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Les deux ennemis > Cardiology: MCAS, CMP, AF, PMP, Pericarditis > Flashcards

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

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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
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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

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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

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5
Q

Bare metal stent (BMS) have a higher risk of …

A

Restenosis.
(but lower risk of stent thrombosis after 4+ weeks)

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6
Q

Can you give ARNI if history of angioedema ?

A

No ARNI CI if hx of hereditary / familial or idiopathic angioedema

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7
Q

Can you give colchicine in pregnancy ?

A

No

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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

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9
Q

CHF exacerbation : Continuous infusion or bolus furosemide ?

A

Continuous infusion to more quickly achieve diuresis but more studies needed

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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)
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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

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12
Q

Contraindications to myocardial perfusion imaging ?

A

Active or severe asthma / COPD, as dypiridamole can cause bronchospasm

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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)

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14
Q

Do you continue GDMT for CHF in patients on chronic dialysis ?

A

Yes

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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
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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.

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17
Q

Does angiogram in NSTEMI for int/high risk patients reduces mortality?

A

No

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18
Q

Does salt restriction improve death in HFrEF ? Hospital visit ?

A

No
Does not improve HF related hospital visit or CV death

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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

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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

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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).

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22
Q

FA : long term rhythm control choices
If heart failure ?

A

LVEF ≤ 40% : amiodarone
LCEF > 40% : amiodarone or sotalol

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23
Q

For pericarditis and NSAID intolerentm what should you use ?

A

Pick colchicine over prednisone in MCQ
(but ideally both)

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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

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25
Q

How do you titrate the quadruple therapy in HFrEF ?

A

Titrate every 2-4 weeks to target or maximally tolerated dose over 3-6 months

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26
Q

How do you treat AD with pre-excitation (WPW) ?

A

DC cardioversion or procainamide

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27
Q

How long DAPT for medically managed ACS (no PCI)?
Which antiplatelet ?

A

Generally 12 months
Tica > clopi > prasugrel

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28
Q

How long of DAPT post ACS (STEMI or NSTEMI/UA)?
What if high risk of bleeding ?

A

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)

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29
Q

How quick should fibrinolysis be administrated in STEMI ?

A

Within 30 minutes of FMC

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30
Q

How should you anticoagulate CKD/ESRD patients for AF?

A

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 !

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31
Q

How to treat HFpEF ?

A

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 %)

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32
Q

How to you treat AF in cardiac amyloidosis ?

A

OAC for everyone regardless of CHADS65

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33
Q

How to you treat AF in patient with hypertrophic CMP ?

A

OAC for everyone (CHADS 65 does not apply)

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34
Q

Hyper acute T waves in STEMI or NSTEMI ?

A

STEMI

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35
Q

In case of dual or triple therapy regimens with warfarin, what should be the INR target ?

A

INR target 2-2.5

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36
Q

In non ACS situation / elective PCI and high risk of bleeding
What do you do with DAPT with a BMS (bare metal stent) ?

A

BMS = DAPT for 1 month then SAPT with ASA 81 or Clopidogrel 75 indefinitely

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37
Q

In non ACS situation / elective PCI and high risk of bleeding
What do you do with DAPT with a DES ?

A

DES = DAPT for 3 months then SAPT with ASA 81 or Clopidogrel 75 indefinitely

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38
Q

In NON ACS situations / elective PCI, DAPT for how long ?
What if high risk of bleeding ?

A

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

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39
Q

Influenza vaccine post myocardial infarction ? Mortality ?

A

Reduced all cause mortality, MI, stent thrombosis at 12 months compared to placebo
Administered within 72h post STEMI/NSTEMI

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40
Q

Is competitive exercice in young patients with hypertrophic CMP associated with mortality ?

A

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.

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41
Q

Max time to give fibrinolysis ?

A

Up to 24h after onset of chest pain w STE

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42
Q

Opioid during STEMI ? YES or NO

A

NO

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43
Q

PERI OP : elective non cardiac surgery, delay surgery for how long
BMS ?
DES ?

