How does idraparinux c/w warfarin in treatment of DVT & PE?
Idraparinux not inferior to warfarin in the DVT Study, but it was inferior in the PE Study.
How does dabigatran c/w warfarin for treatment of VTE, after initial parenteral anticoagulation?
Dabigatran is noninferior to warfarin in the prevention of recurrent VTE and PE events.
True or false? Rosuvastatin a/w significant reduction in risk of VTE?
True. In trial with "healthy" ppl, rosuvastatin a/w significant reduction in VTE risk.
Anti-Parkinsonian drugs (dopamine agonists, eg. pergolide / cabergoline) a/w with significant increased risk of what?
Heart-valve regurgitation. People on these meds should get regular TTE follow-up.
What is OMT for severe AS?
Trick question! No effective medical therapy for severe AS; need mechanical correction. Valve replacement definitive management.
What is better in someone with atherosclerotic renovascular disease: OMT, or OMT+endovascular revascularisation?
OMT alone. Revascularization carried substantial risk, and not a/w any benefit in terms of renal function, blood pressure, renal or cardiovascular events, or mortality.
Renal failure patients at risk of CVD events. Does a regular statin (rosuvastatin) decrease CVD events?
No. AURORA trial found rosuvastatin significantly reduced LDL-C and CRP, but was not a/w reduction in MI, stroke, or death from CVD causes.
True or false? Relatively small reduction in LDL-C level sustained over a lifetime markedly reduces incidence of CHD.
Is it worth prescribing statins to men with hypercholesterolemia, who have no PHx of MI?
Yes. Statin treatment for ~5yrs provided an ongoing reduction in the risk of major CVD events for an additional period of up to 10 yrs. Presumably due to stabilisation of existing plaque and a slowing of the progression of CAD.
What antiHTN should be used in patients >80 years?
HYVET (Hypertension in the Very Elderly trial ie >80 years old) showed that indapamide +/- perindopril significantly reduced risk of death from stroke AND death from any other cause in very elderly patients, and reduced heart failure, with target BP
Which patient groups should get diuretics for treatment of pre/HTN?
First-line for HTN with no other comorbidities: thiazide diuretic - effective AND low cost
Which patient groups should get CCB for treatment of pre/HTN?
Elderly at risk of stroke
Which patient groups should get BB for treatment of pre/HTN?
Appropriate first line therapy if patient does not have pre-existing conditions
Which patient groups should get ACEI/ARB for treatment of pre/HTN?
T2DM and/or renal disease
Is medical therapy indicated in people with preHTN and 1+ CVD RF?
Yes. Choose one of: diuretics, BB, ACEI, ARB, CCB.
What lifestyle changes can help treat mildly elevated BP (pre-HTN) (when pt has no other CVD RFs)?
Weight loss, decrease dietary sodium, stop smoking, exercise.
What is more important in terms of RF for CVD and renal disease: elevated SBP or DBP?
What is the BP target for normal ppl? For ppl with DM or renal failure?
How can you differentiate clinically b/w diastolic and systolic HF?
You can't reliably distinguish between these patients.
What proportion of HF patients have diastolic HF?
What is the definition of diastolic HF?
HF with EF > 50%
Which patients do better? Diastolic or systolic HF?
Similar in-hospital complication rates, 1-yr mortality & morbidity.
According to the AHA Science Advisory (2005), who is the optimal candidate for CRT?
Dilated cardiomyopathy (non/ischemic), LVEF 120ms, SR, NYHA class III or IV despite OMT.
Is CRT worthwhile in those with HF class III, EF
There was significant improvement in NYHA class, but no significant improvement in terms of QOL, 6-minute walk test, LV reverse remodelling; ie) not recommended
Is it worthwhile replacing iron in symptomatic, iron deficient, HF patients? Does it matter if they are anaemic or not?
Good to replace iron in iron deficiency: improves symptoms, physical performance, QOL. Benefit in those with and without anaemia.
Is newer LVAD (continuous-flow) superior to older LVAD (pulsatile-flow)?
Yes. Newer LVAD had less device-related problems less hospitalisations improved QOL.
