Cardiology : Aortopathy and valve disease Flashcards
1
Q
Who should you screen for abdominal aortic aneurysm ?
A
Screen all men > 65 - 80 for AAA once with US
2
Q
Class I indication for tricuspid regurgitation intervention ?
A
Severe TR in patients undergoing left sided valve surgery
3
Q
Class IIA indication for tricuspid regurgitation intervention ?
A
• Addition of an annuloplasty ring for moderate or more TR at the time of left sided valve surgery
• Severe primary or secondary TR if right sided heart failure and no pulmonary hypertension to reduce symptoms and risk of heart failure hospitalization
4
Q
Does TAVI valves need endocarditis prophylaxis ?
A
Yes
5
Q
How do you treat Marfan patients with thoracis aortopathy / aortic aneurysm ?
A
Use a BB or losartan regardless if the patient has HTN
6
Q
How do you treat thoracic aortic dissection ?
A
IV meds ; BB first line (or CCBs 2nd choise)
IV labetalol good first line option
Target HR < 60-80 and BP < 120 (or lowest that maintain perfusion) but DO NOT control BP before HR
7
Q
How do you treat type A thoracic aortic dissection ?
A
Dissection involves ascending aorta -> refer to urgent surgical intervention
8
Q
How do you treat type B thoracic aortic dissection ?
A
Dissection does not involve ascending aorta -> medical management
Unless causes malperfusion (gut ischemia, leg ischemia…), refer for endovascular management
Unless rupture, refer for surgery
9
Q
How often should you ask for an echocardiography in degenerative or bicuspid aortic valve aortopathy ?
A
At time of diagnosis and every 1-3 years
10
Q
How often should you ask for an echocardiography in Loyes=Diez and Marfan ?
A
At the time of diagnosis to assess aortic valve anatomy and function + ETT yearly
11
Q
How should you do surveillance on a 3 to 3.9 cm AAA ?
A
Imaging every 3 years
12
Q
How should you do surveillance on a AAA that is 4-4.9 cm for men or 4-4.4 cm for women ?
A
Imaging every 12 months
13
Q
Severe aortic stenosis are preload or afterload dependent ?
A
Afterload dependent
Caution with vasodilators / afterload reducers (ex: ACEi)
14
Q
Severe aortic stenosis criteria from echo ?
A
- Mean gradient ≥ 40 mmHg
- Max jet velocity ≥ 4 m/s
- AVA < 1 cm2
15
Q
Thoracic aortopathy / aortic aneurysm :
How do you deal with family ?
A
– If gene positive, family members who are also positive should be screened with an echocardiogram
– If no culprit gene identified, first degree relatives should be screened with an echocardiogram
16
Q
Thoracic aortopathy / aortic aneurysm : how do you treat ?
A
Treat HTA with target <140/90, lower may be better …
Use 1) BB 2) ARB
For Marfan : Use BB or losartan regardless if the patient has HTN
Smoking cessation
Statins and / or antiplatelets if evidence of atherosclerosis, statins may be considered for primary prevention if no atherosclerosis
17
Q
What are CLASS 1 indication for intervention for aortic stenosis ?
NAME 5
A
• Severe, symptomatic AS
• Severe, asymptomatic AS with LV dysfunction (LVEF <50%)
• Severe, asymptomatic AS undergoing other CV surgery
• Symptomatic low-flow, low gradient AS with LV dysfunction (LVEF<50%)
• Symptomatic low-flow, low gradient AS with LVEF >50% (“paradoxical” low-flow, low-gradient aortic stenosis)
18
Q
What are CLASS I indication for surgery in case of aortic regurgitation ?
Name 3
A
- Severe, symptomatic AR
- Severe, asymptomatic AR with LVEF = 55%, if no other cause for LV dysfunction identified
- Severe, asymptomatic AR undergoing other CVSx
19
Q
What are risk factors for thoracic aortic dissection ?
A
HTA
Vasculitis
Valvular heart disease (bicuspid ++)
Cocaine
Collagen disorder
20
Q
What are the 4 causes of acute mitral regurgitation ?
A
- Ischemia : papillary muscle dysfunction
- Chord rupture : patients with mitral valve prolapse may rupture a chord actutely, leading to a flailing mitral valve leaflet acute severe MR
- Endocarditis
- Trauma
21
Q
What are the indication of intervention for secondary mitral regurgitation ?
A
We recommend that maximally tolerated GDMT, including cardiac resynchronization therapy (CRT) and revascularization where appropriate, be implemented before consideration of percutaneous mitral valve repair (PMVR) for patients with HFrEF and severe FMR
NO CLASS 1 INDICATION FOR SURGERY/INTERVENTION FOR 2e MR
22
Q
What are the indications for surgery for primary mitral regurgitation ?
