HF, ICDs

Question 1

Defibrillators - primary prevention in CM

Who benefits?

Answer 1

Isch CM -strong if LVEF<30%

LVEF <35% or LVEF <40% w/ NSVT or inducible VT/VF (less strong)

Non-Isc CM
LVEF <35% - less strong but good if <70yo

Also >12mo survival, >40days post MI & on OMM

Question 2

CRT - mortality benefit

Answer 2

SR w/ LBBB (Def)

LVEF<35%, Wide LBBB>150ms, NYHA II(-ambulatory IV), OMM 3/12,

Less strong: QRS 120-149ms but otherwise LVEF<35% etc (or maybe RBBB but >150ms)

AF (if >92% ventricular pacing), RBBB

If QRS<120ms may harm, no QOL improvement,

Question 3

SGLT-2 - what does it block & where

Answer 3

blocks sodium glucose co-transporter in proximal tubule of kidney (S1 segment)

Causes reabsorption 90% glucose

Question 4

SGLT2 in HF

• example dose
• details of ppl excluded
• benefit

Answer 4

Both diab & nondiab.

Combined effect hospitalizations & CV death

10mg Dapaglifloxin

Exclusions: hypoTN, eGFR<30, sx LVEF<40%)

Question 5

Severe IHD determined by

Answer 5

• >10% LV dysfunction
• LMCA/LAD prox (>50% stenosis)
• multivessel 2-3 w/ impaired fxn <35%

Question 6

Stable IHD (ie non ACS non Angina) PCI v OMM

Answer 6

PCI only beneficial in ACS or angina (no mortality benefit, or possible late benefit if mod-sec ischaemia w/o HF, L) main dis, ACS or mod angina)

Question 7

RF modification in AF

Answer 7

• Weight loss
• ETOH reduction

Question 8

Who to ablate in AF

Answer 8

• Intolerant of antiarrhytmic and sx w/ AF
• Consider in HFrEF (dec death & hosp if LV<35% & failed med Rx - CASTLE-AF)
• No mort benefit but reduction in AF burdern

Question 9

Who is more likely to fail AF ablation

Answer 9

• Older
• long standing persistent
• Increased LA size
• Valv/structural HD
• if dont modify RF

Question 10

List RF assoc w/ AF (what is the #1)

Answer 10

• LA enlargemnt (#1)
• dis that cause ie OSA, HTN, valv, CM
• Obesity
• Metabolic syndrome

Question 11

Who benefits more from rhythm control in AF

Answer 11

younger, symptomatic

elderly, asymptomatic equiv rate/rhythm (AFFIRM)

Question 12

Valvular AF - define?

Answer 12

1. mechanical valve
2. MS
   (Eg RhD)

Question 13

How to differentiate VT from SVT

• clinical hx
• ECG (x7)

Answer 13

Clinical clues: Ventricule SCAR

• elderly
• IHD
• Structural HD

ECG clues:

• absence typical BBB morphology
• Extreme axis deviation (dbl neg & avr pos)
• QRS>160ms
• AV dissociation
• caputure/fusion beats
• RSR complex w/ taller L) rabbit ear: most specific (RBBB is Rt rabbit ear)
• neg concordance throughout precordial leads

Question 14

Hypertrophic CM gene mutations (x2)

Answer 14

MYH7
MYBPC3

Question 15

Haemodynamically significant Pb of LVOT in H(O)CM

Answer 15

>50mmHg

Question 16

H(O)CM LV wall thickness

Answer 16

>15mm

(or >13mm if FHx +ve)

Question 17

Rx for H(O)CM

Answer 17

If symptomatic only

1. Bblockers (+/- CCB)
2. Disapyramide
3. Surg
   - heart transplant if progressive LV dysfxn
   - surg myectomy, septal ablation

Question 18

H(O)CM - RF for SCD

Answer 18

1. Hx VT/syncope
2. Spon non sust VT (>3 beats @>120bpm) on holter
3. LV thickness >30mm
4. FHx SCD
5. AbN BP response to exercise

Hx/Fhx + 120/30 (120bpm VT, 30mm wall thickness, BP)

Question 19

What to avoid if high risk SCD in H(O)CM

Answer 19

Cardiac glycosides

(Digoxin)

Question 20

TTE - Severe AS criteria

Answer 20

All of:

• mean gradient >40mmHg
• AVA <1cm
• Vmax >4ms/s

Consider LFLG (severe AS) if **LVEF \<50%** and AVA \<1
 - dobutamine to increase SV by 20% (or gradient \>40)
 \+/- CTCA \>~1500

Question 21

TTE - severe MS criteria

Answer 21

• AVA <1cm
• mean gradient >10mmHg

Question 22

Indications for surgery MR

Answer 22

Primary MR
Severe (as clinically indicated) eg HF
But also new AF, LA enlargement, pulm HTN shows chronicity
LV dilatation - End sys diameter >45
LVEF <60 (aim 30-60%, usu goes up intiially)

If you have severe MR - get repaired (mitraclip) - even some 2ndary benefit

Question 23

Indications for surgery MS

Answer 23

Valve area <1cm (or <1.5cm if others elevated)
Mean gradient >10mmHg
PASP >50mmHg
& fishmouth appearance on TTE (can TOE with dobutamine if needed)

Perc balloon if young esp female planning preg
- avoids mechanical valve & need for AC (UNLESS HAS MR/AS)
Otherwise valve replacement but need DOAC

Question 24

Indications for surgery AR

Answer 24

Severe & sx (regardless of LV fnx)
Or asx w/ HF
Consider if having other cardiac surg eg CABG

Question 25

Indications for surgery AS

Answer 25

Severe w/ sx or HF

Question 26

LVLG AS Ax

Answer 26

AVA \< 1cm but vmax \<4cm or MG \<40mmHG Is this a pseudo AS or true AS but not enough flow? AVR only if true severe AS - which is causing low LVEF (otherwise poor flow gradient is due to shitty LH) Give dobutamine to increase contractility to 'push' open AS then assess (if can push open, SV inc 20%, if not CTCA w/ cutoff 1200-2000 by gender)

Question 27

HOCM - crtieria

Answer 27

\>15mm in any part (usu intravent septum) - \>13mm if FHx if LVOT \>50mmHg : high risk for SCD so sync

Question 28

HOCM - indication for defib

Answer 28

* LVOT \> 50mmHG * Max wall thickness \>30mm * Hx nsVT \>3beats at \>120bpm * AbN response to exercise * FHx SCH * Hx unexplained syncope TTE (extensive GAD \>15% LV mass, apical aneurysm, LVEF\<50%)

Question 29

Most sensitive tests in HCM

Answer 29

ECG (inferolat TWI, q waves) TTE (LV wall thickness \>15mm, look for LVOT (\>50mmHg) Exercise stress echo can guide risk - if resting gradient \<50mmHg

Question 30

HCM - inheritance & mutation

Answer 30

AD w/ variable penetrance genotype: MYH7 - bad (MYBPC3)

Question 31

HCM - screneing

Answer 31

Annual until 20s, then 3yrs

Question 32

CABG over PCI - who?

Answer 32

_CABG:_ - LHF (LVEF \<35%) - DM (presumed multivessel) - MVD or L)main + high syntax \>33 - C/I to DAPT - Recurrent in stent restenosis, other aorta or cardiac surgeries _PCI:_ Old, frail, reduced mobility, MVD w/ low syntax (\<22) AND NO DM, difficult anatomy

Question 33

Post TAVI Meds

Answer 33

DAPT for 3-6months then aspirin lifelong *Possibly aspirin monoRx* NOT DOAC!!!!!!!!!!!!!!!!!!!