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Cardiology Flashcards

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1
Q

Contraindications to exercise stress test

A

Unstable ACS, HF, arrhythmia, AS, dissection
PE, DVT
Active endocarditis, myopericarditis

Uninterpretable baseline: LBBB, WPW, Paced, digoxin, resting STD>1mm

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2
Q

HOCM/MVP Murmur

A
  • Increases with decreased Preload (stand, Valsalva)
  • Decreases with increased preload (squat, leg raise)
  • Decreases with increased afterload (hand grip)

MVP longer murmur earlier click with valsalva

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3
Q

AI/MR Murmur

A
  • Decreases with decreased PL (stand, valsalva)
  • Increases with increased PL (leg raise, squat)
  • Increases with increased AL (hand grip)
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4
Q

AS/MS Murmurs changes w/ maneuvers

A
  • Decreases with decreased PL (stand, valsalva)
  • Increases with increased PL (squat, leg raise)
  • Decreases with increased AL (hand grip)
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5
Q

Reasons to use Plavix (>Ticag) as 2nd anti-plt

A

If ACS:

  • Patient receiving lytics
  • Patient has Afib with CHADS>0 on DOAC
  • Patient has high bleed risk (hx intracranial bleed ever, current non-intracranial bleed, mod-sev liver dz)

Post all elective PCI

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6
Q

Indications/Contraindications for tPA in STEMI

  • door to needle time
  • timing for post-lytic PCI
A

> 120 mins from nearest PCI center

PCI if >12h or cardiogenic shock

Contraindications

  • Bleeding - hemorrhage, ICH ever, stroke <3mo, diathesis, active, anticoag,
  • Trauma: head, dissection, recent OR

*Door to needle time should be <=30 mins FMC
Post TPA PCI should occur w/i 24h

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7
Q

Blood thinners post ACS (no Afib or Afib but CHADS 0)

A

ASA 81 + (Ticag 90 BID or Plavix 75 OD) x 1 yr
After 1 yr:
- If high risk bleed, low thromb risk: ASA alone
- If low risk bleed/high thromb risk: ASA + (Ticag 60 BID or Plavix 75 OD) x 3 years then SAPT

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8
Q

Blood thinners post ACS (Tx PCI) with Afib (CHADS>0)

A
  1. ASA 81 + Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 2.5 BID) x 1 day - 1 month –>
  2. Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 15 OD) x 1 month - 1 year –>
  3. DOAC Lifelong (Apix 5 BID, Dabi 150 BID, Riva 20 OD)
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9
Q

Blood thinners post ACS (No PCI) with Afib (CHADS >0)

A
  1. Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 15 OD) x 1 month - 1 year –>
  2. DOAC Lifelong (Apix 5 BID, Dabi 150 BID, Riva 20 OD)
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10
Q

Blood thinners post- elective PCI with Afib (CHADS >0)

A

If high thrombotic risk:

  1. ASA 81 + Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 2.5 BID) x 1 day - 1 month –>
  2. Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 15 OD) x 1 mo- 1 year –>
  3. DOAC Lifelong (Apix 5 BID, Dabi 150 BID, Riva 20 OD)

If low thrombotic risk:

  1. Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 15 OD) x 1 mo - 1 year –>
  2. DOAC Lifelong (Apix 5 BID, Dabi 150 BID, Riva 20 OD)
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11
Q

Blood thinners post elective PCI (No Afib or Afib CHADS 0)

A

If low bleeding risk:
ASA + Plavix 75 x 6 months (extend up to 3 years if high thrombotic risk) –> ASA lifelong

If high bleeding risk:
1. ASA + Plavix x 1 month if BMS / 3 months DES –> ASA

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12
Q

Indications for ICD in HoCM

A 
Prior VT/VF arrest
Unexplained syncope
Sustained VF >30sec
Family Hx SCD
LV wall >30 mm
NSVT or abN BP response on treadmill w/ other risk factors
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13
Q

