UBC RCE Compiled Notes Flashcards
What is Non HDL comprised of? How is it calculated?
-The sum of chylomicron remnants, VLDL, LDL, Lp(a), LDL
-Calculated on a lipid panel by subtracting HDL from the total cholesterol
Who should be screened for lipid profile? (7)
Everyone over 40 years old
< 40 years old when:
-Clinical ASCVD
-Evidence of Hyperlipidemia (On physical exam)
-CV Risk Factors
-ED
-COPD
-Post menopausal women of women with history of hypertensive disease of pregnancy
Should screening lipids be fasting?
yes, unless G > 4.5 mmol/l
Friedewald: TC = TC - HDL - (TG x 0.45)
When does lipid screening need to be repeated based on FRS
Every 5 years if FRS < 5%, Annually if FRS > 5%
In IR patients, name reasons to start on statin therapy (11)
LDL > 3.5
APO B > 1.05
NON HDL > 4.3
> 50M/60W with one of the following: IFG, Low HDL, High waist circumference, HTN, Smoker
CAC > Non zero
CRP > 2
Lp(a) > 50 mg/dl
What is the most important health intervention for prevention of CVD?
Smoking cessation
What % of total saturated fats should be of total energy
< 9%
What is healthy body weight?
BMI 18.5-25
What target organ damage should prompt BP treatment in office (not hypertensive crisis)
-CAD (ASCVD, HF, LVH)
-CVD
-Hypertensive Retinopathy
-PAD
-CKD (eGR < 60 or Albuminuria)
Patients should have 2 or more of the following to screen for Renovascular Hypertension?
- < 30 years or >55 years worsening or new onset HTN
- Abdominal Bruit
- Cr up by 30% or more with ACEi
- Recurrent Pulmonary Edema with ACEi
- Hypertension resistant to three drugs including a Diuretic
-Other ASCVD established
4 Imaging modalities to evaluate for RAS?
CTA
MRA
Doppler US
Captopril-enhanced radioisotope renal scane
When should FMD be screened for? 4 ways different than Renovascular
-Positive fmaily history of FMD
-FMD in another vascular territory
-Abdominal bruit without apparent atherosclerosis
-1.5 cm difference between kidney size
What test to do after FMD diagnosed?
-Cervicocephalic lesions and intracranial aneurysm
4 reasons to screen for Hyperaldosteronism?
Diuretic induced Hypo K < 3.0
Spontaneous K < 3.5
Incidental adrenal adenoma
Resistance with 3 or more drugs
Approach to diagnosing Hyperaldosteronism
-Plasma renin:aldo ratio
-Saline suppression (2L over 4h) -> positive if Aldo > 280 OR Captopril suppression test
-Adrenal imaging and Adrenal Vein sampling
WC targets for Men and Women?
Men < 102 cm
Women < 88 cm
Three agents to use for isolated systolic hypertension
-Thiazide
-ARB
-CCB
What is the criteria for Metabolic syndrome?
Three or more of the following:
-WC > 102 for men, > 88 for women
-BP > 130/85mmhg
-TG > 1.7 mmol/l
-HDL < 1 (men), < 1.3 (women)
-Glucose > 5.6
Which patients undergoing non cardiac surgery should you screen?
- > 45 years
- Known CVD
What is the RCRI components ? What does it predict?
Predicts 30 day MI, Cardiac arrest, Death following non cardiac surgery
-Cerebrovascular Disease
-Diabetes on Insulin
-CKD Cr > 177
-HF
-CAD
-High risk surgery (intraperitoneal, supra-inguinal vascular, intrathoracic)
Three criteria to proceed with NT BNP testing with Pre op testing? What is BNP cut off?
-Age > 65 years
-RCRI 1 or more
-Age 45-64 with CV condition (CAD, CVD, PAD, Severe PHTN, AS, HOCM, MS)
BNP < 92, NT BNP < 300
What effect does Exercise have on Lipid profile?
-Increase HDL, Decrease LDL, Decrease TG’s
What is resting membrane potential for myocyte membrance?
-70 to -90 mV
What is an example of early after depolarizations? delayed?
-Early: QTC
-Late: Dig toxicity, Ischemia, CPVT, Outflow tract arrhythmias
What Sinus node recovery time is abnormal?
CSNRT > 550msec
8 complications of Catheter ablation?
-Femoral vein/Artery hematoma or vascular injury
-Retroperitoneal bleed
-Pericardial tamponade
-Distal embolization if using retrograde aortic approach
-Damage to AV or coronary arteries
-Damage to the conduction system causing heart block
-Esophogeal atrial fistula
-Atrial arrhythmias
What is definition of Inappropriate Sinus Tachycardia?
HR > 90 bpm on 24 hour holter, no secondary causes.
Two Class 1 indications for Sinus Node Disease?
- Symptomatic sinus node dysfunction
- Symptomatic sinus bradycardia as a consequence of guideline directed management for which no alternative treatment exists
4 Class 1 Indications for AV node disease?
-CHB/MOBTIZ II Regardless of symptoms
-Neuromuscular disease associated with conduction disorders with CHB/2nd Degree/HV > OR 70 msec regardless of symptoms
-AF and symptomatic bradycardia
-Symptomatic AV block as a consequence of GDMT
Two indications for Pacing in conduction system disease with 1:1 AV conduction?
