Cardiology: MCAS, CMP, AF, PMP, Pericarditis Flashcards
1
Q
AF : long term rythm control choices
Which medication to use in case of CAD ?
A
Amiodarone, dronaderone, sotalol
2
Q
AFIB + ACS NO PCI : what treament ?
A
- CHADS 65 = 0 : DAPT
- CHADS > 65 : dual pathway therapy (clopi + apix 5 BID) for 1-12 months post ACS then OAC only
3
Q
AFIB + PCI (elective + ACS) : how do you treat ?
A
LOW RISK thrombotic events + elective PCI no ACS
- CHADS 65 = 0 : DAPT for 6-12 months
- CHADS 65 > 0 : DUAL PATHWAY -> SAPT with a P2Y inhibitor (CLOPI) + OAD for at least 1 month, up to 12 months after PCI, then OAC alone
HIGH RISK thrombotic events or ACS with PCI
- CHADS 65 = 0 : DAPT
- CHADS 65 > 0 : triple therapy x 1-30d THEN dual pathway therapy (clopi + OAC up to 12 months post PCI) then OAC only
4
Q
AFIB + STABLE CAD/PAD : what treatment ?
A
CHADS = 0 : single antiplatelet or consider ASA + low dose rivaroxaban 2.5 BID per COMPASS trial to reduce CV mortality
CHADS > 0.5 : OAC with DOAC only
5
Q
Bare metal stent (BMS) have a higher risk of …
A
Restenosis.
(but lower risk of stent thrombosis after 4+ weeks)
6
Q
Can you give ARNI if history of angioedema ?
A
No ARNI CI if hx of hereditary / familial or idiopathic angioedema
7
Q
Can you give colchicine in pregnancy ?
A
No
8
Q
Can you give OAC in case of liver disease ?
A
No OAC in Child Pugh class C or liver disease associated with significant coagulopathy
9
Q
CHF exacerbation : Continuous infusion or bolus furosemide ?
A
Continuous infusion to more quickly achieve diuresis but more studies needed
10
Q
CI to thromobolysis for STEMI ? HABITS
A
- Hemorrhage (intracranial, ever)
- Aortic dissection
- Bleeding (diathesis or active)
- Intracranial (lesion, malig. etc.)
- Trauma (closed head)
- Stroke (ischemic within 3month)
11
Q
COMPASS trial results in chronic stable CAD ?
A
Low dose ASA + rivaroxaban 2.5 BID is reasonable alternative to ASA alone in patients with CAD + AD CHADS065 = 0
12
Q
Contraindications to myocardial perfusion imaging ?
A
Active or severe asthma / COPD, as dypiridamole can cause bronchospasm
13
Q
Do you choose rate or rythm control in AF ?
A
Rythm control for most stable patient with recent onset AD (recent < 1yr) as it reduced CV death and stroke
(synchronized cardioversion for sinus rythm)
14
Q
Do you continue GDMT for CHF in patients on chronic dialysis ?
A
Yes
15
Q
Do you give 2nd antiplatelet prior to angiography:
STEMI ?
NSTEMI ?
Elective angiogram ?
A
- STEMI: give second antiplatelet before angiogram
– NSTEMI: if angiogram anticipated within 24 hours of presentation, can hold off giving second antiplatelet. If >24h expected before cath, give second antiplatelet
– Elective angiogram: do not routinely treat with second antiplatelet
16
Q
Do you give ACE/ARB/ARNI to black patients or start with hydralazine/ISDN ?
A
In presence of LV dysfunction (CAD or not) still treat with ACEI/ARB/ARNI. Add hydralazine/nitrate combination if ongoing sx despite rx.
17
Q
Does angiogram in NSTEMI for int/high risk patients reduces mortality?
A
No
18
Q
Does salt restriction improve death in HFrEF ? Hospital visit ?
A
No
Does not improve HF related hospital visit or CV death
19
Q
DRIVING RECOMMENDATION :
STEMI/NSTEMI with LVEF > 40%
STEMI/NSTEMI with LVEF </= 40%
STEMI/NSTEMI with no PCI performed
A
1)
private car 2w post d/c
commercial 1m post d/c
2)
1 month post d/c
3 months post d/c
3)
1 month post d/c
3 months post d/c
20
Q
DRIVING RESTRICTION:
UA (ACS without MI)
PCI in non ACS context
Asx CAD stable angina
CABG
A
1)
private 48h w PCI or 7d without PCI
commercial 7d w PCI or 1 month without PCI
2) 48h private and commercial
3) OK to drive both
4) 1 month post d/c private or 3 months post d/c commercial
21
Q
Dual pathway regiments for AF and CAD : what are the OAC ?
