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RCE Guidelines Studying > UBC RCE Compiled Notes > Flashcards

UBC RCE Compiled Notes Flashcards

1
Q

What is Non HDL comprised of? How is it calculated?

A

-The sum of chylomicron remnants, VLDL, LDL, Lp(a), LDL

-Calculated on a lipid panel by subtracting HDL from the total cholesterol

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2
Q

Who should be screened for lipid profile? (7)

A

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

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3
Q

Should screening lipids be fasting?

A

yes, unless G > 4.5 mmol/l

Friedewald: TC = TC - HDL - (TG x 0.45)

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4
Q

When does lipid screening need to be repeated based on FRS

A

Every 5 years if FRS < 5%, Annually if FRS > 5%

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5
Q

In IR patients, name reasons to start on statin therapy (11)

A

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

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6
Q

What is the most important health intervention for prevention of CVD?

A

Smoking cessation

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7
Q

What % of total saturated fats should be of total energy

A

< 9%

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8
Q

What is healthy body weight?

A

BMI 18.5-25

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9
Q

What target organ damage should prompt BP treatment in office (not hypertensive crisis)

A

-CAD (ASCVD, HF, LVH)

-CVD

-Hypertensive Retinopathy

-PAD

-CKD (eGR < 60 or Albuminuria)

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10
Q

Patients should have 2 or more of the following to screen for Renovascular Hypertension?

A
  • < 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

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11
Q

4 Imaging modalities to evaluate for RAS?

A

CTA

MRA

Doppler US

Captopril-enhanced radioisotope renal scane

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12
Q

When should FMD be screened for? 4 ways different than Renovascular

A

-Positive fmaily history of FMD

-FMD in another vascular territory

-Abdominal bruit without apparent atherosclerosis

-1.5 cm difference between kidney size

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13
Q

What test to do after FMD diagnosed?

A

-Cervicocephalic lesions and intracranial aneurysm

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14
Q

4 reasons to screen for Hyperaldosteronism?

A

Diuretic induced Hypo K < 3.0

Spontaneous K < 3.5

Incidental adrenal adenoma

Resistance with 3 or more drugs

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15
Q

Approach to diagnosing Hyperaldosteronism

A

-Plasma renin:aldo ratio

-Saline suppression (2L over 4h) -> positive if Aldo > 280 OR Captopril suppression test

-Adrenal imaging and Adrenal Vein sampling

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16
Q

WC targets for Men and Women?

A

Men < 102 cm

Women < 88 cm

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17
Q

Three agents to use for isolated systolic hypertension

A

-Thiazide

-ARB

-CCB

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18
Q

What is the criteria for Metabolic syndrome?

A

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

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19
Q

Which patients undergoing non cardiac surgery should you screen?

A
  • > 45 years
  • Known CVD
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20
Q

What is the RCRI components ? What does it predict?

A

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)

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21
Q

Three criteria to proceed with NT BNP testing with Pre op testing? What is BNP cut off?

A

-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

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22
Q

What effect does Exercise have on Lipid profile?

A

-Increase HDL, Decrease LDL, Decrease TG’s

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23
Q

What is resting membrane potential for myocyte membrance?

A

-70 to -90 mV

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24
Q

What is an example of early after depolarizations? delayed?

A

-Early: QTC

-Late: Dig toxicity, Ischemia, CPVT, Outflow tract arrhythmias

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25
Q

What Sinus node recovery time is abnormal?

A

CSNRT > 550msec

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26
Q

8 complications of Catheter ablation?

A

-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

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27
Q

What is definition of Inappropriate Sinus Tachycardia?

A

HR > 90 bpm on 24 hour holter, no secondary causes.

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28
Q

Two Class 1 indications for Sinus Node Disease?

A
  1. Symptomatic sinus node dysfunction
  2. Symptomatic sinus bradycardia as a consequence of guideline directed management for which no alternative treatment exists
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29
Q

4 Class 1 Indications for AV node disease?

A

-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

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30
Q

Two indications for Pacing in conduction system disease with 1:1 AV conduction?

A

-Patients with syncope and bundle branch block who are found to have an HV interval > 70 msec

-Alternating BBB

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31
Q

Two indications for Pacing in conduction system disease with 1:1 AV conduction?

A

-Patients with syncope and bundle branch block who are found to have an HV interval > 70 msec

-Alternating BBB

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32
Q

Two contraindications to CSM?

A

-Carotid bruit
-TIA/Stroke/MI within 3 months

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33
Q

4 Major high risk criteria for Syncope based on CCS 2011 guidelines?

A

-HF
-Hypotension < 90mmhg
-History of Cardiac disease
-Abnormal ECG

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34
Q

What dose SF syncope score predict? and what are the components?

A

Predicts serious morbidity/mortality within 7 days of presentation

-Shortness of breath
-Hypotension
-Abnormal ECG
-Anemia Hct < 30%
-CHF

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35
Q

What is prevalence of dual nodal physiology?