-Patients with syncope and bundle branch block who are found to have an HV interval > 70 msec
-Alternating BBB
Two indications for Pacing in conduction system disease with 1:1 AV conduction?
-Patients with syncope and bundle branch block who are found to have an HV interval > 70 msec
-Alternating BBB
Two contraindications to CSM?
-Carotid bruit
-TIA/Stroke/MI within 3 months
4 Major high risk criteria for Syncope based on CCS 2011 guidelines?
-HF
-Hypotension < 90mmhg
-History of Cardiac disease
-Abnormal ECG
What dose SF syncope score predict? and what are the components?
Predicts serious morbidity/mortality within 7 days of presentation
-Shortness of breath
-Hypotension
-Abnormal ECG
-Anemia Hct < 30%
-CHF
What is prevalence of dual nodal physiology?
10%
What are two reasons that accessory pathways don’t lead to pre-excitation pattern on surface ECG?
1) Can only conduct retrograde (Concealed)
2) Conduction down the pathway takes longer than conduction down the AV node
What are 7 risk factors that increase risk of SCD in WPW?
-Male
-AP Refractory period < 240 msec
-Shorted RR during < 250 msec
-High adrenergic state
-Multiple pathways
-Septal location on AP
-Ability to induce sustained AVRT, or AVRT precipitating pre-excited AF
What are three indications for ablation in Pre-excitation?
-Symptomatic patients with AVRT or Pre-excited AF
-Asymptomatic patients with high risk pathway on EPS
-Asymptomatic patients with a high risk job
What is the metabolism pathway for Rivaroxaban?
-CYP3A4 elimination
What is the metabolism pathway for Apixaban?
CYP3A4 elimination
What is unique about Edoxaban pharmacology compared to the other DOACSs?
It is a pro-drug
Name 7 CYP450 Inhibitors
CLAM JUICE give you AIDS and this will inhibit you
CCB
Lansoprazole
Azoles
Macrolides
HIV Protease Inhibitors
Grapefruit Juice
Name the CYP450 Inducers
RC induces PTSD
Rifampin
Carbamazepine
Phenobarb
Ticlodipine
St. John Wart
Dilantin
Three ways to reverse Warfarin?
-Octaplex (2, 7, 9, 10 + Protein C/S)
-Vitamin K
-FFP
What is Renal dosing for Rivaroxaban?
15mg if CrCl 15-50 (Although no RCT data for CrCL 15-30)
When to dose reduce Dabigatran? (3)
Age > 80
Age > 75 with bleeding RFs
CrCl 30-50
What is renal dosing for Edoxaban?
-30mg daily if CrCl 30-50 or less than 60kg
What is the only DOAC that is a prodrug?c
Dabigatran
What DOAC can be dialyzed? Why?
-Dabigatran, because it is only 35% protein bound
What two DOACs are metabolized through CYP3A4 pathway?
Rivaroxaban
Apixaban
What are the 3 reasons to DCCV prior to 3 weeks OAC?
Unstable
< 12 hours with no recent stroke
< 48h hours with CHADS < 2
What are the 7 components of the HAS BLED score?
Hypertension
Abnormal LFTs/Renal Function
Stroke history
Bleeding history
Labile INR
Elderly > 65 years
Drugs/ETOH history
What are two criteria needed as per CCS 2018 Afib update to consider an LAA occluder?
CHADS 2 or more, anti-thrombotic therapy is precluded
What is Procainamide dosing for AFib cardioversion? VT?
15-18 mg/kg over 60 minutes
10 mg/kg over 20 minutes
What is the success rate for Procainamide AF cardioversion?
50%
What is the most significant risk of giving Ibutilide for AF cardioversion?
TDP
What is the unique aspect of Vernakalant?
Atrial selective antiarrhythmic drug.
What is the most frequent that Afib episodes happen to consider a pill in pockey strategy?
monthly
What are 8 contraindications to pill in pocket strategy?
-LVEF < 50%
-CAD
-QRS > 120msec
-PR > 200
-Pre excitation
-Conduction system disease
-Hypotension
-Inability to comply
What is dose for Flecainide and Propafenone for PIP?
-Flecainide: 300mg
-Propafenone: 600mg
4 reasons to present to ED when PIP tried?
-The AF episode didn’t terminate within 6-8 hours
-Felt unwell
-More than one episode in a 24 hour period
-The AF period was associated with severe symptoms at baseline
9 complications of Catheter ablation for Afib?
-Atrio-esophageal fistula
-Perforation
-Tamponade
-Air embolism
-Pulmonary Vein stenosis
-Vascular injury
-Arrhythmia
-Phrenic nerve injury
-Pericarditis
5 ways to reduce Atrial Fibrillation following Cardiac Surgery?
-Beta blockers
-Amiodarone
-Sotalol
-Magnesium
-Biatrial pacing
What is the HATCH Score? What does a score of 5 or more indicate?