HFrEF (EF <40%): Medical Treatment

A

1st line: ARNI ACE/ARB, BB, MRA (ISDN/Nitro if intol to ACE/ARB), SGLT2

  • Add Ivabridine (if SR >70, ie NOT afib, not paced, hosp for HF in last year)
  • Vericiguat if recent HF hospitalization
  • Digoxin if poor AF control

If going NYHA 4 symptoms –> palliative care, add ISDN/Nitro, adv HF therapy

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14
Q

HFrEF: Indications for primary prevention ICD +/- CRT

A

EF <=35% after 3 mo post-revasc/OMT/40d post- MI:

  • NYHA 1: ICD ONLY IF ischemic CM + EF <=30%
  • NYHA 2-3: ICD +/- CRT* (*if sinus rhythm, + LBBB >130 msec, or any BBB >150 msec)
  • NYHA 4: ICD +/- CRT* (only if ambulatory, expected to improve, or candidate for adv tx)
  • expected life expectancy >1y and reasonable QoL
  • weak rec: CRT in frail elderly, permanent AF, chronic RV pacing + symptomatic HFrEF
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15
Q

HFeEF: Indications for secondary prev ICD

A

VT/VF Arrest or Sustained VT (>=30 secs or hemodynamically significant) with structural heart disease or >48 hrs post MI /revasc
No reversible cause found

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16
Q

HFpEF: Medical Treatment

A 
Manage HTN (ACE/ARB = 1st line) 
Diuretics for symptoms
MRA if elevated BNP
Consider candesartan
**no recommendation for ARNI

-empa ?mort benefit

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17
Q

Diagnosis Pericarditis

A

2/4 of:

1) Typical CP (pleuritic, worse when supine)
2) Pericardial Rub
3) ECG: Diffuse STE +/- PR depression w/o reciprocal ST depression
4) New or worsening pericardial effusion on echo

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18
Q

Tx Pericarditis (1st, recurrent, pregnancy)

A

1st episode: NSAID x2weeks + Colchicine x 3 months
Recurrence: NSAID x2weeks + colchicine x6 months
Post MI: High dose ASA (650mg QID) + Colchicine

AI or refractory NSAID: Pred + Colchicine
Pregnancy: No ASA, NSAID, Colchicine.
Breastfeeding: No ASA

Advanced: IVIG, anakinra, azathioprine, pericardioectomy

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19
Q

Tx Thoracic Aortic Dissection

A

Type A - Surgical
Type B (does not involve ascending aorta) - IV labetalol (target HR <60-65, sBP <120), IV nitroprusside if BP refractory to labetalol, consult vascular surg
(can also use CCB or ACEi)

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20
Q

When to operate: Thoracic Ao aneurysm

*how often to screen

A

5.5 cm - degenerative/bicuspid valve
5 cm - Marfan’s, rapid growth
4.5 cm - all other congenital disorders (turner, ehlers-danlos, etc)

*F/U: q6-12mo (dep on rate of change), q6m if genetic aortopathy; MRI if <50yo bc serial radiation

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21
Q

When to operate: AAA

*how often f/u

A

5.5 cm for all
5 cm if: Female, +FHX, Hx CTD, Rapid growth >0.5 cm/year
*F/U: q6-12 mon if <4.5 cm, q3-6 mo >4.5 cm

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22
Q

Monitoring Bicuspid AoV

A

Annual H&P
Repeat echo only if evidence of stenosis, aortic dilatation or new symptoms
- If stenosis: q3-5years mild, q1-2 years moderate, q6-12 mo if severe and not candidate for replacement
- If aortic root dilation: q6-12 mo

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23
Q

AS: Indications for valve replacement

A

1) Severe Symptomatic AS (AVA <1cm, MG >40mmHg, peak veloc >4m/s) (D1)
2) Severe AS w/ LVEF <50% (C2)
3) Symptomatic Low-flow low-gradient AS (AVA <1cm, MG <40/V <4, LVEF <50%) with symptoms if MG>40/V>4 with dobutamine stress test (D2)
4) Symptomatic Low-flow low-grad AS with EF<50% OR if AS most likely cause of sx
5) Severe AS without symptoms if symptoms develop on exercise stress (C1)
6) Sevee AS without symptoms going for other CV surgery