A
Normal dose edoxaban, apixaban, dabigatran BUT rivaroxaban only 15 mg PO daily (10 mg in patients with CrCl 30-50 mL/min).
22
Q
FA : long term rhythm control choices
If heart failure ?
A
LVEF ≤ 40% : amiodarone
LCEF > 40% : amiodarone or sotalol
23
Q
For pericarditis and NSAID intolerentm what should you use ?
A
Pick colchicine over prednisone in MCQ
(but ideally both)
24
Q
How do you manage AF with WPW ?
A
Electrical cardioversion, IV procainamide or ibutilide
Avoid AV nodal blocking agents
Restore sinus rhythm preferred
25
How do you titrate the quadruple therapy in HFrEF ?
Titrate every 2-4 weeks to target or maximally tolerated dose over 3-6 months
26
How do you treat AD with pre-excitation (WPW) ?
DC cardioversion or procainamide
27
How long DAPT for medically managed ACS (no PCI)?
Which antiplatelet ?
Generally 12 months
Tica > clopi > prasugrel
28
How long of DAPT post ACS (STEMI or NSTEMI/UA)?
What if high risk of bleeding ?
aim for 12 months and reassess bleeding at 1year
If High Risk of Bleeding with PCI post ACS, can de-escalate to SAPT after 1-3 months of DAPT OR de-escalate from a more potent second antiplatelet (i.e. change from ASA+ticagrelor to ASA+clopidogrel)
29
How quick should fibrinolysis be administrated in STEMI ?
Within 30 minutes of FMC
30
How should you anticoagulate CKD/ESRD patients for AF?
Stage 3 and 4 : ACO as usual
Apixaban and rivaroxaban are approved for use with stage 4 CKD
Stage 5 CKD (DFG <15) : NO anticoagulation and NO antiplatelet therapy for AF !
31
How to treat HFpEF ?
Symptom driven.
- BP control
- Loop diuretics if congestion
- SGLT2 FOR ALL to reduce HF hospitalizations
- Consider candesartan
- Consider MRA, ARB and ARNI to reduce hospitalizations, particularly if LVEF on lower end of spectrum (40-50 %)
32
How to you treat AF in cardiac amyloidosis ?
OAC for everyone regardless of CHADS65
33
How to you treat AF in patient with hypertrophic CMP ?
OAC for everyone (CHADS 65 does not apply)
34
Hyper acute T waves in STEMI or NSTEMI ?
STEMI
35
In case of dual or triple therapy regimens with warfarin, what should be the INR target ?
INR target 2-2.5
36
In non ACS situation / elective PCI and high risk of bleeding
What do you do with DAPT with a BMS (bare metal stent) ?
BMS = DAPT for 1 month then SAPT with ASA 81 or Clopidogrel 75 indefinitely
37
In non ACS situation / elective PCI and high risk of bleeding
What do you do with DAPT with a DES ?
DES = DAPT for 3 months then SAPT with ASA 81 or Clopidogrel 75 indefinitely
38
In NON ACS situations / elective PCI, DAPT for how long ?
What if high risk of bleeding ?
DAPT for 6 months, then reassess
– If High Risk thrombotic events: extend DAPT up to 3 yrs
– If not at high risk of thrombosis or if now at high risk bleeding: SAPT (ASA or Clop)
High Risk of Bleeding:
– BMS = DAPT for 1 month then SAPT with ASA 81 or Clopidogrel 75 indefinitely
– DES = DAPT for 3 months then SAPT with ASA 81 or Clopidogrel 75 indefinitely
39
Influenza vaccine post myocardial infarction ? Mortality ?
Reduced all cause mortality, MI, stent thrombosis at 12 months compared to placebo
Administered within 72h post STEMI/NSTEMI
40
Is competitive exercice in young patients with hypertrophic CMP associated with mortality ?