A

1 month BMS
3 months DES

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44
Q

PERI OP : semi urgent non cardiac surgery, how long delay surgery
BMS ?
DES ?

A

BMS delay 1 month
DES delay 1 month

(semi urgent sx usuallyy can’t be delayed 1 month)

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45
Q

Post ACS, after 1 year of DAPT, what should you do depending on bleeding risk ?

A

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)

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46
Q

POST PCI trial results in chronic stable CAD ?

A

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

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47
Q

PRE OP : what to do with antiplatelets ?

A

Hold clopidogrel and ticagrelor 5-7d pre op
Hold prasugrel 7-10d pre op
Continue ASA periop whenever possible

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48
Q

Reversal agent for dipyridamole ?

A

Aminophylline

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49
Q

Routine administration O2 during STEMI ? YES or NO

A

NO if SpO2 > 90 %

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50
Q

Should you use ACEi in HCM ?

A

No avoid afterload reducing agents

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51
Q

Should you use canagliflozin CHF ? What is the eGFR cut off ?

A

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

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52
Q

Should you use nitrate in CMP?

A

No avoid preload reducing agents

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53
Q

Si haut risque de saignement contexte ACS, diminuer le temps de DAPT a quelle duree ?

A

1-3 moins non inferieur a duree plus longue
If stepdown to SAPT, choose P2Yinhibitor over ASA

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54
Q

Triple therapy regiments for AF and CAD : which OAC ?

A

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).

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55
Q

Troponins negative or positive in unstable angina ?

A

Negative

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56
Q

What anti diabete medication should you avoid in CHF ?

A

Saxagliptin (but other DPP4i OK), thiazolinediones

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57
Q

What antiplatelets in case of thrombolysis in ACS ?

A

ASA + clopidrogrel

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58
Q

What are contraindications of CCTA ?

A

– ACS
– Severe structural heart disease (AS or HCM)
– Usual CT precautions: Contrast Allergy, Renal Failure, Pregnancy

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59
Q

What are disease modifying therapies in chronic stable CAD ?
Name 4 points

A

– 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

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60
Q

What are drugs that cause pericarditis ?

A

Procainamide, hydralazine, INH, minoxidil, dilantin

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61
Q

What are false negatives of Myocardial Perfusion Imaging ?

A
  • 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)
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62
Q

What are indications of CCTA ?

A
  • Diagnosis of CAD for low to intermediate pre-test prob patients
  • Risk stratification in patients with stable CAD
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63
Q

What are the 3 indications of PCI > fibrinolysis in STEMI ?

A

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

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64
Q

What are the advantages of the drug eluting stents ?

A

Lower rateds of restenosis
Can be used in smaller vessels + CABG grafts

65
Q

What are the antiplatelets to use for elective PCI DAPT ?

A

ASA 81 + clopidogrel 75

66
Q

What are the considerations for amiodarone in terms of long term toxicity?

A

transaminits, pneumonitis, thyroid, derm
LFT, thyroid q6mos
CXR annually

67
Q

What are the considerations in prescribing class Ic drugs in rythm control management for AF ?
(fleicaide or propafenone)

A

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
Q

What are the considerations in prescribing sotalol in AF ryhthm control choices ?

A

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
Q

What are the possible EST results ?

A

Positive, negative, equivocal, uninterpretable

70
Q

What are the strong recommendations for CRT in CHF ?

A
  • Sinus rythm
  • Symptomatic
  • On GDMT
  • LVEF = 35 %
  • TYPICAL LBBB
  • QRSd >/= 130ms
71
Q

What are the three scenarios where you can do cardioversion for AF ?

A
  • HD unstable acute AF
  • NVAF duration < 12 hours and no recent stroke / TIA
  • NVAF duration 12-48h and CHADS 0-1
72
Q

What are the weak recommendation for CRT indications in CHF ? (may respond)

A

In Sinus rhythm
• Symptoms (NYHA II-II, ambulatory IV)
• On GDMT
• LVEF ≤ 35%
• Non-LBBB **
• QRSd ≥ 150ms **

73
Q

What are three clues in HF patients that should make you suspect amyloidosis ?