Hypertension
Age > 75
TIA/Stroke (2)
COPD
CHF (2)
Predicts 10% or more risk of Afib after Aflutter ablation in next 12 months.
What are the two common morphologies for Fascicular VT?
-Left Posterior Fascicle VT: RBBB, Left Superior Axis
-Left Anterior Fascicle VT: RBBB, Right Axis
What is Jervell/Lange Nielsen syndrome?
-Aggressive congenital LQT phenotype
-Autosomal recessive
-Congenital hearing loss
-KCNQ1 mutation
What is Andersen syndrome?
-Long QT, Large U waves, Frequent PVCs, facial dysmorphic features.
What is Timothy syndrome?
-LQT syndrome with autism, developmental disorders, congenital heart defects
-CACNA1c mutation (gain of function)
What Schwartz score needed to make diagnosis of LQT?
3.5 points or more
2 Indications for beta blocker in LQT syndrome?
-Symptomatic VT/VF
-Asymptomatic with QTc > 470 msec
What are three predictors of BB failure in LQT syndrome?
- QTC > 500msec
-VT before age 7
-LQT 2/3 Variants
What are two indications for Left Cardiac Sympathoectomy in patients with LQT?
-ICD indicated but refused
-Failed BB treatment with ICD in place
What are 5 conditions with a SCN5a mutation?
-Brugada (Loss)
-LQT3 (Gain)
-Short QT (Loss)
-Progressive cardiac conduction disease (Loss)
-CPVT (Gain)
Two ways to diagnose Short QT?
< 330 msec
< 360 msec: Pathogenic mutation, Family history of SQT, SCD < 40, VT/VF
What do you need for primary prevention ICD if NYHA 1
LVEF < 30%, Ischemic cardiomyopathy
What are 6 clinical characteristics for CRT non responders?
Ischemic
Absence of true mechanical dyssynchrony despite wide QRS
RBBB
Higher EF
Higher NYHA class
Presence of AF or High PVC burden
What are 5 technical issues which may predict CRT non response?
-LV lead position
-Pacing into scarred area
-Lead migration
-Pacing < 98.5% of time
-Long programmed AV delay
What does the Atrial septum consist of?
The Atrial Septum consists of the thicker septum secundum and the thinner septum primum
Describe fetal circulation:
Placenta -> Umbilical Veins -> IVC using Ductus Venosus -> Foramen Ovale (IVC flow directed by Eustachian valve across FO) -> Ductus Arteriosus (PA -> Aorta) Umbilical arteries -> Iliac arteries -> Mother
How do pulmonary pressures change in the fetus as it is born? What does this due to the septum primum?
Antenatally, the lung is relatively increased resistance -> Postnatally the PVR decreases and this causes increased RV flow and increased LA pressure -> this causes the primum septum seal against the FO and the ductus arteriosus and venosus cosntrict and close
How to screen for Congenital heart disease?
Measurement of nuchal fold thickness on 12 weeks US to screen for chromosomal abnormalities and congenital heart disease (Se 85%, Sp 99%)
What should all Women with CHD be offered at 19-22 weeks? And what % of these studies will identify CHD?
Fetal Echo
45%
What % of infants have CHD?
1%
What is the most common form of isolated CHD?
VSD
What are the signs of DiGeorge Syndrome?
CATCH 22
Conotruncal Cardiac Defects (Interrupted aorta arch, truncus arteriosus, TOF)
Abnormal facies
Thymic aplasia
Cleft Palate
Hypoparathyroidism/Hypocalcemia
Chromosome 22q11 microdeletion
What are 4 cardiac issues in Trisomy 21?
ASD
ASVD
TOF
VSD
What is chromosomal abnormality in Klinefelter syndrome? What are three cardiac issues?
47XXY
PDA, VSD, MVP
What is the inheritance of Noonan syndrome? What are 5 cardiac issues?
PS
PA Stenosis
Aortic Coarctation
ASD
HCM
AUTOSOMAL DOMINANT
What is Williiam syndrome? What is the characteristic Cardiac abnormality?
-7a11.23 deletion
-Supravalvular AS
AUTOSOMAL DOMINANT
What is a secundum ASD?
True defect of the atrial septum involving the fossa ovalis
What is the sinus venosis ASD?
Defect at the Junction of the RA/SVC with almost always partial anomalous PV return
What is a sinus ASD?
Unroofed coronary sinus which is a defect between CS and LA allowing Left to Right shunting (associated with left sided SVC)
What Pregnancy WHO class is ASDs?
If repaired: Class 1
If unrepaired: Class 2
What are four risks in pregnancy with unrepaired ASD?
-TE events
-Atrial arrhythmias
-IUGR
-Pre-eclampsia
What is size cut off that ASD cannot be percutaneously closed?
> 38mm
PVR/SVR > 2/3, when can you still close ASD?
If there is PA vasoreactivity when challenged with a pulmonary vasodilator
What is a Gerbode VSD?
Rare VSD communicating from LV to RA
What is a small (restrictive VSD) ?