A

10%

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36
Q

What are two reasons that accessory pathways don’t lead to pre-excitation pattern on surface ECG?

A

1) Can only conduct retrograde (Concealed)

2) Conduction down the pathway takes longer than conduction down the AV node

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37
Q

What are 7 risk factors that increase risk of SCD in WPW?

A

-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

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38
Q

What are three indications for ablation in Pre-excitation?

A

-Symptomatic patients with AVRT or Pre-excited AF
-Asymptomatic patients with high risk pathway on EPS
-Asymptomatic patients with a high risk job

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39
Q

What is the metabolism pathway for Rivaroxaban?

A

-CYP3A4 elimination

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40
Q

What is the metabolism pathway for Apixaban?

A

CYP3A4 elimination

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41
Q

What is unique about Edoxaban pharmacology compared to the other DOACSs?

A

It is a pro-drug

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42
Q

Name 7 CYP450 Inhibitors

A

CLAM JUICE give you AIDS and this will inhibit you

CCB
Lansoprazole
Azoles
Macrolides
HIV Protease Inhibitors
Grapefruit Juice

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43
Q

Name the CYP450 Inducers

A

RC induces PTSD

Rifampin
Carbamazepine
Phenobarb
Ticlodipine
St. John Wart
Dilantin

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44
Q

Three ways to reverse Warfarin?

A

-Octaplex (2, 7, 9, 10 + Protein C/S)

-Vitamin K

-FFP

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45
Q

What is Renal dosing for Rivaroxaban?

A

15mg if CrCl 15-50 (Although no RCT data for CrCL 15-30)

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46
Q

When to dose reduce Dabigatran? (3)

A

Age > 80

Age > 75 with bleeding RFs

CrCl 30-50

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47
Q

What is renal dosing for Edoxaban?

A

-30mg daily if CrCl 30-50 or less than 60kg

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48
Q

What is the only DOAC that is a prodrug?c

A

Dabigatran

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49
Q

What DOAC can be dialyzed? Why?

A

-Dabigatran, because it is only 35% protein bound

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50
Q

What two DOACs are metabolized through CYP3A4 pathway?

A

Rivaroxaban

Apixaban

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51
Q

What are the 3 reasons to DCCV prior to 3 weeks OAC?

A

Unstable

< 12 hours with no recent stroke

< 48h hours with CHADS < 2

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52
Q

What are the 7 components of the HAS BLED score?

A

Hypertension

Abnormal LFTs/Renal Function

Stroke history

Bleeding history

Labile INR

Elderly > 65 years

Drugs/ETOH history

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53
Q

What are two criteria needed as per CCS 2018 Afib update to consider an LAA occluder?

A

CHADS 2 or more, anti-thrombotic therapy is precluded

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54
Q

What is Procainamide dosing for AFib cardioversion? VT?

A

15-18 mg/kg over 60 minutes

10 mg/kg over 20 minutes

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55
Q

What is the success rate for Procainamide AF cardioversion?

A

50%

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56
Q

What is the most significant risk of giving Ibutilide for AF cardioversion?

A

TDP

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57
Q

What is the unique aspect of Vernakalant?

A

Atrial selective antiarrhythmic drug.

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58
Q

What is the most frequent that Afib episodes happen to consider a pill in pockey strategy?

A

monthly

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59
Q

What are 8 contraindications to pill in pocket strategy?

A

-LVEF < 50%
-CAD
-QRS > 120msec
-PR > 200
-Pre excitation
-Conduction system disease
-Hypotension
-Inability to comply

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60
Q

What is dose for Flecainide and Propafenone for PIP?

A

-Flecainide: 300mg

-Propafenone: 600mg

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61
Q

4 reasons to present to ED when PIP tried?

A

-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

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62
Q

9 complications of Catheter ablation for Afib?

A

-Atrio-esophageal fistula

-Perforation

-Tamponade

-Air embolism

-Pulmonary Vein stenosis

-Vascular injury

-Arrhythmia

-Phrenic nerve injury

-Pericarditis

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63
Q

5 ways to reduce Atrial Fibrillation following Cardiac Surgery?

A

-Beta blockers

-Amiodarone

-Sotalol

-Magnesium

-Biatrial pacing

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64
Q

What is the HATCH Score? What does a score of 5 or more indicate?

A

Hypertension
Age > 75
TIA/Stroke (2)
COPD
CHF (2)

Predicts 10% or more risk of Afib after Aflutter ablation in next 12 months.

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65
Q

What are the two common morphologies for Fascicular VT?

A

-Left Posterior Fascicle VT: RBBB, Left Superior Axis

-Left Anterior Fascicle VT: RBBB, Right Axis

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66
Q

What is Jervell/Lange Nielsen syndrome?

