Cardiology Flashcards

Question

4 causes of PCWP > LVEDP

Answer 1

Usually PCWP should estimate LVEDP. 1. Mitral stenosis 2. Cor triatriatum - congenital defect in which left or right atrium is subdivided by a thin membrane resulting in 3 atrium 3. Atrial myxoma 4. Pulmonary vein stenosis

Answer 2

P = 4Vsquared

Answer 3

1. Nephrotic syndrome 2. Cholestasis 3. Hypothyroidism

Answer 4

Reduces absorption of dietary and biliary cholesterol by inhibiting its transport across the intestinal wall, leading to upregulation of low density lipoprotein receptors on the surface of cells and increased LDL cholesterol uptake into cells.

Answer 5

Paradoxical rise of RA pressure or lack of decline in RA pressure during inspiration. Indicates constriction or RV ischaemia.

Answer 6

1. Anaemia 2. Sepsis 3. Tachycardia 4. Thyrotoxicosis Basically any loading conditions can affect the valve gradient, hence echo evaluating the severity of the valve lesion should be done when patient is stable.

Answer 7

PDA > VSD > ASD

Answer 8

1. R axis deviation 2. Positive QRS complexes in aVR with upright P and T waves 3. Inversion of all complexes with global negativity in lead 1 4. Absent R wave progression in the chest leads Accidental reversal of L and R arm electrodes may produce a similar picture to dextrocardia in the limb leads only (but with normal apperance in the praecordial leads)

Answer 9

Flecainide. Slows conduction through normal and accessory pathway and has a greater effect at higher atrial rates. Potent inhibitor of sodium channels and therefore slows conduction. ECG will show lengthening of PR interval and widening of QRS complex on the ECG.

Answer 10

Stent thrombosis - 1-2% most commonly in the first month Restenosis - most commonly in first 3-6 months, occurs in 5-20% of patients

Answer 11

In STABLE IHD: Minimum of 1 month in BMS, 6 months in DES Longer if minimal bleeding risk Post ACS: At least 12 months regardless of DES/BMS CABG: DAPT with aspirin and P2Y12 inhibitors for 12 months post ACS Fibrinolysis: Aspirin and clopidogrel for minimum of 14 days and ideally at least 12 months

Answer 12

1. In children it is effective 2. Bridging therapy in pregnant women with severe AS or in non-emergent surgery in older patients (eg: hip replacement) 3. Assessment of symptoms whether it relates to the severity of the valve lesion as opposed to other factors such as COPD prior to definitive treatment note: cardiopulmonary bypass in pregnancy has 20-30% chance of fetal loss.

Answer 13

Either upto age of 40, or at least 10 years, whichever is the longest. Ie, if Pt develops rheumatic fevre at age of 5, needs to continue antibiotic prophylaxis for 35 years!!

Answer 14

Increases risk of developing diabetes Increased incidence of stroke particularly in smokers. Therefore not used unless there is a compelling reason such as heart failure or ischaemic heart disease.

Answer 15

Previous DAVID trial showed that RV pacing alone resulted in increase in heart failure and mortality. Subsequently NEJM 2013 article showed that biventricular pacing in heart failure with heart block is effective in reducing combined end point by 26%: 1. Class I - III HF with LVEF <50% 2. Narrow complex 3. Pacing indication present

Answer 16

BNP is produced by left ventricle in response to strain. Acts as a vasodilator, diuretic and natriuretic. Suppresses both sympathetic tone and RAA system.

Answer 17

Qp:Qs = Aorta O2 - Mixed venous O2 / Pulmonary vein O2 - Pulmonary artery O2 Anything more than 7% is considered step up.

Answer 18

Hydroxycobalamin or sodium thiosulphate.

Answer 19

1. Age >65 2. Chronic heart failure 3. Pneumonia as a cause of respiratory failiure 4. Partial pressure of PaCO2 >45 mmHg after extubation 5. Upper airway stridor at extubation.

Answer 20

1. Amiodarone 2. Sotalol 3. TCA 4. Fluoxetine 5. Class 1a antiarrhythmic drugs 6. Erythromycin

Answer 21

Exercise testing with a bike. If delta wave disappears in response to exercise (HR >130) it means that it doesn't conduct at higher HR.

