Cardiology

Question 1

Medications Known to Prolong QTc

Answer 1

Anti Emetics
(most commonly ondansetron)
Antiarrhythmics
Antimicrobials
Antipsychotics
Antidepressants
Triptans, methadone, cisapride, arsenic

Question 2

How to calculate Chads65

Answer 2

Age 65 or over
Prior stroke/ TIA / HTN / HF / DM
CAD or PAD
CHADS 0 –> consider single antiplatelet (COMPASS TRIAL)
>0 -> DOAC

Question 3

Indications for a statin

Answer 3

LDL >/ 5mmol/l (familial DLD or genetial disposition)
Diabetic: + >40 or >30+DM for 15 years or microvascular complications
>50 with CKD eGFR<60 or ACR >3
MI, ACS, TIS, Stroke, CAD on PCI, PAD, AAA>3

Question 4

When to initiate second line therapy for dyslipidemia

Answer 4

second line if LDLc>1.8 ornon-HDL-C ≥2.4 mmol/L or ApoB ≥0.7 g/L
evolocumab or Alirocumab +/- Ezetimibe in patients shown to benefit the greatest from PCSK9 inhibitor
Ezetimibe +/- PCSK9 inhibitor if not in the benefit group for PCSK9i
(CCS DLD guideline 2022)

Question 5

Patients at greatest benefit OF A PCSK9 INHIBITOR

Answer 5

Clinically evident ASCVD and any of the following:
* Diabetes mellitus or metabolic syndrome
* Poly vascular disease (vascular disease in ≥2 arterial beds)
* Symptomatic PAD
* Recurrent MI
* MI in the past 2 years
* Previous CABG surgery
* LDL-C ≥2.6 mmol/L or heterozygous FH
* Lipoprotein(a) ≥60 mg/dL (120 nmol/L)

Recent ACS + Hospitalized index ACS to 52 weeks post index ACS

Question 6

Important Side effects of amiodarone

Answer 6

Hypotension
Bradycardia
Phlebitis
Long term toxicity: thyroid, transaminitis, pneumonitis

Question 7

Import side effect of flecainamide

Answer 7

1:1 AV conduction - First dose to be given in a monitored setting

Question 8

Important side effect of Sotalol

Answer 8

Prolonged QTc, Repeat ECG 48-72 hours after initiation

Question 9

maneuvers that decrease preload

Answer 9

Valsalva x 20 seconds
Squat to Standing

Question 10

Maneuvers that increase afterload

Answer 10

isometric hand grip, listen after 1 minute

Question 11

Clinical features of subclavian Steal syndrome
(Takayasu arteritis)

Answer 11

difference in R and L arm BPs
Neurological symptoms consistent with brainstem or cerebellar ischemia.
Symptoms may be provoked by arm exercise or arm ischemia

Question 12

Medications that cause Atrial fibrillation

Answer 12

ibrutinib
Ivabradine
Theophyline
bisphosphonates smaller risk but listed on up to date

Question 13

first line medical management for orthostatic hypotension

Answer 13

Fludrocortisone

Question 14

Indications for ICD for Primary prevention in CHF

Answer 14

LVEF <30% despite optimal medical management for at least 3 months

Question 15

indications for revascularization in PAD

Answer 15

lifestyle limiting claudication which has not responded to optimal medical therapy

Question 16

ABPI classifications

Answer 16

> 1.4 Normal
1 Probably no PAD
0.81-1 no significant disease / mild
0.5-0.8 Moderate disease
<0.5 Severe
<0.3 critical

Question 17

Non- pharmacological management of PAD

Answer 17

smoking cessation
Exercise program
Daily self foot checks
wound care
Diabetes management

Question 18

pharmacological management of PAD

Answer 18

Statin
Antihypertensives
antithrombotic is symptomatic (ASA +2.5 rivaoxaban BID if high risk, Clopidogrel if low risk for ischemic events)

Question 19

Diagnostic Criteria for Brugada Syndrome

Answer 19

Type 1:
Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave.
This is the only ECG abnormality that is potentially diagnostic.
Type 2
>2mm of saddleback shaped ST elevation.
Type 3
can be the morphology of either type 1 or type 2, but with <2mm of ST segment elevation.

