Cardiology Flashcards
1
Q
HFrEF definition
A
- Symptoms and signs of HF
- AND LVEF <50%
2
Q
HFpEF Definition
A
- Symptoms and signs of HF
- AND LVEF >/=50%
- AND obejective evidence of:
- -Relevant structural heart disease (LV Hypertrophy, LA enlargement)
- -OR Diastolic dysfunction w/ high filling pressure shown by cath, TTE, elevated BNP, or exercise
3
Q
SGLT2 evidence in CCF
A
Shown to reduce hospitalisation and CCF in patients with CCF and diabetes or without diabetes
4
Q
Indications for CRT
A
- NSR, LVEF <35%, and QRS >150 ms despite optimal medical Mx
- Maybe in NSR, LVEF <35% and QRS 130-149 ms
- Maybe in LVEF <50% with high grade AV block requiring pacing to decrease hospitalisation with HF
5
Q
Benefits of CRT
A
Decreases mortality
Decreased HF related hospitalisation
Improved QoL
6
Q
Contraindication to CRT
A
QRS <130 ms due to possible harm
7
Q
Which type of BBB has the best benefit from CRT
A
LBBB >RBBB
8
Q
When can there be an acheived benefit with CRT when a patient has AF
A
Only if they are essentially pacing dependent, at least 92% of the time, otherwise no benefit in AF
9
Q
Who benefits from an ICD insertion for primary prevention
A
Strongest evidence:
-HFrEF due to IHD and an LVEF <35% to decrease mortality
Can be considered in dilated cardiomyopathy with an LVEF <35%, but not as much benefit as IHD
10
Q
What does evidence show in regards to when catheter ablation for AF should be considered
A
HFrEF with LVEF <35% with recurrent admissions for symptomatic AF to decrease mortality and hospitalisation
11
Q
Evidence for iron transfusions in CCF for anemia
A
Transfuse if Tsat <20% and Ferritin <300 OR if Ferritin <100
Shown to improve QoL and hospitalisations
12
Q
BNP cut off
A
Good test for ruling ot CCF
BNP <100 pg/ml = 83% accuracy
13
Q
Why can’t BNP be used for testing when on an ARNI
A
Increased levels due to blockade
Use NT Pro BNP instead
14
Q
Red flags for Advanced HF
A
- Hypotension: persistent SBP <90
- Persistent NYHA 3+ Sx
- Hospitalisations 2+ in 12 months
- Recurrent 2+ ICD shocks
15
Q
Early cause of heart transplant failure
A
Rejection
16
Q
Late cause of heart transplant failure
A
CAD
17
Q
Evidence of stenting non culprit lesion as well as culprit lesion during AMI
A
Reduced mortality in stenting non culprit lesions, but timing is unclear and concern for possible complications during index procedure
Usually manage bystander disease with staged PCI
18
Q
Evidence for Thromboaspiration in STEMI
A
Does not improve mortality or reduce infarct size
Increased risk of strokes
19
Q
Evidence for radial vs femoral access for PCI
A
Radial Access:
-Reduced mortality, reduced bleeding, reduced vascular complications
Particularly for STEMI patients
20
Q
What is a significant FFR
A
<0.8
21
Q
DES vs BMS
A
DES less instent restenosis
22
Q
Evidence for Aspirin in primary prevention
A
No clear benefit of aspirin as primary prevention
23
Q
Evidence for supplemental O2 in STEMI
A
A/W larger infarct size, more recurrent MI and more major arrhythmia
24
Q
Pharmaco-Invasive Approach for STEMI
A
Thrombolysis then PCI 3-24 hours post thrombolysis
25
STEMI: PCI time for PCI capable centre
Ideally <60 min door to PCI time
26
STEMI: PCI time for NOT PCI capable centre
If PCI possible <120 mins, then transfer for PCI
If not possible to have PCI <120 min, then thrombolysis within 30 mins
- If successful - PCI in 3-24 hrs
- If unsuccessful immediate Rescue PCI
