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1

In the PALLAS trial, researchers studied dronedarone in patients with permanent atrial fibrillation (AF) of 6 months’ duration. Which of the following best describes an outcome that occurred in more than twice as many patients in the dronedarone group as in the placebo group?

  A. stroke
  B. cardiovascular death
  C. myocardial infarction
  D. all of the above

   D. all of the above

2

Which of the following statements does not accurately describe a finding from a study of functional mitral regurgitation (MR) in patients with normal leaflet motion and left ventricular ejection fractions 50% who underwent ablation for AF?

  A. Patients with recurrent AF after ablation had significantly less MR than those in sinus rhythm.
  B. Large mitral annular dimension was the patient characteristic most strongly associated with MR.
  C. The mean left atrial volume index was significantly smaller in patients in sinus rhythm after ablation than in those with recurrent AF.
  D. The mean annular dimension tended to be larger in patients with recurrent AF after ablation than in those in sinus rhythm.

A. Patients with recurrent AF after ablation had significantly less MR than those in sinus rhythm.

3

Which of the following is designated a Class I recommendation in the 2011 focused update of the 2006 American College of Cardiology/American Heart Association guidelines for the management of AF?
View Summary
  A. a target resting heart rate of <80 beats per minute
  B. catheter ablation in patients with symptomatic paroxysmal AF who have not responded to antiarrhythmic medications
  C. the use of dronedarone in patients with NYHA class IV heart failure
  D. the combination of aspirin and clopidogrel in patients who are poor candidates for warfarin

B. catheter ablation in patients with symptomatic paroxysmal AF who have not responded to antiarrhythmic medications

4

Which of the following statements accurately describes a finding from a trial comparing a strict target resting heart rate with a lenient one (<80 and <110 beats/minute, respectively) in patients with AF managed with rate control alone?
View Summary
  A. At the end of the dose-titration phase, the resting heart rate did not differ significantly between the strict-control and lenient-control groups.
  B. In the lenient-control group, the resting heart rate at 1 year was significantly higher than it was at the end of the dose-titration phase.
  C. At 3 years, the composite rate of death and major cardiovascular events did not differ significantly between the strict-control and lenient-control groups.
  D. The rate of adverse drug effects during follow-up was significantly higher in the strict-control group than in the lenient-control group.

C. At 3 years, the composite rate of death and major cardiovascular events did not differ significantly between the strict-control and lenient-control groups.

5

Using data from the Women’s Health Study, researchers evaluated the association between smoking and peripheral arterial disease (PAD) in women. Which of the following best describes the researchers’ findings?

  A. Smoking was not associated with excess risk for PAD, when age is considered.
  B. PAD risk associated with smoking was highest among women who also used hormone replacement therapy.
  C. Twenty years after smoking cessation, PAD risk in former smokers approached that of nonsmokers.
  D. At 13 years, former smokers who smoked 15 cigarettes daily were at similar PAD risk as current smokers.

C. Twenty years after smoking cessation, PAD risk in former smokers approached that of nonsmokers.

6

In a controlled trial, patients with peripheral arterial disease were randomized to either aspirin or aspirin plus warfarin and were followed for 3 years. The researchers found that, with regard to the combined primary endpoint of cardiovascular death, myocardial infarction, stroke, and arterial ischemia:

  A. aspirin was superior to aspirin plus warfarin.
  B. aspirin was equivalent to aspirin plus warfarin.
  C. aspirin was inferior to aspirin plus warfarin.
  D. aspirin alone was not effective.

 B. aspirin was equivalent to aspirin plus warfarin.

7

This analysis of the 1999–2004 National Health and Nutrition Examination Survey (NHANES) data demonstrated an inverse relation between bilirubin and peripheral arterial disease. This association is strongest for patients with which characteristic?

