Cardiology

Question 1

Indications for Mitral Valve Repair

Answer 1

Repair&raquo_space; Replacement
chronic severe primary mitral regurgitation
(1) symptomatic patients with left ventricular ejection fraction greater than 30%
(2) asymptomatic patients with left ventricular dysfunction (left ventricular ejection fraction of 30%-60% and/or left ventricular end-systolic diameter ≥40 mm)
(3) patients undergoing another cardiac surgical procedure.

Also reasonable in asymptomatic patients with chronic severe primary mitral regurgitation who have new-onset atrial fibrillation or pulmonary hypertension (pulmonary artery systolic pressure >50 mm Hg).

Question 2

Common side effect of Bevacizumab? Explain pathophysiology

Answer 2

MOA of drug -VEG-F inhibitor, monoclonal antibody
SE - Hypertension, dose dependent, occurs 60 days after initiation of therapy (but can be as early as week 1)

Pathophys - inhibition of VEGF = (1) altered nitric oxide production (2) increased endothelin-1 production (3) alterations in the pressure-natriuresis relationship

Question 3

What characterizes effusive constrictive pericarditis? How do you treat it?

Answer 3

pericardial effusion (can be with tamponade) + constrictive pericarditis. Can occur occur following idiopathic or infectious pericarditis or radiation therapy. Although intrapericardial pressures decrease, Intracardiac pressures remain elevated and equalized despite drainage (pericardiocentsis).

Tx- NSAIDs and Colchicine. if persistent, may need pericardectomy

Question 4

Treatment of Afib in WPW

Answer 4

Procainamide

Do NOT use CCB or beta blockers

Question 5

Aortic stenosis vs. pseudostenosis.

What’s the difference? How to differentiate?

Answer 5

low-flow, low-gradient may be 2/2 severe LV dysfunction with pseudostenosis or critical AoS .
Perform dobutamine echo to distinguish.

In pseudostenosis valve are may be calculated to be low even though it is not due to decreased opening forces from decreased cardiac output, so if ionotrope is given (dobutamine) it will increase CO and valve area will increase.

Question 6

What is Cardiac Syndrome X?

Answer 6

Angina and stress testing abnormalities with negative angiography. Found often in women without traditional risk factors for CAD, but have same symptoms as classic exertional angina with abnormal stress test. Unclear pathogenesis ?microvacsular dysfunction.

Question 7

Preconception counseling for female with Marfan

Answer 7

Advise against pregnancy.
ALL have risk for pregnancy related aortic dissection and rupture.
Especially if has dilated aorta. If diameter =/>4.5cm, (or rapid dilation, or family hx dissection) should have aortic repair surgery before pregnancy to reduce risk.
If diameter <4cm, pregnancy is generally safe.

Question 8

What is a papillary fibroelastoma? What does it look like on echo? Associated symptoms/conditions?

Answer 8

• Small, independently mobile cardiac tumors
• Echo: attached to left sided valvular endocardium by a stalk
• Can be assoc with CVA, TIA, Angina, MI, peripheral embolization (can present with any of these initially)
• If symptomatic treat with surgery

Question 9

How to treat anemia (symptomatic post operative) in a patient with Eisenmenger syndrome? (cyanotic condition)

Answer 9

short course of iron therapy - will increase exercise capacity and improve quality of life. Repeat Hgb in 7-10 days. Discontineu once serum ferritin or transferrin sat is normal.

Question 10

Define ABI ranges - normal, PAD, and noncompressible. How do you assess non-compressible ABI ranges?

Answer 10

>.9-1 = normal 
<0.9 = PAD 
>1.4 = calcified, noncompressible arteries = uninterpretable, so next step is Toe-Bracial index. If systolic pressure <40 or TBI <0.7 = PAD

Question 11

Restrictive Cardiomyopathy VS. Constrictive Pericarditis

Answer 11

BNP > 400 (RCM), BMP <100 (CP)
Pericardiac thickening, calcification, fibrosis (CP)
Ventricular interdependance (CP) - RVp rises during inspration but has to be coupled with decrease in LVp.
Concordant rise/fall of LV and RV systolic pressure (RCM)

Question 12

Aortic dissection - when to medically tx vs. surgery

Answer 12

Surgery – Type A (ascending dissection) OR intramural aortic hematoma OR Type B (descending ao dissection) with complications

Medical - Type B without complication – IV BB and nitro for SBP<120

Question 13

One common SE of ticagrelor (brilinta)

Answer 13

dyspnea

Question 14

How long is DAPT needed post DES angina vs. DES for ACS? bare metal stent?

Answer 14

6 months (no ACS)
12 months for ACS

bare metal -1 month

Question 15

Characteristic of Noonans syndrome

Answer 15

pulmonary stenosis **

short stature, variable intellect, unique facial features, neck webbing, hypertelorism, HCM, ASD, VSD

Question 16

What to do if patient has SX of severe mitral stenosis but echo findings are just moderate?

Answer 16

exercise echo. Symptoms don’t present until valve area <1.5cm2

Question 17

How do you treat Afib in a person with HCM?

Answer 17

anticoagulate with Warfarin (1st line) regardless of type of afib (parox or persistent), if cant take warfarin can do NOAC as 2nd line.

Question 18

How to evaluate a pt with Sx of AoS but discrepancy with echo findings? When would symptoms begin?

Answer 18

Cardiac cath (before aortic valve) Symptoms begin once valve area <1cm2

Question 19

Treatment of frequent symptomatic PVCs

Answer 19

1st - BB or CCB
2nd - catheter ablation
frequent = >10,000 PVCs in 24 hours or >10% of all beats

Question 20

Anticoagulation in pregnant woman with mechanical valve

Answer 20

1st trimester - warfarin (if 5mg or less per day)

2nd and 3rd trimester - warfarin most preferred

Question 21

What tests to order in new onset heart failure?

Answer 21

BNP, CBC, BMP, LFT, TSH

Question 22

Management of Mobtiz type 2 second degree AV block post anterior MI

Answer 22

emergent pacing - bc potentially life threatening complication of anterior MI

Question 23

How to further evaluate patient with bicuspid aortic valve found on echo?

Answer 23

CT angiography of aorta (or MRI)- because bicuspid valve disease is commonly associated with abnormalities of aorta (aneurysm, dissection, coarctation) to eval for aortopathy

Question 24

When to use valsartan-sacubitril? Whats MOA?

Answer 24

Symptomatic HFrEF. replace ACE-i with this, reduces CV death or HF hospitliazation by 20%. BUT can cause hypotension, so don’t start if don’t have BP room or orthostatic hypotension.