27
High Sensitivity Troponin T
Higher negative predictive value
Reduces troponin blind period
Elevation of 13 fold limited positive predictive value
Done at 0 and 2 hours
28
Contraindications for prasugrel
Previous stroke/TIA
Age > 75
Weight <60 kg
Increased bleeding risk
29
Benefits of Stress echo vs nuclear
Nuclear has higher sensitivity and Stress echo has higher specificity
30
Current TGA indications for loop monitors
```
Syncope F.I
Cryptogenic stroke (?AF)
```
31
Familial hypercholesterolaemia
AD
Very elevated LDL usually >4.9
Xanthomata highly suggestive
AMI <45 usually
32
FH Genetics
ApoB/E receptor mutation
| Gain of PSCK9 function
33
Highest points for criteria of FH
```
LDL >8.5 (8points)
Tendon Xanthomata (6 points)
```
34
Mx of FH
Screen al first degree relatives
Statins first line
If LDL >3.3 then PSCK9 inhibitors next
35
Familial combined hyperlipidaemia profile
High chol
High TG/LDL
Low HDL
LDL to apo-B ratio <1.2
36
Dyslipidamia profile in T2DM
High Tg
High LDL
Low HDL
37
Dyslipidamia profile in cholestatic liver/PBC
Marked chol increase - accumulation of lipoprotein X
38
Dyslipidamia profile in nephrotic syndrome
Marked total chol and LDL increase
39
Dyslipidamia profile in CKD
Less prominent increase in LDL and Tg
| Low HDL
40
Dyslipidamia profile in hypothyroidism
Raised LDL predominantly
| Sometimes high Tg
41
Dyslipidamia profile in obesity
```
High chol
High LDL
High VLDL
High Tg
Low HDL
```
42
Dyslipidamia profile in smoking
Low HDL
43
Dyslipidamia profile in ETOH
Raised Tg
44
PCSK9
This protein mainly expressed in the liver and intestines but also present in plasma binds to and degrades LDL-R
Statins increase PCSK9 expression and hence combination therapy should have a synergistic effect
45
PBS indication for PCSK9 inhibitor
Familial homozygous hypercholesterolemia
AND
LDL >3.3
46
Meds that can be used in a hypertensive crisis
Hydralazine
SNP
GTN
Labetalol
47
Target BP for control
<130/80
48
Urinary Gopamine is elevated in what condition
essential HTN
49
B1 adrenergic effect
chronotropy/inotropy/lusitropy (relaxation)/dromotropy (increased conduction)
50
B2 adrenergic effect
bronchodilation, vascular smooth muscle relaxation (vasodilation)
51
B3 adrenergic effect
sympathetic mediation of lipolysis and thermogenesis
52
Reversible causes in Arrest - 4 H's
Hypoxia
Hypovolemia
Hypo/Hyperkalemia/metabolic
Hypothermia/Hyperthermia
53
Reversible causes in Arrest - 4 T's
Thrombosis
Tension pneumothorax
Tamponade
Toxins
54
Drugs in shockable rhythm
- Adrenaline 1mg after 2nd shock (then every 2nd)
| - Amiodarone 300mg after 3rd shock (then every 2nd)
55
Drugs in nonshockable rhythm
-Adrenaline 1mg immediately (then every 2nd)
56
Amount of shock given in CPR
200J biphasic
| 360J monophasic
57
Targeted temp post cardiac arrest
33-36 celsius
58
Indications for PPM
1. SND
- Only if symptomatic
2. AV block
- Pace even if symptomatic in Type 2 AV block, high degree AV block, CHB
- Otherwise only if symptomatic
59
Indication for HIS bundle pacing
Consider if EF 35-50% and will need >40% pacing
60
Mx of inferior infarct with new CHB
Reversible CHB
| Monitor and temporarily pace, but likely will not need PPM
61
Genetic disorders at risk of SCD that benefit from ICD
```
Long QT syndrome
Brugada
HOCM
ARVC (Arrhythmogenic right ventricular cardiomyopathy)
Catecholaminergic polymorphic VT
```
62
RHC Waveforms in order
RA>RV>PA>PCW
63
PCWP =?
