Cardiology Flashcards
Which patients are most likely to benefit from Surgical Revascularisation over PCI?
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
What did the COURAGE Trial demonstrate regarding management of stable coronary artery disease?
No mortality benefit for PCI over optimal medical management in patients with stable coronary artery disease
What does the ISCHAEMIA Trial show for stable coronary artery disease?
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.
What is the expected long term patency of IMA vs SVG bypass grafts?
IMA: 90% at 10 years
SVG: 40-50% at 10 years
Which medical therapies for chronic stable angina have evidence for prognostic benefit?
- Aspirin
- Beta blockers
- ACEi
- Statin
What are the grades of angina? (And what is the grading system?)
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
What are the benefits of Evolocumab? (FOURIER Trial)
Reduced CV death, MI, stroke, revascularisation
ODYSSEY Trial for Alirocumab
60% reduction in LDL with Alirocumab
CASTLE-AF showed that catheter ablation for AF results in what?
Reduced death and Heart Failure Hospitalisation in patients with an Ejection Fraction <35% and who have also failed medical therapy
What are the predictors of failure of Catheter Ablation for AF?
Older age
Long standing persistent AF (versus paroxysmal)
Increasing Left Atrial size
Valvular or Structural Heart Disease
What are the indications for Catheter Ablation in AF?
- 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
Non Valvular Atrial Fibrillation is everything except
Metallic Heart Valves and Moderate to severe Mitral Stenosis
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?
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.
When is Adenosine contraindicated?
Severe Asthma
What is the best predictor of benefit from Cardiac Resynchronisation Therapy?
QRS duration, >150 predicts benefit, more benefit the longer the QRS
In which patients is there evidence for mortality benefit from Ablation for AF?
Patients with Ejection Fraction <35% and failed medical therapy (CASTLE-AF trial)
What is the mechanism of Atrial Flutter?
Macro-reentrant circuit between the atria (Intra-atrial, dependent on the cavo-tricuspid isthmus)
What organism is associated with Infective Endocarditis in patients with Inflammatory Bowel Disease
Strep bovis
What are some of the causes of prolonged fevers in Infective Endocarditis?
Right Sided Infective Endocarditis
Septic Pulmonary Emboli
(Note: Staph aureus endocarditis can result in fevers for up to a week)
Which patient groups should be given antibiotic prophylaxis to prevent Infective Endocarditis?
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
What procedures require prophylactic antibiotics to reduce risk of Infective Endocarditis? (In patients who would require prophylaxis)
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.
What are the HACEK Organisms?
Haemophilus aphrophilus
Actinobacillus
Cardiobacterium hominis
Eikonella corrodens
Kingella kingae
In older patients with cognitive or mobility impairment, what is the result of lowering systolic blood pressure below 130?
Increases mortality (SNAC-K Trial)
When should renovascular disease be considered in patients with hypertension?
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
What is Group I Pulmonary Hypertension?
Idiopathic Pulmonary Arterial Hypertension
- Isolated precapillary pulmonary hypertension
- Very rare, idiopathic
What is Group II Pulmonary Hypertension?
PH Associated with Left Heart Disease
- HFpEF, HFrEF, Valvular Disease
- Raised PCWP >15
Group III Pulmonary Hypertension
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
Group IV Pulmonary Hypertension
Chronic Thromboembolic Pulmonary Hypertension
- V/Q and TTE as initial investigations, followed by RHC and CTPA
- V/Q is better than CTPA for PH
- 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
Group V Pulmonary Hypertension
Pulmonary Hypertension of unclear mechanism
- Associated conditions: Haematologic disease including sickle cell, CML, thalassaemia; Sarcoidosis, Chronic Renal Failure
- RHC results can be variable
-
What are the most common cardiac anomalies in Turner Syndrome?
30% Bicuspid Valve
12% Coarctation
Compare T wave changes in Hyperkalaemia and Acute Ischaemia
Hyperkalaemia: narrow base, pointed
Acute ischaemia: broad base, blunted peak
Causes of LBBB
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
ALS: What should be given for a regular broad complex tachycardia?
IV Amiodarone 300mg over 20-60 minutes, then further 900mg over 24hr.
Exception: Known SVT with BBB (Treat as a regular narrow complex tachycardia)
ALS: Management of Irregular broad complex tachycardia
Correct electrolyte abnormalities
Get good IV access and pads on
IV Mg Sulphate 2g over 10 minutes
ALS: Options for regular narrow complex tachycardia?
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
ALS: Management of irregular narrow complex tachycardia?
Control rate with beta blockers or diltiazem
If evidence of heart failure, digoxin or amiodarone
What are the high risk features for asystole in a patient with bradycardia?
Previous asystole
Mobitz II
Complete heart block with broad QRS
Ventricular pauses >3s
What is the first line management of a patient with bradycardia who has adverse features?
