TRP exam Flashcards by Asma Babar

A 25-year-old female is referred to you with progressive dyspnea and a finding of severe pulmonary hypertension on an echocardiogram.

A) List the five classification groups of pulmonary hypertension and an example from each that would be a plausible etiology in this patient (10)

B) What is the formula for calculating pulmonary vascular resistance in the cardiac catheterization lab? What are the units and normal values? (2)

C) List five (5) classes of pharmacologic therapy that have been shown to improve 6-minute-walk distance in patients with pulmonary arterial hypertension (5)

A)
1. PAH - VIH
2. Secondary cardiac causes - Severe mitral stenosis
3. Secondary pulmonary causes - COPD
4. Chronic thromboembolic - chronic pulmonary embolus
5. Miscellaneous - Sarcoidosis

B) (PAPm-Wedge) / (CO). Normal value 1.25 < Wood unit or < 100 dynes/sec/cm5

C) Improved 6 MWT in PH
- Calcium channel blockers
- PDE5 inhibitors (Viagra)
- Prostanoid agonist (Iloprost)
- Endothelin antagonist (Bosentan)
- Soluble guananyl cyclase stimulateur (Riociguat)

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Briefly describe the specific mechanisms of action of the following medications.

A) Aspirin (2)
B) Carvedilol (2)
C) Fondaparinux (2)

What is the mechanism of action of clopidogrel and ticagrelor? (2 points)
What are their principal differences in terms of how each of these specific molecules interacts with its target? (5 points)

A) Aspirin: Irreversible platelet Cox 1 inhibitor leading to decreased TXA production
B) Carvedilol : Beta 1 and B 2 receptor antagonist + alpha receptor antagonist with anti-inflammatory properties
C) Fondaparinux : Factor Xa inhibitor with indirect activation of antithrombin 3

Clopidogrel : Irreversible inhibitor of P2y12 adenosine diphosphate receptor
Ticagrelor : Reversible inhibitor of P2y12 adenosine diphosphate receptor

Clopidogrel :
Prodrug
Metabolized by CYP2C19
Irreversible

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A 52-year-old woman receives a bi-leaflet mechanical mitral valve replacement for severe rheumatic mitral stenosis.

A) What specific anti-thrombotic regimen is indicated? (3)

Assuming this patient takes the appropriate anti-thrombotic regimen as prescribed, define her approximate annual risk of:
B) Thromboembolism (1)
C) Major bleeding (1)
D) The patient has done well for five years after mitral valve replacement. She is active and denies any chest pain or shortness of breath. Now 57, she requires extensive dental work below the gum-line, and interruption of her anti-coagulant is mandatory. Her dental surgeon refers the patient to you requesting “management/optimization of this patient prior to dental surgery under general anesthesia.” Provide your recommendations as per your consultation letter, as well as a prescription if appropriate. (6)

A) Coumadin with INR 2.5-3.5 goal
B) Thromboembolisme 1-4%
C) Major bleeding (1-2%)
D)
No cardiac contraindication for surgery. No need for further testing
Endocarditis prophylaxis with amoxil 2 g po x 1 dose 1 hour pre-op
Stop Coumadin 5 days before surgery, Take LMWH when INR < 2, Last dose of LMWH the evening before surgery, restart Coumadin and stop LMWH when INR > 2

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Define the following terms:

A) Hibernating myocardium (2)
B) Stunned myocardium (2)

Hibernating myocardium: non-contractile
myocardium due to chronic ischemia, which
will recover function with revascularization.
Stunned myocardium: non-contractile
myocardium immediately post
revascularization, which will recover function
with time.