Qp:Qs < 1.5:1
What is a moderately restrictive VSD?
-Qp:Qs > 1.5:1
What is a non restrictive VSD?
Qp:Qs > 2.1
How do you size VSDs relative to the aortic annulus?
Small: < 1/3 aortic annulus diameter
Moderate: 1/3-2/3 aortic annulus diameter
Large: >2/3 aortic annulus diameter
Any risks with Pregnancy and VSD?
No
What is characteristics of Shone’s Syndrome?
Association of multiple levels of LV inflow and outflow obstruction
-Supravalvular mitral membrane
-Parachute mitral valve
-Subvalvular and valvular aortic stenosis
-Aortic coarctation
When to intervene for suprvalvular LVOT-O based on gradient?
MG > 40 mmhg and symptoms
MG > 40mmhg no symptoms but high procedural success
MG 20-40mmhg with symptoms or LV dysfunction
What is indication for subvalvular LVOT obstruction intervention (2) ?
-MG > 40mmhg and symptoms
-MG > 40mmhg no symptoms but >moderate AR, LV dysfunction
-MG 20-40mmhg with symptoms AND progressive AR
What are 7 associations with Aortic Coarctation?
-PDA
-Aortopathy
-BAV
-Intracranial abnormalities in circle of willis
-Congenital coronary anomalies
-VSD
-Turner’s
what do you see on CXR in Aortic Coarct?
3 sign- indentation of aorta at site of coarctation with dilation before/after the site
What is surveillance post Coarct repair?
-Periodic MRI to look for aneurysm, re-coarct, collaterals
What is WHO class for pregnancy in patients with Coarct post repair?
WHO II
5 complications of Coarct repair?
Recoarct
Pseudoaneurysm
Aortic Rupture
Stroke
Femoral artery injury
What is Ebstein’s Anomaly?
-Incomplete delamination of the septal and posterior leaflets of the TV with leaflets airsing from the ventricular wall below the AV junction (> 8mm)
What are 4 anomalies associated with Ebsteins?
-ASD
-Accessory pathways
-LV non compaction
-MVP
What WHO class is Ebsteins in Pregnancy?
WHO Class II
What is risk of dissection in pregnancy with Marfans?
3%
What is the major determinant for dissection in Marfans?
Aortic Size
What is risk of Aortic dissection in Marfans preganncy is < 4.0 cm
1%
At what aortic size in Marfans is Pregnancy contraindicated?
> 4.5 cm (WHO Class IV)
Is Marfan Aorta is 4-4.5 what is WHO class?
Class III
What is initial screening strategy for Marfan’s aorta and follow up?
-At baseline, and then 6 months. If stable than annually there after (Echo)
q6months thereafter if the aorta is enlarged >4.5 cm
What is aorta screening in Marfan’s after aorta surgery?
1 year, if stable, then in 2-3 years
What are the 4 Revised Ghent Criteria (2010) in absence of FHx?
- Ao + EL
- Ao + FBN1
- Ao + SS 7 or more
- EL + FBN1
Ao = Aortic Root Dilatation Z score greater than 2
Three ways to diagnose Marfans in patients with family history
EL
SS equal greater than 7
Ao
Name 7 Skeletal abnormalities in Marfan Syndrome?
-Pectus Carinatum (sticks out)
-Wrist and Thumb sign
-Hind foot deformity (Pes planus)
-Protusio Acetabuli
-Scoliosis or Thoracolumbar Kyphosis
-Reduced elbow flexion
-Increase arm:height ratio
Name facial features in Marfan’s syndrome? (4)
-Enophthalmos
-Downsloping palpebral fissures
-Malar hypoplasia
-Retrognathia
What can happen to lungs in patient’s with Marfans?
Spontaneous Pneumothorax
Describe the Thumb sign
When the entire distal phalanx of the adducted thumb extends beyond the ulnar border of palm
Describe the wrist sign
When the tip of the thumb covers entire fingernail of 5th digit when wrapped around the other wrist
What is dural ectasia?
Ballooning or widening of the dural sac
What is Protusio Acetabuli?
Intrapelvic displacement of the acetabulum and femoral head
What is Myopia?
Near sightedness
Name 4 isolated shunts with Eisenmenger Physiology?
ASD
VSD
PDA
Aortopulmonary Window
Name 7 complex lesions that can cause cyanotic CHD
TGA
Truncus Arteriosus
Tetralogy of Fallot
Univentricular heart
Tricuspid Atresia
Ebsteins with ASD
Complete AV canal defect
Name 3 hematologic complications of Cyanotic CHD?
-Erythrocytosis
-Iron Deficiency / Hyperviscoscity
-Bleeding
Is home O2 recommended in Cyanotic CHD? Why?
No- Will not help in shunt physiology, can result in dry mucosa/epistaxis
Why is it important to replace iron in cyanotic CHD?
-Fe deficiency increases RBC mass and contributes to hyperviscosity
How to treat Hyperviscosity syndrome? What treatment is not effective
-Treat iron deficiency (decreased RBC size)
Phlebotomy is not effective
Name 2 MSK abnormalities with Cyanotic CHD
Hypertrophic OA
Gout
What can Headache be caused be in patients with Cyanotic CHD? (3)
-Hyperviscosity syndrome
-TIA/Stroke
-Abscess
This is why air filters are important
What are three renal complications from Cyanotic CHD?