A

-Aggressive congenital LQT phenotype

-Autosomal recessive

-Congenital hearing loss

-KCNQ1 mutation

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67
Q

What is Andersen syndrome?

A

-Long QT, Large U waves, Frequent PVCs, facial dysmorphic features.

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68
Q

What is Timothy syndrome?

A

-LQT syndrome with autism, developmental disorders, congenital heart defects

-CACNA1c mutation (gain of function)

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69
Q

What Schwartz score needed to make diagnosis of LQT?

A

3.5 points or more

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70
Q

2 Indications for beta blocker in LQT syndrome?

A

-Symptomatic VT/VF

-Asymptomatic with QTc > 470 msec

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71
Q

What are three predictors of BB failure in LQT syndrome?

A
  • QTC > 500msec

-VT before age 7

-LQT 2/3 Variants

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72
Q

What are two indications for Left Cardiac Sympathoectomy in patients with LQT?

A

-ICD indicated but refused

-Failed BB treatment with ICD in place

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73
Q

What are 5 conditions with a SCN5a mutation?

A

-Brugada (Loss)

-LQT3 (Gain)

-Short QT (Loss)

-Progressive cardiac conduction disease (Loss)

-CPVT (Gain)

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74
Q

Two ways to diagnose Short QT?

A

< 330 msec

< 360 msec: Pathogenic mutation, Family history of SQT, SCD < 40, VT/VF

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75
Q

What do you need for primary prevention ICD if NYHA 1

A

LVEF < 30%, Ischemic cardiomyopathy

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76
Q

What are 6 clinical characteristics for CRT non responders?

A

Ischemic
Absence of true mechanical dyssynchrony despite wide QRS
RBBB
Higher EF
Higher NYHA class
Presence of AF or High PVC burden

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77
Q

What are 5 technical issues which may predict CRT non response?

A

-LV lead position
-Pacing into scarred area
-Lead migration
-Pacing < 98.5% of time
-Long programmed AV delay

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78
Q

What does the Atrial septum consist of?

A

The Atrial Septum consists of the thicker septum secundum and the thinner septum primum

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79
Q

Describe fetal circulation:

A

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

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80
Q

How do pulmonary pressures change in the fetus as it is born? What does this due to the septum primum?

A

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

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81
Q

How to screen for Congenital heart disease?

A

Measurement of nuchal fold thickness on 12 weeks US to screen for chromosomal abnormalities and congenital heart disease (Se 85%, Sp 99%)

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82
Q

What should all Women with CHD be offered at 19-22 weeks? And what % of these studies will identify CHD?

A

Fetal Echo

45%

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83
Q

What % of infants have CHD?

A

1%

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84
Q

What is the most common form of isolated CHD?

A

VSD

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85
Q

What are the signs of DiGeorge Syndrome?

A

CATCH 22

Conotruncal Cardiac Defects (Interrupted aorta arch, truncus arteriosus, TOF)

Abnormal facies

Thymic aplasia

Cleft Palate

Hypoparathyroidism/Hypocalcemia

Chromosome 22q11 microdeletion

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86
Q

What are 4 cardiac issues in Trisomy 21?

A

ASD

ASVD

TOF

VSD

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87
Q

What is chromosomal abnormality in Klinefelter syndrome? What are three cardiac issues?

A

47XXY

PDA, VSD, MVP

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88
Q

What is the inheritance of Noonan syndrome? What are 5 cardiac issues?

A

PS

PA Stenosis

Aortic Coarctation

ASD

HCM

AUTOSOMAL DOMINANT

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89
Q

What is Williiam syndrome? What is the characteristic Cardiac abnormality?

A

-7a11.23 deletion

-Supravalvular AS

AUTOSOMAL DOMINANT

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90
Q

What is a secundum ASD?

A

True defect of the atrial septum involving the fossa ovalis

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91
Q

What is the sinus venosis ASD?

A

Defect at the Junction of the RA/SVC with almost always partial anomalous PV return

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92
Q

What is a sinus ASD?

A

Unroofed coronary sinus which is a defect between CS and LA allowing Left to Right shunting (associated with left sided SVC)

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93
Q

What Pregnancy WHO class is ASDs?

A

If repaired: Class 1

If unrepaired: Class 2

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94
Q

What are four risks in pregnancy with unrepaired ASD?

A

-TE events
-Atrial arrhythmias
-IUGR
-Pre-eclampsia

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95
Q

What is size cut off that ASD cannot be percutaneously closed?

A

> 38mm

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96
Q

PVR/SVR > 2/3, when can you still close ASD?

A

If there is PA vasoreactivity when challenged with a pulmonary vasodilator

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97
Q

What is a Gerbode VSD?

A

Rare VSD communicating from LV to RA

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98
Q

What is a small (restrictive VSD) ?

A

Qp:Qs < 1.5:1

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99
Q

What is a moderately restrictive VSD?