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A 28-year-old woman with progressive shortness of breath over one year is catheterized with the following saturation results:
High SVC 67
Low SVC67
High RA78
Mid RA92
Low RA81
Hi IVC71
Low IVC71
RV Inflow90
Mid RV87
RV Outflow88
PA88
Aorta98
Pulmonary vein98

A) What is the most likely diagnosis? (2)

B) Calculate the Qp / Qs ratio (2)

C) How should this patient be managed at this point in time? (2)

CIA secundum
QP: QS = (Sat Ao - Sat MV) / (Sat PV - Sat PA)
= 98-(3x67+1x71/4=68) / 98-88
= 30/10
= 3

Refer for closure

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List four (4) anatomical differences that distinguish the right from the left atrioventricular valve.

Mitral valve :
2 feuillets
Associé avec le ventricule gauche
Insertion plus basale que la valve mitrale
Continuité mitroaortique

Tricuspid:
3 feuillets
Associé avec le ventricule droit
insertion septal plus apical que la valve mitrale
3 piliers
Pas de continuité tricupido-pulmonarie

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List six (6) genetic or chromosomal conditions that predispose to aneurysm formation in and dissection of the thoracic aorta and that are considered when screening is discussed. (6) For three of these, list the gene product that is deficient or defective.

Marfan - FBN-1
Familial thoracic aortic aneurysm - ACTA2
Turner - XO chromosome
Ehlers Danlos vasculaire
Loeys-Dietz
Bicuspid valve disease

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What defines a left ventricular aneurysm on angiography? Contrast the pathology, angiographic appearance and natural history of a left ventricular aneurysm from an LV pseudo-aneurysm.

Contour anormaliy in systole and diastole

Aneurysm
- 3 layers
- Wide neck
- Less risk of rupture

Pseudoaneurysm
- not all the layers, usually contained rupture
- Narrow neck
- High risk of rupture

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For each of the following conditions, list one (1) commonly associated cardiovascular abnormality:

A) Friedreich’s ataxia
B) Tuberous sclerosis
C) Hereditary hemorrhagic telangiectasia

For each of the following conditions, list one (1) commonly associated cardiovascular abnormality:

A) Friedreich’s ataxia : hypertrophic cardiomyopathy
B) Tuberous sclerosis: Rhabdomyoma
C) Hereditary hemorrhagic telangiectasia : pulmonary AVM

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List the three most common forms of congenital long QT syndrome. For each of these, list the adversely affected gene product, describe the typical appearance on ECG and describe the classic clinical presentation.

LQTS1 - KCNQ1 - Wide t wave base - loss of IKs - exertion
LQTS2 - KCNH2 - humpback t-wave - loss of Ikr - loud noise
LQTS3 - SCN5A - long isoelectric segment before t-wave - gain of function Na1.5 - sleep

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List four (4) Class I indications for early surgery for native valve infective endocarditis.

HF due to valvular dysfunction
Difficult to treat germs
Local complications : abces, AV bloc, valve ripped
Fever despite 5 days of adequate IV antibiotics

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SGLT-2 inhibitors have an evolving role in the management of cardiovascular patients.
A) What is the mechanism of action of this class of medications? (2)
B) Summarize the findings of the DAPA-HF trial. (3)

a) Inhibition of Sodium-glucose co-transporter
2 in the proximal collecting tubule to prevent
reabsorption of glucose.
* b) Dapagliflozin vs placebo in patients with
HFrEF with or without diabetes. Dapagliflozin
significantly reduced the risk of worsening
heart failure or death from cardiovascular
causes in both diabetics and non-diabetics.

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In the initial reports of Brugada Syndrome, three types of ST segment elevation were described. The contemporary definition of Brugada Syndrome is the Type 1 ECG pattern in one or more right precordial leads (i.e. V1 or V2); the Type 1 pattern is diagnostic of Brugada Syndrome whether present spontaneously or with provocation. Describe the Type 1 pattern of ST segment elevation (3)

The Type 2 pattern of ST segment elevation raises suspicion of Brugada Syndrome, but the diagnosis requires the emergence of a Type 1 pattern with provocation. Describe the Type 2 pattern (3). List two agents that can be used to provoke a Type 1 ECG pattern? (2)

What is the relevance of a Type 3 pattern of ST segment elevation? (1)

Type 1 - ST elevation in V1 with J point elevation of > 2mm and coved segment followed by negative T wave

Type 2 - STE with J point elevation > 2 mm and saddleback appearance

Provocative agents: procainamide, flecainide,
ajmaline

Type 3 ECG: no relevance

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List six (6) causes of elevated fasting triglycerides.

