Cardiology - CAD and ACS

Question 1

Goal HR on beta blocker?

Beta blocker contraindicated in patients with?

Answer 1

55-60

#Symptomatic bradycardia you
#High grade AV block
#Acute decompensated heart failure
#Severe reactive airway disease

Question 2

Medical therapy for patients with STABLE angina?

If continued symptoms?

If continued symptoms?

If continued symptoms?

Answer 2

Left heart catheterization

#aspirin
#Beta Blocker
#Long acting Nitrate
#Statin
#sublingual nitroglycerin
#ACE inhibitor (?)

#increase beta blocker deuce
#Increase long-acting nitrate does
#Add calcium channel blocker

#Optimize current medications
#Consider ranolazine

Question 3

Patient with medically refractory angina is not suitable for PCI or surgical revascularization – options for management?

Answer 3

#External enhanced counterpulsation
#Spinal cord stimulation

Question 4

Indications for moderate to high intensity statin?

Answer 4

#LDL over 190
#Diabetes
#7.5% ASCVD 10 year risk

Question 5

Patients at risk for CVD should get which vaccine?

Answer 5

Influenza

Question 6

Calcium channel blockers that are better for CAD?

Answer 6

Non-dihydropyridines (provides coronary vasodilation AND reductions in heart rate)
#Diltiazem 
#Verapamil

Question 7

Calcium channel blocker are contraindicated in patients with?

Answer 7

#Left ventricular systolic dysfunction
#Advanced AV block

Question 8

Ranolazine - MoA? When to prescribe?

Answer 8

Selected inhibitor of late in word sodium channel in the myocardium

For patients who remain symptomatic after beta blockers, nitrates, and calcium channel blockers

Question 9

SYNTAX score?

Answer 9

Anatomic scoring system based on the results of angiography (useful in predicting outcomes of revascularization strategies)

Question 10

PCI versus optimal medical management in stable angina?

Answer 10

No mortality benefit but improvement in quality of life

Question 11

CABG warranted in which patients?

Answer 11

#Left main disease
#Multivessel disease involving proximal LAD

Question 12

Duration of dual antiplatelet therapy in patients with stable angina after:

1. No stent
2. Bare metal stent
3. Drug-eluting stent
4. CABG

Answer 12

1. No do therapy
2. Aspirin and Plavix for one month
3. Aspirin and Plavix for one year
4. Not indicated

Question 13

Duration of dual antiplatelet therapy in patients with unstable angina/NSTEMI or STEMI after:

1. No stent
2. Bare metal stent
3. Drug-eluting stent
4. CABG

Answer 13

Aspirin plus

1. Plavix/ticagrelor for one year
2. Plavix/ticagrelor/prasugrel for 1-12 months
3. Plavix/ticagrelor/prasugrel for 1 year
4. Plavix/ticagrelor for 1 year

Question 14

When to give dual antiplatelet therapy?

Answer 14

#following PCI 
#following ACS

Question 15

Medical therapy for STEMI?

Answer 15

#Aspirin
 #Statin
 #Nitrates
 #BetaBlocker
 #Heparin
 #P2Y inhibitor (clopidogrel, ticagrelor)

Question 15

Contraindications to thrombolytic therapy during MI?

Answer 15

#Any previous intracerebral hemorrhage
#Known cerebrovascular lesion (AV malformation)
#Stroke in prior three months
#Suspected Aortic dissection
#Active bleeding
#Significant closed Head/facial trauma and past three months

Question 16

Thrombolytic options for MI treatment? (TIMI Flow grade 2/3?)

Answer 16

Streptokinase (55%)
Alteplase (75%)
Reteplase (83%)
Tenectoplase (83%)

The higher the flow grade 2/3, the more effective for thrombolytic

Question 17

Arrhythmia that is considered benign if within 24 hours of reperfusion?

Answer 17

Accelerated idioventricular rhythm

Question 18

Thrombolytic failure occurs how often? How to tell if thrombolytics fail?

Answer 18

30%

 #Failure to resolve chest pain
 #Failure to improve ST elevation by 50%

Question 19

Caution using nitrates and analgesics in these type of infarcts? (Why?)

Answer 19

Inferior or right ventricular infarction

Can result in reduced preload and significant hypotension

Question 20

In patient with STEMI, beta blockers recommended in all patients except those with?

Answer 20

#Hypertension
 #Bradycardia
 #Advanced AV Block
 #Heart Failure

Question 21

Dosing of metoprolol in acute ACS?

Answer 21

Three 5 mg increments q5 minutes

Question 22

Contraindications to ACE therapy?

