Cardiology Flashcards
What are the indications for Cardiac resynchronisation therapy in HFrEF?
- LVEF <35% on optimal therapy + QRS >150ms
- consider also if QRS >130ms
- consider if condition requiring pacing + LVEF <50%
No longer required to be LBBB morphology
Can be done in AF, but needs >92% BiV capture
What is the median survival of a cardiac transplant?
11 years
2016B Q59
Which of the following most strongly supports a non-cardiogenic cause of pulmonary oedema?
A. APO due to sepsis
B. Normal pulmonary capillary wedge pressure
C. Normal left ventricular ejection fraction on echocardiography
D. Normal troponin
E. Abnormal CXR
A. ARDS is a cause of non-cardiogenic PO but doesn’t really exclude concurrent cardiogenic element
B. YES as this appears to be the major diagnostic tool
C. can have normal LVEF in cardiogenic PO (in diastolic HF, volume overload of any cause, hypertensive crisis)
D. don’t need to be ischaemic to be in cardiogenic APO
E. not helpful at all, will just see pulmonary oedema
2009 B QUESTION 11
Which of the following is the strongest indication for the implantation of a biventricular pacemaker defibrillator in a patient with heart failure who survives an out‐of‐hospital arrest?
A. An ejection fraction of 20% on gated blood pool scan
B. QRS of 190ms on ECG
C. BNP 500 (normal <125)
D. A normal coronary angiogram
E. Abnormal Doppler Index on echocardiography
B. QRS of 190ms on ECG -> wide QRS
2010 A Question 61 What is the most characteristic ECG finding which differentiates between wide QRS SVT and VT? A. AV dissociation B. QRS>140 C. Bizarre ECG changes neither RBBB nor LBBB D. Axis -90 to 180
A - AV dissociation Pre-test probability of a wide complex tachycardia being VT is 80%. Key features that favour VT in a wide complex tachycardia: - AV dissociation - fusion beats / capture beats - concordance - extreme Right axis deviation
HR x ____ = Cardiac output
Stroke volume
In AF, when is warfarin required rather than a NOAC?
Mechanical heart valve / severe mitral stenosis eGFR <30
Those on interacting drugs such as phenytoin or HIV protease inhibitors
In HFrEF, who should be on an ACEI?
What is the benefit?
Everyone should be on an ACEI, unless it is not tolerated. Mortality and decreased hospitalisations
If truly not tolerate -> ARB
Management of new onset AF: What is the management of new onset AF of <48 hours duration, including anticoagulation?
HD unstable -> urgent cardioversion HD stable -> Acute rate control with BB or CCB Check UEC and TFT Do TTE to check for structural heart disease Reasonable to try and revert Anticoagulation -> Start NOAC simultaneously and continue for 4 weeks
Medication options for rate control in AF?
1st line: beta blockers - atenolol - metoprolol *if HF, then use a cardioselective BB Alternative: non-dihydropyridine calcium channel blockers (do not use in LVF) - verapamil - diltiazem 2nd line: Can add amiodarone Can add digoxin
Name 5 key risk factors in HCM that would lead to insertion of an ICD?
Family hx of SCD Syncope nSVT Septum >30mm Abnormal BP response during exercise
Of the HF-specific beta blockers, which is least cardioselective and should be avoided in airways disease?
Which beta blockers should be chosen in COPD?
Carvedilol (good to treat co-morbid HTN)
In airways disease -> bisoprolol or metoprolol XR
Pathophysiology of AF - Where does the arrhythmic foci initially begin?
Pulmonary veins This then leads to atrial remodelling, further perpetuating the cycle and leading to permanent AF
What is the Sokolov-Lyon criteria for LVH on ECG?
S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm
What are some key risk factors for AF? (name 10)
Demographic:
- age
- male
Co-morbidities:
- HTN
- Valvular heart disease (MS)
- heart failure
- HOCM
- Hyperthyroidism
- lung disease
- obesity
- diabetes
What are the benefits of using beta blockade in HFrEF?