Recently published LIVE-HCM (JAMA 2023) showed that vigorous/competitive exercise in young (mean age 39) patients with HCM was not associated with increased mortality/syncope/ICD shocks compared to nonvigorous exercise.
41
Max time to give fibrinolysis ?
Up to 24h after onset of chest pain w STE
42
Opioid during STEMI ? YES or NO
NO
43
PERI OP : elective non cardiac surgery, delay surgery for how long
BMS ?
DES ?
1 month BMS
3 months DES
44
PERI OP : semi urgent non cardiac surgery, how long delay surgery
BMS ?
DES ?
BMS delay 1 month
DES delay 1 month
(semi urgent sx usuallyy can’t be delayed 1 month)
45
Post ACS, after 1 year of DAPT, what should you do depending on bleeding risk ?
If HIGH RISK bleed: SAPT ASA 81 or Clopidogrel 75
If LOW RISK bleed: Continue DAPT - Good evidence for up to 3 years
DAPT After 12 months: Suggest ASA + one of:
• Ticagrelor (60 mg po bid) (reduced dose, not standard dose)
• Clopidogrel (75 mg po daily)
• Prasugrel (10mg po daily) (weaker recommendation that others for extended therapy)
46
POST PCI trial results in chronic stable CAD ?
Investigated patients post-PCI for high risk CAD (left main, multiple lesions, bifurcating/long lesions, diabetes) undergoing routine stress testing at 1 year vs. usual care (symptom driven)
– No differences in all cause death, MI or hospitalization for angina with surveillance strategy on routine stress testing
Don’t need to stress patients routinely unless they have a change in symptom
47
PRE OP : what to do with antiplatelets ?
Hold clopidogrel and ticagrelor 5-7d pre op
Hold prasugrel 7-10d pre op
Continue ASA periop whenever possible
48
Reversal agent for dipyridamole ?
Aminophylline
49
Routine administration O2 during STEMI ? YES or NO
NO if SpO2 > 90 %
50
Should you use ACEi in HCM ?
No avoid afterload reducing agents
51
Should you use canagliflozin CHF ? What is the eGFR cut off ?
Only if T2DM + GFR > 30
Dose is 100 mg/d, optinal increase to 300mg/d at 13w
There is no trial for canagliflozin in NON diabetics so far
52
Should you use nitrate in CMP?
No avoid preload reducing agents
53
Si haut risque de saignement contexte ACS, diminuer le temps de DAPT a quelle duree ?
1-3 moins non inferieur a duree plus longue
If stepdown to SAPT, choose P2Yinhibitor over ASA
54
Triple therapy regiments for AF and CAD : which OAC ?
Warfarin daily, rivaroxaban 2.5 mg PO BID, or apixaban 5 mg BID (reduced to 2.5 mg if they met two or more of the following dose reduction criteria: age > 80 years of age, weight < 60 kg, or Cr > 133 μmol/L).
55
Troponins negative or positive in unstable angina ?
Negative
56
What anti diabete medication should you avoid in CHF ?
Saxagliptin (but other DPP4i OK), thiazolinediones
57
What antiplatelets in case of thrombolysis in ACS ?
ASA + clopidrogrel
58
What are contraindications of CCTA ?
– ACS
– Severe structural heart disease (AS or HCM)
– Usual CT precautions: Contrast Allergy, Renal Failure, Pregnancy
59
What are disease modifying therapies in chronic stable CAD ?
Name 4 points
– ACE inhibitors: HTN, T2DM, LVEF <40%, CKD, can be considered for all for vascular protection
– Beta blockers: LVEF<40%
• *If no previous MI and LVEF >50 = use of BB therapy does not ↓ MACE, in absence of other indication for BB (eg for control of HTN or rapid afib)
– CAD + DM: SGLT2i or GLP1RA
– Hypertension, dyslipidemia, diabetes management
60
What are drugs that cause pericarditis ?
Procainamide, hydralazine, INH, minoxidil, dilantin
61
What are false negatives of Myocardial Perfusion Imaging ?
- Drug interactions with dipyridamole : caffeine / theophylline - hold before test
- Severe flow limiting triple vessel or left main disease (balanced ischemia so no perfusion mismatch detected)
62
What are indications of CCTA ?