PCWP = LA = LVEDP
64
Atrial pressure waveform: A wave
Atrial systole
65
Atrial pressure waveform: X descent
Atrial Contraction
67
Atrial pressure waveform: Y descent
Atrial emptying
68
Large V wave and prominent y descent
TR
69
Prominent X and y descent
Constrictive pericarditis
70
Large A wave
TS
71
Which atrial waveforms are not seen in AF
A and v wave
72
Kussmaul's sign: Inspiratory rise or lack of decline in RA pressure: ?Cause
Cosntriction or RV ischemia
73
Causes of Constrictive pericarditis
```
TB pericarditis
REcurrent pericarditis
PRevious mediastinal RTx
Uraemia
CTD
```
74
Causes of Restrictive cardiomyopathy
```
Idiopathic
Infiltrative
-Amyloidosis
-Sarcoidosis
-Haemochromatosis
Post radiation
Endocardial fibroelastosis
```
75
Mx of Constrictive pericariditis
Pericardial stripping
76
Mx of restrictive cardiomyopathy
Medical therapy
| Transplant
77
Differentiating Constrictive pericariditis and Restrictive cardiomyopathy on Ix
TTE:
- Both have diastolic function
- Eprime low in restriction (if >8, then constriction)
CT chest - thickened pericardium suggestive of constrictive
78
HOCM inheritance and pathophysiology
AD
Proteins encoding proteins of thick and thin myofilament contractile components of the cardiac sarcomere or Z-disk
Most commonly involves beta-myosin heavy chain (40%) and myosin-binding protein C (40%)
79
Diagnosis of HOCM
Wall thickness > 15mm in one or more LV myocardial segments
Not explained by other conditions
80
Mx HOCM
Treatment of Symptomatic LVOTO
- BB (reduce LVOTO and Ventricular arrhythmia)
- Central CCB (2nd line)
- Disopyramide (Class 1 A antiarrhthymic
- Amiodarone for AF
- Myoectomy in some cases
- ICD in medium to high risk
- ICD if previous VT/VF arrest
81
ARVC
Dilation and myocardial thinning of the RV, particularly inflow, outflow and posterolateral LV
Replacement of myocardium with fibrofatty tissue
Genetic mutations predominantly of desmosomal proteins (intercellular adhesion complexes that provide connections between myocytes)
-Desmoplakin, Plakoglobin
82
ARVC ECG
Prolonged S-wave upstroke
Epsilon wave
Twave inversion V1-V3
83
ARVC Mx
Activity restriction (risk of arrhthymia and CCF)
BB
ICD if high risk
84
Drugs causing Long QT
```
Psychotropics
Class 2 antiarrhythmics (amiodarone, sotalol)
TCAs
SSRIs/SNRIs
Macrolides
HCQ
```
85
LQT Genes
LQT1: KCNQ1 (K+Channel)
LQT2: KCNH2 (K+ Channel)
LQT3: SCN5A (Na Channel)
86
LQT1
Most common form
Loss of function mutation of KCNQ1
Associated with sensorineural hearing loss
Triggered by exercise
87
LQT2
Loss of function mutation of KCNH2
Triggered by sleep and emotion, post partum, auditory triggers
88
LQT3
Gain of function mutation of SCN5A - sodium channel
Triggered by sleep
89
Tx of Long QT
1. BB (Propanolol is best)
2. Left cardiac sympathetic denervation
3. ICD
90
Tx of Torsades
```
MgSO4 2g (20ml of 10%) up to 6 g
Correct K
Isoprenaline
Temporary pacing
DCR
```
91
Brugada
More common in males
Associated with SCZ
Due to loss of function mutation in SCN5A and SCN10A
Fever can be a precipitant
92
Brugada Mx
Antipyretics
ICD if previous arrest
Quinidine/amiodarone
Catheter ablation to reduce freq of arrhythmia
93
Best way to differentiate constrictive pericarditis from restrictive cardiomyopathy
Systolic area of index
(Ratio of RV pressure: LV pressure in inspiration vs expiration)
>1.1 = Constrictive pericarditis
Constrictive pericarditis = Increase in RV pressure with inspiration
94
Elevated RVSP
= Pulmonary HTN or RVOTO
95
What Mx will have the most improvement in 6MWT in Pulm HTN
Exercise training
96
Oximetry sampling in shunts: ASD
Step up in RA
97
Oximetry sampling in shunts: VSD
Step up in RV
98
Oximetry sampling in shunts: PDA
Step up in PA
99
Types of ASD
Ostium Primum
- More common in Down syndrome
- Partial AVSD
Osteium Secundum
- Most common
- Amenable to percutaenous closure
ASD associated with right ventricular volume overload
100
Sinus Venosus
SVC more common than IVC
Associated with anomalous pulmonary venous return
101
When to close an ASD?