Answer 22

LGE identifies regional but not diffuse myocardial fibrosis. Patients with NICM with LGE+ did the worst in terms of requiring device therapy much earlier compared to those without LGE!

Answer 23

1. Bradycardia and hypotension (negatively inotropic) 2. Visual blurring 3. Oral paraesthesia.

Answer 24

``` Low diastolic BP Wide pulse pressure Displaced apex, S3, LVF Waterhammer pulse Long duration of murmur ```

Answer 25

1. Delayed onset of action depending on the loading dose given (slower if 300mg given compared to 600mg - 2-6hrs vs 12-24 hours) 2. Poor metabolizers specifically CYP2C19 3. Drug interaction with PPIs Therefore prasugrel is preferred over clopidogrel - prasugrel has earlier production and greater concentration of the active metabolite compared to clopidogrel.

Answer 26

1. Unsuitable anatomy 2. Endocarditis 3. LV thrombus 4. Life expectancy <1 year 5. Other conditions which may not alleviate symptoms eg COPD, pulmonary hypertension

Answer 27

Usually benign Seen in young fit individuals and reflect high vagal tone No indication for PPM

Answer 28

Mitral. Aortic valve disease is second.

Answer 29

PVR = mPAP - mLAP / Qp (pulmonary blood flow) PVR is measured in Wood's unit = mmHg/L/min Anything below <5 WU is low and suggests that there is no significant pulmonary vascular disease (ie left heart driven disease)

Answer 30

Irreversible inhibition of COX-1 which is required to make thromboxane, which is required to facilitate platelet aggregation. Because platelets do not have a nucleus, effect persists until its death 7-10 days.

Answer 31

Aortic sinus dilatation leading to aortic aneurysm, dissection, regurgitation. (90%) Also mitral valve prolapse in 75%

Answer 32

1. U waves 2. small or absent T waves (occasionally inversion) 3. prolong PR interval 4. ST depression 5. long QT

Answer 33

1. Diabetes 2. Obesity 3. Alcohol

Answer 34

endocardial cushion defect (c. 40%, also known as atrioventricular septal canal defects) ventricular septal defect (c. 30%) secundum atrial septal defect (c. 10%)

Answer 35

Activates peroxisome proliferator activated nuclear receptors and modulate lipoprotein synthesis and catabolism. Reduces TGL, moderately increase HDL and have a variable effect on LDL concentration.

Answer 36

Magnesium stimulates calcium reuptake via calcium activated ATPases

Answer 37

Both antiplatelet and vasodilating properties by inhibiting activity of adenosine deaminase and phosphodiesterase, causing accumulation of adenosine, adenine nucleotides, and cAMP. Side effects include headache, dizziness, nausesa, diarrhoea, worsening of angina

Answer 38

Absent a wave - AF Cannon a wave - complete heart block - atrial contracts against closed tricuspid valve Large a wave - increased resistance in ventricular filling eg pulmonary hypertension, tricuspid stenosis Large v wave - tricuspid regurgitation - increased volume into R atria during atrial diastole Steep y descent - constrictive pericarditis due to restriction in adequate stretch of the cardiac wall.

Answer 39

1. VSD 2. Overriding aorta 3. Pulmonary stenosis causing RVOTO 4. RVH

Answer 40

Neprilysin degrades natriuretic peptides such as ANP, BNP and CNP which cause vasodilatation, decreases cardiac fibrosis/hypertrophy, and increases natriuresis and diuresis which are all beneficial effects in HF. Therefore neprilyn blockade allows beneficial effects to persist. Neprilysin inhibition must be accompanied by simultaneous RAAS blockade as neprilysin also metabolizes AT I/II and inhibition of neprilysin alone results in increase of AT II, counteracting the potential benefits.

Answer 41

Atrialisation of the RV due to apical displacement of the septal leaflets resulting in RA hypertrophy and relatively small RV. Also commonly associated with concurrent ASD/PFO and 20% have accessory pathway resulting in tachyarrhythmias

Answer 42

In descending order of severity: 1. Angina 2. Syncope 3. Heart failure (worst)

Answer 43

1. CHB with broad complex QRS 2. Recent asystole 3. Mobitz type 2 AV block 4. Ventricular pause >3sec

Answer 44