Is CRT+ICD useful in mild HF (class I or II) with reduced EF and wide QRS?
Yes. A/w 34% reduction in risk of death or HF events, and TTE showed improved LVEF after 1yr.
What is superior therapy in symptomatic AF with EF
Pulmonary vein isolation was superior; significant improvements in EF, 6-min walk test.
Which ACEI has been found to have a favourable effect on glucose metabolism in people with DM? (ie. Effects regression to normal glucose levels?)
What is the best approach to preventing CVD morbidity/mortality in T2DM?
Appropriate management of hypertension, dyslipidemia, and other CVD risk factors
Does intensive glucose control in T2DM decrease microvascular complications (severe renal changes, decreased GFR, laser treatment, cataract extraction, vitrectomy, and new neuropathy)?
No (tested over a 5-6 year period)
Does intensive glucose control in T2DM decrease rate of CVD events?
Do the newer, atypical antipsychotics have a better arrhythmia profile c/w older typical antipscyhotics?
Current users of typical antipsychotic drugs and of atypical antipsychotic drugs in the study cohort had a similar dose-related increased risk of sudden cardiac death.
In patients in ICU post-resusc for cardiac arrest, which of the following is a/w increased in-hospital mortality? Arterial hypoxia, normoxia, or hyperoxia?
True or false? Air pollution can impact cardiovascular health.
In APO, is NIV better, the same, or worse, than standard O2 therapy?
NIV is better. Safely provides earlier improvement and resolution of SOB, respiratory distress, and metabolic abnormalities. These do NOT improve rates of survival
What does apixaban target?
Apixaban is an oral factor Xa inhibitor
What was the outcome when apixaban given to patients post-ACS already on aspirin+/- clopidegrol?
Caused significant increase in bleeding events (including fatal and intracranial bleeding), without significant reduction in recurrent ischemic events.
Is there a role for widespread coronary artery calcification screening in asymptomatic adults?
Not recommended: no data shows that screening ultimately results in improved outcomes and reduced coronary events
Name two biomarkers useful for predicting death
BNP, CRP, Homocysteine, Renin, Urinary ACR. Biomarkers only added moderately to overall prediction of risk, c/w conventional CVD RFs.
Name two biomarkers useful for predicting major CVD events
BNP, Urinary ACR. Note: biomarkers only added moderately to overall prediction of risk, c/w conventional CVD RFs.
By what % does aspirin, used as primary prevention, reduce risk of MI?
Aspirin used as primary prevention reduces risk of MI by 30%
How does DAT (clop+aspirin) c/w aspirin alone, in terms of reducing risk of CVD events amongst people with stable CVD or people with multiple CVD RFs?
DAT was not significantly better than aspirin alone at reducing rate of MI, stroke, or death from CVD in this population of patients AND increased risk of mod-severe bleeding.
What is the difference b/w ticagrelor c/w clopidegrol in patients with N/STEMI?
Significantly reduced death from CVD causes, without an increase in the rate of overall major bleeding but with an increase in the rate of non-procedure-related bleeding.
Is there any benefit in prasugrel v clopidegrol in patients with ACS?
No siginficant benefit seen of prasugrel over clopidegrol in patients with ACS
How does fondaparinux c/w enoxaparin 9 days post-ACS?
How does fondaparinux c/w enoxaparin 30 days post-ACS?
Fondaparinux has substantially lower bleeding risk c/w enoxaparin lower long-term mortality and morbidity.
For the 48-hours post fibrinolysis for STEMI, how does unfractionated heparin infusion c/w enoxaparin?
Enoxaparin superior to infusing unfractionated heparin
Who does better? STEMI patients t/f post-fibrinolysis for early PCI, or those who are t/f only if fibrinolysis fails?
Early-PCI did much better c/w salvage PCI for failed fibrinolysis, in terms of death, re-MI, recurrent ischemia, CHF, cardiogenic shock, at 30 days post STEMI.
Is it worthwhile doing PCI on persistently occluded infarct-related artery 3-28 days post MI?