A
- Severe symptomatic primary MR irrespective of LVEF
- Severe asymptomatic primary MR + LV systolic dysfunction (LVEF ≤ 60, LVESD ≥ 40mm)
THE GOAL OF THERAPY is to correct MR before onset of LV systolic dysfunction
23
Q
What are the management consideratios for AF and mitral stenosis in case of HR ?
A
- MS does not like high HRs : loss of diastolic filling time
NEED HR 60-70 !!!!! - MS does not like AF : loss of atrial kick
24
Q
What are the mimics of thoracic aortic dissection ?
A
– ACS (e.g.STEMI) – usually inferior STEMI
– Valvular heart disease (aortic regurgitation leading to heart failure)
– Pericardial effusion, cardiac tamponade
– Syncope
– Stroke, focal neuro symptoms
– Renal failure, limb ischemia, spinal cord injury
25
What are the risk factors necessitating a different INR goal in case of an AVR ?
AF, prior clot, LV dysfxn, hypercoagulable state
26
What are the surveillance recommendations for AAA ?
– 3.0 to 3.9 cm: imaging every 3 years
– 4.0 to 4.9 cm men, 4.0 to 4.4 cm women: imaging every 12 months
– >5.0 cm men, >4.5 cm women: imaging every 6 months
27
What are the THREE cardical symptoms for « rule in » for thoracic aortic dissection ?
- focal neuro deficit (LR + 6.6-33)
- pulse deficit / differential BP (LR + 5.7)
CHECK BILAT BPs
- enlarged aorta or mediastinum on CXR (LR + 2)
28
What are the threshold for surgery for AAA for both sex ?
– Men: 5.5 cm or more or <5.5 cm if symptoms attributable to AAA (class I)
– Women: 5.0 cm or more or <5.0 cm if symptoms attributable to AAA (class I)
– If rate of growth is greater than 0.5 cm in 6 months, AAA repair is reasonable class IIb)
29
What are the threshold for surgery for AAA for men ?
5.5 cm or more or < 5.5cm if sx attributable to AAA
30
What are the threshold for surgery for AAA for women ?
5cm or more or < 5cm if sx attributable to AAA
31
What is a CLASSIC low flow low gradient aortic stenosis
Suspicious if AVA < 1 with non severe gradients (<40) / V max (4m/s)
Seen in cas of LV systolic dysfunction
Do a dobutamine stress echo or calcium score of the valve
32
What is a critical aortic stenosis ?
Aortic velocity > 5 m/s
33
What is a PARADOXICAL low flow low gradient AS ?
In a patient who has a small LV cavity with concentric LVH
The stroke volume is low because the LV cavity is small and the ejection fraction is nornal (> 55 %) and often hyperdynamic (>65%) to maintain cardiac output.
They will have a LOW stroke (***SV index < 35***) despite a normal LVEF
34
What is the antithrombotic therapy after valve replacement with mechanical valves ?
- Life long therapy with warfarin
- Add ASA if another antiplatelet indication
35
What is the antithrombotic therapy for bioprosthetic valves ?
- Lifelong therapy with ASA 75-100 daily
- Surgical valve : consider VKA (INR 2.5) in addition to ASA
- TAVI : may consider DAPT (clopi) or VKA (INR 2.5) if low risk bleed
****** ASA monotherapy likely safer per guideline text ******
36
What is the antithrombotic therapy in case of TAVI ?
ASA 75-100mg daily
May consider DAPT (clopidogrel) or VKA (INR 2.5) if low risk bleed
BUT ASA MONOTHERAPY LIKELY SAFER
37
What is the best first line imaging modality for thoracic aortic dissection ?
CT scan / MRI if < 50 y
38
What is the goal INR for an AVR with risk factors ?
INR 2.5-3.5
AF, prior clot, LV dysfxn, hypercoagulable state
39
What is the goal INR for an old AVR (ball-in-cage)
INR 2.5-3.5
40
What is the goal INR in case of AVR with LV dysfunction ?
INR 2.5-3.5
41
What is the goal INR in case of mechanical valves ?
- INR 1.5-2 on X valve (new generation aortic valve, needs low dose ASA)
- INR 2-3 for current generation AVR and no other risk factors
- INR 2.5=-.5 for any MVR or old AVR (ball-in-cage) or AVR with risk factors
RF : AF, prior clot, LV dysfxn, hypercoagulable state
42
What is the goal INR in case of MVR ?