A

-Qp:Qs > 1.5:1

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100
Q

What is a non restrictive VSD?

A

Qp:Qs > 2.1

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101
Q

How do you size VSDs relative to the aortic annulus?

A

Small: < 1/3 aortic annulus diameter

Moderate: 1/3-2/3 aortic annulus diameter

Large: >2/3 aortic annulus diameter

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102
Q

Any risks with Pregnancy and VSD?

A

No

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103
Q

What is characteristics of Shone’s Syndrome?

A

Association of multiple levels of LV inflow and outflow obstruction
-Supravalvular mitral membrane

-Parachute mitral valve

-Subvalvular and valvular aortic stenosis

-Aortic coarctation

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104
Q

When to intervene for suprvalvular LVOT-O based on gradient?

A

MG > 40 mmhg and symptoms

MG > 40mmhg no symptoms but high procedural success

MG 20-40mmhg with symptoms or LV dysfunction

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105
Q

What is indication for subvalvular LVOT obstruction intervention (2) ?

A

-MG > 40mmhg and symptoms

-MG > 40mmhg no symptoms but >moderate AR, LV dysfunction

-MG 20-40mmhg with symptoms AND progressive AR

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106
Q

What are 7 associations with Aortic Coarctation?

A

-PDA
-Aortopathy
-BAV
-Intracranial abnormalities in circle of willis
-Congenital coronary anomalies
-VSD
-Turner’s

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107
Q

what do you see on CXR in Aortic Coarct?

A

3 sign- indentation of aorta at site of coarctation with dilation before/after the site

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108
Q

What is surveillance post Coarct repair?

A

-Periodic MRI to look for aneurysm, re-coarct, collaterals

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109
Q

What is WHO class for pregnancy in patients with Coarct post repair?

A

WHO II

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110
Q

5 complications of Coarct repair?

A

Recoarct

Pseudoaneurysm

Aortic Rupture

Stroke

Femoral artery injury

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111
Q

What is Ebstein’s Anomaly?

A

-Incomplete delamination of the septal and posterior leaflets of the TV with leaflets airsing from the ventricular wall below the AV junction (> 8mm)

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112
Q

What are 4 anomalies associated with Ebsteins?

A

-ASD

-Accessory pathways

-LV non compaction

-MVP

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113
Q

What WHO class is Ebsteins in Pregnancy?

A

WHO Class II

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114
Q

What is risk of dissection in pregnancy with Marfans?

A

3%

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115
Q

What is the major determinant for dissection in Marfans?

A

Aortic Size

116
Q

What is risk of Aortic dissection in Marfans preganncy is < 4.0 cm

A

1%

117
Q

At what aortic size in Marfans is Pregnancy contraindicated?

A

> 4.5 cm (WHO Class IV)

118
Q

Is Marfan Aorta is 4-4.5 what is WHO class?

A

Class III

119
Q

What is initial screening strategy for Marfan’s aorta and follow up?

A

-At baseline, and then 6 months. If stable than annually there after (Echo)

q6months thereafter if the aorta is enlarged >4.5 cm

120
Q

What is aorta screening in Marfan’s after aorta surgery?

A

1 year, if stable, then in 2-3 years

121
Q

What are the 4 Revised Ghent Criteria (2010) in absence of FHx?

A
  1. Ao + EL
  2. Ao + FBN1
  3. Ao + SS 7 or more
  4. EL + FBN1

Ao = Aortic Root Dilatation Z score greater than 2

122
Q

Three ways to diagnose Marfans in patients with family history

A

EL

SS equal greater than 7

Ao

123
Q

Name 7 Skeletal abnormalities in Marfan Syndrome?

A

-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

124
Q

Name facial features in Marfan’s syndrome? (4)

A

-Enophthalmos

-Downsloping palpebral fissures

-Malar hypoplasia

-Retrognathia

125
Q

What can happen to lungs in patient’s with Marfans?

A

Spontaneous Pneumothorax

126
Q

Describe the Thumb sign

A

When the entire distal phalanx of the adducted thumb extends beyond the ulnar border of palm

127
Q

Describe the wrist sign

A

When the tip of the thumb covers entire fingernail of 5th digit when wrapped around the other wrist

128
Q

What is dural ectasia?

A

Ballooning or widening of the dural sac

129
Q

What is Protusio Acetabuli?

A

Intrapelvic displacement of the acetabulum and femoral head

130
Q

What is Myopia?

A

Near sightedness

131
Q

Name 4 isolated shunts with Eisenmenger Physiology?

A

ASD

VSD

PDA

Aortopulmonary Window

132
Q

Name 7 complex lesions that can cause cyanotic CHD

A

TGA

Truncus Arteriosus

Tetralogy of Fallot

Univentricular heart

Tricuspid Atresia

Ebsteins with ASD

Complete AV canal defect

133
Q

Name 3 hematologic complications of Cyanotic CHD?