No. C/w medical therapy, PCI was more expensive, and initial benefits (in first few months post-PCI) in physical function not sustained at 1 year.
CABG or PCI for patients with three-vessel and/or L) main coronary artery disease?
CABG. Lower rate of major CVD events at 1 year. Standard of care.
Is there a difference in long-term survival or risk of MI for BMS v DES?
No difference. DES especially good at reducing clinical restenosis in patients with lesions at high risk for restenosis (high risk=2-3 of DM, small vessel diameter, long lesion).
Which patients benefit from DES more than BMS?
DES more effective than BMS in reducing need for target-vessel revascularisation in patients at highest risk for restenosis after PCI, (ie) those who had 2 of 3 RFs - DM, small vessel diameter, long lesion). DES are of minimal benefit to patients at lower risk of restenosis.
In terms of initial management strategy for stable CAD, what is better: optimal medical therapy (OMT) alone, or OMT+PCI?
PCI reduced prevalence of angina, but did not reduce death, MI, or hospitalisation for ACS c/w OMT alone.
What are the risks a/w calcium supplements without coadministered Vit D?
Calcium supplements WITHOUT coadministered Vitamin D are a/w increased risk of MI (by 30%).
What constitutes OMT for patients post-MI? (name 5)
Aspirin, BB, statins, ACEI or ARB, clopidegrol (or a relative) given over one year a/w significantly lower mortality
In patients with AF, how does apixaban c/w warfarin in preventing stroke / VTE?
Apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality.
In patients with AF, how does dabigatran (110mg and 150mg dose) c/w warfarin in preventing stroke/VTE?
110-mg dabigatran a/w similar rates of stroke & VTE and lower rates of major hemorrhage 150-mg dabigatran a/w lower rates of stroke & VTE but similar rate of major hemorrhage.
In patients with AF, how does rivaroxaban c/w warfarin in preventing stroke/VTE?
Rivaroxaban was noninferior to warfarin. No significant difference in safety (bleeds).
In patients with AF, what is better - lenient or strict rate control?
Lenient non-inferior to strict rate control in preventing major CVD events
In patients with AF and congestive HF, what is better - rate or rhythm control?
C/w rate control, rhythm control did not reduce rate of death from CVD. Also, rate control required reduced hospitalisation (no cardioversion). Recommended rate-control for AF+CHF.
What is the appropriate management for patients with AF at increased risk of stroke, who can't take warfarin?
C/w aspirin alone, clop+aspirin=reduced rate of major CVD events, primarily due to reduced risk of stroke. However, significant increase in risk of major haemorrhage.
What % success rate does pulmonary vein radiofrequency catheter ablation have in patients with AF without clinically significant structural heart disease?
In cardiogenic shock, how does noradrenaline c/w dopamine in terms of death rate?
No significant difference in terms of rate of death. However, dopamine has serious S/E: a/w more arrhythmias.
True or false? High BMI in childhood a/w greater risk of CHD in adulthood?
True or false? Genetic variation has effect on clopidegrol?
True. Carriers of a reduced-function CYP2C19 allele have significantly lower levels of the active metabolite of clopidogrel, diminished platelet inhibition, and a higher rate of major adverse cardiovascular events, including stent thrombosis.
Name three conditions in which ICD is recommended for preventing SCD?
High-risk patients (primary prevention (HOCM, LQTS, Brugada syndrome, sarcoidosis, arrhythmogenic RV dysplasia, some congenital HD), and secondary prevention eg. previous potentially fatal arrhythmia / cardiac arrest).
In ALS, what's the benefit of defib-ing early?
- Delayed defib = significantly less likely to survive to hospital d/c
What's the best management for young, "well" athletes, with abnormal ECG, but no evidence of structural HD?
May be an underlying, as yet undetectable, cardiomyopathy, which will develop in later years. Continue to monitor ECGs over time.
In someone with LQTS, what does structural imaging (eg echo) show?
What is the key to diagnosing LQTS?
Resting ECG. Long QT suggests diagnosis
What's the differentials for a long QT on ECG?
What is the mainstay of LQTS therapy?