A

NORMOTENSIVE LVH
- Low flow low gradient AS w EF > 40
- Unexplained sensorimotor neuropathy / dysautonomia
- Bilateral carpal tunnel history

74
Q

What do to with antiplatelets in case of AFIB and SCA ?

A

– 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
Q

What do you do usually do on EKG in case of cardiac amyloidosis ?

A

Low voltage, pseudoinfarctio pattern

76
Q

What is % EF of HFmEF ?

A

41-49 %

77
Q

What is % of EF for HFpEF ?

A
  • > /= 50 %
78
Q

What is a CCTA (coronary CT angiography) ? What medication is given?

A

Low dose CT with beta blockade +/- IV nitro given ( HR target < 60), breath hold

79
Q

What is a complex PCI ? 8 points.

A

Just need 1:
• Left main
• 3 vessels
• 3 lesions
• 3 stents
• >60mm stent
• Bifurcation stents
• Bypass graft PCI
• Atherectomy, CTO procedure

80
Q

What is a maximal EST result?

A

Should reach 85% of age predicted max HR
220 - age

81
Q

What is a positive EST test ?

A

> /= 1mm STE
= 1mm STD : horizontal or downslopping

82
Q

What is antianginal tx for chronic stable CAD ?
( symptomatic benefit )

Name 3 points

A

– 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
Q

What is CAC score indication for statin ?

A

CAC > 100 regardless of FRS

84
Q

What is iron deficiency in CHF ?

A

Ferritin < 100 or ferritin 100-299 + Tsat < 20%

85
Q

What is loading dose of clopidogrel ?

A

300-600

86
Q

What is loading dose of prasugrel ?

A

60mg

87
Q

What is loading dose of ticagrelor ?

A

180 mg

88
Q

What is maintenance dose of ticagrelor ?

A

90 BID x 12 months then 60 BID

89
Q

What is the ACS triad ?

A

Antiplatelet + anticoag + antianginals

90
Q

What is the basic treatment for ALL chronic stable CAD ?

A

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
Q

What is the definition of STABLE coronary artery disease ?

A

No PCI or ACS in preceding 12 months

92
Q

What is the definition of valvular AF ?

A

Mechanical heart valves
Rheumatic mitral stenosis
Moderate-severe non-rheumatic mitral stenosis

93
Q

What is the disadvantage of DES ?

A

Takes longer to endotheliaze

94
Q

What is the dose and eGFR for dapagliflozin in CHF ?

A

10 mg/d, OK if eGFR ≥ 25 mL

95
Q

What is the dose and eGFR for empaglifozin in CHF ?

A

10mg/d, OK if eGFR ≥20

96
Q

What is the dose of apixaban for AF ?

A

– 5mg PO BID
– 2.5 mg PO BID if 2/3: ≥80 years, ≤ 60kg, creatinine ≥133umol/L

97
Q

What is the dose of dabigatran for AF?

A

– 150 mg PO BID
– 110 mg PO BID if age > 75 years or eCrCl 30-49 mL/min

98
Q

What is the dose of edoxaban for AF ?

A

– 60 mg PO daily
– 30 mg PO daily if CrCL 30-50 mL/min, ≤ 60kg, or concomitant use of potent P-glycoprotein inhibitors

99
Q

What is the dose of rivaroxaban for AF ?

A

– 20 mg PO daily
– 15 mg PO daily if CrCl 30-49mL/min

100
Q

What is the EF usually in cardiac amyloidosis ? What is the clinical presentation ?

A

Presents with HF (usually HFpEF)
- Presyncope/syncope,
- Atrial arrhythmia (Afib, sometimes Ventricular arrhythmias),
- Bradyarrhythmia
- Higher rates of AS as well

101
Q

What is the investigation in case of cardiac amyloidosis ?

A

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
Q

What is the ischemic cascade ?

A
  1. Blood flow changes (myoc perfusion)
  2. Diastolic then systolic dyfct (wall motion aN)
  3. ECG changes
  4. Sx
  5. Necrosis
103
Q

What is the maintenance dose of prasugrel ?