```
Symptoms
RV enlargement
Qp:Qs >1.5
Paradoxical embolism
Playpnea-orthodeoxia syndrome
```
102
When not to close an ASD
Eisenmenger
103
VSD presentation
Murmur
CCF (dilated LV)
Endocarditis
Cyanosis (PHTN)
104
When to close VSD
```
Symptoms
LV enlargement
Qp:Qs >2:1
PHT with net L to R shunt
Endocarditis
AR
RVOTO
```
105
PDA presentation
Continuous murmur
| If large CCF
106
When to close PDA
Left chamber enlargement
PHTN (net left to right shunt)
Previous endarteritis
Audible murmur
107
Most common cause of eisenmenger in order
PDA>VSD>ASD
108
Coarctation presentation
HTN in upper limbs
-Reduced femoral pulses, femoral-femoral delay, Arm-leg BP gradient
Exercise intolerance
-Angina, claudication
109
Coarctation associations
Bicuspid Aortic valve +Aortopathy
Cengenital heart disease (VSD, PDA, etc)
Berry aneursyms
110
Mx Coarcatation
Stenting
| Monitor afterwards for residual HTN and risk of wall complication (aneurysm)
111
Causes of pulmonary stenosis
Noonans Syndrome
-AD, skeletal abnormalities, learning difficulties
William's syndrome
"Double chamber RV"
112
Ebstein anomaly
Tricuspid valve regurg
Accessory pathway
80% have ASD or PFO as well
Tx: Closure of ASD/PFO and repair of TVR
113
Tetralogy of Fallot
VSD
Overriding Aorta
RVH
RVOTO (Pulmonary stenosis or pulmonary atresia)
114
High risk cardio conditions in pregnancy
```
Severe PHTN
Eisenmenger Syn
Cardiomyopathy (NYHA2+, EF <40%)
Severe obstructive cardiac lesion (AS, PS, MS)
Marfan Syn with aortic root >40 mm
Previous severe peripartum CM
```
115
Which patient groups get endocarditis prophylaxis
Prosthetic cardiac valve
Congenital heart disease (unrepaired cyanotic, repaired with residual disease)
PRevious endocarditis
Cardiac transplant patients with valvular disease
116
Procedure that will need endocarditis prophylaxis in high risk groups
Dental with manipulation of gingival tissue
Invasive resp tract procedures
Procedure within infected skin, tissue
Tx:
Single dose Amoxy or Clinda 30-60 mins pre op
117
AF ablation in patients with HF
Evidence shows reduced mortality and HF hospitalisations
118
2 Most common genes in HOCM
MYBPC3 (cardiac myosin binding protein C)
MYH7 (Beta-myosin heavy chain)
119
Catecholaminergic polymorphic VT gene
RYR2
120
Causes of MS
1. Rheumatic heart disease
2. Mitral annular calcification
Radiation
Carcionid
SLE/RA
Fabrys, Whipple's
121
MS severity based on area
Mild: >1.5 cm2
Mod: 1.0-1.5 cm2
Severe: <1.0 cm2
122