What features recommend ICD insertion, in LQTS?
People with LQTS at high risk of SCD: especially long QT intervals, onset of syncope with sudden noise or at rest, certain ECG patterns.
Which therapy is considered the optimal reperfusion strategy in pts with STEMI?
What is the recommended time frame for door-to-balloon (ie cath lab) in STEMI?
At what point should an asymptomatic AAA be repaired?
If it is >5.5/cm diameter, if it becomes tender, or if it grows >1cm/yr
Explain mechanism of microvascular obstruction occuring peri-PCI
PCI can open infarct-related artery, but sometimes it dislodges some plaque/thrombus which wedges in a vessel downstream, and causes increase in infarct size, reduced recovery of ventricular function, and increased mortality.
What effect does simvastatin+ezetimibe have, c/w simvastatin alone, on ppl with familial hypercholesterolemia?
Reducing LDL-C by addition of ezetimibe to simvastatin did not reduce intima-media thickness of carotid-artery wall in pts with familial hypercholesterolemia, despite reduced LDL-C levels
Name 2 benefits of ACEI in people with HF, LV dysfunction, previous vascular disease alone, or high-risk DM
ACEI reduce rates of death, MI, stroke, and HF in pts with HF, LV dysfunction, previous vascular disease alone, or high-risk DM.
C/w placebo, ARB reduces rate of what in pts with systolic HF?
ARB, as c/w placebo, reduces rate of death or hospitalisation for HF in pts with low EF & HF, who either could not tolerate ACEI or were already receiving one
ARB, c/w BB, reduces what, in high-risk pts with HTN & LVH?
ARB, as c/w BB, reduce vascular events in high-risk pts with HTN & LVH
How does carotid endarterectomy c/w carotid stenting for carotid artery disease?
-No significant difference in incidence of major CVD events b/w people getting carotid endarterectomy and carotid stenting for carotid artery disease
Stenosis of which coronary artery carries the worst prognosis in CAD?
Narrowing of L) main A puts pts at high risk, it has the worst prognosis of any form of CAD.
Does a home-AED confer any advantages for people who have had anterior-wall MI in the past, and not suitable for ICD?
There was no significant reduction in death from any cause with a home AED
Stroke, vascular events, HF
All of the above
Which antiHTN shown to significantly reduce risk of death and stroke AND death from any other cause in pts > 80 years old? (also shown to reduce HF). What is the target BP for these lovely older ppl?
HYVET (Hypertension in the Very Elderly trial) showed that anti-HTN meds indapamide +/- perindopril significantly reduced risk of death from stroke AND death from any other cause in very elderly patients, and reduced heart failure, with target BP
Name 2 arrhythmias that can cause SCA
What is bivalirudin?
Reverse direct thrombin inhibitor
How does bivalirudin c/w heparin+glycoprotien IIb/IIIa inhibitor (ie. abciximab / eptifibatide / tirofiban) when used in primary PCI for STEMI?
In patients with evolving STEMI who are undergoing primary PCI, the use of bivalirudin alone, as compared with heparin plus a glycoprotein IIb/IIIa inhibitor, results in significantly reduced 30-day rates of major bleeding and increased event-free survival.
Which is best for ppl in AF with CHF: rate or rhythm control?
For people in AF with CHF, the routine use of rhythm-control strategy did not reduce the rate of death from cardiovascular causes, compared with rate-control strategy. In addition, rate-control does not need repeated cardioversion, and is a/w reduced rates of hospitalisation. Therefore, study suggests rate-control should be primary approach for patients with AF and CHF.
What is rivaroxaban?
Rivaroxaban oral direct inhibitor of factor Xa; peak plasma concentration achieved in 2.5-4 hours
What's better for extended thromboprophylaxis post THR: prophylactic dose enoxaparin, or rivaroxaban?
This trial showed that oral, once-daily rivaroxaban has potential for extended thromboprophylaxis after total hip arthroplasty. Rivaroxaban was significantly more effective than enoxaparin for the prevention of venous thromboembolic events.
What's better for thromboprophylaxis post TKR: prophylactic dose enoxaparin, or rivaroxaban?