  A. black race
  B. male sex
  C. older age
  D. history of diabetes

   B. male sex

8

The APPRAISE-2 trial of the factor Xa inhibitor apixaban as an adjunct to antiplatelet therapy for prevention of recurrent ischemia in patients with acute coronary syndromes was halted early. The rate of which of the following outcomes was significantly higher in the apixaban group than in the placebo group?

  A. mortality
  B. recurrent myocardial infarction (MI)
  C. major bleeding
  D. the composite of cardiovascular death, MI, and ischemic stroke

   C. major bleeding

9

Which of the following statements accurately describes a finding from the ROCKET AF study of rivaroxaban versus warfarin in moderate-to-high-risk patients with atrial fibrillation (AF)?

  A. The primary event rate was higher in the rivaroxaban group than in the warfarin group.
  B. The international normalized ratio of warfarin recipients was in the therapeutic range about 50% of the time.
  C. The rate of systemic embolism was higher in the warfarin group than in the rivaroxaban group.
  D. Intracranial and fatal bleeding were more common in rivaroxaban recipients than in warfarin recipients.

 B. The international normalized ratio of warfarin recipients was in the therapeutic range about 50% of the time.

10

Which of the following statements accurately describes a finding from a study of apixaban versus aspirin in patients with AF and 1 risk factor for stroke who were not considered appropriate candidates for warfarin treatment?

  A. The rate of the primary outcome was more than twice as high in the aspirin group as in the apixaban group.
  B. The rate of major bleeding was significantly higher in the apixaban group than in the aspirin group.
  C. The rate of cerebrovascular events or MI was lower in the aspirin group than in the apixaban group.
  D. Treatment-related adverse events were more common in the apixaban group than in the aspirin group.

   A. The rate of the primary outcome was more than twice as high in the aspirin group as in the apixaban group.

11

In a large, manufacturer-funded trial, patients with AF were randomized to receive warfarin or twice-daily doses of either 110 mg or 150 mg of dabigatran. Compared with warfarin, both doses of dabigatran were associated with a significant improvement in which of the following outcomes?

  A. study-drug discontinuation
  B. hemorrhagic stroke
  C. stroke or systemic embolism
  D. major bleeding

   B. hemorrhagic stroke

12

Name the types of atrial septal defects

Ostium secundum (70% of ASDs)
associated with Holt-Oram syndrome (tri-phalangeal thumbs)
ECG: RBBB with RAD

Ostium primum
present earlier than ostium secundum defects
associated with abnormal AV valves
ECG: RBBB with LAD, prolonged PR interval

13

Describe the heart sound S4


S4 (fourth heart sound)
may be heard in aortic stenosis, HOCM, hypertension
caused by atrial contraction against a stiff ventricle
in HOCM a double apical impulse may be felt as a result of a palpable S4

14

Which drug will cause complete heart block if combined with a beta-blocker?

Verapamil

15

What are the features of Ivrabadine?

Ivabradine
a new class of anti-anginal drug which works by reducing the heart rate
acts on the If ('funny') ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity
adverse effects: visual effects, particular luminous phenomena, are common. Bradycardia, due to the mechanism of action, may also be seen
there is no evidence currently of superiority over existing treatments of stable angina

16

What is the acute mx of SVT?

Acute management
vagal manoeuvres: e.g. Valsalva manoeuvre
intravenous adenosine 6mg → 12mg → 12mg: contraindicated in asthmatics - verapamil is a preferable option
electrical cardioversion

17

Describe the modified Duke criteria

pathological criteria positive, or
2 major criteria, or
1 major and 3 minor criteria, or
5 minor criteria

Pathological criteria

Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic fragments or intracardiac abscess content)

Major criteria

Positive blood cultures
two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group, or
persistent bacteraemia from two blood cultures taken > 12 hours apart or three or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis, or
positive serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci, or
positive molecular assays for specific gene targets

Evidence of endocardial involvement
positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves), or
new valvular regurgitation

Minor criteria
predisposing heart condition or intravenous drug use
microbiological evidence does not meet major criteria
fever > 38ºC
vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots

18

Criteria for AVR

Symptomatic patients with severe aortic stenosis (<1cm)

Patients with severe aortic stenosis undergoing coronary artery bypass surgery

Patients with severe aortic stenosis undergoing surgery on the aorta or other heart valves

Patients with severe aortic stenosis and LV systolic dysfunction (ejection fraction < 0.50)

19

What is the classification of critical and severe AS?