INR 2.5-3.5
43
What is the goal INR in case of X valve on aortic position ?
INR 1.5 - 2
+ low dose ASA
44
What is the goal INR with current generation AVR and no other risk factors ?
INR 2-3
45
What is the imaging modality for surveillance of AAA ?
Ultrasound first line, CT if ultrasound not adequate
46
What is the size criteria for surgery for bicuspid aortic valve aortic aneurysm ?
5.5 cm
47
What is the size criteria for surgery in case of familial aortopathy aortic aneurysm ?
5
48
What is the size criteria for surgery in case of Marfan syndrome aortic aneurysm ?
5 (root, not ascending)
49
What is the size criteria for surgery in case of aortic aneurysm for a patient already undergoing cardiac surgery ?
5 (4.5 if expert centre, IIa)
50
What is the size criteria for surgery in case of degenerative aortic aneurysm ?
5.5 (5 if expert centre, IIa)
51
What is the size criteria for surgery in case of Loeys-Dietz aortic aneurysm ?
Complicated. Generally > 4.5 but will vary depending on the genetic variant.
52
What kind of valve for patients 50-65 y ?
Individualized decision making
53
What kind of valve is put in TAVI ?
BIOPROSTHETIC
54
What medical therapy should you consider for asymptomatic AAA ?
Smoking cessation is the only medical therapy proven to reduce risk of rupture
Also:
- BP management, < 140/90 or <130/80
- Statin PRN
- Low dose ASA is atherosclerotic disease present
55
What should you do for surveillance for AAA > 5cm in men or > 4.5cm in women ?
Imaging every 6 months
56
What test to ask if you suspect a CLASSIC low flow low gradient AS ?
Dobutamine stress echo or calcium score of the valve
57
What test to order if you suspect a paradoxical low flow low gradient AS ?
Cardiac CT for calcium scoring of the valve (> 2000 in men, > 1300 in women is severe)
Dobutamine echo is not helpful
58
What type of valve for older patients > 65y ?
Bioprosthethic
59
When is anticoagulation (VKA) indicated for rheumatic mitral stenosis ?
- Prior embolic event
- LA thrombus
- AF
60
When is mitral valve surgery indicated ?
(commissurotomy +/- repair OR replacement)
- Severe symptomatic MS + acceptable surgical risk + CI/failed PMBC
- Severe MS and other cardiac surgery planned
61
When is percutaneous mitral ballon commissurotomy (PMBC) for mitral stenosis contraindicated?
CONTRAINDICATED if:
i) LA thrombus (need preop TEE)
ii) ≥ moderate MR
62
When is percutaneous mitral balloon commissurotomy indicated for mitral stenosis ?
- Severe, symptomatic MS + favourable valve anatomy + can be performed at comprehensive valve centre
63
When should you choose TAVI when you need to intervene for aortic stenosis ?
- For intermediate, high, prohibitive surgical risk patients
- Age > 80 or younger patients with life expectancy < 10y
- Consider for patients ages 67-80
64
When should you introduce antithrombotic therapy for bioprosthetic valves ?
Initial 3-6 months post implantation
65
Which medication increases risk of aneurysm rupture ?
FLUOROQUINOLONES
Avoid of aortopathy !
66
Which type of valve for younger patients < 50 y ?
Mechanical
67
Who should you screen for peripheral arterial disease ?
Adults age > 50 with risk factors (smoking, diabetes) even if asx
No screening if no risk factors
Use ankle brachial index or TBI
68
What is a normal ankle brachial index ?
0.9 to 1.4
(highest of ankle pressure as numerator / highest of brachial pressure as denominator)
69
What is an abnormal ankle brachial index ?
0.8 and under : some to severe arterial disease
Greater than 1.4 indicates calcification of the arteries
70
When should you introduce antithrombotic in peripheral arterial disease management ?
Only if symptomatic
First line : ASA + low dose rivaroxaban 2.5 BID if high risk of ischemic events and low bleeding risk
Otherwise SAPT (clopi > ASA)
71
When is revascularization indicated in case of peripheral arterial disease ?
If sx affecting QoL and good targets to revascularize
Avoid endovascular repair in common femoral / femoral profundus
72
What is the antithrombotic treatment post revascularization for peripheral arterial disease ?
- Elective endovascular repair : ASA + low dose rivaroxaban 2.5 BID first line (DAPT otherwise)
- Elective open repair : same but single antiplatelet or VKA otherwise
- Emergent revascularization, post op: full dose anticoag + SAPT or ASA + low dose rivax or DAPT
73
Does the clinical examination predict lower extremity PAD ?