In this trial of thromboprophylaxis after total knee arthroplasty, we found that rivaroxaban, an orally active direct inhibitor of factor Xa, was more effective than enoxaparin in preventing venous thrombosis, with similar rates of bleeding.
In APO, does NIV (CPAP or NIPPV) improve rate of survival, c/w standard O2 therapy?
No. But does provide early improvement & resolution of dyspnoea, resp distress, & metabolic abN, c/w standard O2 therapy
What's better for weight loss? Mediterranean restricted-calorie diet, low-CHO non-restricted calorie diet, or low-fat restricted calorie diet?
All effective for weight loss. Low-CHO & Mediterrean diet also had beneficial metabolic effects
What's the most effective treatment for relieving angina in ppl with chronic CAD: PCI, OMT, or both?
Both OMT, and OMT+PCI, can relieve angina, but OMT+PCI improved angina better (as self-assessed).
Which type of angina-patient gains most benefit from PCI for relief of angina symptoms?
Patients with more severe and more frequent angina gain more benefit from PCI for relief of symtpoms
In patients with HF who receive ICD for primary prevention of SCD, what is the implications of getting both appropriate & inappropriate ICD shocks?
In patients with HF who receive an ICD for primary prevention of SCD, both appropriate and inappropriate ICD shocks a/w marked increase in subsequent risk of death, particularly death form progressive heart failure.
What is the strongest RF for stroke?
High BP strongest RF for stroke, and lowering BP (esp if SBP>160) reduces risk of stroke
Lowering BP with what medication/s has been shown to reduce rate of recurrent stroke?
Studies show post-stroke, lowering BP with ACEI & diuretic, reduces rate of recurrent stroke
Does ARB reduce risk of recurrent stroke? (NB: ACEI&diuretic shown to reduce risk)
No. Also does not reduce risk of major CVD events, or of new-onset DM
xxxxx reduces risk of stroke recurrence by 23% c/w placebo
Aspirin reduces risk of stroke recurrence by 23% c/w placebo
xxxxx, c/w aspirin, has 8% relative risk reduction of stroke recurrence
Clopidegrol, c/w aspirin, has 8% relative risk reduction of stroke recurrence
xxxxxx superior to clopidegrol in prevention of recurrent stroke
Aspirin + dipyridamole superior to clopidegrol in prevention of recurrent stroke
xxxxx + aspirin, c/w aspirin alone, better for prevention of recurrent strokes.
Aspirin + dipyridamole, c/w aspirin alone, better for prevention of recurrent strokes, and for prevention of first time strokes, MI, death from vascular causes; no increased risk of major bleeding.
In stroke patients with multiple RFs, aspirin+xxxxxxx, c/w xxxxx alone, no more efficacious, but significant increased incidence of bleeding
In stroke patients with multiple RFs, aspirin+clopidegrol, c/w clopidogrel alone, no more efficacious, but significant increased incidence of bleeding
Aspirin+xxxxx, c/w aspirin alone, has increased risk of moderate bleeding
Aspirin+clopidegrol, c/w aspirin alone, has increased risk of moderate bleeding
In which clinical presentations has PCI been shown to reduce rate of death to a rate lower than that achieved with OMT alone?
ACS & AMI (in contrast to stable angina) are the only clinical presentations in which PCI has been show to reduce the rate of death to a rate lower than that achieved with medical therapy alone.
T/F? In T2DM, a period of tight control of BP can have carry-on effects ('legacy effect') years after intevention ceased (and BP similar to those in control group)
False. Relative risk reductions seen in the tight BP-control group did not persist when BP differences were no longer maintained. Optimal BP control is of major importance in reducing the risks of microvascular and macrovascular disease in T2DM but must be maintained if these benefits are to be sustained.
T/F? In T2DM, a period of tight control of BSL can have carry-on effects ('legacy effect') years after intevention ceased (and BSL similar to those in control group)
True. Benefits of intensive glucose-control in T2DM sustained for up to 10yrs after cessation of intervention. These benefits persisted despite the fact that people's glucose levels soon matched 'normal' control group once intervention ceased: 'legacy effect'.