Answer 22

#Systolic blood pressure under 90
#Advanced kidney dysfunction
#Hyperkalemia

Question 23

How long to IDEALLY continue dual antiplatelet therapy after STEMI?

Minimum duration of dual antiplatelet therapy?

Answer 23

One year

Four weeks if bare metal stent implanted

Question 24

Role of heparin in acute ACS? Prefer unfractionated or low molecular weight heparin? When using heparin for primary PCI, guidelines recommend concomitant administration of?

Answer 24

Reduced incidence of reocclusion Unfractionated (can monitor degree of anticoagulation) Glycoprotein 2b/3a inhibitor

Question 25

Instead of heparin + glycoprotein 2B/3A inhibitor, can consider using? Advantage?

Answer 25

Bivalirudin (Direct thrombin inhibitor) Similar rate of ischemic events but fewer bleeding events

Question 26

Diabetic presents with ACS, gold glucose level?

Answer 26

Under 180

Question 27

After/During MI, patient develops hypotension, jugular venous distention, but has clear lung fields. Cause? EKG finding? ECHO finding? PA catheter finding?

Answer 27

Right ventricular infarction ST segment elevation in V3R and V4R; dilated RV with reduced systolic function; elevated RA and RV pressure with low wedge pressure

Question 28

After/During MI, patient develops systolic blood pressure under 90? Cause? EKG finding? ECHO finding? PA catheter finding?

Answer 28

LV infarction ST elevation in anterior leads Severe LV dysfunction CI under 2; wedge pressure over 18

Question 29

After/During MI, patient develops holosystolic murmur along left sternal border. Often also presents with this sound? Cause? EKG finding? ECHO finding? PA catheter finding?

Answer 29

VSD; thrill Nonspecific (50% associated with anterior wall MI) ``` #High velocity left-to-right systolic jet #systolic turbulence RV side ``` ``` #Large V waves in wedge pressure tracing #Step up in oxygen saturation from right atrium to left ventricle ```

Question 30

After/During MI, patient develops Holosystolic murmur at the left sternal border. Crackles on pulmonary exam. May also present with this auscultation finding? Cause? EKG finding? ECHO finding? PA catheter finding?

Answer 30

Papillary muscle rupture (radiation of murmur to axillae) Usually inferior/inferior-posterior wall MI ``` #Flail mitral valve leaflet with attached mass (papillary muscle head) #Severe MR ``` Prominent large V waves in wedge pressure tracing

Question 31

After/During MI, patient develops hypotension, jugular venous distention, and distant heart sounds. Cause? EKG finding? ECHO finding? PA catheter finding?

Answer 31

Left ventricular free wall rupture Potentially pulseless electrical activity ``` #Pericardial fusion with Tamponade #Discrete wall motion abnormality #Defect in myocardium ``` ``` #Equalization of diastolic pressures #CI under 2 ```

Question 32

Sinus bradycardia typically occurs after which type of myocardial infarction? May also see these type of arrhythmias?

Answer 32

Inferior wall MI ``` #Atrial fibrillation #Heart block ```

Question 33

Ventricular rhythm is arrhythmias suggest poorer mortality/mobility if?

Answer 33

After first 24 hours

Question 34

Patient develops persistent high degree atrioventricular block or symptomatic bradycardia after MI - next step?

Answer 34

Temporary transcutaneous or transvenous pacemaker

Question 35

RV infarction triad?

Answer 35

``` #Hypotension #Elevated JVP #Clear lung exam ```

Question 36

RV infarction treatment?

Answer 36

inotropes (dopamine or Dobutamine) until RV function improves (usually 2-3 days)

Question 37

VSD after MI – management?

Answer 37

``` #Vasopressor agents #Intra-aortic balloon pump ``` Must get SURGERY (or if not, percutaneous VSD closure device)

Question 38

Etiologies of mitral regurgitation after STEMI?

Answer 38

``` #LE dysfunction with annulus that location #Worsening of pre-existing mitral vegetation #Rupture of papillary muscle/chordae tendinae ```

Question 39

Treatment of mitral regurgitation after STEMI?

Answer 39

``` #Vasodilators to reduce afterload #Diuretics to decrease preload #If unstable, intra-aortic balloon pump ```

Question 40

Risk factors for LV rupture?

Answer 40

``` #Female #Anterior Myocardial Infarction #Incomplete Reperfusion ```

Question 41

LV thrombus is common (how common?) after which type of MI? Treatment?

Answer 41

10-20% after anterior wall MI Warfarin for 3-6 months