- Diagnosis of CAD for low to intermediate pre-test prob patients
- Risk stratification in patients with stable CAD
63
What are the 3 indications of PCI > fibrinolysis in STEMI ?
1) If timely
- PCI capable hospital : FMC to balloon time < 90 min
- Non PCI capable hospital : FMC to balloon time < 120 min
2) If later presentation (12-24h)
3) If cardiogenic shock
64
What are the advantages of the drug eluting stents ?
Lower rateds of restenosis
Can be used in smaller vessels + CABG grafts
65
What are the antiplatelets to use for elective PCI DAPT ?
ASA 81 + clopidogrel 75
66
What are the considerations for amiodarone in terms of long term toxicity?
transaminits, pneumonitis, thyroid, derm
LFT, thyroid q6mos
CXR annually
67
What are the considerations in prescribing class Ic drugs in rythm control management for AF ?
(fleicaide or propafenone)
Need give BB or ND CCB 30 min prior to prevent 1:1 conduction
Watch out for 1:1 av conduction, first dose given in monitored setting
Not appropriate if structural heart disease or ISCHEMIC CAD, EF < 40, liver failure, CrCL < 35
68
What are the considerations in prescribing sotalol in AF ryhthm control choices ?
Do not use if QT long, CrCl < 40%, other RF for TdP (≥ 65y, women, reduced renal function, concomitant potassium-wasting diuretics)
What out for QT prolongation, TdP : repeat ECG 48-72h on therapy for QT
69
What are the possible EST results ?
Positive, negative, equivocal, uninterpretable
70
What are the strong recommendations for CRT in CHF ?
- Sinus rythm
- Symptomatic
- On GDMT
- LVEF = 35 %
- TYPICAL LBBB
- QRSd >/= 130ms
71
What are the three scenarios where you can do cardioversion for AF ?
- HD unstable acute AF
- NVAF duration < 12 hours and no recent stroke / TIA
- NVAF duration 12-48h and CHADS 0-1
72
What are the weak recommendation for CRT indications in CHF ? (may respond)
In Sinus rhythm
• Symptoms (NYHA II-II, ambulatory IV)
• On GDMT
• LVEF ≤ 35%
• Non-LBBB ******
• QRSd ≥ 150ms ******
73
What are three clues in HF patients that should make you suspect amyloidosis ?
NORMOTENSIVE LVH
- Low flow low gradient AS w EF > 40
- Unexplained sensorimotor neuropathy / dysautonomia
- Bilateral carpal tunnel history
74
What do to with antiplatelets in case of AFIB and SCA ?
– Dual pathway (clopidogrel+OAC) recommended over previous strategy of triple therapy for 1-30 days in most patients (but the small text says they need to receive 1 dose of ASA at PCI time, so it is like they only received 1 dose of triple therapy)
75
What do you do usually do on EKG in case of cardiac amyloidosis ?
Low voltage, pseudoinfarctio pattern
76
What is % EF of HFmEF ?
41-49 %
77
What is % of EF for HFpEF ?
- >/= 50 %
78
What is a CCTA (coronary CT angiography) ? What medication is given?
Low dose CT with beta blockade +/- IV nitro given ( HR target < 60), breath hold
79
What is a complex PCI ? 8 points.
Just need 1:
• Left main
• 3 vessels
• 3 lesions
• 3 stents
• >60mm stent
• Bifurcation stents
• Bypass graft PCI
• Atherectomy, CTO procedure
80
What is a maximal EST result?
Should reach 85% of age predicted max HR
220 - age
81
What is a positive EST test ?
>/= 1mm STE
= 1mm STD : horizontal or downslopping
82
What is antianginal tx for chronic stable CAD ?
( symptomatic benefit )
Name 3 points
– Beta blockers: reduce HR/contractility, indicated for most patients
– CCBs: reduce HR/contractility (non- dihydropyridine, beware if LVEF<40%), reduce preload (dihydropyridine)
– Nitrates: venodilate, reduce LVEDP
83
What is CAC score indication for statin ?
CAC > 100 regardless of FRS
84
What is iron deficiency in CHF ?
Ferritin < 100 or ferritin 100-299 + Tsat < 20%
85
What is loading dose of clopidogrel ?
300-600
86
What is loading dose of prasugrel ?
60mg
87
What is loading dose of ticagrelor ?