Do ppl with HF+AF benefit from pulm vein isolation ablation as much as those with AF and no HF?
Which therapy would you recommend for systolic HF & symptomatic AF: pulm vein isolation ablation, or AV ablation+CRT
In patients with symptomatic AF and an EF
CRP levels often high in IHD / vascular disease. Do these high levels cause the trouble, or are they a benign marker of the disease?
The increase in the risk of ischemic vascular disease associated with higher plasma CRP levels observed in epidemiologic studies may not be causal, but rather that increased CRP levels are simply a marker for atherosclerosis and ischemic vascular disease.
Risk of SCD post-MI is highest in first xxxx months
Risk of sudden death post MI is highest in first 12 months.
T/F Low EF predicts risk of death post-MI
Name 2 conditions which pt can develop post-MI which puts them at increased risk of SCD
Those in whom ventricular remodeling and heart failure develop are at greatest risk of SCD
EF > xxx% post-MI are not considered as a candidate for ICD?
EF > 35% post MI - not considered candidate for ICD.
What features make you think your post-MI pt needs an ICD?
What effect does irbesartan (ARB) have on diastolic HF?
Effect of irbesartan versus placebo in patients who had diastolic HF: no significant benefit of irbesartan was shown for a variety of cardiovascular outcomes, including death from any cause and hospitalization for cardiovascular causes.
What is a better therapy post-stroke: carotid arteyr stenting, or carotid endarterectomy?
Both have similar outcomes, and are clinically durable
What is the difference in outcome when a lay person does CPR (chest compressions + rescue breathing) v chest compressions alone?
No significant difference
In patients with ACS referred for early invasive strategy, what is the difference b/w getting regular clopidogrel dose v 2x normal dose for 7 days?
No significant difference in terms of CVD death, MI, or stroke
In patients with ACS referred for early invasive strategy, which dose of aspirin is optimal (in terms of reducing CVD events) over the 7 day period: 300-325mg, or 75-100mg?
No significant difference in terms of CVD death, MI, or stroke
How does transcatheter aortic valve implantation (TAVI) c/w standard medical therapy (balloon aortic valvuloplasty) for pts with severe AS who can't get surgery?
TAVI superior to standard therapy: reduce rate of death from any cause, from CVD cause, and rate of repeat hospitalisations. TAVI a/w sig reduction in NYHA symptoms. TAVI should be new standard of care for severe AS who can't get surgery
Does adding PPI (omeprazole) to clopidogrel to reduce GI bleed, increase risk of CVD events (by interfering with absorption)?
No increase in CVD events in patients getting clopidegrol and omeprazole
Does addition of PPI to DAT significantly reduce GI bleeding?
Significant reduction in risk of GI events, including upper GI bleeds, in patients getting DAT and also PPI
Does n-3 fatty acid supplements (EPA+DHA and ALA fatty acids) prevent future CVD events?
Daily intake of EPA+DHA or ALA fatty acids did not significantly reduce rate of major CVD events in patients post-MI who were receiving optimal antihypertensive, antithrombotic, lipid-modifying therapy
In cases of large-vessel stenting, which is best at reducing clinical need for target-vessel revascularisation: BMS, DES 1st or 2nd generation?
Both first- and second-generation DES superior to BMS in reducing clinical need for target-vessel revascularisation after large-vessel stenting
What's the difference in rates of late death from cardiac causes or nonfatal MI b/w DES & BMS?
Similar rates of late death from cardiac causes or nonfatal MI b/w DES and BMS groups
What's the difference b/w 1st & 2nd generation DES when used in large-vessel stenting?
Similar outcomes between first and second generation DES when used in large-vessel stenting
In pts with NYHA II/III HF with LV systolic dysfunction & wide QRS complex, is there benefit to adding CRT to the use of ICD and OMT?
The addition of CRT to the use of an ICD and OMT reduced rates of death and hospitalization for heart failure among patients who had NYHA class II or III heart failure with LV systolic dysfunction and a wide QRS complex