-Proteinuria
-Stones (uric acid)
-CKD
6 annual things to follow in cyanotic CHD?
CBC
Ferritin
Coagulation profile
Renal function
Uric acid
Echocardiogram
In DTGA what is the aorta’s position to the PA?
Anterior and Rightward relative to the PA (usually posterior and to the right)
What are infants with DTGA dependent on in first days of life?
PDA and PFO
What proportion of patients with DTGA have associated abnormalities?
1/3
What are associated anomalies seen in DTGA? (4)
-VSD
-PS
-PDA
-Coarctation
What is the Lecompte maneuver?
The PA is translocated anterior to the Aorta
What special procedure can be done in DTGA if there is VSD present?
-Rastelli operation: Blood flow from the ventricular level (LV outflow tunnelled to the aorta) is redirected and a valved conduit from the RV to PA is created again. The LV supports the systemic circulation.
What are 6 complications following Atrial switch?
-Systemic AV regurgitation
-Systemic RV failure
-Atrial Arrhythmias
-Ventricular arrhyhthmias
-Baffle leak
-Pulmnoary venous obstruction
What are 6 complications following an arterial switch?
-Significant PA stenosis
-Coronary arterial obstruction
-Severe neo-AV regurgitation or neo aortic root dilation
-Systemic RV failure
-Systemic AV regurgitation
-Arrhythmias
Which of the two type of repair for DTGA are more well tolerated in Pregnancy?
-Arterial switch better tolerated (WHO II)
What WHO class is Atrial switch? When should pregnancy be counselled against
-WHO III
-Arterial Switch and severe RV dysfunction or severe TR
What are 3 complications of LTGA?
-Systemic RV failure
-Systemic AV regurgitation
-CHB
What WHO class is LTGA? When should be counselled against?
-WHO Class III
-NYHA III-IV, EF < 40%
Describe the classic Fontan procedure
RAA anastomosed to main PA
2 complications of classic fontan (why it is not routinely performed anymore)
RA enlargement leads to:
-Arrhythmias
-Thrombosis
Describe the modern 3 step procedure for single ventricle physiology
1) Systemic-PA shunt or banding: BT shunt between subclavian and PA
2) SVC to PA connection: Bidirectional Glenn Shunt
3) Total cavopulmonary connection: Modified fontan
Describe the effects of Pregnancy on Eisenmengers Physiology?
Systemic Vasodilation accentuates Right to left shunting which decreases pulmonary blood flow and causes more cyanosis and decreased CO
5 Lifestyle counselling for Eisenmengers?
-Avoid altitude with exercising
-Avoid smoking
-Avoid IVDU
-Avoid dehydration (Hyperviscosity)
-Excellent oral hygeine
What would hemoptysis in Eisenmengers most likely be due to?
-Pulmonary hemorrhage
Why can’t you repair a shunt in Eisenmengers?
Usually there is advanced irreversible pulmonary vascular disease and there is no left to right shunt demonstrated
Name 10 supportive measures for Eisenmengers?
-Iron deficiency treatment
-IV air filters
-IE prophylaxis
-Vaccinations
-Phelbotomy to keep HCT < 0.65 only if iron already replaced
-Platelet, FFP, Vitamin K, Cryo and DDAVP for bleeding
-Restore sinus rhythm
-ICD if syncope/VT
-Pulmonary vasodilators may be helpful
What is the definition of Acute Limb Ischemia?
< 2 weeks of severe limb pain with:
Pain
Pallor
Pulselessness
Poikilothermia
Paresthesias
Paralysis
What is definition of critical limb ischemia?
-Chronic > 2 weeks ischemic rest pain with non healing wound or ulcer or gangrene in 1 or both legs due to objectively proven arterial occlusive disease
What are 4 predictors of progressive PAD?
DM
Smoking
ABI < 0.5
Ankle pressure < 70mmhg
Desbribe the Leriche-Fontaine Classification system?
1: Asymptomatic PAD
2: Intermittent Claudication
2a: Pain walking > 200m
2b: Pain walking < 200m
- Rest pain or nocturnal pain
- Arterial ulcer necrosis or gangrene
What are 6 causes of Pseudoclaudication?
-Degenerative disc disease
-Diabetic neuropathy
-Deconditioning
-Muscular strain
-Baker’s cyst
-Hip/Foot/Ankle arthritis
What population should be screened for PAD?
> 50 years with RF (Smoking, DM) as per 2022 CCS guidelines
How to measure ABI?
Measure systolic BP in bilateral brachial arteries, dorsalis pedis and posterior tibialis
Choose the right highest ankle pressure and highest arm pressure
same with left
What to do if ABI > 1.4
Use toe brachial index
< 0.6 is abnormal and diagnostic of PAD
What ABI is cut off for PAD?
< 0.9
What is utility of an exercise ABI?