Corticosteroids
Alcohol intake
Nephrotic syndrome
Anorexia
Oral contraception
Hypothyroidism

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The following pressures were obtained at right heart catheterization in a patient with heart failure undergoing transplant assessment. Interpret the hemodynamics.

RA 15 mean
RV 45/5/15
PA 45/30/37
PCWP 15/20/17
PA sat 61%
Ao sat 95%
CO 4 L/min

Could this patient be listed for transplant now? Show your work and rationale. (5)

Mean PAP 37
GTP 37-17 = 20
RVP 20/4 =5

No a transplant candidate because RVP > 3 and transpulmonary gradient > 15 mmhm.

Currently elevated RA pressure, could benefit from diuretics before repeat swan

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A) Define resistant hypertension: (3)

B) In what conditions is the 4th Korotkoff sound recommended as the diastolic BP? (2)

Hypertension malgré 3 tx anti-HTA à dose maximale y compris 1 diurétique.

Lorsque 5 bruit non-audible
Pregnancy
Severe AI

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Outline the Modified WHO Classification of Maternal Cardiovascular Risk.

List eight (8) cardiac conditions where pregnancy is generally considered contraindicated and where termination of pregnancy would be discussed?

Who 1 - little morbidité, no mortalité
Who 2 - moderate morbidité, little mortalité
Who 3 - High morbidité, increased mortalité
Who 4 - High morbidité and mortalité, pregnancy pas recommandé

Pulmonary arterial hypertension
Severe aortic coarctation
Severe aortopathie (ex Marfan > 4.5 cm)
FEVG < 30% ou NYHA 3-4
Severe sx AS
Severe MS
CMP peripartum avec FEVG non-récupérée
Fontan avec complications

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A 48-year-old woman has breast cancer. Treatment with doxorubicin is being considered. What is the most clinically important cardiac side effect of this medication? List six (6) strategies to decrease the adverse cardiac effects of doxorubicin in this patient.

Cardiotoxicity of anthracyclines: cardiomyopathy/LV systolic dysfunction

To limit this cardiotoxicity:
1. Use another drug
2. Limit the dose/use continuous infusions
3. Avoid concomitant use of trastuzumab (anti-HER2, Herceptin)
4. Add dexrazoxane (if 300mg/m2 of doxorubicin is used)
5. Close monitoring
6. Avoid/treat other cardiac stresses (e.g. HTN)
7. Early treatment/prophylactic treatment with ACE/BB/?statin

A) What is the definition of a continuous murmur? (2)

B) List eight (8) conditions that can produce a continuous murmur. (8)

A continuous murmur is heard through S2.
Continuous murmurs result when there is a continuous
pressure gradient during systole and diastole.
They can be classified as 1) aorto pulmonary
connections; 2) arterio-venous; 3) abnormal arterial
flow; and 4) abnormal venous flow

PDA
A-P window
Aortic-RV/RA/LA fistula
BT shunt, Potts,
Waterston
Coronary AV fistula
Coarctation
COTA collaterals
Bronchial collaterals
Venous hum
Mammary souffle
ALCAPA
Periphl pulm stenosis
Pulmonary AV fistula
Severe T of F, truncus
arteriosus, tricuspid
atresia, TAVR
Lutembacher Syndrome

List eight (8) interventions that decrease the risk of atrial fibrillation around the time of cardiac surgery, independent of the procedure itself?

Beta blockers
Sotalol
Amiodarone
Steroids
Colchicine
Magnesium
(Bi)-atrial pacing
Omega 3 fatty acids/Vit A and E
Botulinum toxin into fat
10.Statins probably not!

Place the following oxygen saturations in order from highest to lowest. Explain.