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24
Q

AI: Indications for valve repair/replacement

A

1) Severe Symptomatic AI
2) Severe AI with LVEF <55% if no other cause for reduced LVEF
3) Severe asymptomatic AI going for other CV Surgery

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25
Rheumatic MS: Indications for valve repair/replacement
``` Percutaneous Mitral balloon Commisurotomy (PBMC): Severe MS (dw: MVA <=1.5 cm, PAP >50, dBP 1/2t >=150) + NYHA 3-4 + no contraindications (>= mod MR, LA thrombus) + fav anatomy ``` MV surgery (commisurotomy +/- repair/replacement): - Failed or contraindication for PBMC + acceptable surgical risk - Severe MS going for other CV surgery
26
MS: Indications for anticoagulation and targets
1. Afib 2. TIA/Stroke 3. LA Thrombus VKA --> Target INR 2.5-3.5
27
MR (primary): Indications for MVR
1. Severe primary symptomatic MR 2. Severe primary asympatomatic MR with LVEF <60% or LVESD >=40mm Hg For secondary: must be on OMT, including CRT & revascularization
28
TR: Indications for TVR
Severe TR going for other left sided valve surgery
29
Anti-coagulation post valve-replacement | mech vs bioprosthetic targets and agent
Mechanical = Lifelong VKA - Modern AVR - INR 2-3 - Mitral or ball in cage AVR - INR 2.5-3.5 Bioprosthetic First 3-6mo: Surgical: VKA (INR 2-3) + ASA; vs/ TAVR: DAPT (Plavix) or VKA (INR 2-3) +ASA - Then ASA for life
30
A.fib: Who gets anticoagulation, exclusion, and when to use VKA
1. >= 65 2. <65, but 1 of: CHADS (CHF, HTN, DM, Stroke 3. Mitral stenosis * *Exclusion: No anticoagulation for ESRD with eGFR <15 VKA: if mechanical valve, rheumatic MS, mod/severe non rheumatic MS
31
DOAC Doses for Afib
1. Apix 5 BID (2.5 BID if 2 of: Age>=80, Cr >=133, Wt <60kg) - ok till eGFR 15 2. Rivaroxaban 20 OD (15 OD if CrCl <50) - ok till eGFR 15 3. Dabi 150 BID (110 BID if CrCl <50 or age >75) - ok till eGFR 30 4. Edoxaban 60 OD (30 OD if CrCl <50 or weight <60kg) - ok till eGFR 30 * See other CAD slides for doses if being combined with anti-plt
32
Afib: Who gets immediate cardioversion
Electrical cardioversion (w 4 weeks AC post) if: 1) Hemodynamically unstable 2) NVAF <12 hrs and no prior stroke 3) NVAF 12-48 hrs and CHADS2 0-1 (age >75 not 65 as per CHADS65) *All others, start rate control and 3 weeks of anticoagulation and reassess for cardioversion as outpatient
33
Persistent Afib: Who gets rhythm control > rate and how?
Who: 1. Afib <1 year 2. High symptom burden/QoL impact 3. Multiple recurrence or difficulty achieving rate control 4. CHF secondary to afib How: 1. Anticoagulate x 3 weeks (unless meeting criteria for immed cardioversion) 2. Electrical or chemical cardioversion 3. Initiate maintenance anti-arrhythmic if Sx improve with cardioversion
34
Paroxysmal Afib: Treatment Algorithm
Low Symptom burden: Observe vs pill in pocket | High symptom burden: Maintenance anti-arrhythmic +/- catheter ablation
35
A.fib: Which maintenance AADs to use
``` If HFrEF (<40%): Amiodarone If HF (>40%): Amio or sotalol (caution if LVH or torsades risk) CAD: Amio, sotalol, dronaderone WPW: Procainamide, Ibutilide ; avoid AV nodal blocker No HF or CAD: Sotalol, dronaderone, flecainide, propafenone ```
36
Indications for PPM