-USeful to distinguish true claudication from pseudoclaudication and it is useful to evaluate borderline/equivocal resting ABI results
How to do exercise ABI?
Exercise for 5 minutes on treadmill at 2 mph, 12% grade
Diagnostic if post exercise ankle pressure decrease by 30mmhg or ABI decrease by 20%
When should imaging be considered for diagnosis of PAD?
Only useful if revascularization considered, not for first line imaging
In addition to the usual therapy for CAD, what is unique to conservative therapy for PAD?
-Foot care
What are the benefits of Exercise program in patients with PAD?
-Improves exercise capacity by 180%, improves QoL and functional status
-Structured program 40-45 mins, 3x/week
What unique pharmacotherapy is available for PAD? What is the mechanism?
Cilostazol: Reduces claudication symptoms
PDE-3 inhibitor that promotes vasodilation and inhibits platelet aggregation
When should Cilostazol be avoided?
CHF (Black box warning)
What is the indication for Revascularization in PAD?
-Ongoing symptoms limiting lifestyle despite maximum medical therapy
Does stenting in PAD result in less amputation?
No, decreases symptoms though
What % of all limb ischemia is upper extremity?
5%
What can the three etiologies of upper limb ischemia be grouped into?
Large Vessel disease: Vasculopathy, Vascular and neurovascular entrapment (Thoracis outlet syndrome), Embolic disease, Aneurysmal disease
Small Vessel disease: Collagen vascular disease with associated vasculitis, Hematological disease with hypercoagulable states and blood dyscrasias, Buerger’s disease, Embolic disease
Vasospastic disease (Raynaud’s Disease)
Where does the pathology occur in Subclavian Artery Stenosis?
Ostium or proximal third of the artery stenosis
What is the mechanism of subclavian steal syndrome?
-Retrograde flow from the posterior cerebral circulation via the vertebral artery
What is on exam for SC artery stenosis?
-SBP difference of 15mmhg or more between arms
What is indication for revascularization in Subclavian Artery Stenosis? Modality?
-Symptoms, asymtomatic if already going for CABG with LIMA
-Endovascular therapy preferred
What is the class 1 indication for intervention for RAS?
Severe RAS and unexplained CHF/Flash pulmonary edema
What are two criteria for the definition of a True Aneurysm?
-Dilation of an artery > 50% with all three layers of the arterial wall present (intima, mieda, adventitia)
Name the anatomic cut offs for Aortic root, ascending Aorta, Aortic arch and descending aorta
Aortic root: Aortic valve cusps, sinuses of valsalva
Ascending Aorta: Sino tubular junction to the brachiocephalic artery
Aortic arch: Origin of the brachiocephalic artery to the origin of the left subclavian
Descending Thoracic aorta: After ligamentum arteriosum/Left subclavian
What is the histopathology in marfan’s aortic dilation?
Decrease elastin in the aortic media which leads to medial degeneration
5 cardiac manifestations of Marfan?
Aortic aneurysm
PA dilatation
MVP
TVP
MAC
What is the gene implicated in Type 4 Vascular ED? What does it code for?
-COL3A1
-Type 3 Collagen
What are the two Craniofacial abnormalities in LD syndrome?
-Hypertelorism (widely spaced out eyes)
-Cleft palate
What are 3 extra cardiac/physical abnormalities in Turners?
-Webbed neck
-Short stature
-Low set ears
Name 6 inflammatory diseases for aortopathy?
-GCA
-Takayasu
-Behcets
-Ank Spond
-IBD
-Reiter’s syndrome
Name 2 infectious etiologies for Aortopathy?
-Syphilis
-TB
Name 5 things that put at increased risk of Aortic dissection
Aortic size > 6cm
Rapid growth > 0.5cm/yr
Smoking
Uncontrolled hypertension
Family history
CTD
BAV
What should imaging screening schedule be for Marfan’s?
Baseline -> 6 months to determine rate of progression
If stable -> annual
If significant change from baseline or diameter > 4.5 -> more frequent
What is imaging surveillance for non marfan genetic aortopathy?
-Complete aortic imaging at initial and 6 months, then annually
What is surveillance schedule for Turner’s?
Complete assessment at baseline, annual imaging if abnormalities
Otherwise complete aortic imaging every 5 years
What is the mechanism for ARBs stopping TAA growth?
Inhibits TGF-Beta signalling
What is TAA surgical cut off in degenerative TAA?
5.5 cm
What is TAA surgical cut off in Marfan Syndrome?
5 cm (4.1-5cm if woman considering surgery)
What is TAA surgical cut off in LDS and ED?
4-5cm
Undergoing Cardiac surgery?
> 4.5 cm
What should Post op surveillance be after aortic repair?
If no residual aortopathy, then image entire aorta every 3-5 years post repair
MRI should be considered in patients < 50 years to reduce radiation
What is the pathology of Aortic Dissection?
-Tear in the intima that allows access of blood into the media under systolic pressure leading to separation of the inner and outer media and formation of a true and false lumen
What is the pathology of an intramural hematoma?