IVC
SVC
Coronary Sinus
Pulmonary vein

PV
IVC
SVC
CS heart extracts maximally at
rest

A) Define Ebstein’s anomaly. (4)

B) List the ECG findings associated with Ebstein’s anomaly. (2)

C) Why may an adult patient with significant Ebstein’s become cyanotic with exercise but have normal saturations at rest? (1)

Apical displacement of the TV leading to atrialization of the RV

ECG findings
1. WPW (may have multiple pathways)
2. Right atrial enlargement (Himalyan p waves)
3. First degree AV block
4. Atypical RBBB
5. T wave inversion V1-V4 and inferior leads

Cyanotic with exercise?
Shunt right to left with exercise across either ASD or PFO

Absolute contraindications to lytics (STEMI ACC AHA 2013)

Any prior ICH
Known structural cerebral vascular lesion (e.g., arteriovenous
malformation)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 mo, EXCEPT acute ischemic stroke within 4.5 h
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 mo
Intracranial or intraspinal surgery within 2 mo
Severe uncontrolled hypertension (unresponsive to emergency therapy)
10.For streptokinase, prior treatment within the previous 6 mo

List four (4) medications that can improve symptoms of refractory angina, and outline the mechanism of action of each.

Allopurinol: inhibits xanthine oxidase, a main source of reactive oxygen species—less
oxygen wastage, and less endothelial injury.

Ranolazine: inhibits the late sodium current (INa), which decreases calcium overload and
improves diastolic function.

Trimetazidine: stimulates myocardial glucose consumption by inhibiting fatty acid
metabolism.

Nicorandil: nitrate-like moiety plus a moiety that opens mitochondrial ATP-sensitive
potassium channels (mimicking ischemic preconditioning and dilating resistance
vessels).

Ivabradine: slows heart rate by inhibiting If SA node pacemaker current.

Several scores have been developed to estimate a patient’s risk of bleeding in the context of oral anticoagulation for atrial fibrillation. Name one of these and describe how it is used.

HAS-BLED: 0-1 points= 1%, 5 points= 12.5% Hypertension Abnormal renal or liver function Stroke Bleeding history or predisposition Labile INR Elderly (age > 65) Drugs/alcohol concomitantly

List five (5) indications for ICD implantation that are endorsed as Class I by either the CCS or ACC/AHA clinical practice guidelines.

1. ICD therapy is indicated in patients who are survivors of cardiac arrest due to VF or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes. (Level of Evidence: A) (16,319–324) 2. ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable. (Level of Evidence: B) (16,319–324) 3. ICD therapy is indicated in patients with syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study. (Level of Evidence: B) (16,322) 4. ICD therapy is indicated in patients with LVEF less than or equal to 35% due to prior MI who are at least 40 days post-MI and are in NYHA functional Class II or III. (Level of Evidence: A) (16,333) 5. ICD therapy is indicated in patients with nonischemic DCM who have an LVEF less than or equal to 35% and who are in NYHA functional Class II or III. (Level of Evidence: B) (16,333,369,379) 6. ICD therapy is indicated in patients with LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF less than or equal to 30%, and are in NYHA functional Class I. (Level of Evidence: A) (16,332) 7. ICD therapy is indicated in patients with nonsustained VT due to prior MI, LVEF less than or equal to 40%, and inducible VF or sustained VT at electrophysiological study. (Level of Evidence: B) (16,327,329)

A 68-year-old man and his 38-year-old daughter are referred to you for non-valvular atrial fibrillation. A) What is “non-valvular AF?” (3) B) They are both asymptomatic on diltiazem for rate control. Both have CHADS2 scores of 0, and neither has a history nor clinical evidence of atherosclerosis. State the antithrombotic regimen recommended for each patient and refer to the relevant guidelines (CCS, AHA or ESC) that justify your response. (4)

A) Afib in the absence of mechanical valve, moderate or severe SM B) Man CHADS65> 1 = a/c with AOD Woman 38 CHADS65 = 0 = no a/c

Novel Oral Anticoagulants (NOACs) are all the rage for stroke prevention in atrial fibrillation. Name the four NOACs currently approved for stroke prevention in AF, the mechanism of action of each, the respective large randomized clinical trials that support the use of each, and state the degree to which (as a percent of ingested drug) these agents are renally excreted.