A

10mg daily (reduce to 5mg if < 60kg)

104
Q

What is the most common phenotype in hypertrophic cardiomyopathy ?

A

Asymmetric septal hypertrophy

105
Q

What is the most common type of cardiac amyloidosis ?

A

AL (cancer-associated) vs. ATTR (wild type vs. hereditary = slowly progressive more common to clinically present in older men)

106
Q

What is the quadruple therapy for HFrEF ?

A

ARNI / IECA-ARB
MRA
SGLT2
BB

107
Q

What is the salt restriction recommened in HFrEF ?

A

< 2-3g/day

108
Q

What is the treatment of acute pericarditis in case of a first episode ?

A

High dose NSAID 1-2 weeks (as needed until pain/CRP resolves) + colchicine x 3 months

109
Q

What is the treatment of acute pericarditis in case of a recurrence ?

A

High dose NSAID x 2 weeks (as needed until pain/CRP resolves) + colchicine x 6 months

110
Q

What is the treatment of acute pericarditis in case of pregnancy ?

A

– < 20 weeks à ASA (1st line), NSAIDs, Tylenol, pred
– > 20 weeks à Tylenol, pred; [NO ASA or NSAIDs]
– Breastfeeding : avoid ASA
– NO colchicine

111
Q

What is the treatment of acute pericarditis in context of post MI ?

A

Use ASA instead of NSAIDs (high dose ASA 650 po QID)

112
Q

What is the treatment of cardiac amyloidosis ?

A
  • DIURETICS ++++
  • Cautious use / avoidance of BB, CCB, IECA/ARB, dig
    ( fixed stroke volume as restricive )
  • ATTR : tafamidis or inotersen or patisiran +/- liver transplant
113
Q

What is the treatment of hypertrophic CMP ?

A
  • 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
Q

What kind of CMP is cardiac amyloidosis ?

A

Restrictive usually

115
Q

What should you monitor for with metolazone use ? Name 4

A
  • Hypok
  • HypoNa
  • Contraction alkalosis
  • Renal function
116
Q

What timing is necessary for angiogram for int / high risk patients having a NSTEMI ?

A

Within 48h
Reduces risks of rehospitalization for ACS but no mortality benefit

117
Q

What to do with antiplatelets in case of AFIB in context of STABLE CAD?

A

– 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
Q

When do you anticoagulate for AF in pregnancy ?

A

Anticoag if AF and structural disease OR no structural heart disease but CHADS >/= 1

119
Q

What will ACEi do on HCM murmur ?

A

INCREASED murmur as reduced afterload

Increased afterload opens the LVOT, increases ventricular volume, decreasing gradient and improving obstruction

120
Q

What will be the sodium and chloride on urine in case of metabolic alkalosis ?

A

Low urine chloride, high urine sodium
You can use acetazolamide

121
Q

What will bradycardia / BB do on the HCM murmur ?

A

REDUCE

Bradycardia (eg beta blockade) gives more diastolic filling time and increases ventricular volume, which improves obstruction

122
Q

What will handgrip do on HCM murmur ?

A

Increases afterload
REDUCED murmur

123
Q

What will passive leg raise do on HCM murmur ?

A

Increase venous return
REDUCED murmur

124
Q

What will standing up do on HCM murmur ?

A

INCREASED MURMUR as lower venous return

125
Q

What will valsalva do on HCM murmur ?

A

INCREASED murmur bc venous return diminished

126
Q

When are BB indicated in chronic stable CAD ?

A

LVEF < 40 %
If no previous MI and LVEF > 50 : use of BB does not lower MACE in absence of other indication

127
Q

When ca you start ARNI for HFrEF ?

A

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
Q

When is anticoagulation stopped in ACS ?

A

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
Q

When is CABG preferred in case of chronic stable CAD ?
Name 4 points

A

– 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
Q

When is CAC (coronary artery calcium) score indicated ?

A
  • 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
Q

When is coronary angiography indicated in context of CHF ?