MS severity based on Gradient (mmHg)
Mild <5
Mod 5-10
Severe >10
123
Effect on gradient in MS with exercise
Gradient increases with HR and exercise, so can get APO
124
Mx of MS
MEdical therapy
-BB, diuretics if overloaded
Balloon valvuloplasty
125
Indications for Balloon valvuloplasty in MS
Mod to severe MS (<1.5 cm2 area)
Symptomatic
Asymptomatic +
- New AF
- PASP >50mmHg at rest
126
Contraindications for balloon valvuloplasty in MS
>mild MR
LA thrombus
Heavy calcification
Predominant subvalvular involvement
127
Wellen's Syndrome Definition and ECG
Severe proximal stenosis of LAD, usually with a rich collateral supply
Usually no chest pain but recent severe angina in the last 24-48hrs
• Classic ECG: Deep and symmetric T wave inversion in V1-V6, aVL and I (at least V2-V5), no ST changes. *highest risk if aVL and I are involved
Mx: Urgent Angio
128
Acute instent thrombosis
<24 hours
129
Subacute instent thrombosis
<30 days
130
Late instent thrombosis
1-12 months
131
Very late instent thrombosis
>12 months
132
Stent restenosis
• Gradual renarrowing of the stented segment (usually after 3-12 months)
133
Greatest predictor of death post MI
REduced LVEF
134
Evidence for PCI of occluded vessels when asymptomatic
Even if post AMI
Shown to increase mortality and worsen LV function if PCI performed
Only PCI if symptomatic
135
Geneticsi n MArfan's Syndrome
AD
| FBN1 gene for protein fibrillin-1
136
Diagnostic Criteria for Marfan's Syndrome
W/O FHx:
-Aortic cteria +one other major criteria or FBN1 mutation
W/ FHx
-Any one of the major criteria
Major:
- Aortic diameter Z >2 if above 20 yo, Z>3 if below 20 yr old, or aortic root dissection
- Ectopia Lentis
- Systemic score >7 based on smaller clinical findings
137
Features suggesting successful thrombolyisis
Improvement/relief of chest pain
reduction by 50% of the initial ST-segment elevation within 60–90 minutes
reperfusion arrhythmias (e.g. accelerated idioventricular rhythm)
restoration of haemodynamic and/or electrical stability
138
ECG Changes suggestive Right ventricular infarct
ST elevation in the right-sided leads (V3R-V6R)
• ST elevation in V1 – the only standard ECG lead that looks directly at the right ventricle.
• ST elevation in lead III > lead II – because lead III is more “rightward facing” than lead II and hence more sensitive to the injury current produced by the right ventricle.
• ST elevation in V1 + ST depression in V2 (= highly specific for RV MI).