A collection of blood within the wall of the aorta without a discernable entry tear believed to be secondary to spontaneous bleeding from the damaged vasa vasorum
What % of IMH progresses to dissection?
10%
What are 4 mechanisms of AR in dissection?
-Aortic root dilatation
-Prolapse of dissection flap into LVOT
-Prolapse of AV leaflet
-Pre-existing AI due to anerysm of BAV
Describe the DeBakey calssification system
Type 1: Originates in the ascending Aorta and extends beyond the brachiocephalic
(Involves ascending and Descending)
Type 2: Confined to the ascending aorta
Type 3: Begins distal to the left subclavian
What are the indications for surgical intervention in chronic Type a Dissection (> 6 weeks)
Same as for TAA dilation
What are 4 indications for EVAR in type B dissection (Complicated dissection) ?
-Malperfusion
-Rupture
-Rapid expansion
-Refractory pain
After conservative management for Type B dissection, what is imaging schedule in first year post discharge?
1, 3, 6, 12 months
What is cut off for AAA diagnosis?
3 cm
What is the most commonly effected segment for AAA?
Aorta between renal artery and inferior mesenteric artery
What is screening recommendations for AAA?
Men aged 65-80
What is surveillance for AAA if <4cm, if 4-5.4 cm?
US q2-3y
US 6-12 months
When EVAR for AAA?
Symptoms
> 5.5 cm
> 1cm / year growth
What are the two types of endoleaks?
Type 1: Failure to adequately seal the proximal or distal end of the stent graft
Type 2: Retrograde flow from small branch arteries back into the aneurysm sac
Does EVAR have lower early mortality than open repair in AAA?
Yes, but associated with higher risk of future aortic rupture and the need for more secondary procedures
What is a Bovine arch?
The Left carotid artery and Brachicephalic trunk share a common origin
Where does the Carotid artery stenosis more frequently develop?
At the bifurcation of the common carotid
What is characteristic of Radiation Induced Carotid Artery Disease?
-Often affect long arterial segments and atypical locations
Why is CEA relatively contraindicated in Radiation Induced Carotid Artery Disease?
Surgical treatment is complicated by Radiation effects on soft tissue and skin overlying
Carotid Artery Stenting has the advantage of no cranial nerve injury and no wound complications
What should Carotid US be followed by if it is positive?
-CTA/MRA: Can define aortic arch and intracranial vessel anatomy
When is CEA indicated for CA stenosis?
-Symptomatic > 70-99% (Class 1), >50% (Class 2) within 14 days
-Asymptomatic 70-99% (Class 2)
What is the only antiplatelet agent that is OK for breast feeding?
Aspirin
When is the fetus most susceptible to radiation?
-1st trimester (organogenesis)
What should fetal radiation be kept to ideally?
Keep lower than 50 mGy
When to try and delay radiation exposure until?
12 weeks (organogenesis is complete)
Give some examples of WHO 1 Class (No increased maternal risk)
Uncomplicated repaired ASD, VSD, PACs, PVCs, Small PDA, Mild MVP or PS
Give some examples of WHO Class 2?
Unrepaired ASD, VSD, Repaired ToF, Most arrhythmia, Turners with no Aortic dilation
What should follow up be for WHO2 classification?
Once per trimester
What are examples of WHO IV (40-100% maternal CV event rate)? (11)
-PAH / Eisenmengers
-Systemic Ventricular Function < 30% or NYHA III-IV
-PPCM with residual impairment (LVEF < 55%)
-Severe MS or Severe Symptomatic AS
-Fontan with any complication (Otherwise III)
-Severe Coarctation or Recoarctation
-Vascular Ehler’s Danlos or LDS (Regardless of Aortic size)
-Aortopathies: MFS > 4.5cm, BAV > 5cm, Turner ASI > 25mm/m2
-Coronary Dissection (CCS Pregancy)
What should follow up for WHO IV be?
Monthly minimum
Name the CARPREG II risk factors? (12)
-Previous cardiac events or arrhythmias
-Baseline NYHA III-IV
-Mechanical Valve
-LVEF < 55%
-AVA < 1.5
-MVA < 2
-LVOT Obstruction
-PH > 49mmhg
-High Risk Aortopathy
-CAD
-No prior cardiac intervention
-Late pregnancy assessment
Why is early epidural anesthesia recommended in obstetric cardiology?
Prevents peaks in BP
When should Warfarin be held as Labor approaches?
1 week prior to planned delivery, change to LMWH or UFH (AHA 2020 VHD)
Switch from LMWH to UFH 36h prior to Labor, Stop UFH 6h prior to Labor
When should Anticoagulation be held prior to Labor?
6 hours
Switch from LMWH -> UFH 36 hours prior to planned delivery -> Stop 6h prior to Planned Labor
When can UFH be continued after Vaginal delivery? C Section?
-6 hours
-12 hours
Is Warfarin safe in breast feeding?
Yes
Do you need IE prophylaxis with C section?
No
What are some contraindications to Vaginal Delivery?
