Cardiology

Question 1

Definition of Severe Aortic Stenosis?

Answer 1

Aortic valve area (AVA) <1cm^2, Mean Pressure Gradient >40mmHg, Peak Aortic Jet Velocity of >4m/s (remembered as the 1, 4, 4)

Question 2

Syptoms and signs of PE?

Answer 2

Dyspnoea (73%)
Chest pain (66%) - this implies infarction and occurs 3-7 days after embolism.
Cough (37%)
Haemoptysis (13%)

Few signs - only tachypnoea, tachycardia, hypoxia which is often mild.

Question 3

Components of a Thrombophilia Screen?

Answer 3

Antithrombin 3
Protein C and S
Factor 5 Leiden
Plasminogen
Fibrinogen
Activated Protein C Resistance

Question 4

Wells Score for PE Components?

Answer 4

There are 7 components:
Clinical DVT (3)
Alternative Diagnosis is less likely than PE (3)
Tachycardia (1.5)
Immobilisation or Surgery in last 4 weeks (1.5)
Previous VTE (1.5
Haemoptysis (1)
Active Cancer (1)

Score of 4 or lower indicates PE is unlikely –> proceed to PERC.

Question 5

PERC Score Components?

Answer 5

8 components:
Age <50y
Pulse < 100
Sp02 > 94%
No haemoptysis
No exogenous oestrogen
No previous DVT or PE
No surgery of trauma with in 4 months
No unilateral leg swelling.

Question 6

What are the 5 groups of pulmonary hypertension?

Answer 6

Group 1 - isolated precapillary pulmonary hypertension (PAH)
Group 2 - Pulmonary Hypertension due to Left heart disease
Group 3 - Pulmonary hypertneion due to lung disease and hypoxia
Group 4 - Pulomary artery obstruction (CTEPH)
Group 5 - Pulmonary hypertneion with unclear/multifactorial mechanisms

Question 7

How is probability of Pulmonary Hypertension determined on initial testing?

Answer 7

Echocardiogram - Peak tricuspid regurgitation velocity. >3.4 m/2 indicates high probability.
Other features include enlargement of the pulmonary artery, RV, RA and inferior vena cava

Question 8

Haemodynamic definition of Pre-capillary hypertension on right heart catheterisation?

Answer 8

mPAP is high (>20mmHg)
PAWP is low <15mmHg (surrogate marker of left ventricular pressure)
PVR high >3 WU (pulmonary vascular resistance)

Question 9

Haemodynamic definition of isolated post-capillary hypertension on right heart catheterisation?

Answer 9

mPAP >20
PAWP high >15 mmHg
PVR low <3

Question 10

PAH treatment targeting the Endothelin pathway?

Answer 10

Endothelin Recepter Antagonists:
Ambriesantan, Bosentan, Macitentan.

Question 11

PAH treatments targeting the Nitric oxide pathway?

Answer 11

PDE5 - posphodiesterase type 5 inhibitors - which increase endogenous nitric oxide levels. Sildenafil, Tadalafil, Riociguat

Question 12

PAH treatments targeting the prostacyclin pathway?

Answer 12

Epoprostenol (intravenous), iloprost (nebulised), Seleipag (oral prostenoid).

Question 13

What are the heart failure beta-blockers?

Answer 13

BC-MN
Bisoprolol
Carvedilol
Metoprolol CR
Nebivolol

Question 14

Sokolow-Lyon criteria for LVH

Answer 14

S wave V1 + R wave in V5 >35mm (7 large sqares).
OR R wave in aVL > 11mm

Question 15

Testing in stable coronary artery disease?

Answer 15

CTCA

Echo

Nuclear medicine

Question 16

FFR

Answer 16

Angiography with fractional flow reserve has

FFR = distal pressure / proximal pressure

FFR <0.8 indicates haemodynamically significant stenosis that will benefit from stenting.

Question 17

LDL goal for Ischaemic Heart Disease

Answer 17

< 1.8 with statin

If not meeting goal, add with ezetimibe

If not meeting goal add PCSK9i

Question 18

Indications for aspirin

Answer 18

Only secondary prevention

Consider if no MI but evidence of CVD on imaging

No role for primary prevention

Question 19

COMPASS Study

Answer 19

Low dose rivaroxaban + aspirin improved outcomes compared to aspirin alone (for secondary prevention)

Question 20

Low dose Colchicine

Answer 20

IIb - can be considered for secondary prevention for CAD

Question 21

Diabetes and CAD

Answer 21

Aim HbA1c < 7 %

Empagliflozen

Liraglutide

Question 22

Indications for revascularisation in patients with STABLE or silent ischaemic heart disease?

Answer 22

2 reasons:

1) for prognosis:
Left main disease with >50% stenosis
Proximal LAD disease with >50% stenosis
2 or 3 vessel disease with >50 stenosis and LVEF <35%
Large areas of ischaemia on functional testing (>10% of LV)
Single remaining patent CA with stenosis >50%

or 2) for symptoms:
- significant stenosis in the presence of limiting angina or angina equivalent that has persisted with maximal medical therapy.

Question 23

Medical therapy vs PCI for STABLE CAD?

Answer 23

No difference in outcome

Improved symptoms with PCI.

Question 24

CABG vs PCI

Answer 24

STITCHES Trial - multi vessel disease with LV < 35%, CABG is better.

FREEDOM Trial - DM with multi-vessel disease - CABG better.

Question 25

Difference between CABG and PCR

Answer 25

High need for repeat procedure for PCI