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Medical > In-Training - Arrhythmias > Flashcards

In-Training - Arrhythmias Flashcards

1
Q

Which patients are ICD placement in HCM recommended (secondary prevention)?

A
  • prior documented cardiac arrest
  • VF
  • VT (hemodynamically significant)
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2
Q

What is an abnormal BP response to exercise?

A

failure to increase SBP by 20 mmHg

or

drop of 20 mmHg during effort

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3
Q

What is the mechanism of death in HCM?

A

VT emanating from an abnormal myocardial substrate consiting of myocyte disarray and interstitial and replacment fibrosis

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4
Q

What are the five primary risk factors (indications for ICD - primary prevention) for SCD in HCM?

A
  • FH of premature HCM-related death
    • particularly if sudden death, and in close or multiple relatives
  • Syncope (unexplained)
    • determined to be non-neurocardiogenic
    • particularly if recent, in young patients
  • NSVT on serial ambulatory ECG’s
    • particularly when bursts are multiple, repetitive, or prolonged
  • Hypotensive or attenuated BP response to exercise
  • LV hypertrophy (LV wall thickness >30mm)
  • Extensive LGE ( > 15% of LV mass) on CMR
    • twofold risk compared with no LGE
  • Double or compound genetic mutations
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5
Q

What is a key determinant influencing SCD in HCM patients?

A
  • Age
    • noninvasive risk markers are most applicable to young and middle-aged HCM patients
    • achievement of advanced age ( > 60 years) is associated with low risk, even in the presence of conventional risk factors
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6
Q

What are additional risk factors/subgroups (other than 5 primary) that may contribute to risk stratificaiton of HCM patients?

A
  • LGE ( >15% of LV mass) on CMR
  • LV apical aneurysm
  • LVEF < 50%
    • “end stage” systolic dysfunction
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7
Q

What is the next best step in a HCM patient:

  • no FH
  • asymptomatic (no syncope)
  • LVOT gradient 40mmHg
  • Normal BP response to exercise
A

ECG (ambulatory) monitoring

  • continued evaluation for NSVT/VT for primary prevention
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8
Q

What is the best treatment option for:

  • supine hypertension
  • orthostatic symptomatic hypotension
A
  • Droxidopa
    • indicated for neurogenic orthostatic hypotension
    • MOA: induces peripheral arterial/venous vasoconstriction
      • class = inotropes/pressors
  • Other options: pyridostigmine, midodrine, fludrocortisone
    • drugs may exacerbate hypertension
  • Lifestyle modifications:
    • put head of bed up about 30 degrees to offset the supine and evening hypertension when there is often fluid retention
    • avoid eating very sweet carbohydrate-laden foods in the morning
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9
Q

Dual chamber PPM (for SND and 3rd degree heart block) presents with palpitations. What is the best way to decrease his symptoms?

A

Beta-blocker therapy (Metoprolol) 25mg BID

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10
Q

What is the diagnosis?

Treatment?

A
  • Vasovagal syncope
    • Mixed vasodepressor and cardio-inhibitory vagal response
  • Patient reassurance and education, emphasizing fluid and salt intake, physical counterpressure maneuvers
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11
Q

What is the best medication for maintenance of sinus rhythm after DCCV for Atrial fibrillation?

  • decompensated CHF (JVP 16 cm H2O, dullness over right lung base, obese abdomen with palpable liver edge, warm extremities + trace edema)
  • EKG: rapid A-fib with LBBB
  • Echo: EF 35%, end-diastolic dimension 60mm
  • GFR = 30cc/min
A

Amiodarone –> restoration of NSR may improve HF (if tachycardia induced)

  • Sotalol, Dofetilide contraindicated 2/2 renal failure
  • Flecainide (class Ic agents) contraindicated in HF
  • Dronedarone contraindicated in NYHA IV or II-III with recent decompensation requiring hospitalization and permanent A-fib
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12
Q

What are the major side effects of Ticagrelor?

A
  • dyspnea (15% of patients within the first week of treatment)
  • bradycardia
  • bleeding
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13
Q

What is the MOA of ticagrelor?

What trial compared ticagrelor and clopidogrel?

What were the results?

A
  • P2Y12 inhibitor –> reversibly binding, direct-acting agent
  • PLATO trial
  • ticagrelor was associated with lower:
    • death
    • stroke
    • stent thrombosis
    • higher risk of bleeding (CABG-related bleeding)
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14
Q

What medication can lead to decreased effectiveness of ticagrelor?

A

high-dose ASA

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15
Q

How long does BB therapy provide a mortality benefit in patients with CAD?

A

3 years (hasn’t been studies longer)

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16
Q

During a routine cardiac catheterization, what is one method for reducing total X-ray dose produced by the X-ray system during a procedure.

A

Using lower frame rates

  • lowering acquisition framing rate will help lower the XR dose
17
Q
  • What should be assessed in the doppler assessment of AS?
  • What measurements are required?
A
  • AVA
  • Max (peak) velocity
  • Mean pressure gradient
  • Measurements required:
    • LVOT diameter - 2D
    • LVOT velocity, VTI - PWD
    • Peak AV velocity, VTI - CWD
18
Q

What measures of AS are the most heavily weighted?

A

MG and PV >>> AVA

19
Q
A

AVNRT

20
Q

What are the current classification for antiarrhythmic drugs used in SVT during pregnancy?

A
  • Everything –> Class C
  • Sotalol –> Class B
  • Atenolol, Amiodarone –> Class D
21
Q

What are the indications for treatment of SVT in pregnancy?

A
  • Symptoms (are intolerable)
  • Hemodynamic instability
22
Q

What are the first line treatment agents for SVT in pregnancy?

A
  • Digoxin
    • safest
    • experience is extensive
    • efficacy for arrhythmia treatment or prophylaxis is lacking
  • Beta-blockers
    • propanolol, metoprolol
    • should be avoided in the the 1st trimester
23
Q
A

Atrial flutter with 2:1 conduction

24
Q

What are the measures of severe TS?

A
  • PHT > 190 msec
  • TVA < 1.0 cm2
25
Q

What are the Class I indications for MV surgery in Severe, Asymptomatic (stage C) MR?

A

LVEF 30% - ≤ 60%

or

LVESD ≥ 40 mm

**Stage C2

26
Q

What are the next steps/paramters to evaluate in a patient with Severe, Asymptomatic (Stage C) MR?

A
  • Stage C2 –> MV surgery (class I)
    • LVEF 30% - ≤ 60%

or

LVESD ≥ 40 mm

  • Stage C1 (repair vs. surgery vs. monitoring)
    • LVEF > 60%

and

LVESD

  • Stage C1 (repair vs. surgery vs. monitoring)
    • New-onset AF

or

PASP > 50 mmHg

27
Q

What are the next steps/paramters to evaluate in a patient with Severe, Asymptomatic (Stage C1) MR with LVEF > 60% and LVESD < 40 mm?

A
  • Progressive increase in LVESD

or

Decrease in EF

* MV surgery (IIa) * Likelihood of successful repair \> 95% and successful repair \> 95% and expected mortality \< 1%
* Yes --\> MV repair (IIa)
* No --\> Periodic monitoring
28
Q

What are the quantitative measures of severe MR?

A
  • VC: > 0.7cm
  • RVol: > 60mL
  • RF: > 50%
  • EROA > 0.4cm2
29
Q
A
30
Q
A

Medical (69 decks)

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