Cardiology Flashcards
In AF, for what duration is anticoagulation required prior to DCCV if it had lasted for >48 hours?
3 weeks
Which are the two proteins implicated in cardiac amyloidosis?
AL
Transthyretin
What clinical features would you expect to see with cardiac amyloidosis? Name 6.
HFpEF
Restrictive
AF
Increased wall thickness
Voltage criteria negative
GLS apical sparing
What is E/e’, and what are the reference ranges?
Ratio between early mitral inflow velocity and mitral annular early diastolic velocity. Reflects LA pressure.
E = flow from LA to LV during active relaxation e' = active myocardial relaxation (velocity of descent away from apex)
E/e’ <8 is normal (grade 1)
E/e’»_space; 14 abnormal (grade 3 - restrictive)
e’ 15-20mm - watch
What is tafamidis helpful treatment for?
Transthyretin amyloid cardiomyopathy
Decreased mortality and increases quality of life
What are the 5 groups of pulmonary hypertension?
- Pulmonary arterial hypertension
- PH associated with left heart disease
- PH with resp disease +/- hypoxia
- Chronic venous thromboembolic disease
- Misc
With right heart catheterisation, what is the normal reference range for pulmonary capillary wedge pressure?
4 to 12 mmHg
With right heart catheterisation, what is the normal reference range for cardiac output?
4 to 8 L/min
With right heart catheterisation, what is the trans pulmonary gradient calculation, and what is the normal range?
TPG - transpulmonary gradient is mPAP - mean PCWP
Normal < 12 mmHg
With right heart catheterisation, what is the calculation for pulmonary vascular resistance, and what is the normal reference range?
PVR = transpulmonary gradient/cardiac output
Normal <3 Wood units
How do you use PCWP to determine group 2 PHT?
PCWP < 15 mmHg suggests pre-capillary PHT
PCWP > 15 mmHg suggests post-capillary PHT (i.e. group 2 left-sided)
How is severe high grade aortic stenosis defined? Name 3 parameters.
Peak velocity > 4m/sec
Mean gradient > 40mmHg
AVA < 1cm^2
In patients with asymptomatic aortic stenosis who are regularly monitored, what adverse prognostic features would prompt you to refer the patient for intervention besides symptomatology? Name 2.
LV dysfunction
Pulmonary hypertension
In patients with asymptomatic mitral valve stenosis, when do you consider intervention? 3 parameters.
Mean gradient > 10mmHg
PA systolic pressure > 30mmHg
Valve < 1.5 cm^2
Exercise test may be useful
In patients with asymptomatic mitral valve regurgitation, when do you consider intervention? 5 parameters.
Onset of AF
Pulmonary hypertension
LVEF 30-60% and/or LVESD > 40-45mm
LVEF < 30% - high risk
LVEF > 60% and LVESD < 40mm is considered well-compensated
How long can event recorders be used for at a time?
7 days
20 minutes pre-event memory
How long can loop recorders be used for at a time?
Up to 3 years
Single V2 lead ECG
What is the cure rate of ablations for AF?
50%
Ablation combined with weight loss has a cure rate of 90%
What are the stipulations a patient must meet in order to receive ivabradine?
LVEF < 35%
HR > 70
What treatments do you give for HFrEF?
ACE
B blocker
MRA
If < 35% LVEF, consider ARB, ARNI and/or ivabradine
If persistent HF with LVEF < 40%, change ACEi/ARB to ARNI
What is the washout period between ACEi and ARNIs, and why?
36 hours
Avoid angioedema due to build up of bradykinin
Why do ARNIs need to be given in combination with ARBs?
ARNIs inhibit neprolysin
Neprolysin inhibition results in less breakdown of angiotensin receptor 2, hence ARB required
In HFrEF, what options can be considered if ACEi/ARB/ARNI aren’t well tolerated?
Nitrates +/- hydralazine
Add digoxin if refractory Sx
Post MI, how soon after would you consider insertion of an ICD, and with what stipulations? Name 3.
40 days post MI
LVEF <35% NYHA I or III
LVEF <30% NYHA I
LVEF <40% NSVT or inducible VT/VF
What feature on cardiac MRI would you expect to see with IHD?
Subendocardial scarring
What do T1 and T2 (in general terms) on a cardiac MRI provide information on?
T1 - fibrosis
T2 - oedema, iron
What are the benefits of cardiac nuclear stress scanning? Name 3.
Helping to guide revascularisation
Risk stratification before non-cardiac surgery
Prognosis
When would you consider intervention with asymptomatic aortic regurgitation? Name 3 conditions.
LVEF <50%
Previous cardiac surgery
LVEF >50% but LVESD >50mm or LVEDD >70mm
With regard to aortic stenosis, what is the dimensionless index, and what does it indicate?
Velocity LV outflow (V1) ÷ velocity valve (V2)
0.5 is half of normal area
<0.25 is severe AS
What are contraindications for TAVI? Name 6.
Endocarditis
Peripheral vascular/thoracic aorta issues
LV apical thrombus
Bicuspid aortic valve
Aortic annulus/ascending aorta size criteria
Life expectancy <1 year
When should an ASD be closed? Name 4 stipulations.
If HD significant
If symptomatic
RV enlargement
Qp:Qs >1.5
Do not close Eisenmenger’s
When should a VSD be closed? Name 3 stipulations.
If symptomatic
If LV enlargement
Qp:Qs > 2:1
How can Eisenmenger’s be treated?
Bosentan
Sildenafil
When would you consider an ICD in the setting of HCM? Name 3 considerations.
LVH > 30mm
Unexplained syncope
Family history of sudden death
Name 3 considerations for a heart transplant.
Severe symptomatic HF
Frequent discharges from AICD
Intractable angina
Name the principal genes involved in LQT 1, 2 and 3 respectively.
LQT1 - gain in K channel KCNQ1 (loss of gene in familial AF and SQTS)
LQT2 - gain in K channel KCNH2 (HERG) (loss of gene in SQTS)
LQT3 - gain in Na channel SCN5A (loss of gene in Brugada and Lenegre’s)
What are the common triggers for LQTS 1, 2 and 3?
LQT1 - swimming/exertion
LQT2 - post-partum period, auditory triggers
LQT3 - occurs during sleep
What drugs are typically given for LQT 1, 2 and 3?
LQT1 - beta blockers
LQT2 - beta blockers
LQT3 - beta blockers, mexiletine
What receptor is affected in CPVT, and a mutation in which gene is responsible?
Ca/ryanodine receptor
Calsequestrin 2 (CASQ2)
Name 2 prominent genes implicated in HCM.
MYBC3 (cardiac myosin binding protein 3)
MYH7 (beta myosin heavy chain)
There are about 35 genes involved with HCM however
Which gene variant in ARVCM results in typically earlier onset of symptoms and VT/VF?
PKP2