A

-Erythrocytosis

-Iron Deficiency / Hyperviscoscity

-Bleeding

134
Q

Is home O2 recommended in Cyanotic CHD? Why?

A

No- Will not help in shunt physiology, can result in dry mucosa/epistaxis

135
Q

Why is it important to replace iron in cyanotic CHD?

A

-Fe deficiency increases RBC mass and contributes to hyperviscosity

136
Q

How to treat Hyperviscosity syndrome? What treatment is not effective

A

-Treat iron deficiency (decreased RBC size)

Phlebotomy is not effective

137
Q

Name 2 MSK abnormalities with Cyanotic CHD

A

Hypertrophic OA

Gout

138
Q

What can Headache be caused be in patients with Cyanotic CHD? (3)

A

-Hyperviscosity syndrome

-TIA/Stroke

-Abscess

This is why air filters are important

139
Q

What are three renal complications from Cyanotic CHD?

A

-Proteinuria

-Stones (uric acid)

-CKD

140
Q

6 annual things to follow in cyanotic CHD?

A

CBC

Ferritin

Coagulation profile

Renal function

Uric acid

Echocardiogram

141
Q

In DTGA what is the aorta’s position to the PA?

A

Anterior and Rightward relative to the PA (usually posterior and to the right)

142
Q

What are infants with DTGA dependent on in first days of life?

A

PDA and PFO

143
Q

What proportion of patients with DTGA have associated abnormalities?

A

1/3

144
Q

What are associated anomalies seen in DTGA? (4)

A

-VSD

-PS

-PDA

-Coarctation

145
Q

What is the Lecompte maneuver?

A

The PA is translocated anterior to the Aorta

146
Q

What special procedure can be done in DTGA if there is VSD present?

A

-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.

147
Q

What are 6 complications following Atrial switch?

A

-Systemic AV regurgitation

-Systemic RV failure

-Atrial Arrhythmias

-Ventricular arrhyhthmias

-Baffle leak

-Pulmnoary venous obstruction

148
Q

What are 6 complications following an arterial switch?

A

-Significant PA stenosis

-Coronary arterial obstruction

-Severe neo-AV regurgitation or neo aortic root dilation

-Systemic RV failure

-Systemic AV regurgitation

-Arrhythmias

149
Q

Which of the two type of repair for DTGA are more well tolerated in Pregnancy?

A

-Arterial switch better tolerated (WHO II)

150
Q

What WHO class is Atrial switch? When should pregnancy be counselled against

A

-WHO III

-Arterial Switch and severe RV dysfunction or severe TR

151
Q

What are 3 complications of LTGA?

A

-Systemic RV failure

-Systemic AV regurgitation

-CHB

152
Q

What WHO class is LTGA? When should be counselled against?

A

-WHO Class III

-NYHA III-IV, EF < 40%

153
Q

Describe the classic Fontan procedure

A

RAA anastomosed to main PA

154
Q

2 complications of classic fontan (why it is not routinely performed anymore)

A

RA enlargement leads to:

-Arrhythmias

-Thrombosis

155
Q

Describe the modern 3 step procedure for single ventricle physiology

A

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

156
Q

Describe the effects of Pregnancy on Eisenmengers Physiology?

A

Systemic Vasodilation accentuates Right to left shunting which decreases pulmonary blood flow and causes more cyanosis and decreased CO

157
Q

5 Lifestyle counselling for Eisenmengers?

A

-Avoid altitude with exercising

-Avoid smoking

-Avoid IVDU

-Avoid dehydration (Hyperviscosity)

-Excellent oral hygeine

158
Q

What would hemoptysis in Eisenmengers most likely be due to?

A

-Pulmonary hemorrhage

159
Q

Why can’t you repair a shunt in Eisenmengers?

A

Usually there is advanced irreversible pulmonary vascular disease and there is no left to right shunt demonstrated

160
Q

Name 10 supportive measures for Eisenmengers?

A

-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

161
Q

What is the definition of Acute Limb Ischemia?

A

< 2 weeks of severe limb pain with:

Pain

Pallor

Pulselessness

Poikilothermia

Paresthesias

Paralysis

162
Q

What is definition of critical limb ischemia?

A

-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

163
Q

What are 4 predictors of progressive PAD?

A

DM

Smoking

ABI < 0.5

Ankle pressure < 70mmhg

164
Q

Desbribe the Leriche-Fontaine Classification system?

A

1: Asymptomatic PAD

2: Intermittent Claudication

2a: Pain walking > 200m

2b: Pain walking < 200m

  1. Rest pain or nocturnal pain
  2. Arterial ulcer necrosis or gangrene
165
Q

What are 6 causes of Pseudoclaudication?

A

-Degenerative disc disease

-Diabetic neuropathy

-Deconditioning

-Muscular strain

-Baker’s cyst

-Hip/Foot/Ankle arthritis

166
Q

What population should be screened for PAD?