A
  • 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
Q

When is left atrial appendage occlusion indicated for stroke prevention in AF ?

A

Absolutely cannot tolerate OAC (cerebral amyloid angiopathy and high CHADS AF)

133
Q

When is PCI indicated in chronic stable CAD ?

A

– Poor surgical candidate
– Single vessel disease
– Diabetes with LM and low/intermediate
complexity CAD consider as alternative to CABG

134
Q

When is prasugrel CI ?

A

Prior TIA / Stroke
Active bleeding
Hypersensitivity reaction

135
Q

When is ticagrelor CI ?

Name 5 indications

A
  • previous intracranial hemorrhage
  • active pathological bleeding
  • moderate / severe hepatic impairment
  • combinations with CYP34A inhibitors (ketoconazole, clarithro, ritonavir)
  • Heart block or bradycardia
136
Q

When should invasive angiography be considered ?

A

High risk features on non invasive testing
Medically refractory sx

137
Q

When should PCI occur if fibrinolysis is done ?

A

Within 24h

138
Q

When should you choose rythm control over rate control for persistent AF ?

A
  • Recently diagnosed AF within 1y
  • Highly sx or significant QOL impairment
  • Multiples recurrences
  • Difficulty to achieve rate control
  • Arrhythmia-induced cardiomyopathy
139
Q

When should you consider ICD in hypertrophic CMP ?

A
  • 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
Q

When should you give steroids for pericarditis ?

A

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
Q

When should you stop ASA / NSAIDs during pregnancy for pericarditis ?

A

NO ASA or NSAIDS after 20 weeks (ductus arteriosis)
NO ASA for breastfeeding

142
Q

When should you use drug coated ballon ? 3 indications

A

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
Q

When to consider digoxin in HFrEF ?

A

Persistent sx ddespite rx
Above or poor rate cntrl with AFIB

144
Q

When to consider hydralazine / ISDN in HFrEF ?

A

If black pts on optimal GMPT
If unable to take ACE / ARB / ARNI

145
Q

When to consider ivabradine ?

A

Sinus rythm and HR > 70
Use if hospitalized in last 12 months for CHF + HR > 70
Maximize dose of BB first

146
Q

When to consider revascularisation in chronic stable CAD ?

A

Consider revascularization if refractory symptoms, high risk structural disease (e.g. LM disease), LV dysfunction, severe MR

147
Q

When to consider vericiguat ?

A

If recent HF hospitalization

148
Q

When to use functional imaging ?

A
  • Cannot accurately assess ischnia on ECG : LBBB, paced, preexcitation, ST changes at rest
  • Need specific anatomic correlation (prior revasc)
149
Q

When you should you choose rythm control for AF management ?

A

Is QoL impaired (symptomatic despite rate control) or hemodynamically unstable

150
Q

Which cardiomyopathy is associated with
- Dynamic LV outflow tract obstruction
- SAM : eccentric MR
- Papillary muscle abnormality

A

Hypertrophic cardiomyopathy

151
Q

Who do you anticoagulate in case of secondary atrial fibrillation ?

A

No OAC only exceptions :
- abnormal substrate
- risk for recurrence estimated to be high
- acute thyrotoxicosis until euthyroid state is restored

152
Q

Who should you screen in the family in case of hypertrophic CMP ?

A

1st degree relatives

153
Q

Why should you use a score to decide if you should hospitalize your patient presenting for CHF ?

A

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
Q

In which situation is standard DAPT only 6 months ?

A

Elective PCI with stable CAD

155
Q

In which situation is ticagrelor frankly preferred over prasugrel ?

A

ACS without PCI
TICAGRELOR OVER CLOPI
Do not pick prasugrel if no PCI

156
Q

What is the only OAC studied after ACS without PCI in case of AFIB ?

A

Apixaban 5 po BID

157
Q

Is there less stroke in PCI or CABG groups ?

A

Conflicting stroke data

158
Q

Is there a mortality benefit with CABG over PCI ?

A

Yes in highly selected scenarios like diabetes

Les deux ennemis (7 decks)

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