFpEF or HFrEF), you cant mount a gradient/velocities in the severe range
When should you be suspicious of low-flow low-gradient AF?
AVA<1 and non-severe gradient Vmax
Check the EF and SV
How is low-flow, low gradient AS diagnosed?
Dobutamine stress echo
What are the class 1 indications for aortic valve replacement?
- Severe symptomatic AS
- Severe asymptomatic AS with LV dysfunction
- EF<50
- Severe asymptomatic AS undergoing other CV surgery
- Symptomatic low-flow, low-gradient AS with LV dysfunction (EF<50)
- Symptomatic low-flow, low-gradient AS with LVEF >50 if AS is the most likely cause of symptoms
List indications for TAVI
- For intermediate, high and prohibitive surgical risk candidates
- age>80 or younger patients with life expectancy <10 years
- Consider for age 65-80 vs SAVR
When is TAVI contraindicated
if comorbidities preclude benefit
Palliative care is recommended instead if life expectancy with reasonable QOL <1year
What are 4 etiologies of acute AR
- Dissection
- Endocarditis
- Trauma
- Prosthetic valve dysfunction
List some of the etiologies of chronic AR
- Primary aortic problems
- Dilation
- AI conditions
- Syphilis
- Marfan
- Bicuspid
- HTN
- Dissection
- Trauma
- Dilation
- Primary valve problem
- Degenerative (calcific)
- Bicuspid
- Rheumatic
- endocarditis
- VSD
What are class 1 indications for valve surgery in AR
- Severe symptomatic AR
- Severe asymptomatic AR with LVEF ≤55% if no other cause for LV dysfunction identified
- Severe asymptomatic AR undergoing other CV surgery
*Severe AR defined by echo parameters
What are the etiologies of Mitral stenosis?
Almost always rheumatic
Others are MAC, radiation, autoimmune
What are the indications for anticoagulation in Mitral stenosis?
- Rhematic MS and AS
- Rheumatic MS and prior embolic event
- Rheumatic MS and LA thrombus
How does mitral stenosis respond to AF and high HR hemodynamically
- High HR: Loss of diastolic filling time
- AS: Loss of atrial kick
What are the criteria for severe MS?
- MV area < 1.5 (<1 is very severe)
- PASP>50
- Diastolic pressure half time ≥150
What are the class 1 indications for PMBC in AS?
- Severe symptomatic AS + favorable valve anatomy + can be performed at a “comprehensive valve centre”
What are the contraindications to PMBC in MS?
- LA thrombus
- ≥ moderate MR
What are the class 1 indications for MV surgery in MS
- Severe symptomatic MS + acceptable surgical risk + contraindicated or failed PMBC
- Severe MS and other CV surgery
What are the etiologies of acute MR
- Ischemia → Papillary muscle rupture
- Endocarditis
- Trauma
What are the etiologies of chronic MR
- Primary (degenerative, the valve is the problem)
- Valve leaflet
- MVP (myxomatous, fibroelastic deficiency)
- Rheumatic
- Annulus
- Calcification
- Chordae
- Trauma
- infection
- idiopathic
- Papillary muscle
- trauma
- Valve leaflet
- Secondary (functional)
- Dilated or ischemic CMP
What are the class 1 indications for surgery in primary MR
- Severe, symptomatic primary MR irrespective of LVEF
- Severe asymptomatic primary MR with LVEF <60, LVESD ≥40
*Severe MR is defined using specific echocardiographic parameters
**Here the goal is to prevent LV dysfunction
Who should be considered for valve procedure in secondary MR
- Maximally tolerated GDMT including revascularisation and CRT before considering valve repair
- As per CCS, in patients with symptomatic HF despite GDMT and severe MR, should be evaluated for percutaneous mitral valve repair