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BPT > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Which patients are most likely to benefit from Surgical Revascularisation over PCI?

A

The major benefit of survival is in the sickest patients. Those with severe ischaemic symptoms, multivessel disease, Diabetes, LMCA/Proximal LAD Disease and those with Left Ventricular Dysfunction

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2
Q

What did the COURAGE Trial demonstrate regarding management of stable coronary artery disease?

A

No mortality benefit for PCI over optimal medical management in patients with stable coronary artery disease

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3
Q

What does the ISCHAEMIA Trial show for stable coronary artery disease?

A

Similar findings to COURAGE. No difference in CV death, MI, hospitalisation for unstable angina, Heart failure between early revascularisation and optimal medical therapy. Some symptom benefit in first year.

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4
Q

What is the expected long term patency of IMA vs SVG bypass grafts?

A

IMA: 90% at 10 years
SVG: 40-50% at 10 years

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5
Q

Which medical therapies for chronic stable angina have evidence for prognostic benefit?

A
  • Aspirin
  • Beta blockers
  • ACEi
  • Statin
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6
Q

What are the grades of angina? (And what is the grading system?)

A

Canadian Cardiovascular Score:
Grade I: only with strenuous exertion
Grade II: symptoms with moderate exertion (slight limits on ordinary activity)
Grade III: symptoms with mild exertion (limits ordinary activity)
Grade IV: symptoms at rest

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7
Q

What are the benefits of Evolocumab? (FOURIER Trial)

A

Reduced CV death, MI, stroke, revascularisation

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8
Q

ODYSSEY Trial for Alirocumab

A

60% reduction in LDL with Alirocumab

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9
Q

CASTLE-AF showed that catheter ablation for AF results in what?

A

Reduced death and Heart Failure Hospitalisation in patients with an Ejection Fraction <35% and who have also failed medical therapy

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10
Q

What are the predictors of failure of Catheter Ablation for AF?

A

Older age
Long standing persistent AF (versus paroxysmal)
Increasing Left Atrial size
Valvular or Structural Heart Disease

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11
Q

What are the indications for Catheter Ablation in AF?

A
  • Asymptomatic paroxysmal or persistent AF, which is either refractory or intolerant to at least one Class I or Class III anti arrhythmic medication
  • Can be considered for symptomatic disease in patients with CCF with reduced ejection fraction without the need to have failed anti-arrhythmic medication
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12
Q

Non Valvular Atrial Fibrillation is everything except

A

Metallic Heart Valves and Moderate to severe Mitral Stenosis

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13
Q

A patient with no previous history of arrhythmia or symptoms suggestive of arrhythmia has delta waves on their ECG. When might an EP study be considered?

A

High Risk Occupations, and particularly if <40. Patients older than 40 who have a delta wave present without symptoms have low to zero risk of adverse outcomes.

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14
Q

When is Adenosine contraindicated?

A

Severe Asthma

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15
Q

What is the best predictor of benefit from Cardiac Resynchronisation Therapy?

A

QRS duration, >150 predicts benefit, more benefit the longer the QRS

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16
Q

In which patients is there evidence for mortality benefit from Ablation for AF?

A

Patients with Ejection Fraction <35% and failed medical therapy (CASTLE-AF trial)

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17
Q

What is the mechanism of Atrial Flutter?

A

Macro-reentrant circuit between the atria (Intra-atrial, dependent on the cavo-tricuspid isthmus)

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18
Q

What organism is associated with Infective Endocarditis in patients with Inflammatory Bowel Disease

A

Strep bovis

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19
Q

What are some of the causes of prolonged fevers in Infective Endocarditis?

A

Right Sided Infective Endocarditis
Septic Pulmonary Emboli
(Note: Staph aureus endocarditis can result in fevers for up to a week)

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20
Q

Which patient groups should be given antibiotic prophylaxis to prevent Infective Endocarditis?

A

Prosthetic Valve Replacement (Including TAVI)
Congenital Cyanotic heart Disease
Congenital Heart Disease which has been repaired with a prosthesis in the last 6 months
Previous Infective Endocarditis

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21
Q

What procedures require prophylactic antibiotics to reduce risk of Infective Endocarditis? (In patients who would require prophylaxis)

A

Dental procedures involving manipulation of the gingiva
Procedures involving treatment of an active infection
Perforation of the GIT
All patients getting an ICD/PPM/CRT etc.

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22
Q

What are the HACEK Organisms?