A direct sinus node inhibitor. Class II to IV NYHA heart failure For CHF with impaired systolic function <35% Recent HF hospitalization within 12 months Sinus rhythm >70 bpm Despite maximum tolerated beta blockers. Showed that it reduces hospitalization for heart failure but not CV death (does reduce mortality if HR >77 bpm) It is NOT a beta blockade substitute, but aids HF management if: 1. If HR remains high >77 bpm despite adequate BB use as it reduces mortality in this subgroup 2. If asthma precludes use of beta blockers 3. Beta blockers are truly not tolerated due to side effects

Answer 45

Ventricular interdependence is seen in constrictive pericarditis. Discordance in LV/RVSP with respiration. While RVSP increases during inspiration, LVSP pressure decreases. These changes reverse during expiration. In restrictive cardiomyopathy, these changes are CONCORDANT. This is because in constrictive cardiomyopathy, the pericardium is fibrosed while the septum is not involved. Therefore inspiration causes increased RV filling with IV septum to bulge into the LV, causing reduced LV filling.

Answer 46

1. Prevention of embolism - Vegetation >10mm AFTER embolic event despite appropriate antibotic therapy - Embolism is rare after at least 2 weeks of antibiotic therapy 2. Heart failure 3. Failure of local control with development of abscess, fistula, enlarging vegetation. Also fungal infection.

Answer 47

P wave. Atrial contraction against the stiff ventricles. Seen in HTN, HOCM, AS.

Answer 48

In high risk individuals defined by: 1. Prosthetic valve - either biological or mechanical 2. Previous endocarditis 3. Cyanotic congenital heart disease 4. High risk lesions such as PDA 5. Rheumatic heart disease Undergoing procedures which involve: 1. Gingival tissue or tooth root manipulation 2. Perforation of the oral mucosa 3. Tonsillectomy/adenoidectomy 4. GI/GU procedure with intercurrent infections Choice of antibiotics: 1. Amoxycillin PO/IM/IV, 1hr/30min/immediately before procedure 2. Clindamycin if amoxicillin is contraindicated or already taking long term penicillin prophyalxis

Answer 49

Reversible direct thrombin inhibitor. | Used as an adjunct therapy in primary PCI

Answer 50

Through a1, a2 and beta1 receptors. Unlike epinephrine which also triggers b2 receptors, noradrenaline has a stronger vasoconstrictive action. Combination of a1 and b1 stimulation increases systemic and pulmonary blood flow, myocardial contractility and cardiac output. Heart rate can decrease due to intense alpha 1 stimulation. Potent a2 agonist effect can cause intense peripheral vasoconstriction resulting in organ hypoperfusion and ischaemia.

Answer 51

1. mean gradient >40mmHg 2. valve area <1cm 3. Dimensionless index <0.25

Answer 52

1. TB 2. Recurrent pericarditis of any cause 3. Previous radiotherapy 4. Uraemia 5. CTD

Answer 53

1. ICD | 2. No prognostic benefit from anti-arrhythmics (only for symptom control and ICD discharge prevention)

Answer 54

Calcium influx, potassium efflux

Answer 55

Absence of pupillary light and corneal reflexes at 72 hours. Absence of vestibulo-ocular reflexes at 24 hours or longer and Glasgow coma motor score of 2 or less at 72 hours or longer are less reliable. Myoclonus status in adults was strongly associated with poor outcome, but rare cases of good neurological recovery have been described and accurate diagnosis can be difficult.

Answer 56

1. Beta blockers in all patients - most benefit in LQTS 1 2. Avoid QTc prolonging drugs 3. If previous VT or high risk for VT (QTc >500ms, LQTS1-3, male gender) - ICD

Answer 57

Usually murmur of AS should be loudest at the second right ICS radiating to carotids. In Gallavardin phenomenon, murmur is loudest at the apex like MR but without classical radiation to the axilla. Due to stiff ventricles.

Answer 58

Thienopyridine. Binds irreversibly binds to ADP - P2Y12 receptor, therefore inhibiting binding of ADP to its platelet receptor.

Answer 59

Autosomal dominant Due to LDL receptor mutation - liver uptake of LDL via LDL receptor is affected. Homozygous or heterozygous - homozygous generally die by age 30s unless drastically managed eg with liver transplant, ileal bypass, LDL apheresis.