No clinical exam alone not sufficient to rule in or rule out
74
In case of leg pain consistent with claudication, what are tests that help RULE IN PAD ?
- Any pulse abnormality in symptomatic leg (LR+4.7)
- Presence of bruit in symptomatic leg (LR+5.6)
- Symptomatic leg cooler to touch (LR+5.9)
- Wounds or sores (LR+5.9)
- Discoloration (LR+2.8)
75
To screen for PAD, even though ABIs should be done, what physical exam test can help RULE IN PAD ?
Presence of femoral bruit (LR + 4.8)
Any pulse abnormality (LR + 3)
76
In what settings might one hear a pulsus paradoxus ?
Cardiac tamponade (sens 98%)
Severe asthma / exaggerated inspiratory efforts
Also described in RV infarction, PE, severe pectus excavatum, severe asthma/COPD
77
When is Kussmaul heard ?
Restrictive cardiomyopathy and constrictive pericarditis
78
What is the best LR to rule in cardiac tamponade ?
Presence of pulsus > 12 mmHg
Sensitive also : tachycardia (SN 77%), elevated JVP (SN 76%)
Not helpful : hypotension, diminished heart sounds (SN around 25%)
79
How is S2 in atrial septal defect ?
Wide, fixed S2
80
What is the murmur in atrial septal defect ?
Don’t actually hear murmur from flow through defect.
What you hear is a diastolic rumble due to increased flow over tricuspid valve
Pulmonary ejection murmur (systolic flow murmur) over 2nd LICS
81
What do you hear in case of atrial septal defect ?
Wide fixed S2
Diastolic rumble due to increased flow over tricuspid valve
Pulmonary ejection murmur (systolic flow murmur) over 2nd LICS
82
What murmur do you hear in ventricular septal defect ?
Holosystolic murmur 3-4th ICS with thrill
Smaller defect generate higher pitched and louder murmurs
If larger defect : quieter, lower pitched murmurs but greater flow with LV enlargement = *enlarged and displaced apical impulse*
83
What is the carotid pulse in case of aortic stenosis ?
Parvus et tardus : montée lente, pic tardif, faible amplitude
84
What is the carotid pulse in case of HCM?
Brisk initially
Bisferiens
85
What is the precordial exam in HCM ?
Diffuse / sustained apical impulse or double tap
86
How are the S1 / S2 in aortic stenosis ?
Dec intensity of S2
87
How are S1 / S2 in HCM ?
Paradoxic split S2 with severe obstruction
S4 in 50 % of patients
88
What is the murmur heard in case of aortic stenosis ?
Cresc-decresc murmur on ICS / RUSB
Radiates : clavicle, carotid
89
What is the murmur heard in case of HCM ?
Midsystolic cresc-decresc at apex, left lateral sternal border
Radiates axilla, base (NOT neck)
(Can have a MR murmur too : high pitched pansystolic murmur heard at the apex)
90
How can you differentiate aortic stenosis from HCM with manoeuvers ?
BOTH will be softer if :
Increase afterload
Decrease preload to differentiate :
AS will be softer
HCM will be louder (LR + 14)
The murmur is similar but not heard at the same location
AS : 2nd ICD / RUSB
HCM : apex / LLSB
91
How can you differentiate aortic stenosis from mitral regurgitation with manoeuvers ?
AS softer with increase afterload
MR louder with increase afterload
92
Impact of valsalva on hemodynamics ?
Decrease preload
93
Impact of squat -> stand on hemodynamics ?
Decrease preload
94
Impact of hand grip on hemodynamics ?
Increase afterload
95
Impact of IECA on hemodynamics ?
Decrease afterload
96
What are the three tips to RULE IN aortic stenosis on physical exam ?
- Slow rate of rise of carotid pulse (LR 2.8-130)
- Mid to late peak murmur (LR 8-101)
- Soft S2 (LR 3.1-50)
97
What is the tip to RULE OUT aortic stenosis on physical exam ?
Absence of radiation to right carotid (LR 0.05-0.10)
98
What are the two conditions that cause wide split S2 ?
RBBB, LV permanent pacemaker
99
What are the two conditions that cause a wide fixed S2 ?
ASD, RV failure
100
What are the five conditions that cause paradox split S2 ?
LBBB, WPW, fixed LVOT, AS, HOCM
101
How is A2 in CoA ?
Loud A2
102
What causes soft A2 ?
Aortic insufficiency or severe calcific aortic stenosis
103
What causes a soft P2 on physical exam ?
Pulmonary stenosis, low pulm artery pressure
104
What are the 3 causes of a wide split S1 ?