Question 20

First line therapy for isolated Systolic Hypertension

Answer 20

Thiazide, Long acting DHP CCB, ARB

Question 21

First line therapy for diastolic hypertension +/- Systolic hypertension

Answer 21

Thiazide,
BB Only if <60,
ACEi/ARB,
Long acting CCB

Question 22

Quadruple therapy for HFrEF

Answer 22

BB
ARNI or ACEi/ARB
MRA
SGLT2i - even if not diabetic

Question 23

Aortic regurgitation: indications for surgery

Answer 23

Severe symptomatic AR
Severe Asymptomatic AR with EF<55%
Severe Asymptomatic AR undergoing other CVS surgery

Question 24

Absolute Contraindications to exercise stress test

Answer 24

Acute MI (within 2 days)
Ongoing unstable angina
Uncontrolled hemodynamically-significant arrhythmia
Active endocarditis
Symptomatic severe AS
Decompensated heart failure
Acute PE, pulmonary infarction, DVT
Acute myocarditis, pericarditis
Acute aortic dissection
Physical limitations

Question 25

Positive Exercise stress test result

Answer 25

Positive test – ≥ 1mm STE – ≥ 1 mm STD (horizontal or downsloping)

Question 26

High risk features on Exercise stress test

Answer 26

High risk features* – Duke Treadmill Score -11 or less – <5 METs achieved – Low threshold angina / ischemia – STE – Severe STD ≥ 2mm – Ischemia on ≥ 5 leads – Ischemia ≥ 3 mins into recovery – Abnormal BP response [failure to achieve SBP>120, drop in BP >10, drop below baseline] – Ventricular arrhythmia

Question 27

Contraindications to Dipyridamole stress test

Answer 27

active or severe asthma/COPD, as dipyridamole can cause bronchospasm

Question 28

reversal agen for Dipyridamole

Answer 28

aminophylline

Question 29

Coronary Artery Calcium Score

Answer 29

CAC scoring is recommended for further risk stratification of intermediate risk (FRS 10-19%) asymptomatic patients aged > 40 who are not candidates for statin based on other risk factors - Can consider CAC scoring for low risk patients with family hx premature CV Dz and genetic dyslipidemia - CAC score > 100 is basically a statin indicated condition; start therapy regardless of FRS

Question 30

CT Coronary arteries

Answer 30

* Procedure specifics: – Low dose CT with beta blockade +/- IV nitro given (HR target <60), breath hold – 2-4mSv (~background annual radiation dose) * Indications: – Diagnosis of CAD for low to intermediate pre-test prob patients – Risk stratification in patients with stable CAD * Contraindications: – ACS – Severe structural heart disease (AS or HCM) – Usual CT precautions: Contrast Allergy, Renal Failure, Pregnancy

Question 31

Treatment of chronic stable CAD

Answer 31

General Principles * Educate on symptom management, lifestyle changes, medication adherence, target #SDOH risk factors, multidisciplinary team based care [ACC/AHA 2023] * 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 * COURAGE 2007, ORBITA 2017, ISCHEMIA 2019 * ISCHEMIA: Median 3.2 years follow-up; no difference in primary outcome (MACE) invasive strategy vs. conservative strategy – Extended 7-year follow-up data showed no difference in all-cause mortality was no different with invasive strategy. However, CV death was lower (offset by non-CV death for reasons that are unclear). Bottom line is all-cause was not reduced by an invasive strategy.

Question 32

Revascularization with Chronic CAD (ACC/AHA 2023)

Answer 32

* CABG if: – Left Main or Multivessel dz with LVEF ≤ 35% ↑survival over GDMT alone – Left Main associated with high complexity CAD ↑survival over PCI – Multivessel dz with high complexity CAD ↑survival over PCI – Multivessel dz in DIABETES with LAD involvement amenable to LIMA ↑survival and ↓revascularization over PCI * PCI if: – Poor surgical candidate – Single vessel disease – Diabetes with LM and low/intermediate complexity CAD consider as alternative to CABG