Answer 60

1. Infiltration of LDL into the tunica intima and subsequent oxidization of LDL 2. Oxidized LDL causes release of MCP-1 from endothelial and resident SMC to attract monocytes 3. Monocytes differentiate into macrophages and takes up oxidized LDLs to form foamy macrophages 4. Foam cells stimulate smooth muscle proliferation 5. Smooth muscles deposit collagen to form fibrous cap

Answer 61

1) HDL inhibits oxidation of LDL 2) HDL promotes cholesterol efflux from foam cell 3) HDL inhibits adhesion molecule expression

Answer 62

1. Reduction in preload 2. Reduction in afterload 3. Increase in contractility Therefore anything which causes above such as cilazapril, GTN infusion, frusemide etc will worsen LVOT.

Answer 63

Pulmonary regurgitation

Answer 64

LQT1 - K channelopathy. Execise induced arrhythmia. Fail to shorten QT with HR. If homozygous, will present as Jervell-Lange-Nielsen syndrome with associated deafness. Treated with beta blockade. Events are highest for LQT1. Gene involved KCNQ1 LQT2 - also K channelopathy. Seecond most common type. Precipitant mostly emotional reaction or startle. Respond to beta blockade. KCNH2 LQT3 - Na channelopathy. Events mainly occur during sleep. Beta blockade CONTRAINDICATED. If male with LQT3, need to have ICD inserted. Gene involved SCN5A (gain of function mutation. Loss of function mutation leads to Brugada syndrome) LQT3 gets least events but they are more likely to be fatal.

Answer 65

1. Inferior STEMI pattern 2. ST elevation higher III>II 3. ST elevation in V1>V2 or ST depression in V2 (highly specific for RV infarction) 4. Place VR4 leads to check for ST elevation V1 is the only standard lead which looks directly into RV.

Answer 66

1. RVH 2. RBBB 3. WPW 4. Posterior infarction 5. Muscular dystrophy 6. Normal variant in infants and young adults

Answer 67

1. myocardial infarction less than 7 days ago 2. unstable angina 3. uncontrolled hypertension (systolic BP > 180 mmHg) or hypotension (systolic BP < 90 mmHg) 4. severe aortic stenosis 5. left bundle branch block: this would make the ECG very difficult to interpret

Answer 68

1. Post-procedural vessel diameter 2. Long lesion/plaque 3. Diabetes 4. Chronic renal failure Cigarette smokers require target lesion revascularization (TLR) significantly less frequently than nonsmokers (6.6 versus 10.1 percent in one study) Despite this difference in clinical restenosis, the angiographic restenosis rate does not differ between the groups and the rates of subsequent death and myocardial infarction are significantly higher for smokers. Explanations for this paradox include a reduced sensitivity to restenosis or a greater reluctance to seek medical attention for recurrent angina in smokers.

Answer 69

1. Rest angina more than 20min duration 2. New onset angina that markedly limits physical activity 3. Increasing angina that is more frequent, longer in duration, or occurs with less exertion than previous angina

Answer 70

Differ primarily in whether the ischaemia is severe enough to cause sufficient myocardial damage to release detectable quantities of troponins. Prior to availability of troponins, clinically difficult to distinguish between the two.

Answer 71

All are used to identify those who are at highest risk for further cardiac event who may benefit from more aggressive therapeutic approach. If composite end point of death or MI at 1 year is used, GRACE is better than TIMI and PURSUIT. If composite end point of death or MI at one year and area under the survival curve and need or urgent revascularisation at 30 days, all three predictors were comparable with TIMI somewhat better than GRACE and PURSUIT.

Answer 72

1. Age >65 2. Presence of at least 3 risk factors for CAD (HTN, DM, dyslipidaemia, smoking, family history of early MI) 3. Prior coronary stenosis >50% 4. ST deviation on admission ECG 5. At least 2 anginal episode over past 24 hours 6 Elevated troponin 7. Use of aspirin in prior seven days (probably a marker for more severe CAD) ``` 0-2 = low risk 3-4 = intermediate risk 5-7 = high risk ```