180 mg
88
What is maintenance dose of ticagrelor ?
90 BID x 12 months then 60 BID
89
What is the ACS triad ?
Antiplatelet + anticoag + antianginals
90
What is the basic treatment for ALL chronic stable CAD ?
MEDICAL TX NOT INFERIOR TO REVASC
- ASA + statin
- Clopidogrel if ASA intolerent (trials showing reduced MACE with clopidogrel as SAPT)
- Smoking cessation
- Cardiac rehabilitation
- Lifestyle
- Alcohol : reduce ≤1/d women, ≤ 2/d men
- Vaccines
91
What is the definition of STABLE coronary artery disease ?
No PCI or ACS in preceding 12 months
92
What is the definition of valvular AF ?
Mechanical heart valves
Rheumatic mitral stenosis
Moderate-severe non-rheumatic mitral stenosis
93
What is the disadvantage of DES ?
Takes longer to endotheliaze
94
What is the dose and eGFR for dapagliflozin in CHF ?
10 mg/d, OK if eGFR ≥ 25 mL
95
What is the dose and eGFR for empaglifozin in CHF ?
10mg/d, OK if eGFR ≥20
96
What is the dose of apixaban for AF ?
– 5mg PO BID
– 2.5 mg PO BID if 2/3: ≥80 years, ≤ 60kg, creatinine ≥133umol/L
97
What is the dose of dabigatran for AF?
– 150 mg PO BID
– 110 mg PO BID if age > 75 years or eCrCl 30-49 mL/min
98
What is the dose of edoxaban for AF ?
– 60 mg PO daily
– 30 mg PO daily if CrCL 30-50 mL/min, ≤ 60kg, or concomitant use of potent P-glycoprotein inhibitors
99
What is the dose of rivaroxaban for AF ?
– 20 mg PO daily
– 15 mg PO daily if CrCl 30-49mL/min
100
What is the EF usually in cardiac amyloidosis ? What is the clinical presentation ?
Presents with HF (usually HFpEF)
- Presyncope/syncope,
- Atrial arrhythmia (Afib, sometimes Ventricular arrhythmias),
- Bradyarrhythmia
- Higher rates of AS as well
101
What is the investigation in case of cardiac amyloidosis ?
S/U PEP, serum free ligh chains in AL
Tc 99m PYP scan in ATTR (both wild type + hereditary)
Genetic testing for hereditary ATTR
102
What is the ischemic cascade ?
1. Blood flow changes (myoc perfusion)
2. Diastolic then systolic dyfct (wall motion aN)
3. ECG changes
4. Sx
5. Necrosis
103
What is the maintenance dose of prasugrel ?
10mg daily (reduce to 5mg if < 60kg)
104
What is the most common phenotype in hypertrophic cardiomyopathy ?
Asymmetric septal hypertrophy
105
What is the most common type of cardiac amyloidosis ?
AL (cancer-associated) vs. ATTR (wild type vs. hereditary = slowly progressive more common to clinically present in older men)
106
What is the quadruple therapy for HFrEF ?
ARNI / IECA-ARB
MRA
SGLT2
BB
107
What is the salt restriction recommened in HFrEF ?
< 2-3g/day
108
What is the treatment of acute pericarditis in case of a first episode ?
High dose NSAID 1-2 weeks (as needed until pain/CRP resolves) + colchicine x 3 months
109
What is the treatment of acute pericarditis in case of a recurrence ?
High dose NSAID x 2 weeks (as needed until pain/CRP resolves) + colchicine x 6 months
110
What is the treatment of acute pericarditis in case of pregnancy ?
– < 20 weeks à ASA (1st line), NSAIDs, Tylenol, pred
– > 20 weeks à Tylenol, pred; [NO ASA or NSAIDs]
– Breastfeeding : avoid ASA
– NO colchicine
111
What is the treatment of acute pericarditis in context of post MI ?
Use ASA instead of NSAIDs (high dose ASA 650 po QID)
112
What is the treatment of cardiac amyloidosis ?
- DIURETICS ++++
- Cautious use / avoidance of BB, CCB, IECA/ARB, dig
( fixed stroke volume as restricive )
- ATTR : tafamidis or inotersen or patisiran +/- liver transplant
113
What is the treatment of hypertrophic CMP ?