139
Exam Findings: Hypotension, jugular venous distension, clear lungs
Right ventricular infarct
140
What medication should be given with thrombolysis
Aspirin and clopidigrel loading
| Enoxaparin (IV better than SC)
141
Absolute contraindications to thrombolysis
- Previous ICH or stroke of unknown origin at anytime
- Ischemic stroke in the last 6 months
- CNS damage/neoplasma/AV malformations
- REcent major trauma/surgery/head injury within last month
- GI bleeding in last month
- Known bleeding disorder
- Aortic dissection
- Non compressible punctures in last 24 hours
142
Relative contraindications to thrombolysis
```
TIA in last 6 months
-Oral anticoagulant therapy
-Pregnancy or within 1 week postpartum
-Refractory HTN SBP >180
-Advanced lvier disease
IE
-Active peptic ulcer
-Prolonged or traumatic resus
```
143
Indication for CABG
Multivessel disease
Left main disease
Proximal LAD disease
T2DM with multivessel disease
144
What risk factor has the greatest risk of extension of a pre-existing AAA
Smoking
145
Mx of CHB
Unstable:
- Atropine
- Transcutaneous pacing
- If unable to pace: isoprenaline
- Low BP: Dopamine
- HF: IV dobutamine
- Normal BP and no HF: Transvenous pacing
Stable:
- Transcutaneous pacing
- Look for reversible causes
- None: PPM
146
Diagnostic criteria for pericarditis
```
At leas 2:
Typical chest pain
Pericardial friction rub
Suggestive ECG changes
New or worsening pericardial effusion
```
147
Mx of Aortic Dissection
Aim SBP <120 and HR <60
IV BB, SNP, or GTN
148
Biggest risk factor for arrhythmia post CABG
AF most common
| Age is greatest risk factor for AF post CABG
149
Mx of stable VT
IV amiodarone/lignocaine
IF fails can consider retrial or cardioversion
Treat underlying cause too
150
CHADSVASC
* Congestive heart failure / left ventricular dysfunction
* Hypertension
* Age ≥ 75 (x2)
* Diabetes
* Stroke (x2)
* Vascular disease
* Age 65-74
* Sex (female) (x2)
151
HASBLED
* Hypertension
* Abnormal renal/liver function
* Stroke
* Bleeding history or predisposition
* Labile INR
* Elderly
* Drugs/alcohol
152
MAjor risk factors for stroke in AF
* Major: past stroke, age >75, valve disease, mitral stenosis, mechanical valve
* Alone are indications for anticoagulation
153
Which antihypertensive should not be prescribed in HFrEF
Moxonidine
154
Benefit of AF ablation in HF
Improves survival
155
MR and LV dysfunction relationship
Irreversible LV contractile dysfunction may occur despite "normal" EF and without symptoms
Early: Increase in EF because ejecting into low pressure LA (decrease afterload and increase preload)
Late: Increase LV size and interstitial fibrosis (increase afterload) leads to decrease EF into "normal range" (70-60%)
156
Indications for AR repair
If Symptomatic - Treat
If asymptomatic:
- Resting EF <50%
- Cardiac surgery/CAGS
- Rest EF >50%, but LV Diastolic >70mm or LV systolic >50 mm
157
Moderate AS
Gradient 20-40
Area 1-1.5
Velocity <0.25
158
SEvere AS
Gradient >40 mmHg
Area <1 cm2
Velocity <0.25 DI
Flow 4
159
Indication for TAVI
Symtomatic severe AS
160
CI to TAVI
```
Aortic annulus too small
LV apical thrombus
Peripheral vascular access issues
Active endocarditis
Life expectancy <1 yr
```
161
Tavi Cx
Heart block
AR
Tavi thrombosis
162
SAVR Cx
AKI
New AF
Major bleeding
163
Flecainide MOA and CI
```
Blocks fast inward sodium channels (class 1c)
•
ECG effects prolonged PR, QRS widening
```
CI: structural heart disease, CAD
164
Amiodarone MOA
Multiple sites of action potassium channels,
alpha/beta adrenoceptors, others (sodium and calcium
channels)
165
Sotalol MOA
Inhibits rapid component of delayed potassium
rectifier Ikr current (class III) and beta receptors
•
ECG effects sinus brady, AV blockade, QT
prolongation (significant TDP risk)
Reduce dose in renal impairment
166
Digoxin MOA
Inhibits sodium potassium ATPase --> increases
intracellular Ca 2+2+--> positive inotropic effect
•
Increases vagal tone --> slows AV conduction
167
Sacubitril valsartan MOA
Sacubitril inhibits neprolysin --> raises levels of
endogenous vasoactive peptides (natriuretic
peptides, bradykinin)
168
Type 1 MI
Spontaneous MI due to primary coronary event
169
Type 2 MI
MI secondary to ischemia due to either increased O2 demand or decreased supply
170
Type 3 MI
Sudden unexpected cardiac death
171
Type 4 MI
4a - assocaiated with PCI
4b - stent thrombosis
172
Type 5 MI
Associated with cardiac surgery eg. CABG