Answer 73

1. Haemodynamic instability/cardiogenic shock 2. Severe LV dysfunction/heart failure 3. Recurrent/persistent rest angina despite intensive medical therapy 4. New/worsening MR or new VSD 5. Sustained ventricular arrythmia

Answer 74

Oral amiodarone: 1. Prolonged QTc due to potassium channel blockade without proarrythmic activity 2. Inhibits inactivated sodium channel of phase 0, primarily seen at rapid heart rate (class I effect) 3. Non-competitive beta receptor blockade causing sympathetic activity (class II effect) 4. Also some class IV effect with blockage of slow calcium channels IV amiodarone: 1. Compared to PO dosing, produces much smaller increase in action potential duration and refractory period in atrial and ventricular myocardium, therefore little to no increase in QTc/QRS duration 2. Little or no slowing of the sinus rate 3. More potent and rapid antiadrenergic activity 4. Blocks sodium channel activity to a lesser extent than PO dosing

Answer 75

1. Maintenance of rhythm control in pAF 2. Post-cardiac surgery AF prophylaxis 3. Treatment of ventricular arrhythmias and NSVT in CHF (does not increase mortality even in severe heart failure) 4. Primary prevention of SCD in ischaemic cardiomyopathy who cannot or refuse to have ICD (not used for secondary prevention as ICD is much superior) 5. Decrease in shock burden in patients with ICD Not usually used for other atrial arrhythmias such as A flutter/atrial tachycardia as there are other drugs available with lower toxicity rates and high success rates of ablative therapy.

Answer 76

1. Restoration and maintenance of sinus rhythm in critically ill patients with hemodynamically unstable atrial fibrillation (AF) 2. Rate control in critically ill patients with AF with rapid ventricular response in whom the tachycardia is contributing to hemodynamic compromise (when standard rate controlling therapies have been unsuccessful or contraindicated due to hypotension) 3. Prevention of AF following cardiac surgery

Answer 77

1. Hypertension - responsible for 39% of HF in men, 59% in women 2. Coronary artery disease - 34% in men, 13% in women Effect of diabetes and obesity is largely mediated through hypertension.

Answer 78

Carvedilol was shown to be safe in COPD despite its non-selective nature, therefore beta blockers can be used in COPD. Howevre asthma still remains a contraindication to beta blockade. Should do lung function test to test for reversible bronchospasm - if <15% reversibility, can undergo careful supervised initiation. In asthma, need to use cardioselective beta blockers (bisoprolol, metoprolol, nebivolol).

Answer 79

In class III or IV heart failure with EF <30% provided CrCl >30 ml/min and K <5 mmol/L Associated with decrease in CV death and heart failure hospitalization.

Answer 80

Arg719Trp mutation which is involved in beta-myosin heavy chain mutation.

Answer 81

1. Ischaemic/dilated cardiomyopathy with LVEF <35% 2. Sinus rhythm 3. NYHA class III, IV 4. LBBB with QRS >120ms 5. NYHA II with LBBB, QRS >150 ms 6. Symptomatic despite optimal medical therapy

Answer 82

Wider QRS LBBB Females Non-ischaemic cardiomyopathy

Answer 83

BLOCK-HF trial - included high degree AV block, NYHA class I-III, LVEF <50%, no indications for CRTD Showed decrease in all cause death or hospitalization.

Answer 84

For PCI following MI - no driving for 2 weeks Elective PCI - 2 days CABG - 4 weeks

Answer 85

Needs to have EF >40%

Answer 86

From age of 35

Answer 87

Mitral stenosis (10-15% year)

Answer 88

In 10-30% of cases, mutations in the SCN5A gene, which encodes the cardiac voltage-gated sodium channel Nav 1.5, have been found. These loss-of-function mutations reduce the sodium current (INa) available during the phases 0 (upstroke) and 1 (early repolarization) of the cardiac action potential. This decrease in INa is thought to affect the right ventricular endocardium differently from the epicardium. Thus, it underlies both the Brugada ECG pattern and the clinical manifestations of the Brugada syndrome.