Decreased mortality
Decreased risk of SCD
Reduced hospitalisations
What are the indications for ICD in primary prevention of sudden cardiac death? What is the indication for CRT-D within this?
Ischaemic cardiomyopathy: >40 days after AMI
- LVEF <35% and NYHA class 2-3
- LVEF <30% and NYHA class 1
- Non-ischaemic dilated cardiomyopathy:
- LVEF <35% and NYHA class 2-3
If LVEF <35% and NYHA class 2-3 PLUS broadened QRS >120ms, should have combined CRT-D device
What are the main causes of AF-related mortality? (2)
Stroke Heart failure
What condition is the commonest cause of sudden cardiac death in people <35 years of age? What is the most sensitive test for this?
Hypertrophic cardiomyopathy ECG is most sensitive test (may have normal echo)
What does this image show?
Epsilon wave -> specific sign for ARVC
Other features
- TWI in V1-3
- Prolonged S-wave upstroke of 55ms in V1-3
What does this ECG show?
Wolff-Parkinson-White (pre-excitation)
- Sinus rhythm with very short PR interval (< 120 ms)
- Broad QRS complexes with a slurred upstroke to the QRS complexes (DELTA wave)
What does this ECG show?
Brugada Syndrome
Sodium channelopathy
Type 1 = Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave.
Only ECG abnormality that is potentially diagnostic.
It is often referred to as Brugada sign
What does this ECG show?
HCM
Classic HCM pattern with asymmetrical septal hypertrophy
- Voltage criteria for left ventricular hypertrophy.
- Deep narrow Q waves < 40 ms wide in the lateral leads I, aVL and V5-6.
What is a very effective medication for congenital long QT syndrome?
Beta blockers
What is rhythm control strategy for new onset AF of >48 hours or unknown duration?
Cardioversion options: - anticoagulate for at least 3 weeks -> cardiovert -> continue anticoagulation for 4 weeks post - perform TOE to rule out LA thrombus -> cardiovert -> continue anticoagulation for 4 weeks post
What is the CHADSVasc score?
Used to determine if someone with AF should be anticoagulated. C - congestive cardiac failure H - hypertension A2 - age >75 D - diabetes S - stroke / TIA V - vascular disease (MI, PVD) A - age 65-74 Sc - female Benefit usually outweighs risk at score >1 At score 2 -> ~3.7% annual stroke risk
What is the difference between NYHA Class II and Class III HF?
Class II - reduced physical capacity during medium exercise
Class III - severely reduced physical capacity with slight exercise
What is the indication for ablation in AF?
Symptomatic AF refractory to medications *does not change need for anticoagulation **may improve mortality in heart failure only (not in other populations)
What is the most reliable feature on history or exam which correlates with elevated PCWP?
Orthopnea
What is the role of loop diuretics in HF?
Symptomatic benefit, not mortality
To achieve euvolaemia
What is the treatment of choice for atrial flutter?
Catheter ablation It is difficult to rate control or revert pharmacologically
What kind of AV blocks require a PPM?
2nd degree AV block -> Mobitz Type II - fixed PR interval with non-conducted P waves - PPM indicated if symptomatic or very bradycardic 3rd degree AV block
What should be the HR target in chronic asymptomatic AF?
Lenient as per RACE II Trial -> Less than 110 bpm No difference in HF, stroke, mortality compared with strict control
When initiating beta blocker therapy, when are the adverse effects most promiment?
In the first 3 months
Where is the re-entrant circuit in atrial flutter?
Right atrium
Which anti-hypertensives should be avoided in HFrEF? (3)
Non-dihydropyridine CCBs: Verapamil / diltiazem
Moxonidine
Alpha-1 blockers e.g. prazosin
Which ARBs have RCT data in HFrEF? (3)
Candesartan
Losartan
Valsartan
Which are the HF-specific beta blockers?