A

Haemophilus aphrophilus
Actinobacillus
Cardiobacterium hominis
Eikonella corrodens
Kingella kingae

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23
Q

In older patients with cognitive or mobility impairment, what is the result of lowering systolic blood pressure below 130?

A

Increases mortality (SNAC-K Trial)

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24
Q

When should renovascular disease be considered in patients with hypertension?

A

Increase in serum creatinine of at least 50% occurring within 1 week of initiating an ACEi or ARB
Severe hypertension and a unilateral smaller kidney, or difference in kidney size > 1.5cm
Recurrent flash APO

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25
Q

What is Group I Pulmonary Hypertension?

A

Idiopathic Pulmonary Arterial Hypertension
- Isolated precapillary pulmonary hypertension
- Very rare, idiopathic

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26
Q

What is Group II Pulmonary Hypertension?

A

PH Associated with Left Heart Disease
- HFpEF, HFrEF, Valvular Disease
- Raised PCWP >15

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27
Q

Group III Pulmonary Hypertension

A

Pulmonary Hypertension associated with underlying lung disease
- Indistinguishable from Group 1 on RHC
- Treat underlying lung disease
- Vasodilators risk disruption of normal autoregulation leading to V/Q mismatch and worsening hypoxaemia

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28
Q

Group IV Pulmonary Hypertension

A

Chronic Thromboembolic Pulmonary Hypertension
- V/Q and TTE as initial investigations, followed by RHC and CTPA
- Lifelong anticoagulation for all
- Operable: Pulmonary Endarterectomy is first line
- Nonoperable: Riociguat (improved 6MWD, reduced PVR)
- Reccurrence/persistent symptoms: Medical therapy, also consider Balloon Pulmonary angioplasty

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29
Q

Group V Pulmonary Hypertension

A

Pulmonary Hypertension of unclear mechanism
- Associated conditions: Haematologic disease including sickle cell, CML, thalassaemia; Sarcoidosis, Chronic Renal Failure
- RHC results can be variable
-

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30
Q

What are the most common cardiac anomalies in Turner Syndrome?

A

30% Bicuspid Valve
12% Coarctation

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31
Q

Compare T wave changes in Hyperkalaemia and Acute Ischaemia

A

Hyperkalaemia: narrow base, pointed
Acute ischaemia: broad base, blunted peak

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32
Q

Causes of LBBB

A

Hypertensive Heart Disease
Ischaemic Heart Disease
Valvular Heart Disease

An isolated “new” LBBB without a clear ACS history or Troponin rise is not indicative of acute ischaemia

33
Q

ALS: What should be given for a regular broad complex tachycardia?

A

IV Amiodarone 300mg over 20-60 minutes, then further 900mg over 24hr.

Exception: Known SVT with BBB (Treat as a regular narrow complex tachycardia)

34
Q

ALS: Management of Irregular broad complex tachycardia

A

Correct electrolyte abnormalities
Get good IV access and pads on
IV Mg Sulphate 2g over 10 minutes

35
Q

ALS: Options for regular narrow complex tachycardia?

A

Vagal Manoeuvres
Adenosine 6mg rapid IV bolus; if no effect give 12mg; can then repeat further 12mg if not successful
Escalate if still not successful, consider beta blocker to slow rate

36
Q

ALS: Management of irregular narrow complex tachycardia?

A

Control rate with beta blockers or diltiazem
If evidence of heart failure, digoxin or amiodarone

37
Q

What are the high risk features for asystole in a patient with bradycardia?

A

Previous asystole
Mobitz II
Complete heart block with broad QRS
Ventricular pauses >3s

38
Q

What is the first line management of a patient with bradycardia who has adverse features?

A

IV/IO Atropine 500-600mcg

39
Q

What are the contraindications to Fibrinolysis?

A

BP >180/110
Recent trauma/surgery
GI/GU bleeding in the last 4 weeks
Stroke/TIA in last 12 months
Any previous intracranial bleeding
Current anticoagulation or bleeding diathesis

40
Q

Criteria for Severe Mitral Stenosis

A

Valve Area < 1
Mean gradient >10
PAP > 50

41
Q

Is Mitral Regurgitation tolerated better following TAVI or Open Aortic Valve replacement?

A

TAVI

42
Q

What does stimulation/agonism of Beta 2 Receptors result in?

A

Vasodilation
Bronchodilation
Hepatic glycogenolysis
GIT relaxation
GU Relaxation

43
Q

What does stimulation/agonism of Beta 1 receptors cause?