Answer 89

Lifestyle changes: Avoidance of drugs that may induce ST-segment elevation in right precordial leads Avoidance of excessive alcohol intake and large meals Prompt treatment of any fever with antipyretic drugs. ICD implantation in patients who are survivors of an aborted cardiac arrest and/or have documented spontaneous sustained ventricular tachycardia (VT).

Answer 90

Increased PR and QRS duration. Flecainide should be monitored if history of CKD, liver disease, concurrent amiodarone treatment.

Answer 91

ATLAS-2 study showed that when low dose rivaroxaban was added to DAPT 4-5 days following ACS, it reduced the composite end point of CV death/MI/stroke but with increase in bleeding events (2x ICH events but no increase in fatal bleeding) Normal dose of rivaroxaban showed similar result with more increase in bleeding events (mainly ICH but no increase in fatal bleeding event) This reduction in composite end point is thought to be due to reduction in sudden death...

Answer 92

If it occurs early, usually vagally mediated and is responsive to atropine. Temporary pacing is required only if HD compromise. Permanent pacing is often not required.

Answer 93

1. Ischaemic cardiomyopathy - Needs to be at least 40 days post MI - LVEF <35% and NYHA class II or III - LVEF < 30% and NYHA class I - LVEF <40%, non sustained VT, inducible VT/VF at EP study 2. Non-ischaemic cardiomyopathy - LVEF <35% and NYHA class II/III - Slight benefit in SCD rates but no overall mortality benefit. - If wide QRS, CRTD. 3. SCD at risk patient eg: LQTS, Brugada, HOCM, ARVC ICD should only be inserted if reasonable expectation of survival with a good functional status for more than a year.

Answer 94

PDA connects aorta to pulmonary artery. Close if: 1. Left chamber enlargement 2. Pulmonary hypertension 3. Previous endarteritis 4. Audible murmur. Late complications of PDA is CHF, endocarditis (10% lifetime risk)

Answer 95

Commonly presents with HTN of upper limbs, reduced femoral pulses, radio-femoral delay, arm-leg BP gradient. Also exercise intolerance with claudication/angina. Prognosis is poor if untreated, with reduced life expectancy (75% die before age of 46 in one study) Treatment is with percutaneous intervention if native and recurrent coarctation - stenting is better than balloon angioplasty. Treatment is to prevent complications such as stroke, heart failure, aortic dissection. Follow up is important - residual HTN in 30%, need to check for recurrence and aneurysm formation.

Answer 96

LVEDP >12 mmHg NSVT QRS >180ms

Answer 97

1. Severe MR in 2-10% 2. Cardiac tamponade 3. ASD 4. LV perforation upto 4% 5. Embolic phenomena upto 3%

Answer 98

Moderate to severe MS (valve area <1.5 cm2) Suitable valve anatomy (pliable, non calcified, minimal subvalvular fusion) Symptomatic, OR, Asymptomatic with new onset AF, PASP >50mmHg at rest, >60mmHg with exercise

Answer 99

1. More than mild mitral regurgitation 2. LA thrombus 3. Heavy calcifications of both commissures 4. Predominant subvalvar involvement

Answer 100

1. Symptomatic (do exercise test) In asymptomatic patients: 1. Resting EF <50% 2. Cardiac surgery required eg: CABG 3. Resting EF >50% but LVEDD >65mm or LVESD >50

Answer 101

In low gradient AS, AV area is reduced in relative fashion due to poor output across the valve. This may be due to low stroke volume or low/normal EF. Do dobutamine stress echo - by increasing stroke volume in non severe AS, dobutamine will cause increased gradient and increased AV area, while as true severe AS will have increased gradient but unchanged AV area.

Answer 102

TAVI and surgical AVR had similar 2 year survival. TAVI is associated with greater TIA/CVA (5.5% vs 2.4%), vascular complications and paravalvar AR. Surgical AVR is associated with more major bleeding and new AF.

Answer 103

In symptomatic severe aortic stenosis who are at high risk for surgery. 4 contraindications are: 1. Bicuspid aortic valve 2. LV apical thrombus 3. Peripheral vascular/thoracic aorta access issue 4. Unsuitable anatomy

Answer 104