- Symptomatic: tachy brady, sinus pause/brady, to increase GDMT, chronotropic incompetence - Mobitz II 2nd degree AVB, 3rd deg AVB +/- symptoms - Alternating LBBB/RBBB - Permanent Afib with symptomatic bradycardia (either spont or tx induced)
37
Indications for PPM Post-MI
Mobitz-T2, 3rd AVB, alternating BBB, symptomatic persisting >5d post-MI - Consider in new BBB or isolated fascicular block, or transient AVB that resolves *consider pacing in post-cardiac surgery, post-TAVI, asystolic syncope during tilt testing, cardioinhibitory carotid sinus syndrome
38
Syncope: High risk features warranting further Ix (beyond Hx/Px/ECG/basic BW)
- Symptoms suggestive of cardiac syncope (Symptoms just before during or just after exertion or without prodrome) - Hx CVD (valve, CADm arrythmia) - Concomitant trauma - FHX SCD <50 years - Abn VS or cardiac exam - Elevated trop/BNP - High risk ECG: Sinus node dysfxn (brady <50, pause >3sec), blocks (QRS >120, bifascicular block, Mobitz 2, 3rd degree), ventricular pre-excitation, SVT, AF, NSVT, QTc <340/>460, Brugada, LVH, current or past ischemia)
39
Right sided murmurs increase with:
Inspiration
40
Left sided murmurs increase with:
Expiration
41
VSD
Holosystolic murmur @ LLSB with thrill Radiates to RLSB Maneuvers = same as MR --> Decreases with reduced preload (standing, valsalva), Increases with increased PL (squat, leg raise), Increases with increased AL (handgrip)
42
Systolic Murmurs
Pansystolic: MR (Apex rad to axilla), TR (LLSB), VSD (LLSB to RLSB), MVP (LLSB rad to LUSB or back) SEM: AS (RUSB rad to clavicle/carotid, parvus), Aortic sclerosis (RUSB, no carotid radiation, no parvus), HoCM (apex/LLSB radiates to axilla/base)
43
Diastolic Murmurs
Low pitched rumble: MS (at apex, hear opening snap after S2) High pitched: AI (RUSB) +/-Austin Flint (functional MS without opening snap)
44
Continuous murmurs
``` PDA Aortopulmonary window Coarctation AVMs Ruptured sinus of valsalva to atrium Internal Mammary artery Venous hum in jugular Arterial stenosis (ie. subclavian) ` ```
45
ASD
Wide fixed split S1 + S2, loud S1 and P2 Diastolic rumble due to flow over TV SEM over LUSB due to flow over PV
46
Loud S1
MS, TS ASD, PDA (due to pressure equalization) Short PR (less time for leaflet to drift together) Exercise (ventricular contraction)
47
Quiet S1
Calcific MS MR Valves close early (long PR, AI, LBBB)
48
Variable S1
A.fib AV dissociation (complete heart block, VT) Severe Tamponade
49
Wide split S1
RBBB ASD Ebstein's anomaly
50
Loud S2
A2: HTN, CoA, Aneurysm P2: pHTN, ASD
51
Quiet S2
A2: AI, severe calcific AS P2: Low pulm artery Pressure, PS
52
Wide split S2
RBBB, LV PPM
53
Wide fixed S2
ASD, RV failure
54
Paradoxically split S2
LBBB, WPW, Fixed LVOT, AS, HOCM
55
Differentiating Tamponade, Pericarditis, Restrictive CM
Tamponade: + Pulsus, - Kussmaul, Blunted Y-dec, high JVP, (quiet S1/2), + ventric interdependence Constrictive: - Pulsus, + Kussmaul, Prominent Y-dec, high JVP, (peric knock), + Ventricular interdependence Restrictive: - Pulsus, + Kussmaul, Prom Y-dec, high JVP, (manifestations amyloid /sarcoid), no ventricular interdependence
56
Driving guidelines post ACS/CABG
ACS/CABG with WMA: 1 month private, 3 months commercial ACS (no WMA) tx with PCI: 48 hrs private, 7 days commercial ACS (no WMA) tx WITHOUT PCI: 7 days private, 30 days commercial If ICD: 1 mo (if primary prev)/6 months (secondary) if private, NO commerc PPM: 7d private, 1mo w/ N ECG commerc