Carvedilol
Bisoprolol
Nebivolol
Metoprolol XR
2009 B QUESTION 68
An 82 year old female with chronic renal impairment (estimated GFR 30), obesity, and COPD presents with shortness of breath. Her plasma BNP is 922 (normal < 125). What is the most likely cause of her elevated BNP?
A. Advanced age
B. Chronic renal failure
C. Congestive cardiac failure
D. COPD
E. Obesity
B - chronic renal failure
Factors which can increase BNP =
- Age
- female gender
- AF
- renal failure
Obese BMI decreases BNP
What is the significance of transmural myocardial fibrosis on MRI for revascularisation?
This means the damage is not amenable to revascularisation
What is the role of dapagliflozin in HFrEF?
Now recommended even for those without diabetes, for patients with HFrEF who have persistent symptoms and an elevated BNP on optimal pharmacologic and device therapy.
Name 5 key causes of heart failure
Ischaemic heart disease
Valvular disease
Hypertension
Arrhythmias
Thyrotoxicosis
What are the classical TTE findings in cardiac amyloid?
- abnormal global longitudinal strain with apical sparing
- diastolic dysfunction
- dilated atria
- speckled myocardium
What are the group of chemotherapy agents with most cardiotoxic effects?
Anthracyclines e.g. doxorubicin
What does measurement of PCWP reflect?
Left atrial pressure / left ventricular preload.
Elevated in conditions which raise LV end-diastolic pressure:
- LV systolic heart failure
- LV diastolic heart failure
- Hypervolaemia
What is a normal PCWP?
<12 mmHg
What is numerical cut-off in HF for reduced ejection fraction?
Less than 50%
What is the diagnostic criteria for HFpEF?
Symptoms and signs of HF
AND
LVEF >50%
AND
evidence of diastolic dysfunction/high filling pressures on TTE / RHC / BNP
OR
evidence of relevant structural heart disease (LV hypertrophy / LA enlargement)
What is the indication for Entresto (sacubitril / valsartan) in HFrEF?
Switch to this from ACEI if ongoing symptomatic HF and LVEF <40% after 3-6 months of optimal therapy
Need to washout ACEI for 36 hours prior to commencement
What is the indication for ivabradine in HFrEF?
If HR remains >70 despite maximal BB. Must be in sinus rhythm
What is the investigation of choice to diagnose cardiac amyloid?
MRI +/- cardiac biopsy
What is the main benefit of eplerenone over spironolactone?
Eplerenone is more specific for mineralocorticoid receptor than spiro, so has less gynacomastia/endocrine effects
What is the typical finding on electron microscopy of amyloidosis?
Congo red staining with apple green birefringence
What should happen to HF therapy if LVEF normalises on optimal treatment?
It should be continued.
Evidence has shown that cessation of therapy has high risk of recurrence, unless there was a very clearly reversible cause of HF
When should a mineralocorticoid receptor antagonist be used in HFrEF?
What are the main risks?
For patients with symptomatic HFrEF and LVEF ≤35% on optimal ACEI / BB (LVEF ≤40% if post AMI)
Main risk is hyperkalaemia
How do PCSK9 inhibitors work?
PCSK9 is an enzyme primarily produced in the liver, which tags the LDL receptor for internalisation.
Inhibition of this leads to the LDL receptor remaining on the surface of cells for longer, which allows ongoing removal of LDL from bloodstream, lowering plasma levels
What is the current indication for PCSK9 inhibitor therapy (evolucumab) on PBS?
Familial homozygous hypercholesterolaemia, with LDL >3.3 and already on maximal statin
How much do PCSK9 inhibitors reduce LDL in addition to statin therapy?
By 61%
What are the 4 groups of patients for whom statin therapy is indicated?
Secondary prevention after CV event (CAD, stroke/TIA)
Primary prevention for
- anyone with diabetes
- very high LDL >4.9
- age 40-75 with 10 year CV risk >7.5%
MCQ
Side effects of statins may include:
- muscle pain
- LFT derangement
- rhabdomyolysis
- death
- cognitive impairment
- new onset diabetes
- all of the above
- All of the above
For initial investigation of anginal chest pain, what investigation should be used?