A

Inotropy
Chronotropy
Dromotropy
Increased renin release

44
Q

Distinguishing HOCM murmur from AS

A

Louder with Valsalva
Doesn’t radiate to carotids

45
Q

Echocardiogram diagnostic cut off for HOCM

A

> /= 15mm in any LV region
or 13-14mm in an individual with first degree relative with HOCM

46
Q

Risk factors for SCD in HOCM (i.e. indications for ICD implantation)

A

Sudden death in a first degree relative or close relative <50
LV wall thickness >30mm
1 or more episodes of syncope thought to be arrhythmic in origin
LV apical aneurysm
LVEF <50%
History of sustained VT

47
Q

Key features Fabry Disease

A

Increased LV wall thickness
Male predominance (X linked)
Neuropathic pain
Renal dysfunction
Telangiectasia
Angiokeratomas
Younger patients

48
Q

Compare types of Amyloid

A

AL:
Multiorgan disease associated with plasma cell dyscrasia.
Clinical Manifestations: heart failure, nephrotic syndrome, hepatosplenomegaly, bleeding diathesis, periorbital purpura, macroglossia, carpal tunnel syndrome
Serum protein electrophoresis assists with diagnosis, demonstrating clonal plasma cell dyscrasia.
Treatment of the haematological malignancy controls Amyloid

ATTR:
Hereditary mutation of TTR gene, male predominance, slightly older patients.
Key clinical manifestations: Cardiomyopathy, Carpal Tunnel Syndrome, Spinal Stenosis, Neuropathy.
Treatment: Tafamidis is a protein stabiliser which reduces hospitalisations and improves mortality

49
Q

Indications for surgical management of thoracic aortic aneurysm

A

Rapid expansion (>0.5cm/yr)
Diameter >/= 5.5cm
Aortic root or ascending aorta aneurysms >4.5cm who are planned for CABG or Valve surgery
Marfan Syndrome >5.0cm
Loeys Dietz >4.2cm
Turner Syndrome >27mm/m^2

50
Q

Benefits and Complications of EVAR

A

Benefits: lower morbidity, shorter hospital stay
Complications: stroke, spinal ischaemia, endoleak

Higher rate of repeat intervention

51
Q

Which antihypertensive is first line for managing hypertension in patients with acute aortic syndromes?

A

Beta blocker

(Or consider Lorsartan in Marfan Syndrome)

52
Q

Monitoring Abdominal Aortic Aneurysms

A

<4cm: every 2-3yr
4-5.4cm: every 6-12 months
>/= 5.5cm: CTA or MRA to actively plan for repair

53
Q

Most common cause of periprocedural death post ablation

A

Tamponade

54
Q

Mechanism and benefit of Sacubitril

A

Blocks neprolysin which reduces degradation of natriuretic peptides

20% reduced risk of cardiovascular death, and first hospitalisation for heart failure

55
Q

Fractional Flow Reserve

A

Assesses functional impact of coronary artery stenosis. Not validated in ACS, only for use in stable CAD. FAME and DEFER trials, with cutoff of <0.8 and <0.75 for severe disease respectively

56
Q

Role for Calcium Scoring

A

Risk stratification in asymptomatic individuals with risk factors

57
Q

Role for CT Coronary Angiography

A

Exclusion of occlusive CAD in low to intermediate risk patients with symptoms

58
Q

Most specific finding of Stress ECG for significant CAD

A

Inadequate rise in blood pressure

59
Q

Evidence for Ezetimibe

A

IMPROVE-IT: No mortality benefit, but reduces MI and Stroke risk

Avoid use with Fenofibrate, combination increases risk of biliary disease

Benefit of adding Ezetimibe is greater than benefit of increasing statin dose

60
Q

Empagliflozin in Heart Failure

A

EMPA-REG, EMPOROR-REDUCE, EMPOROR-Preserved
- Reduces heart failure admissions
- Reduces cardiovascular and all cause mortality in patients
- Benefit exists whether patients are diabetic or not
- Also evidence of benefit in HFpEF

61
Q

Dapagliflozin in Heart Failure

A

DAPA-HF
- 30% RRR in HF events
- 18% RRR in cardiovascular events
- All cause mortality reduced

62
Q

Radial versus Femoral approach for PCI

A

MATRIX and RIVAL trials showed better outcomes with Radial approach

63
Q

Ticagrelor versus Clopidogrel for ACS (PLATO Trial)

