Cardiology

Question 1

Warfarin use in older adults as per Beers criteria

Answer 1

Potentially inappropriate medication
Higher risk of major bleeding
Lower effectiveness
DOAC preferred for NVAF/VTE
Recent study showed that switching warfarin to DOAC sig inc risk for bleeding in frail older adults

Question 2

Rivaroxaban and dabigatran vs. apixaban

Answer 2

Both have higher risk of major bleeding and GIB vs. apix
Riva - if OD dosing needed

Question 3

Screening for AF

Answer 3

Opportunistic in those 65+ yo
Pulse check or ECG

Question 4

Ticagrelor and prasugrel vs. clopidogrel

Answer 4

Both inc risk of major bleeding in older adult vs. clopidogrel
Especially if 75+
May be offset by CV benefits in select patients

Question 5

Benefits and risks of anticoagulation in AF

Answer 5

Benefits
1. Reduced risk of stroke
2. Reduced risk of PE/DVT

Risks
1. Major bleeding like ICH, GIB
2. Other minor bleeding

Question 6

What medication would you prescribe for patient with AF (GFR 30)?

Answer 6

Apixaban
5 mg PO BID
Normal dose 5 mg PO BID, dose reduce if 2 of:
1. Cr 133+
2. Age 80+
3. Weight <60 kg

Question 7

Target HR for AF

Answer 7

<100 BPM

Question 8

In hospital cardiac arrest: survival, % home, % neuro deficits

Answer 8

Survival = 25%
Home = 50%
Deficits = 40%

Question 9

Cardiac arrest and frailty outcomes

Answer 9

Frailty associated with:
Decreased likelihood of ROSC
Inc hospital mortality
Inc discharge to LTC

Question 10

Ddx for AF with RVR, not responding to BB and diarrhea

Answer 10

1. Hyperthyroidism
2. Hypovolemia from diarrhea causing RVR
3. Amyloid
4. Caffeine

Question 11

3 steps for immediate medical treatment for patient in rapid AF in CHF

Answer 11

1. Supplemental O2
2. IV Diuresis
3. Electrical cardio version if unstable

Question 12

Rate vs rhythm control in AF

Answer 12

Rate control for medium term
Longer term
Rhythm control preferred if:
- Recently diagnosed AF (1 yr)
- Highly symptomatic
- Multiple recurrences
- Difficult to achieve rate control
- Arrhythmia induced cardiomyopathy

Question 13

4 contraindications to anticoagulation in AF

Answer 13

1. Recurrent irreversible pulmonary bleed
2. Recurrent irreversible GI bleed
3. Recurrent irreversible urogenital bleed
4. Esophageal varices

Question 14

What is arterial compliance and what is a surrogate physiologic measurement?

Answer 14

Ability of blood vessel to expand and contract passively with changes in pressure (change in volume divided by change in pressure)
Surrogate measure = pulse pressure (SBP-DBP)

Question 15

What is POTS? What is tx?

Answer 15

POTS = postural orthostatic tachycardia syndrome
Increase in HR>30 from supine to standing without significant BP drop
Sx: light head, palpitations, tremulous, chest pain
Tx: stop offending meds, inc salt/water intake, compression stockings, abdominal binder, exercise
Propanolol, ivabradine, midodrine (if also HOTN)

Question 16

Would you treat DLD in 80+ yo with MI?

Answer 16

Good evidence for secondary prevention
Significant reduction in major vascular events
Also good evidence for primary prevention

Question 17

How are HDL and LDL affected by aging?

Answer 17

HDL-c inc
TG and LDL declined

Question 18

6 clinical findings for acute limb ischemic

Answer 18

1. Pain
2. Pallor
3. Pulselessness
4. Poikilothermia
5. Paralysis
6. Paresthesia

Question 19

When do you refer patient for surgery with PVD?

Answer 19

Critical limb ischemia
Inadequate response to optimal medical therapy

Question 20

Symptoms of chronic PAD?

Answer 20

Claudication
Skin discolouration
Cold to touch
Ulcer
Pulse abnormalities

Question 21

Four atypical ways in which elderly may present with MI?

Answer 21

1. GI symptoms
2. SOB
3. Dizzy
4. Delirium
5. Fatigue

Question 22

Management of CHF with diastolic dysfunction?

Answer 22

1. Candesartan
2. Tx HTN
3. Loop diuretics (Lasix)
4. Spironolactone
5. SGLT-2 inh

Question 23

SAGE-AF trial found that 25% participants received inappropriate DOAC dose. What are 3 factors associated with inappropriate dosing?

Answer 23

1. Advanced age
2. Hx of renal failure
3. Higher CHADS VASC score

Question 24

Apixaban is metabolized by what?

Answer 24

CYP 3A4

Question 25

List 5 patient risk factors that might indicate futility of TAVI or SAVR

Answer 25

1. Advanced dementia 2. Bedbound/immobile 3. Cachexia/sev sarcopenia 4. Disability for all/most aDLs 5. End stage renal/liver/lung malignant dx

Question 26

4 physiologic changes to CV systems that predispose to CHF

Answer 26

1. Isolated systolic HTN due to atherosclerosis 2. LV wall thickening (inc myocyte, inc collagen) 3. Reduced LV early diastolic filling 4. Inc atrial contribution to filling

Question 27

Four ways heart rate and rhythm change in normal aging

Answer 27

1. Resting HR decrease 2. Max HR decrease 3. Respiratory variation decreases 4. Inc PVCs

Question 28

4 advantages to transitioning from warfarin to DOAC

Answer 28

1. No need for monitoring blood work 2. Lower risk of ICH/major bleed 3. More effective at stroke prevention 4. Fewer drug drug interactions Two disadvantages 1. Twice a day dosing 2. Harder to reverse

Question 29

4 risk factors that might indicate futility of TAVI or SAVR

Answer 29

ABCDE mnemonic Advanced dementia Bedbound/non mobile Cachexia/severe sarcopenia Disability for most/all BADLs End stage lung/liver/renal/malignant disease

Question 30

List three patient factors that favour TAVI over SAVR?

Answer 30

1. Frailty 2. Age 75+ 3. Limited mobility 4. Limited life expectancy 5. Risk of surgical morbidity or mortality intermediate risk or greater

Question 31

What factors are associated with delirium post TAVI?

Answer 31

1. BADL impairment 2. IADL impairment 3. Malnutrition 4. Impaired mobility 5. MMSE <27

Question 32

What are 2 reasons why rivaroxaban is avoid use as per Beers?

Answer 32

1. Higher risk of ICH 2. Higher risk of GI bleed

Question 33

What DOAC is use with caution in Beers?

Answer 33

Dabigatran