``` Class IC indication if stenosis >70% Could also consider CAGS for moderate stenosis 50-70% at the time of valve surgery (class IIa C evidence) ```

Answer 105

If truly asymptomatic (confirmed with stress testing), then annual sudden death rate in SEVERE AS is less than 1% However, once you develop any symptoms (angina, syncope, heart failure), <50% 5 year survival.

Answer 106

1. Symptomatic severe AS 2. Asymptomatic AS who are having other cardiothoracic surgery 3. Asymptomatic severe AS but with LV dysfunction thought to be related to the valve 4. Severe asymptomatic AS but with abnormal stress test thought to be due to AS

Answer 107

Almost always done as a valve replacement 1. Severe symptomatic AR 2. Asymptomatic severe AR with LVEF <50% 3. Having other cardiothoracic surgeries

Answer 108

Normal ascending aorta dimensions <35 mm Surgery indicated if: 1. Marfans with ascending aorta >50mm 2. Marfans with >45mm with risk factors (eg: family history of rupture, ie operate earlier) 3. Bicuspid >50mm with risk factors 4. For everyone else, consider surgery >55mm

Answer 109

Severe TR is almost always the consequence of some other pathology (eg pulmonary hypertension). Therefore fixing the TR wont fix the underlying problem. Pretty much if you are fixing the L sided valves then you may as well do the right side as well... Isolated TV surgery is rare. Also surgery is indicated in symptomatic patients with severe TS.

Answer 110

Requires 2 major criteria, or 1 major/3 minor criteria, or all 5 minor criteria. Major criteria: 1. Growth of appropriate organisms for at least 2 separate blood cultures 2. Single positive for coxiella 3. Imaging shows vegetation, abscess, perforation, new dehiscence of prosthetic valve, or abnormal PET/SPECT for valve >3 months since implantation Minor criteria: 1. Predisposition - heart disease, IVDU 2. Fever 3. Embolic phenomena 4. Immunologic phenomena 5. Microbiology not meeting major criteria

Answer 111

Ampicillin + flucloxacillin + gentamicin Vancomycin + gentamycin +/- rifampicin if prosthetic valve <12 months

Answer 112

Surgery is usually not indicated, and given high rates of IVDU, there are concerns about recurrence and anticoagulation etc. Could consider surgery in: 1. Difficult to eradicate organism or culture positivity after 7 days 2. Persistent vegetation >20mm after PE 3. Refractory RHF secondary to severe TR

Answer 113

Start them on statins if they are not on it already. Shown to reduce mortality. This is because non obstructive plaques actually matter - majority of MI occur on no-obstructive lesions. 3 vessel non-obstructive plaques have a HR of around 5. In contrast, if you have a normal CTCA result, then you have a very low incidence of cardiac event of 0.17%/year, therefore have a 'warranty' period of 5 years.

Answer 114

Most useful in excluding obstructive CAD. 1. Equivocal stress test in a young patient 2. Chest pain with intermediate risk of CAD, where exercise test will be precluded by uninterpretable ECG or unable to exercise 3. Excluding CAD in cardiomyopathy 4. Checking patency of bypass grafts (100% sensitivity for bypass graft stenosis) or coronary stents >3.5mm (eg left main stents) 5. Assessment prior to non-coronary cardiac surgery

Answer 115

Mid wall LGE suggests interstitial fibrosis. LGE predicts higher risk of MACE (death, heart failure, and ICD discharge) and also predicts lack of improvement in newly diagnosed DCM.

Answer 116

Ezetimibe reduces the small intestinal enterocyte uptake and absorption of cholesterol by binding to Niemann-Pick C1 Like 1 (NPC1L1), which keeps cholesterol in the intestinal lumen for excretion.