A

Ticagrelor better than Clopidogrel for all NSTEMI/STEMI presentations:
- Reduced all cause mortality
- Reduced cardiovascular death
- Reduced cardiovascular events

64
Q

Choice of CABG vs PCI in diabetics (FREEDOM Trial)

A

Diabetics with triple vessel disease should have CABG rather than PCI

65
Q

ICD Insertion in HFrEF

A

NYHA II - III
Ischaemic Cardiomyopathy
LVEF ≤35% despite 3 months maximally tolerated medical therapy

Reduces mortality by 25%

66
Q

CRT insertion in HFrEF

A

NYHA II - III, LVEF ≤35% despite 3 months maximally tolerated medical therapy

PLUS

QRS >130 with LBBB

67
Q

Ivabradine in Heart Failure

A

SA Node Inhibitor

SHIFT Study: patients in sinus, EF <35%, HF admission in last 12 months

Reduces cardiovascular death and HF hospitalisation by 18%

Benefit greatest in patients with higher heart rates

Recommended in patients with ongoing symptoms with optimal medical management and HR >70bpm

68
Q

Class IB Antiarrhythmics

A

Mechanism: Sodium channel blockade
Examples: Lignocaine
Use: Ventricular arrhythmia
Side Effects: Headache, dizziness, seizures (Lignocaine specific)
Contraindications: Advanced liver disease

69
Q

Class IC Antiarrhythmics

A

Mechanism:
Examples: Flecainide
Use: AF, SVT
Side Effects: Headache, dizziness
Contraindications: Ischaemic or structural heart disease, SA node disease, 2nd or 3rd degree AV block, bundle branch block without PPM

70
Q

Class II Antiarrhythmics

A

Mechanism: Beta blocker
Examples: Metoprolol, Propranolol, Carvedilol, atenolol, bisoprolol
Use: Rate control of atrial arrhythmia, DVT
Side Effects: Fatigue, dizziness, drowsiness, bronchospasm, cool peripheries
Contraindications: Severe asthma, cardiogenic shock, 2nd and 3rd degree AV block, pre-excitation

71
Q

Class III Antiarrhythmics

A

Mechanism: Potassium channel blockade
Examples: Sotalol
Use: AF, Flutter, ventricular arrhythmias
Side Effects: Headache, dizziness, bradycardia, fatigue, dyspnoea
Contraindications: Renal failure, QT prolongation, bradycardia or AV block without PPM

72
Q

Class IV Antiarrhythmics

A

Mechanism: Non dihydropyridine Calcium Channel Blockers
Examples: Verapamil, Diltiazem
Use: SVT, rate control of atrial arrhythmias
Side Effects: Dizziness, constipation, dependent oedema, nausea
Contraindications: Significant SA node dysfunction, 2nd or 3rd degree AV block without PPM, pre-excitation

73
Q

Amiodarone

A

Mechanism: K, Na, Ca channel blockade
Use: Atrial arrhythmias, Ventricular arrhythmias, arrest
Side Effects: Fatigue, dizziness, nausea/vomiting, constipation or diarrhoea, tremor, organ toxicities: liver, lung, thyroid, eye; QT prolongation, photosensitivity
Contraindications: Advanced liver, lung or thyroid disease; sick sinus syndrome, symptomatic bradycardia, 2nd or 3rd degree heart block without PPM

Monitoring: TFTs, PFTs if respiratory symptoms

Least negatively inotropic anti-arrhythmic, so typically well tolerated in heart failure

IV dosing:
150-300mg over a few minutes in an emergency
Loading: 5mg/kg over 20 minutes to 2 hours, followed by maintenance of 15-20mg/kg/24hr (max 1.2g/24hr)

Oral dosing:
No loading if non urgent
Maintenance 100-200mg daily
Commence oral maintenance dosing prior to ceasing infusion

74
Q

ARISTOTLE Trial

A

Apixaban superior to Warfarin for stroke prevention and mortality; reduced frequency of all bleeding including intracranial and fatal bleeding

75
Q

Indications for Apixaban dose reduction

A

2 or more of the following:
Creatinine >/= 133
Age >/= 80
Weight </= 60kg

76
Q

Dabigatran vs Warfarin

A

RE-LY trial
Non inferior to Warfarin for stroke prevention
No change in overall bleeding, but reduced major bleeding risk

77
Q

ROCKET-AF Trial

A

Rivaroxaban vs Warfarin
Non inferior to Warfarin for stroke prevention
No change in overall bleeding, reduced intracranial and fatal bleeding

78
Q
A

BPT (15 decks)

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