57
Driving guidelines VT/VF
No ICD: 6 months private, NO driving commercial
58
Driving guidelines CHF
NYHA 1-2: no restrictions private, NO commercial driving if LVEF <=35% NYHA 3: no restrictions private, NO commercial driving NYHA 4, LVAD, Inotropes: No driving
59
Cocaine Associated Chest Pain : Tx
1) ASA Load + Benzos 2) NTG/Nitroprusside for HTN / persistent CP 3) If STEMI/NSTEMI - Tx as usual but avoid BB acutely
60
ECG Features Suggestive of VT
Complete axis deviation (QRS + in aVR, - in I, II and aVF) QRS >160 msec RSr' (left bunny ear higher) in V1 - most specific AV dissociation Capture / Fusion beats Concordance across all precordial leads Absence of LBBB or RBBB Morphology Brugada sign (distance from QR to S >100 msec) Josephson's sign - notched S wave
61
RE-LY Trial Dabigatran 150 was associated with _(a)_ efficacy and _(b)_ bleeding risk compared to warfarin Dabigatran 110 was associated with _(c)_ efficacy and _(d)_ bleeding risk compared to warfarin
a) superior b) equivalent c) equivalent d) decreased
62
Left atrial mobile mass arising from intact septum
Atrial Myxoma
63
Treatment recurrent pericarditis
1) NSAID 2wks + Colchicine x6 months 2) If recurs again - add prednisone (0.2-0.5 mg/kg) then slow taper 3) If still recurrent: Anakinra (anti-IL1), Aza, IVIG 4) If recurrent despite the above, pericardectomy
64
Mitral Valve Prolapse
Pan-systolic murmur at apex with radiation to base or back with mid-systolic clic Maneuvers = identical to HoCM No change with inspiration/expiration Increased PL: murmur quieter + shorter, click later Dec PL: murmur louder + longer, click earlier Inc AL: Murmur quieter + shorter, click later
65
ECG Features in HoCM
Left atrial enlargement LVH with ST/T wave abn from repolarization Deep, narrow, dagger like Q waves in lateral>inf leads Giant precordial Twave inversions WPW Arrhythmias (afib, SVT, PACs, PVCs, VT)
66
Max HR for TST
85% of max HR (220-age)
67
Consider CABG if:
``` L main dz (>50%) Proximal LAD stenosis 3-vessel disease 2- or 3-vessel disease with LVEF <40% Multivessel dz with diabetes/LV dysfcn/CHF ```
68
Antiplatelet dose
Loading: ASA 160, Ticag 180, Plavix 300-600 Maintenance: ASA 81, Ticat 90 q12h, Plavix 75
69
RF for bleed in DAPT/stent
Drugs: OAC, NSAID, prednisone Patient: Age >75, frail, Low BW (<60kg), bleed within past year, previous stroke/intracranial bleed, HTN Labs: Hgb <110, CKD (CrCL <40), abnormal LFT, labile INR
70
Preop Antiplatelets - Holding - Neuraxial anesthesia
Plavix and Ticag 5-7d preop; 7d if neuraxial anesthesia Prasugel 7-10d Continue ASA periop if possible
71
Syncope Drive
Vasovagal: can drive private/commerc if not provoked sitting | Recurrent unexplained: 3mo syncope free private, 12mo syncope free commerc
72
Cardiac Amyloid Tx
Restrictive CM: Diuretics *Avoid: BB, CCB, ACE/ARB, dig OAC for afib (regardless of CHADS; similar to HOCM) ATTR : tafamidis or inotersen or patisiran +/- liver transplant AL: chemotherapy +/- autologous stem cell transplant ICD - consult EP
73
When to workup HFrEF for advanced therapy