PROMISE study: Can use either CT coronary angiogram or functional stress test.
CT angiogram led to more angiograms being performed, but a lower proportion of these were normal/unnecessary
Who should have a coronary calcium score undertaken?
How is this performed?
Those at intermediate CV risk - 10-20% 10 year risk
Measured by fast, low-radiation CT scan. Calculates Agatston score.
No contrast used, does not correspond with degree of luminal stenosis
Not of use in elderly
What measurement during angiography has best evidence to guide need for stenting?
What drug is used to measure this?
Fractional flow reserve (FFR) -> if <0.8 as per FAME study, lesion is functionally significant
Adenosine used to induce hyperaemia for FFR
Out of clopidogrel, prasugrel and ticagrelor, which has slowest onset of action?
Clopidogrel
Among those with ACS planned for invasive angiography, which is the best antiplatelet to use alongside aspirin?
ISAR-REACT 5 Trial -> prasugrel is preferred over ticagrelor, with lower composite endpoint and no difference in major bleeding
For patients with ACS for who a non-invasive approach is most likely, which is the antiplatelet of choice alongside aspirin?
Ticagrelor (shown to be superior to clopidogrel, and prasugrel is not superior to clopidogrel).
If high bleeding risk due to prior hemorrhagic stroke, ongoing bleeding, bleeding diathesis, or clinically relevant anemia or thrombocytopenia -> clopidogrel preferred
What is the mechanism for ticagrelor causing dyspnoea?
It leads to a build up of adenosine
How do ticagrelor, prasugrel and clopidogrel work?
They work by blocking the P2Y12 receptor on platelets.
This prevents the binding of ADP to the receptor, which inhibits platelet aggregation and reaction of platelets to stimuli of thrombus aggregation such as thrombin
In patients with STEMI who have been thrombolysed, which antiplatelet (in addition to aspirin) should be used?
Clopidogrel 300mg load (unless age >75, then use 75mg)
Which form of access is preferred in coronary angiography?
What benefit is conferred?
Radial access (MATRIX trial)
Mortality benefit (due to less bleeding complications)
Should thrombectomy be performed routinely for STEMIs?
NO -> no benefit, and associated with higher risk of stroke
What is the SYNTAX score?
How is it derived?
SYNTAX score is a measure of complexity of multivessel coronary disease.
It is based purely upon angiographic findings.
What is the current recommendation around stenting non-culprit lesions during angio post ACS?
Ongoing controversy
Currently -> stent culprit lesions only during index procedure
Preventative PCI not recommended
In multivessel stable CAD, what are the indications for PCI and CABG respectively?
CABG
- anyone with diabetes
- intermediate or high SYNTAX score
PCI - only for non-diabetics with low SYNTAX score should be considered for PCI
What are the two main indications for coronary angiography in stable angina?
- Significant symptomatic angina despite maximal medical therapy
- Patients with high likelihood of severe ischemic heart disease (eg, imaging or strongly positive treadmill test suggesting a large amount of viable myocardium at risk)
Should stable angina be treated with revascularisation?
As per ORBITA trial, medical therapy should be first line.
- Anti-anginal medications with beta blockers / CCBs / long acting nitrates
- Aspirin
- High intensity statin
What role does aspirin have in primary prevention for healthy adults?
None! ASPREE Trial has shown lack of benefit, and possible harm in elderly or those with increased risk of bleeding
What is the genetic locus consistently associated with coronary artery disease?
9p21
What is the effect on BP measurement of a cuff that is too small?
OVER - estimation of BP
What are the targets for lipid-lowering in primary prevention?
And in secondary prevention?
LDL-C
for primary prevention: less than 2.0 mmol/L
for secondary prevention: less than 1.8 mmol/L
Total cholesterol (TC) < 4.0 mmol/L
HDL-C > 1.0 mmol/L
Triglycerides < 2.0 mmol/L
3 classic ECG findings in large pericardial effusion?