- Avoid hypovolemia
- BB > CCB > dysopyramide
- For refractory sx and LVOTO : septal myomectomy/ETOH ablation
- OAC for anyone with AF (CHADS 65 does not apply)
AVOID AFTERLOAD REDUCING AGENTS (ACEi) and AVOIR PRELOAD READUCING AGENTS (nitrates, diuretics)
114
What kind of CMP is cardiac amyloidosis ?
Restrictive usually
115
What should you monitor for with metolazone use ? Name 4
- Hypok
- HypoNa
- Contraction alkalosis
- Renal function
116
What timing is necessary for angiogram for int / high risk patients having a NSTEMI ?
Within 48h
Reduces risks of rehospitalization for ACS but no mortality benefit
117
What to do with antiplatelets in case of AFIB in context of STABLE CAD?
– OAC monotherapy preferred over OAC+aspirin in stable CAD (from the AFIRE trial which showed rivaroxaban+ASA had more bleeding with no reduction on ischemic events compared to rivaroxaban alone)
118
When do you anticoagulate for AF in pregnancy ?
Anticoag if AF and structural disease OR no structural heart disease but CHADS >/= 1
119
What will ACEi do on HCM murmur ?
INCREASED murmur as reduced afterload
Increased afterload opens the LVOT, increases ventricular volume, decreasing gradient and improving obstruction
120
What will be the sodium and chloride on urine in case of metabolic alkalosis ?
Low urine chloride, high urine sodium
You can use acetazolamide
121
What will bradycardia / BB do on the HCM murmur ?
REDUCE
Bradycardia (eg beta blockade) gives more diastolic filling time and increases ventricular volume, which improves obstruction
122
What will handgrip do on HCM murmur ?
Increases afterload
REDUCED murmur
123
What will passive leg raise do on HCM murmur ?
Increase venous return
REDUCED murmur
124
What will standing up do on HCM murmur ?
INCREASED MURMUR as lower venous return
125
What will valsalva do on HCM murmur ?
INCREASED murmur bc venous return diminished
126
When are BB indicated in chronic stable CAD ?
LVEF < 40 %
If no previous MI and LVEF > 50 : use of BB does not lower MACE in absence of other indication
127
When ca you start ARNI for HFrEF ?
Start ARNI if hospitalized with new dx HFrEF
Switch to ARNI if
Hospitalized for HF on ACE / ARB
Symptomatic (NYHA 2+) despite max ACE/ARB
** requires 36h washout period after ACEI use !!
128
When is anticoagulation stopped in ACS ?
Continued for 48h until discharge or 8 daysm stop if revasculariwed
RIGHTtrial(ESCmeeting,2023)showedthat,inSTEMI,48hourspostPCI anticoagulation (different regimens, lower doses overall, similar to DVT prophylaxis or slightly more) showed no difference in death, MI, stroke, revascularization, stent thrombosis.
129
When is CABG preferred in case of chronic stable CAD ?
Name 4 points
– Left Main or Multivessel dz with LVEF ≤35%
↑survival over GDMT alone
– Left Main associated with high complexity CAD (= high syntax score)
↑survival over PCI
– Multivessel dz with high complexity CAD
↑survival over PCI
– Multivessel dz in DIABETES with LAD involvement amenable to LIMA (left internal mammary artery)
↑survival and ↓revascularization over PCI
*** less repeat revasc with CABG
130
When is CAC (coronary artery calcium) score indicated ?
- recommended for further risk
stratification of intermediate risk (FRS 10-19%) asymptomatic patients aged > 40 who are not candidates for statin based on other risk factors
- Can consider CAC scoring for low risk patients with family hx premature CV Dz and genetic dyslipidemia
131
When is coronary angiography indicated in context of CHF ?
- Recomment if HF with angina
- Consider if LVEF < 35, at risk of CAD, irrespective of angina
- Consider if systolic HF and non invasive coronary perfusion consistent with high risk
Has to likely be a good candidate for revascularization
132
When is left atrial appendage occlusion indicated for stroke prevention in AF ?
Absolutely cannot tolerate OAC (cerebral amyloid angiopathy and high CHADS AF)
133
When is PCI indicated in chronic stable CAD ?