None
When should Induction be done by in all women with CV disease?
by 40 weeks
Name 6 conditions in which C Section can be considered? (Not an absolute CI to Vaginal delivery)
-On OACs with pre-term labor
-High risk Aortopathy
-Intractable HF
-Severe PHtn
What are 5 adverse effects of Warfarin on the fetus?
-Warfarin Embryopathy
-Developmental delay
-Fetal loss
-Short fingers
-Nasal hypoplasia
-Stippled Epiphyses
How frequently to monitor INR in pregnancy on Warfarin?
q2 weeks
Why is Vaginal delivery on VKA contraindicated?
Fetal ICH during Labor
Why is LMWH/UFH chosen around Labor compared to Warfarin?
LMWH/UFH do not cross the placenta
What needs to be done when using LMWH?
Factor Xa monitoring
How to manage high risk TE women on LMWH around labor?
Convert to UFH 36h prior, then stop UFH 6h prior to delivery
What is the issue with Digoxin in Pregnancy?
Serum levels are unreliable
What is timing cut off for pre-existing vs. Pregnancy induced hypertension?
20 weeks
What is BP target for DBP in pregnancy?
85mmhg
What are the three 1st line agents for HTN in pregnancy?
-Nifedipine
-Labetalol
-Methyldopa
What are three 2nd line agents for HTN management in pregnancy?
-Clonidine, Hydralazine, Thiazide diuretics
When is delivery recommended for gestational HTN or mild Pre-eclampsia?
37 weeks
Cut off to admit pregnant woman for severe HTN?
> 160/110 mmhg
What women should get ASA?
ASA for all women at moderate or high risk of Preeclampsia from 12 weeks GA to 36-37 weeks
Management of Pre-eclampsia?
Admit for Immediate delivery
MgSO4 4gram IV
Target BP < 160/110mmhg
Are ACE inhibitors safe in pregnancy? In breast feeding?
Not in pregnancy, yes with breast feeding
What are indications for valve intervention prior to pregnancy?
-Any severe symptomatic valvular disease or as per standard indications (Class 1)
-Asymptomatic Severe MS
-Asymptomatic Severe AS
-Asymptomatic Severe MR with high chance of repair
What are three indications for valve intervention during pregnancy?
-NYHA III/IV Severe AS despite Medical therapy
-NYHA III/IV Severe MS despite Medical therapy
-NYHA IV Severe MR despite medical therapy
In Pregnant women on anticoagulation, how to manage ASA?
-Stop ASA during first trimester, resume afterwards
What is the best timing during pregnancy for OHS?
13-26 weeks
What should pregnant woman get prior to OHS?
Steroids
Beyond what week should a C section be performed prior to OHS?
26 weeks onwards
If pregnant woman is hypotensive/pre arrest, how to position?
Place in left lateral decubitus position to relieve aortocaval compression
What to do during arrest in pregnant woman in addition to standard measures?
Continuous manual left uterine displacement
When should Perimortem C-Section be considered?
If no ROSC at 4 minutes
What two time periods in Pregnancy do dissections occur?
Third trimester or early post partum
What is the EF criteria for PPCM?
LVEF < 45%
What are 5 risk factors for PPCM?
-Advanced Age
-Black
-Preeclampsia
-Hypertension
-Multiple gestations
What is Bromocriptine’s role in PPCM?
May be considered to stop lactation and enhance LV recovery (Need prophylactic anticoagulation)
What % of patients have EF recovery > 50% post PPCM?
75%
What is recurrence risk for PPCM ?
25% risk if normal LVEF
50% recurrence if residual LV dysfunction
What are the three targeted pathways for Pulmonary hypertension?
-Endothelin
-Nitric Oxide
-Prostacyclines
What are 8 causes of PAH?
Idiopathic
Heritable
Drug/Toxin induced
CHD
CTD
Portal HTN
HIV
Schistosomiasis
Name three medications that cause PHTn
Aminorex, Fenfluramine, Dexfluramine, Methamphetamines
What are three contraindications for RHC?
-Mechanical TV or PV
-Right heart masses
-Right sided IE
What is the criteria for a positive vasoreactivity response?
-decrease in mPAP > 10 to a value less than 40 with no decrease in Cardiac output
What are 3 ways to do Vasoreactivity testing?
NO
Epoprostenol
Adenosine
What does vasoreactivity predict?
Response to CCB with improved survival
How to measure PCWP?
Should be recorded as the mean of 3 measurements at end expiration
How to convert woods units to dynes?
WU x 80 = Dynes
What PH group has the worse prognosis?
Class III, rest are comparable
What are 5 classes of medical therapy for PH?
CCBs
Prostanoids (Prostacyclin)- Selexipag
Endothelin receptor antagonists- Bosentan
PDE-5 inhibitors- Taladafil, Sildenafil
Soluble guanylate cyclase stimulators
What are 9 determinants of >10% mortality in PAH?
-Clinical signs of right heart failure
-Progression of symptoms
-Repeated syncope
-WHO class IV functional status
-6MWD < 165m
-CPX < 11
-NT Pro BNP > 300
-Pericardial effusion, RA > 26 (dilated)
-Hemodynamics: RAP > 14, CI < 2, SVO2 < 60%