- tachycardia
- low voltage QRS
- electrical alternans
What are the hallmark ECG features of left ventricular aneurysm?
Persistent ST elevation (> 2 weeks after STEMI) plus pathological Q waves
Which cardiac abnormality is most commonly associated with bicuspid aortic valve?
Aortic root / ascending dilation
What is the duration of Abx prophylaxis for prevention of recurrent rheumatic heart disease?
- 10 years after the most recent episode of acute rheumatic fever, or until 21 years of age (whichever is longer) for patients without moderate or severe rheumatic heart disease
- until 35 years of age for patients with moderate rheumatic heart disease
- until 40 years of age or lifelong for patients with severe rheumatic heart disease and those who require or have had cardiac valve surgery for rheumatic heart disease.
What is the antibiotic of choice for rheumatic fever secondary prevention?
Benzathine penicillin IM monthly
Which conditions require abx prophylaxis for IE when having invasive dental work?
- Prosthetic cardiac valve, including transcatheter-implanted prosthesis or homograft
- Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords
- Previous infective endocarditis
- Congenital heart disease but only if it involves:
- unrepaired cyanotic defects, including palliative shunts and conduits
- repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation) - Rheumatic heart disease in high-risk patients (ATSI, low SES)
What is the effect of a BP cuff that is too big?
UNDER - estimation of BP
What is the BP target for those with atherosclerotic disease (including patients with stroke/TIA; CKD; DM; PVD) ?
125-130/<80
What is the BP target for those aged >65 years (unless multiple co-morbidities / postural hypotension) ?
125-130/<80
What is the goal BP for those with CV risk >15% over 10 years?
125-130/<80
What is the BP target for those under 65 without atherosclerotic disease or other additional risk factors?
135-140 / <90
What are the first line options for treating essential HTN?
ACEI / ARB + CCB or diuretic
What is the definition of Resistant HTN ?
Uncontrolled BP (confirmed by ABPM) despite being compliant with an antihypertensive regimen that includes 3 or more drugs (including a diuretic, and each at optimal doses)
What are the two main causes of renovascular HTN?
Atherosclerosis
Fibromuscular dysplasia
Name 5 endocrine causes of secondary HTN?
Conn’s
Cushing’s
Phaeo
Hypothyroidism
Hyperparathyroidism
What is the role of PCSK9?
What does inhibition of this result in?
PCSK9 is a liver enzyme which binds to the LDL receptor on the surface of hepatocytes, leading to the degradation of the LDL-R and higher plasma LDL levels
Antibodies to PCSK9 interfere with its binding of the LDL-R leading to higher hepatic LDL-R expression and lower plasma LDL-C levels
What is the mode of transmission of familial hypercholesterolaemia?
Autosomal dominant
What is the classic lab finding in familial hypercholesterolaemia?
What is the classic exam finding?
Vey elevated LDL
Xanthomata
At what LDL level can a diagnosis of familial hypercholesterolaemia be definitively made?
LDL >8.5
What effect does T2DM classically have on lipid profile?
Increased Tg, increased LDL and low HDL
What effect does hypothyroidism classically have on lipid profile?
Raises LDL
What effect does smoking classically have on lipid profile?
Lowers HDL
What effect does ETOH classically have on lipid profile?
Elevates Tg
What is the indication for evolucumab in Australia?
What is it?
PCSK9 inhibitor
FH
What is the lifestyle intervention proven to have greatest inpact on BP?
Diet -> DASH diet
Which anti-HTN med class tends to cause constipation?
CCBs
What is the main factor responsible for systolic hypertension in the elderly?
Reduced arterial compliance
What is the most common cause of severe mitral stenosis?
Rheumatic heart disease
What is the best predictor of survival on cardiac bypass during surgery?
RV function
What is Kussmaul’s sign?
The lack of an inspiratory decline in JVP
What is Pulsus paradoxus?
When is it seen?