Eliquis - 10a inhibitor - Aristotle - 25% Xarelto - 10a inhibitor - Rocket AF - 33% Lixiana - 10a inhibitor - Engage-AF timi 48 - 50% Pradaxa - 2a inhibitor - Rely - 80 % renal

List five conditions that should be met before cardiac resynchronization therapy is considered definitely indicated.

FEVG < 35% BBG complet, typique QRS > 150 msec RS NYHA 2-4 (ambul) on GDMT

What are the effective regurgitant orifice (ERO) and regurgitant volume criteria for chronic severe mitral regurgitation when the etiology is primary vs secondary? List the Class I and IIa indications for proceeding with mitral valve surgery in chronic severe primary mitral regurgitation. List the Class I and IIa indications for mitral valve surgery in chronic severe secondary mitral regurgitation.

EROA > 0.4 cm2 Vol regurg > 60% IM primaire sévère - Symptomatique - Dysfunction VG FEVG < 60% ou dilatation VG systolique > DTSVG > 4 cm - 95% chance de repair et faible risque chx - NYHA 3-4 avec risque chx prohibitif, TEER IM secondaire - Symptomatique et FEVG 20-50%, DTSVG < 7 cm, PAPs<70 mmHg - Lors de chx pontages

State the valve hemodynamics for each of the following varieties of aortic stenosis: (15) a. Mild AS b. Moderate AS c. Severe high-gradient AS d. Very severe AS e. Severe low-flow/low-gradient AS with reduced LVEF f. Paradoxical low-flow severe AS

a. Mild AS AVA>1.5 Vmax> 2 MG > 20 b. Moderate AS AVA>1-1.5 Vmax> 3 MG > 30 c. Severe high-gradient AS AVA< 1 Vmax> 4 MG > 40 d. Very severe AS AVA< 0.5 Vmax> 5 MG > 60 e. Severe low-flow/low-gradient AS with reduced LVEF FEVG<50% AVA<1 MG< 40 Vmax<4 f. Paradoxical low-flow severe AS FEVG>50% AVA<1 MG< 40 Vmax<4 SVi < 35ml/m2

State the strength of the recommendation for surgery in each of the following cases: (6) a. Mild AS, no symptoms b. Moderate AS, patient requires CABG c. Severe high-gradient AS, patient has symptoms d. Very severe AS, no symptoms e. Severe low-flow/low-gradient AS with reduced LVEF, patient has symptoms f. Paradoxical low-flow severe AS, patient has symptoms

a) No surgery b) 2b c) 1 d) 2a e) 1 f) 1

List five underlying conditions that can predispose to (non-atherosclerotic) spontaneous coronary artery dissection (SCAD)? Describe the angiographic classification of SCAD.

1. FMD 2. Connective tissue disease (Marfan, Ehler Danlos, etc.) 3. Pregnancy 4. Vasculitis 5. Hormone treatment 6. Coronary spasm Type 1 : Multiple lumens visible Type 2 : Long lesion due to intramural hematoma Type 3 : Focal or tubular stenosis

What is the ankle brachial index (ABI), i.e. how is it calculated? How should ABI results be reported, i.e. what are the four possible result categories, and what are the corresponding numerical ranges?

ABI = highest systolic pressure (DP vs PT) in foot highest systolic pressure (R vs L) in arms <= 0.9 Abnormal 0.91-0.99 Borderline 1.0-1.4 Normal >1.4 Non-compressible

What does FFR stand for? How is it calculated (i.e. what is the simplified equation for FFR)? How is it performed? How is it used clinically, and list the two major trials that support this clinical use of FFR.