A

> 50 years with RF (Smoking, DM) as per 2022 CCS guidelines

167
Q

How to measure ABI?

A

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

168
Q

What to do if ABI > 1.4

A

Use toe brachial index

< 0.6 is abnormal and diagnostic of PAD

169
Q

What ABI is cut off for PAD?

A

< 0.9

170
Q

What is utility of an exercise ABI?

A

-USeful to distinguish true claudication from pseudoclaudication and it is useful to evaluate borderline/equivocal resting ABI results

171
Q

How to do exercise ABI?

A

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%

172
Q

When should imaging be considered for diagnosis of PAD?

A

Only useful if revascularization considered, not for first line imaging

173
Q

In addition to the usual therapy for CAD, what is unique to conservative therapy for PAD?

A

-Foot care

174
Q

What are the benefits of Exercise program in patients with PAD?

A

-Improves exercise capacity by 180%, improves QoL and functional status

-Structured program 40-45 mins, 3x/week

175
Q

What unique pharmacotherapy is available for PAD? What is the mechanism?

A

Cilostazol: Reduces claudication symptoms

PDE-3 inhibitor that promotes vasodilation and inhibits platelet aggregation

176
Q

When should Cilostazol be avoided?

A

CHF (Black box warning)

177
Q

What is the indication for Revascularization in PAD?

A

-Ongoing symptoms limiting lifestyle despite maximum medical therapy

178
Q

Does stenting in PAD result in less amputation?

A

No, decreases symptoms though

179
Q

What % of all limb ischemia is upper extremity?

A

5%

180
Q

What can the three etiologies of upper limb ischemia be grouped into?

A

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)

181
Q

Where does the pathology occur in Subclavian Artery Stenosis?

A

Ostium or proximal third of the artery stenosis

182
Q

What is the mechanism of subclavian steal syndrome?

A

-Retrograde flow from the posterior cerebral circulation via the vertebral artery

183
Q

What is on exam for SC artery stenosis?

A

-SBP difference of 15mmhg or more between arms

184
Q

What is indication for revascularization in Subclavian Artery Stenosis? Modality?

A

-Symptoms, asymtomatic if already going for CABG with LIMA

-Endovascular therapy preferred

185
Q

What is the class 1 indication for intervention for RAS?

A

Severe RAS and unexplained CHF/Flash pulmonary edema

186
Q

What are two criteria for the definition of a True Aneurysm?

A

-Dilation of an artery > 50% with all three layers of the arterial wall present (intima, mieda, adventitia)

187
Q

Name the anatomic cut offs for Aortic root, ascending Aorta, Aortic arch and descending aorta

A

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

188
Q

What is the histopathology in marfan’s aortic dilation?

A

Decrease elastin in the aortic media which leads to medial degeneration

189
Q

5 cardiac manifestations of Marfan?

A

Aortic aneurysm

PA dilatation

MVP

TVP

MAC

190
Q

What is the gene implicated in Type 4 Vascular ED? What does it code for?

A

-COL3A1

-Type 3 Collagen

191
Q

What are the two Craniofacial abnormalities in LD syndrome?

A

-Hypertelorism (widely spaced out eyes)

-Cleft palate

192
Q

What are 3 extra cardiac/physical abnormalities in Turners?

A

-Webbed neck

-Short stature

-Low set ears

193
Q

Name 6 inflammatory diseases for aortopathy?

A

-GCA

-Takayasu

-Behcets

-Ank Spond

-IBD

-Reiter’s syndrome

194
Q

Name 2 infectious etiologies for Aortopathy?

A

-Syphilis
-TB

195
Q

Name 5 things that put at increased risk of Aortic dissection

A

Aortic size > 6cm

Rapid growth > 0.5cm/yr

Smoking

Uncontrolled hypertension

Family history

CTD

BAV

196
Q

What should imaging screening schedule be for Marfan’s?

A

Baseline -> 6 months to determine rate of progression

If stable -> annual

If significant change from baseline or diameter > 4.5 -> more frequent

197
Q

What is imaging surveillance for non marfan genetic aortopathy?

A

-Complete aortic imaging at initial and 6 months, then annually

198
Q

What is surveillance schedule for Turner’s?

A

Complete assessment at baseline, annual imaging if abnormalities

Otherwise complete aortic imaging every 5 years

199
Q

What is the mechanism for ARBs stopping TAA growth?

A

Inhibits TGF-Beta signalling

200
Q

What is TAA surgical cut off in degenerative TAA?

A

5.5 cm

201
Q

What is TAA surgical cut off in Marfan Syndrome?

A

5 cm (4.1-5cm if woman considering surgery)

202
Q

What is TAA surgical cut off in LDS and ED?

A

4-5cm

203
Q

Undergoing Cardiac surgery?