NYHA 2-4 +1 of: - EF < 25%, worsening RHF/PH, end organ dysfcn - Need pressors, refractory to diuresis or have to stop meds - Repeat hospitalizations, 1y mortality, can't do ADLs, cachexia, hypoNa - 6MWT distance < 300m
74
Medical therapy for valves
AS: ACE/ARB after TAVI (NO afterload reduction otherwise), tx HTN/DLPD as normal AR: ACE/ARB or ARNI for symptoms or LV systolic dysfcn + prohibitive surgical risk, tx HTN as normal MS: VKA if afib, stroke, LA thrombus MR/TR: Tx HF as normal. NO vasodilators if normal EF and asymptomatic primary MR
75
TAVI indications
>80yo or younger pt w/ <10y life expectancy intermed/high/prohibitive surgical risk Reasonable QoL with life expectancy >1y *bioprosthetic valve req IE ppx
76
Causes of pericarditis
* Vascular – post MI or CV Sx * Infectious - Coxsackie, echovirus, adenovirus, flu, parvo, TB, fungal * Autoimmune – RA, SLE ... * Metabolic - uremia, dialysis, hypothyroidism * Iatrogenic – Radiation, Meds (hydralazine, dilantin, INH, procainamide, minoxidil) * Neoplastic - mesothelioma, breast/lung/melanoma mets, leukemia, lymphoma
77
Reasons to admit pericarditis
* Fever T>38C * Hemodynamic instability * Myopericarditis (Troponin elevation) * Significant effusion (>20mm) or cardiac tamponade * Immunocompromised * Trauma * Oral anticoagulation therapy * Subacute onset * Lack of improvement after 7d appropriate therapy
78
OAC for AF in liver dz, Ca, CHD, frail, preg, thyroid
Liver: Not if CP-C or signif coagulopathy Cancer: DOAC>VKA, individualize Congenital heart dz: OAC for HCM Frail elderly: OAC 2ndary AF: no OAC EXCEPT risk for recurrence, or acute thyrotoxicosis (until euthyroid) Pregnancy: No DOAC. Give LMWH/warfarin (T2-T3)
79
VT management a) Storm b) polymorphic +/- prolong QT
Storm (>3 in 24h): NSBB (eg propranolol), IV amio, sedation Polymorphic: -Normal QT - ischemia (ACS tx, amio/lido), vs no ischemia (amio); -Prolonged QT: IV Mg, NSBB, overdrive pacing +/-lidocaine if refractory Stable: cardiovert vs procainamide. 2nd line: amio, lidocaine
80
Cardiac pacing for vasovagal syncope
- Patients >/= 40 with ++sx - Symptomatic asystole > 3s or asymptomatic asystole >6s - Tilt-induced asystole > 3s or HR < 40 bpm for > 10s
81
Different PVD ulcer characteristics
Arterial ulcer = punched out, on toes, feet Venous stasis ulcer = medial calf Diabetic ulcer = plantar foot, heel
82
PVD Tx
NonPharm: Exercise, self foot examination, wound care Pharm: ASA/Plavix, ASA+Riva2.5BID for stable CAD/PAD ACEi + statin in all Smoking cessation Cilostazol (PDE3i) - CONTRAINDICATED in CHF Anticoag for acute limb ischemia Revasc only if critical limb ischemia
83
Precordial TWI DDx
``` Wellens - proximal LAD occlusion Brugada Increased ICP PE RBBB, RVH HOCM, LVH ```
84
BP and bruit differences in Coarctation vs Takayasu
Coarctation: lower in LE, higher in UE. NO subclavian bruit Takayasu: higher in LE, lower in UE, subclavian bruits
85
High risk features on exercise stress test
Duke Treadmill Score -11 or less STE or STD >=2mm or >1mm with <5 METS/ >=5 leads/ persisting >3 min into recovery VT/VF Abnormal BP response (fail to increases BP >120, drop >10, drop below BL)
86
Tall R wave in V1 DDX
``` Hypertrophic cardiomyopathy RBBB /RVH/strain WPW Posterior MI (STE Leads 7-9) Dextrocardia Muscular/myotonic dystrophy ```

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