– Poor surgical candidate
– Single vessel disease
– Diabetes with LM and low/intermediate
complexity CAD consider as alternative to CABG
134
When is prasugrel CI ?
Prior TIA / Stroke
Active bleeding
Hypersensitivity reaction
135
When is ticagrelor CI ?
Name 5 indications
- previous intracranial hemorrhage
- active pathological bleeding
- moderate / severe hepatic impairment
- combinations with CYP34A inhibitors (ketoconazole, clarithro, ritonavir)
- Heart block or bradycardia
136
When should invasive angiography be considered ?
High risk features on non invasive testing
Medically refractory sx
137
When should PCI occur if fibrinolysis is done ?
Within 24h
138
When should you choose rythm control over rate control for persistent AF ?
- Recently diagnosed AF within 1y
- Highly sx or significant QOL impairment
- Multiples recurrences
- Difficulty to achieve rate control
- Arrhythmia-induced cardiomyopathy
139
When should you consider ICD in hypertrophic CMP ?
- CLASS I : Sustained VA or prior cardiac arrest
- CLASS IIa :
FMHx of SCD
LV wall thickness >30 mm (however positive predictive value low, most who die < 30mm thickness)
Unexplained syncope
Apical aneurysm
****LVEF <50%******
- CLASS IIb :
Extensive LGE on MRI
NSVT on Holter monitoring
140
When should you give steroids for pericarditis ?
INCREASE RECURRENCE RISK so avoid unless immune-mediated etiology or clearly non-responsive/CI to ASA/NSAIDs
Should give colchicine in addition
Low dose 0,25-0,5 mg/kg/d
141
When should you stop ASA / NSAIDs during pregnancy for pericarditis ?
NO ASA or NSAIDS after 20 weeks (ductus arteriosis)
NO ASA for breastfeeding
142
When should you use drug coated ballon ? 3 indications
Expand a blood vessel and deliver antiproliferative agents (paclitaxel) without delivering a stent
Useful for in-stent restenosis, bifurcating/branch lesions, buying time for definitive tx
143
When to consider digoxin in HFrEF ?
Persistent sx ddespite rx
Above or poor rate cntrl with AFIB
144
When to consider hydralazine / ISDN in HFrEF ?
If black pts on optimal GMPT
If unable to take ACE / ARB / ARNI
145
When to consider ivabradine ?
Sinus rythm and HR > 70
Use if hospitalized in last 12 months for CHF + HR > 70
Maximize dose of BB first
146
When to consider revascularisation in chronic stable CAD ?
Consider revascularization if refractory symptoms, high risk structural disease (e.g. LM disease), LV dysfunction, severe MR
147
When to consider vericiguat ?
If recent HF hospitalization
148
When to use functional imaging ?
- Cannot accurately assess ischnia on ECG : LBBB, paced, preexcitation, ST changes at rest
- Need specific anatomic correlation (prior revasc)
149
When you should you choose rythm control for AF management ?
Is QoL impaired (symptomatic despite rate control) or hemodynamically unstable
150
Which cardiomyopathy is associated with
- Dynamic LV outflow tract obstruction
- SAM : eccentric MR
- Papillary muscle abnormality
Hypertrophic cardiomyopathy
151
Who do you anticoagulate in case of secondary atrial fibrillation ?
No OAC only exceptions :
- abnormal substrate
- risk for recurrence estimated to be high
- acute thyrotoxicosis until euthyroid state is restored
152
Who should you screen in the family in case of hypertrophic CMP ?
1st degree relatives
153
Why should you use a score to decide if you should hospitalize your patient presenting for CHF ?
COACH-HF TRIAL : use of risk score tool (EHMRG30-T) stratifying patients into low risk and high risk for admission was associated with lower rates of overall death and hospitalization
154
In which situation is standard DAPT only 6 months ?
Elective PCI with stable CAD
155
In which situation is ticagrelor frankly preferred over prasugrel ?
ACS without PCI
TICAGRELOR OVER CLOPI
Do not pick prasugrel if no PCI
156
What is the only OAC studied after ACS without PCI in case of AFIB ?
Apixaban 5 po BID
157
Is there less stroke in PCI or CABG groups ?
Conflicting stroke data
158
Is there a mortality benefit with CABG over PCI ?
Yes in highly selected scenarios like diabetes