A

> 4.5 cm

204
Q

What should Post op surveillance be after aortic repair?

A

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

205
Q

What is the pathology of Aortic Dissection?

A

-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

206
Q

What is the pathology of an intramural hematoma?

A

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

207
Q

What % of IMH progresses to dissection?

A

10%

208
Q

What are 4 mechanisms of AR in dissection?

A

-Aortic root dilatation

-Prolapse of dissection flap into LVOT

-Prolapse of AV leaflet

-Pre-existing AI due to anerysm of BAV

209
Q

Describe the DeBakey calssification system

A

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

210
Q

What are the indications for surgical intervention in chronic Type a Dissection (> 6 weeks)

A

Same as for TAA dilation

211
Q

What are 4 indications for EVAR in type B dissection (Complicated dissection) ?

A

-Malperfusion

-Rupture

-Rapid expansion

-Refractory pain

212
Q

After conservative management for Type B dissection, what is imaging schedule in first year post discharge?

A

1, 3, 6, 12 months

213
Q

What is cut off for AAA diagnosis?

A

3 cm

214
Q

What is the most commonly effected segment for AAA?

A

Aorta between renal artery and inferior mesenteric artery

215
Q

What is screening recommendations for AAA?

A

Men aged 65-80

216
Q

What is surveillance for AAA if <4cm, if 4-5.4 cm?

A

US q2-3y

US 6-12 months

217
Q

When EVAR for AAA?

A

Symptoms

> 5.5 cm

> 1cm / year growth

218
Q

What are the two types of endoleaks?

A

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

219
Q

Does EVAR have lower early mortality than open repair in AAA?

A

Yes, but associated with higher risk of future aortic rupture and the need for more secondary procedures

220
Q

What is a Bovine arch?

A

The Left carotid artery and Brachicephalic trunk share a common origin

221
Q

Where does the Carotid artery stenosis more frequently develop?

A

At the bifurcation of the common carotid

222
Q

What is characteristic of Radiation Induced Carotid Artery Disease?

A

-Often affect long arterial segments and atypical locations

223
Q

Why is CEA relatively contraindicated in Radiation Induced Carotid Artery Disease?

A

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

224
Q

What should Carotid US be followed by if it is positive?

A

-CTA/MRA: Can define aortic arch and intracranial vessel anatomy

225
Q

When is CEA indicated for CA stenosis?

A

-Symptomatic > 70-99% (Class 1), >50% (Class 2) within 14 days

-Asymptomatic 70-99% (Class 2)

226
Q

What is the only antiplatelet agent that is OK for breast feeding?

A

Aspirin

227
Q

When is the fetus most susceptible to radiation?

A

-1st trimester (organogenesis)

228
Q

What should fetal radiation be kept to ideally?

A

Keep lower than 50 mGy

229
Q

When to try and delay radiation exposure until?

A

12 weeks (organogenesis is complete)

230
Q

Give some examples of WHO 1 Class (No increased maternal risk)

A

Uncomplicated repaired ASD, VSD, PACs, PVCs, Small PDA, Mild MVP or PS

231
Q

Give some examples of WHO Class 2?

A

Unrepaired ASD, VSD, Repaired ToF, Most arrhythmia, Turners with no Aortic dilation

232
Q

What should follow up be for WHO2 classification?

A

Once per trimester

233
Q

What are examples of WHO IV (40-100% maternal CV event rate)? (11)

A

-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)

234
Q

What should follow up for WHO IV be?

A

Monthly minimum

235
Q

Name the CARPREG II risk factors? (12)

A

-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

236
Q

Why is early epidural anesthesia recommended in obstetric cardiology?

A

Prevents peaks in BP

237
Q

When should Warfarin be held as Labor approaches?

A

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

238
Q

When should Anticoagulation be held prior to Labor?

A

6 hours

Switch from LMWH -> UFH 36 hours prior to planned delivery -> Stop 6h prior to Planned Labor

239
Q

When can UFH be continued after Vaginal delivery? C Section?

A

-6 hours

-12 hours

240
Q

Is Warfarin safe in breast feeding?

A

Yes

241
Q

Do you need IE prophylaxis with C section?

A

No

242
Q

What are some contraindications to Vaginal Delivery?

A

None

243
Q

When should Induction be done by in all women with CV disease?

A

by 40 weeks

244
Q

Name 6 conditions in which C Section can be considered? (Not an absolute CI to Vaginal delivery)

A

-On OACs with pre-term labor

-High risk Aortopathy

-Intractable HF

-Severe PHtn

245
Q

What are 5 adverse effects of Warfarin on the fetus?

A

-Warfarin Embryopathy

-Developmental delay

-Fetal loss

-Short fingers

-Nasal hypoplasia

-Stippled Epiphyses

246
Q

How frequently to monitor INR in pregnancy on Warfarin?

A

q2 weeks

247
Q

Why is Vaginal delivery on VKA contraindicated?