Exaggeration of normal drop in SBP during inspiration
Occurs in moderate to severe cardiac tamponade, and occasionally constrictive pericarditis
When are cannon A waves seen on JVP?
When are A waves absent?
Cannon - Complete heart block
Absent in AF
When are prominent V waves seen on JVP?
Tricuspid regurgitation
What is the most common cardiac manifestation of IgG4 disease?
Aortitis
Which of the P2Y12 antiplatelets is a reversible binder of the receptor?
Ticagrelor
Prasugrel and Clopidogrel are irreversible binders
What are the Class 1a indications for revasculation in Stable CAD?
- Left main disease (CABG preferred unless SYNTAX <22)
- LAD >50%
- Multi-vessel disease + LVF
What does the y descent on JVP signify?
When is it typically absent?
Opened tricuspid valve → rapid blood flow from the right atrium into the right ventricle = sudden fall in right atrial pressure
Absent or attenuated in cardiac tamponade, due to impaired filling of the ventricle
Which valve is affected in Epstein’s anomaly?
Tricuspid valve
What defines severe aortic stenosis?
Mean gradient >40mmHg
AVA <1cm2
Vmax >4m/s
What are the main features of Epstein’s anomaly?
Tricuspid malformation
ASD
PFO
Which patient group will generally be most suitable for Surgical AVR rather than TAVI?
Low surgical risk patients, with anatomy that precludes TAVI
What are the general indications for aortic valve replacement in aortic stenosis?
- severe symptomatic AS
- severe AS + LVEF <50% of no other cause
- severe AS + abnormal exercise testing, likely due to AS
- severe AS needing cardiac surgery anyway
What are the general indications for surgery in aortic regurgitation?
- significant enlargement of ascending aorta
- Symptomatic
- LVEF <50%
- LVEDD >70mm OR LVESD >50mm (i.e. LV enlargement)
What are causes of acute severe AR?
Endocarditis
Trauma
Dissection
Most common cause of chronic AR worldwide?
Rheumatic heart disease
Why must bradycardia be avoided in Aortic regurgitation?
Bradycardia increases total diastolic time, which increases degree of AR.
May precipitate decompensated heart failure
What is the murmur of mitral stenosis?
MS: Low-pitch, rumbling diastolic murmur best heard at apex w/ Pt in L) lateral position
What are the indications for intervention in mitral stenosis?
Valve area <1.5cm2 +
- symptomatic
- pulmonary HTN
- new AF
In mitra stenosis, what are key contraindications to mitral valvotomy that would necessitate a surgical MVR?
- left atrial thrombus
- significant mitral regurgitation
- severe calcification
- CAD requiring CABG
What is the anticoagulation agent preferred in valvular AF (secondary to mitral stenosis) ?
Warfarin
What are indications for intervention in primary mitral regurgitation?
- Symptomatic severe MR, in absence of severe LVF (LVEF must be >30%)
- Asymptomatic severe MR with LVEF <60% or LVESD >45mm
- New AF
What is the Class 1 indication for surgery in chronic SECONDARY mitral regurgitation?
Severe MR undergoing CABG, LVEF >30%
Which patient population is most appropriate for Mitral Clip?
For patients requiring intervention for severe MR, but are high risk surgical candidates.
Improves QoL, but no survival benefit
What are the 3 types of Congenital Long QT?
What are the triggers for each?
Which types are beta blocker responsive?
Type 1 -> potassium
- KCNQ1
- Triggers -> swimming, exertion
- Responds well to beta blockers
Type 2 -> potassium
- Gene in KCNH2
- Auditory triggers
- Beta blockers good but less effective than T1
Type 3 -> sodium
- SCN5A -> Same mutation as Brugada, but GAIN of function
- No particular triggers
- No response to beta blockers
Which artery is usually involved in aortic dissection with MI?
Right coronary artery
In aortic dissection -> what is the site when hypotension is prominent, vs hypertension?
Syncope, hypotension, and/or shock at initial presentation are more common in patients with ASCENDING aortic dissection
Hypertension is more common in patients with descending aortic dissection