Pd/Pa In the cath lab under maximal hyperemia using IV or IC adenosine Hemodynamically significant lesion if < 0.8 FAME 1 FAME 2

In 2014, neprilysin inhibition, in combination with an ARB, was demonstrated to be an effective treatment for systolic heart failure when compared with an ACE-inhibitor. What is the mechanism of benefit of a neprilysin inhibitor? Why does co-administration with an inhibitor of the renin-angiotensin-aldosterone system (RAAS) make biologic sense? Why should a neprilysin inhibitor not be co-administered with an ACE-I?

Inhibits degradation of ANP, BNP, angiotensin 2 bradykinins Good: more ANP, BNP, bradykinin Bad: more angiotensin II (hence ARB); more bradykinin and substance P (therefore more angioedema, much more when combined with ACE-I)

What are the driving restrictions (private and commercial) in each of the following conditions? a) Stable CCS 2 angina b) Stable NYHA III, LVEF 38% c) One episode of unexplained syncope List five indications for supplemental oxygen during a commercial airline flight. (5)

a) No restriction b) No restriction, no commercial driving c) 1 week, 12 months Angine CCS>3 Heart failure NYHA > 3 PaO2 < 70% CMP cyanogène HT pulmonaire

The Revised Cardiac Risk Index (RCRI) score has six components. One of these is high-risk surgery. What constitutes high-risk surgery (be specific)? (3 points) List the five other components of the RCRI score (be specific). (5 points) The CCS guidelines recommend testing before elective non-cardiac surgery when the RCRI score is >= 1 (or if the patient is >= 65 years of age or is 45-64 years of age and has significant cardiovascular disease). What test is recommended? (1 point) How is this test used (be specific)? (4 points)

a ) Intrathoracic, intraperitoineal, vascular suprainguinal MCAS AVC IC IRC creat > 177 Diabète ss insuline BNP if normal, no further testing if abnormal, tropos, ECG q24h x 48-72h

You are seeing a 40-year-old man with hypertrophic cardiomyopathy (HCM). A) What conditions constitute a Class I indication for ICD referral? (3) B) If this patient develops atrial fibrillation, how do you decide about oral anticoagulation to reduce the risk of stroke? And if an antiarrhythmic drug is indicated, which two medications are preferred? (4)

A) Sudden cardiac death Sustained VT B) Regardless of CHADS Disopyramide, amiodarone

List the three most common forms of amyloidosis based on the chemical classification of the disease. One of these forms has two subtypes, one that is genetic and the other that is acquired; name them. Which form of amyloidosis is the most commonly encountered worldwide? Which of the above forms of amyloidosis does not typically involve the heart? Which form of amyloidosis is the most likely to present with low voltages on the ECG? For each of the above forms of amyloidosis, including the two subtypes of one form, what is the mainstay of therapy?

AA, AL, ATTR ATTR-wt, ATTR-H AA AA AL AA - treatment of predisposing condition AL - greffe moelle osseuse, chimie ATTR - greffe hépatique ou tafamidis

Draw the simultaneous left ventricular and aortic pressure tracings of a patient with obstructive hypertrophic cardiomyopathy at baseline and post-PVC. You can draw on a piece of paper, take a photo by your phone, and upload it here. (4) B) What features are characteristic of the post-PVC response in the cath lab and at the bedside? (2) C) List the two most commonly affected genes and mode of inheritance in hypertrophic cardiomyopathy. (4)

Myosin heavy chain 7 Myosin binding protein C3 Dominant

Long term complications of Mustard

Dysfunction VD systémique Baffle leak Baffle thrombosis Dysfunction tricuspide Stenosis CCVD ou CCVG Flutter auriculaire PAH Sinus node disease

Jatene complcations

Neoaortic root dilation AR PA narrowing Compression of coronary arteries by dilated neo-aorta

Fixing T-wave oversensing

Decrease sensitivity (increase sensitivity number) Algorithm Lead repositioning Change polarity Strict rate control