A

Fetal ICH during Labor

248
Q

Why is LMWH/UFH chosen around Labor compared to Warfarin?

A

LMWH/UFH do not cross the placenta

249
Q

What needs to be done when using LMWH?

A

Factor Xa monitoring

250
Q

How to manage high risk TE women on LMWH around labor?

A

Convert to UFH 36h prior, then stop UFH 6h prior to delivery

251
Q

What is the issue with Digoxin in Pregnancy?

A

Serum levels are unreliable

252
Q

What is timing cut off for pre-existing vs. Pregnancy induced hypertension?

A

20 weeks

253
Q

What is BP target for DBP in pregnancy?

A

85mmhg

254
Q

What are the three 1st line agents for HTN in pregnancy?

A

-Nifedipine

-Labetalol

-Methyldopa

255
Q

What are three 2nd line agents for HTN management in pregnancy?

A

-Clonidine, Hydralazine, Thiazide diuretics

256
Q

When is delivery recommended for gestational HTN or mild Pre-eclampsia?

A

37 weeks

257
Q

Cut off to admit pregnant woman for severe HTN?

A

> 160/110 mmhg

258
Q

What women should get ASA?

A

ASA for all women at moderate or high risk of Preeclampsia from 12 weeks GA to 36-37 weeks

259
Q

Management of Pre-eclampsia?

A

Admit for Immediate delivery

MgSO4 4gram IV

Target BP < 160/110mmhg

260
Q

Are ACE inhibitors safe in pregnancy? In breast feeding?

A

Not in pregnancy, yes with breast feeding

261
Q

What are indications for valve intervention prior to pregnancy?

A

-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

262
Q

What are three indications for valve intervention during pregnancy?

A

-NYHA III/IV Severe AS despite Medical therapy

-NYHA III/IV Severe MS despite Medical therapy

-NYHA IV Severe MR despite medical therapy

263
Q

In Pregnant women on anticoagulation, how to manage ASA?

A

-Stop ASA during first trimester, resume afterwards

264
Q

What is the best timing during pregnancy for OHS?

A

13-26 weeks

265
Q

What should pregnant woman get prior to OHS?

A

Steroids

266
Q

Beyond what week should a C section be performed prior to OHS?

A

26 weeks onwards

267
Q

If pregnant woman is hypotensive/pre arrest, how to position?

A

Place in left lateral decubitus position to relieve aortocaval compression

268
Q

What to do during arrest in pregnant woman in addition to standard measures?

A

Continuous manual left uterine displacement

269
Q

When should Perimortem C-Section be considered?

A

If no ROSC at 4 minutes

270
Q

What two time periods in Pregnancy do dissections occur?

A

Third trimester or early post partum

271
Q

What is the EF criteria for PPCM?

A

LVEF < 45%

272
Q

What are 5 risk factors for PPCM?

A

-Advanced Age

-Black

-Preeclampsia

-Hypertension

-Multiple gestations

273
Q

What is Bromocriptine’s role in PPCM?

A

May be considered to stop lactation and enhance LV recovery (Need prophylactic anticoagulation)

274
Q

What % of patients have EF recovery > 50% post PPCM?

A

75%

275
Q

What is recurrence risk for PPCM ?

A

25% risk if normal LVEF

50% recurrence if residual LV dysfunction

276
Q

What are the three targeted pathways for Pulmonary hypertension?

A

-Endothelin

-Nitric Oxide

-Prostacyclines

277
Q

What are 8 causes of PAH?

A

Idiopathic

Heritable

Drug/Toxin induced

CHD

CTD

Portal HTN

HIV

Schistosomiasis

278
Q

Name three medications that cause PHTn

A

Aminorex, Fenfluramine, Dexfluramine, Methamphetamines

279
Q

What are three contraindications for RHC?

A

-Mechanical TV or PV

-Right heart masses

-Right sided IE

280
Q

What is the criteria for a positive vasoreactivity response?

A

-decrease in mPAP > 10 to a value less than 40 with no decrease in Cardiac output

281
Q

What are 3 ways to do Vasoreactivity testing?

A

NO
Epoprostenol
Adenosine

282
Q

What does vasoreactivity predict?

A

Response to CCB with improved survival

283
Q

How to measure PCWP?

A

Should be recorded as the mean of 3 measurements at end expiration

284
Q

How to convert woods units to dynes?

A

WU x 80 = Dynes

285
Q

What PH group has the worse prognosis?

A

Class III, rest are comparable

286
Q

What are 5 classes of medical therapy for PH?

A

CCBs

Prostanoids (Prostacyclin)- Selexipag

Endothelin receptor antagonists- Bosentan

PDE-5 inhibitors- Taladafil, Sildenafil

Soluble guanylate cyclase stimulators

287
Q

What are 9 determinants of >10% mortality in PAH?

A

-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%

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