Always done with TTE

Mean gradient (mmHg) >70 is critical, >40 is severe

Valve area <0.6 is critical, <1.0cm is severe

20

What are the lines of drug therapy in long term maintenance of AF in terms of ventricular control?

B- blocker first line
Then diltiazem
then verapamil

21

When would you consider Digoxin in the control of rapid AF?

Useful in the elderly
Useful in both AF and heart failure as other drugs may be contraindicated or needed to be introduced slowly (i.e. beta blockers)

Not that useful in younger and more active patients

IV dosing has little therapeutic advantage so just give oral

22

Rate or rhythm control for AF?

AFFIRM trial
 - no difference in mortality or QOL
 - no imperative for cardioversion
 - only that QOL may be improved by being in sinus rhythm

Always try to have an ax of LV function and any coronary disease when starting rhythm and rate control drug as they may depress the myocardium or have proarrhythmic potential.

23

What is atrial 'stunning'?  Why is it important?

Risk of atrial 'stunning' following cardioversion (electrical, pharmacological or spontaneous). 

- unpredictable failure of the atria to contract.

- more common after longer attacks and may persist for hours to days. 

- fresh thrombus can form in the hypocontractile atria, and this constitutes an embolic risk even if a TOE an hour or two earlier was clear.

24

What is post -cardioversion maintenance therapy?

Not required if AF was associated with a transient condition.
Anticoagulate for 6-12 months
Long-term antiarrhythmics - flecainide, sotalol, amiodarone
Consider ablation if poorly controlled on antiarrhythmic therapy

If using sotalol, watch out for prolonged QTc (>500ms or >20% from baseline, avoid in renal impairment)

25

What consideration do you need to make in Warfarinising an elderly person?

There is a high risk of bleeding in the first year after starting warfarin in patients aged more than 80 years, and the decision whether to start oral anticoagulation or not is often a difficult one, especially as patients at higher risk of thromboembolism also tend to be those with a higher risk of bleeding.

26

Epidemiology of atrial myxoma

Most common primary cardiac tumor in adults
Mean presentation around 50 (but can be any age)
Women
Associated with MEN (can have myxomas elsewhere too)

27

What are the clinical features of atrial myxoma?

1.   valvular obstruction
        left sided: dyspnoea, orthopnoea, pulmonary oedema
        right sided: symptoms of right heart failure

2.  embolic event
        distribution will depend on location of tumour
        most are left sided, and therefore most are systemic (brain or extremities)
    

3.  constitutional symptoms
        weight loss, fatigue, weakness
        may resemble infective endocarditis (fever, arthralgia, lethargy)

28

What is the characteristic heart sound of someone with an atrial myxoma?

On auscultation a cardiac murmur is usually present. A characteristic finding in patients with pedunculated and prolapsing myxoma is the so called "tumour plop"

In up to 20% of patients

29

What is the histopath of atrial myxoma?

Benign, often haemoorhagic
Usually pedunculated and over variable size
Usually in the LA attached to the interatrial septum in the fossa ovale region

30

What does an atrial myxoma look like on CT?


Myxomas, as is the case with other cardiac tumours, appear as intra-cardiac masses, most often in the left atrium and attached to the interatrial septum. They are usually heterogeneously low attenuating (approximately 2/3 of cases). Due to repeated episodes of haemorrhage, dystrophic calcification is common. 

If the mass is pedunculated, the motion within the heart can be demonstrated, including prolapse through the mitral valve.