DELTA

Question 1

What is the normal E/e’ value?

Answer 1

<8

Question 2

What is the appearance of abnormal myocardium on MRI + Gadolinium?

Answer 2

normal = black
scar = white

Question 3

Causes of:
- subendocardial scar
- transmural scar
- mid wall scar
- subepicardial scar
- endocardial

Answer 3

MI
MI
non-ischaemic with remodelling
myocarditis
amyloidosis

Question 4

Treatment approach for HFpEF

Answer 4

SGLT2i - not available on PBS to non-diabetics
Diuretics to maintain normal filling pressures
ARBs
Salt restriction
Exercise training
Manage comorbidities

Question 5

EMPEROR-preserved study

Answer 5

HFpEF patients given Empa or placebo
Non-diabetic + diabetic
reduced 1’ end point (mainly driven by HF admissions)

Question 6

b-blockers; most cardioselective

Answer 6

metoprolol and bisoprolol
nebivolol is intermediate
carvedilol also action on b2, a1, vasodilator effects also

Question 7

Ivabradine
- indications

Answer 7

must be in sinus rhythm, maximal b-blocker therapy
reduction in CV death / hospitalisations in those with
target <77

Question 8

What is the effect of neprilysin

Answer 8

breaks down BNP

Question 9

How long should ACEi / ARB be stopped prior to commencement of ARB/ARNI?

Answer 9

36 hours
risk of angioedema

Question 10

Chemo and cardiotoxicity / HF

Answer 10

frequent monitoring
give ACEi and B-blockers
consider dose reduction

Question 11

Hypertrophic CM
- inheritance pattern

Answer 11

autosomal dominant
variable penetrance
age related disease expression

Question 12

Hypertrophic CM
- effects

Answer 12

“Myocyte disarray”
asymmetric septal, mid-ventricular, apical and concentric patterns
can occur with or without LVOT obstruction

Question 13

HCM
- presentation

Answer 13

asymptomatic screening
palpitations and syncope
sudden death in young - most common cause
endocarditis
dyspnoea and angina

Question 14

HCM
- risk factors for SCD

Answer 14

FHx premature SCD
Recurrent syncope
Non-sustained VT
Severe LVH (septum >2.5-3cm)
Severe obstruction
Abnormal exercise BP response
myocardial fibrosis on MRI
Specific genotypes

Question 15

Amyloidosis
- configuration of deposited protein
- staining pattern
- types

Answer 15

antiparallel beta-pleated sheets
congo red stain - apple-green
AL amyloid (primary) e.g multiple myeloma
AA amyloid (secondary) e.g. RA, IBD, chronic infection
ATTR amyloid - wt or inherited
Other: dialysis, heritable, age related, organ specific

Question 16

Amyloidosis
- presentation

Answer 16

HFpEF, low voltage ECG, AF
Hepatomegaly
Periorbital purpura
Ventricular hypertrophy on echo

Question 17

Amyloidosis
- ECHO

Answer 17

abnormal longitudinal strain, increased wall thickness, speckled

Question 18

Amylodosis
- diagnosis

Answer 18

serum and urine electrophoresis
bone scintography for transthyretin
if transthyretin confirmed then go on to have genetic testing

Question 19

Cardiac amyloid treatment

Answer 19

Treat HF and treat amyloid
- HF: b-blockers and ACEi usually poorly tolerated, use digoxin with caution
-AL amyloid - chemotherapy
- TTR amyloid - tafamidis

Question 20

Restrictive cardiomyopathy

Answer 20

predominant RHF, normal LV function
Diastolic dysfunction, dilated atria.

Question 21

Advanced heart failure

Answer 21

MDT approach
inotropes
Mechanical devices (CRT, defibrillators, VADs)
Transplant

Question 22

Indications for ICD

Answer 22

1’ prevention
- LVEF<35% (especially ischaemic, less consensus in non-ischaemic), NYHA 2-3 on optimal therapy

Question 23

CRT indications

Answer 23

EF <35% on optimal medical therapy, NYHA 2-4, wide QRS (esp >150ms)

Question 24

Indications for transplant

Answer 24

Refractory NYHA IV HF
VO2 max < 14 mL/kg/min and anaerobic metabolism
Severe ischaemic not amenable to intervention
Recurrent refractory ventricular arrhythmias

Question 25

Indications for PFO closure
Scoring system used
Who benefits most

Answer 25

CVA without alternate cause
RoPE score
Young people with CVA with PFO and no alternate cause

Question 26

TAVI
- indications

Answer 26

symptomatic severe AS, initially in high risk patients but now evidence in low surgical risk too

Question 27

How do you differentiate AS from HOCM clinically?

Answer 27

AS - radiates to carotids
HOCM - augmented by valsalva, may have ICD

Question 28

Indications for mitraclip
NNT to prevent HF hospitalisation

Answer 28

severe secondary MR, not candidate for surgical valve
NNT = 3 to prevent heart failure hospitalisation

Question 29

Indications for left atrial appendage closure
- is the evidence good?

Answer 29

AF, contraindication to anticoagulation
- not yet, 2 pending trials

Question 30

AF - rate or rhythm control

Answer 30

either may be reasonable
new evidence:
early (within 1 year) rhythm control may be associated with fewer cardiovascular outcomes
Those most likely to benefit from ablation are those with heart failure, especially those related to tachyarrythmia related cardiomyopathy

Question 31

What is PICM

Answer 31

pacemaker induced cardiomyopathy
- HF symptoms in 10% of patients following pacemaker
- risk factors; EF<50%, pacing burden >40%, previous MI, CKD, single chamber pacing.