RBBB, ASD, Ebstein’s anomaly
105
What does squat does on hemodynamics ?
Increase venous return
106
How will the murmur of AS/MS vs AR/MR change according to afterload ?
When is the murmur louder?
AS/MS : louder with decreased afterload
AR/MR : louder with increased afterload
107
Which wave is usually the dominant wave on JVP ?
the a wave
108
How can you describe the JVP wave according to the carotid or brachial pulses ?
Time the peak of the pulse with the largest wave. If they concoinde : v is higher than a
109
When is S3 heard on the cardiac cycle ?
After S2
110
When is S4 heard on the cardiac cycle ?
Just precedes S1
111
Describe the JVP wave.
A : atrial contraction
c : tricuspid valve closure
v : passive atrial filling / ventricular contraction
x : atrial diastole
y : atrial emptying
112
Describe the dynamic auscultation of a mitral valve prolapse.
Misystolic click
If LV is full = squatting : the click will be later
If LV is less full = standing : the click will occur earlier
113
What is the signification of S3 ?
Bloood distending a baggy ventricle : LV systlic dysfunction
Look for other signs of LV enlargement and CHF
114
What is the signification of S4 ?
Due to blood distending a stiffened ventricle
Most often associated with diastolic heart failure (HFpEF)
115
Continuous murmur : through systole and diastole. DDX ?
Coarctation
PDA
Arterial stenosis (subclavian) or arterial to venous fistula
Ruptured sinus of valsalva to atrium
116
What is the first line procedure for mitral stenosis : percutaneous mitral ballon commisurotomy or commissurotomy +/- repair OR replacement ?
PMBC
117
What is the antithrombotic therapy if bioprosthetic valve within 3 months + new onset FA ?
VKA
118
What is the best anti hypertensive drugs for aorta aneurysm ?
What is the BP target?
BB 1st choice then ARB
Target < 140/90 but lower may be better CCS 2023 mentions 130/80
119
Patient avec sténose mitrale rhumatismale. Quel signe serait le plus suggestif d’une hypertension pulmonaire?
A) B2 palpable en parasternal G
B) Souffle diastolique
C) B2 dédoublé en parasternal G avec B2P fort
D) B2 dédoublé à l'apex
C)
Si fonction VD préservé : augmentation de l’intensite de B2P qui peut devenir palpable
Si VD defaillant : TVC augmenté, a wave proéminente ou v wave proeminente si IT
Aussi B3 ou B4
Wide splitting of B2
Holosystolic murmur of tricuspid regurg and in more severe disease diastolic pulmonic reg murmur
120
Jeune femme 38 ans qui a des palpitations occasionnelles. Pas d'autres symptômes et examen normal. ECG normal sauf pour quelques extraystoles ventriculaires. Que faites-vous?
1. MIBI à l'effort
2. Coro
3. Électrophysiologie
4. Réassurance
Reassurance
121
. Patient de 60 a, qu'on voit en pré-op d'une chirurgie élective. Pt asymptomatique présentant un souffle systolique 2/6 irradiant à l'aisselle, B1 diminué, B2 prolongé (large), montée carotidienne rapide, mais de faible amplitude et augmentation du souffle en position accroupie. Apex déplacé vers la gauche d'environ 3cm au 5e espace intercostal. SV normaux. Quelle est l'étiologie du souffle du patient?
1- Dégénérescence myxomateuse de la valve mitrale
2- Maladie rhumatismale
3- CMP hypertrophique
4- Sténose aortique
2) maladie rhumatismale mais prob des erreurs dans la question
IM
- B1 diminue
- B2 dedoublé, P2 aumenté si HTAP
- B3 fréquent
- Choc apexien vigoureux etale et deplace
- Pouls carotidien N
- Souffle holosystolique irradit axillaire
122
Femme de 26 ans, avec ATCD de désintox il y a 3 mois, référée par son nouveau médecin de famille en raison d'un souffle. Souffle 4/6 PSG, avec augmentation du souffle lorsqu'elle vous sert les mains très fort. B1, B2 normaux. RXP et ECG normaux. Quelle est l'étiologie de ce souffle?
1- IT
2- Dégénérescence myxomateuse de la valve mitrale
3- Sténose aortique
4- CIV
CIV
Soufle qui augmente avec handgrip en faveur
En petite CIV, ECG N tout comme B1 B2 N puisque pas HTP
Gros souffle dans ce cas aussi
123
Régurgitation aortique chronique. Quel est le meilleur indicateur de régurgitation aortique sévère
a. Intensité du murmure
b. B4
c. Pulse pressure
d. Augmentation du souffle avec compression des pouls
Pulse pressure