IV/IO Atropine 500-600mcg
What are the contraindications to Fibrinolysis?
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
Criteria for Severe Mitral Stenosis
Valve Area < 1
Mean gradient >10
PAP > 50
Is Mitral Regurgitation tolerated better following TAVI or Open Aortic Valve replacement?
TAVI
What does stimulation/agonism of Beta 2 Receptors result in?
Vasodilation
Bronchodilation
Hepatic glycogenolysis
GIT relaxation
GU Relaxation
What does stimulation/agonism of Beta 1 receptors cause?
Inotropy
Chronotropy
Dromotropy
Increased renin release
Distinguishing HOCM murmur from AS
Louder with Valsalva
Doesn’t radiate to carotids
Echocardiogram diagnostic cut off for HOCM
> /= 15mm in any LV region
or 13-14mm in an individual with first degree relative with HOCM
Risk factors for SCD in HOCM (i.e. indications for ICD implantation)
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
Key features Fabry Disease
Increased LV wall thickness
Male predominance (X linked)
Neuropathic pain
Renal dysfunction
Telangiectasia
Angiokeratomas
Younger patients
Compare types of Amyloid
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
Indications for surgical management of thoracic aortic aneurysm
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
Benefits and Complications of EVAR
Benefits: lower morbidity, shorter hospital stay
Complications: stroke, spinal ischaemia, endoleak
Higher rate of repeat intervention
Which antihypertensive is first line for managing hypertension in patients with acute aortic syndromes?
Beta blocker
(Or consider Lorsartan in Marfan Syndrome)
Monitoring Abdominal Aortic Aneurysms
<4cm: every 2-3yr
4-5.4cm: every 6-12 months
>/= 5.5cm: CTA or MRA to actively plan for repair
Most common cause of periprocedural death post ablation
Tamponade
Mechanism and benefit of Sacubitril
Blocks neprolysin which reduces degradation of natriuretic peptides
20% reduced risk of cardiovascular death, and first hospitalisation for heart failure
Fractional Flow Reserve
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
Role for Calcium Scoring
Risk stratification in asymptomatic individuals with risk factors
Role for CT Coronary Angiography
Exclusion of occlusive CAD in low to intermediate risk patients with symptoms
Most specific finding of Stress ECG for significant CAD
Inadequate rise in blood pressure
Evidence for Ezetimibe
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
Empagliflozin in Heart Failure
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
Dapagliflozin in Heart Failure
DAPA-HF
- 30% RRR in HF events
- 18% RRR in cardiovascular events
- All cause mortality reduced
Radial versus Femoral approach for PCI
MATRIX and RIVAL trials showed better outcomes with Radial approach
Ticagrelor versus Clopidogrel for ACS (PLATO Trial)
Ticagrelor better than Clopidogrel for all NSTEMI/STEMI presentations:
- Reduced all cause mortality
- Reduced cardiovascular death
- Reduced cardiovascular events
Choice of CABG vs PCI in diabetics (FREEDOM Trial)
Diabetics with triple vessel disease should have CABG rather than PCI
ICD Insertion in HFrEF
NYHA II - III
Ischaemic Cardiomyopathy
LVEF ≤35% despite 3 months maximally tolerated medical therapy
Reduces mortality by 25%
CRT insertion in HFrEF
NYHA II - III, LVEF ≤35% despite 3 months maximally tolerated medical therapy
PLUS
QRS >130 with LBBB
Ivabradine in Heart Failure
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
Class IB Antiarrhythmics
Mechanism: Sodium channel blockade
Examples: Lignocaine
Use: Ventricular arrhythmia
Side Effects: Headache, dizziness, seizures (Lignocaine specific)
Contraindications: Advanced liver disease
Class IC Antiarrhythmics
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
Class II Antiarrhythmics
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
Sotalol
Class III Antiarrhythmic
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
Class IV Antiarrhythmics
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
Amiodarone
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
ARISTOTLE Trial for Apixaban
Apixaban superior to Warfarin for stroke prevention and mortality; reduced frequency of all bleeding including intracranial and fatal bleeding
Indications for Apixaban dose reduction
2 or more of the following:
Creatinine >/= 133
Age >/= 80
Weight </= 60kg
Dabigatran vs Warfarin
RE-LY trial
Non inferior to Warfarin for stroke prevention
No change in overall bleeding, but reduced major bleeding risk
ROCKET-AF Trial
Rivaroxaban vs Warfarin
Non inferior to Warfarin for stroke prevention
No change in overall bleeding, reduced intracranial and fatal bleeding
Features of Tetralogy of Fallot
Right ventricular outflow tract obstruction
Malalignment ventricular septal defect
Overriding aorta
Concentric RV hypertrophy
