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What is the Bruce Protocol? What is a MET

Exercise stress test with a set of speed and elevation setting devised to achieve a specified target. The modified Bruce protocol adds two stages below I.

1 MET = 3.5ml of oxygen/kg/min corresponds to a sitting resting postion
3-5 METS = light walking
5-7 METS = shoveling snow
9 METS = playing squash


What is a positive stress test

Abnormal symptoms: chest pain, dyspnea, or syncope at less then 5 METS
Abnormal ECG: ST depression > 2 mm down sloping at < 6 METS, ST elevation, or arrhythmias
Abnormal blood pressure response: hypotension (a drop in SBP of 10 or more), inability to achieve SBP > 120
abnormal heart heart response: Inability to achieve a HR of 85% or more of expected, or bradycardia
Inability to achieve 6 METS


What is post pericardiotomy syndrome

Clinical entity caused by non-infectious inflammation of the pericardium after heart surgery

symptoms: Malaise, fever, pericardial rub, and chest pain

Investigation: ECG, non-specific chest leads ST elevation, Cardiomegaly on CXR and leukocytosis

It occurs one to two weeks after surgery and may last up to 6 to 8 weeks. Usually self limited, however, NSAIDS may help (ASA 650 mg po QID). Steriods are not indicated.


What are risks for perioperative stroke given degree of carotid stenosis

Carotid stenosis < 50% risk about 2%
Carotid 50 to 80% risk is 10%
carotid stenosis > 80% the risk 11 to 19%


Describe Heparin Induced Thrombocytopenia and classify

HIT is a clinical entity classified by a drop in platelet count attributable to the use of Heparin.
Results from IgG antibody against Heparin-PF4 complex.
Binding of the IfG antitbody to the platelets Fc receptor and PF4 leads to aggregation and consumption.

Type 1 HIT: mild drop in plt count > 100 000 without evidence of thrombosis Management is continued monitoring only
Type 2 HIT: moderate to severe drop in plt count to < 100 000 without evidnece of thrombosis. The management is to stop heparin, alternative anticoagulation and monitor for thrombosis
Type 3 HIT: HIT WITH evidence of thrombosis: management
Stop hepaiir/alternative anticoagultion/echo/vascular dropplers/check Anti-PF4/ treat ischemia


What are interesting facts of amio

Take 2 to 3 days to really work

Elimination half life is 25 to 100 days

interferes with metabolism of digoxin and warfarin


List side effects of amiodarone toxicity

chronic interstitial pneumonitis (most common)
organizing pneumonia (ARDS)
dry cough, malaise,
Cardiac arrhythmias
transient rise in LFT
cirrhosis and liver failure is rare
Occular changes
Skin changes
sleep/tremor/peripheral neuropathy


How do statins work

Inhibits the conversion of HMG CoA to mevalonate, the rate limiting step of cholesterol biosynthesis

LDL lowers by 30%
HDL increase by 5 to 10%
TG decrease by 20-40%


Treatment of a patient refractory to medical therapy for atrial fibrillation

AV node ablation withe VVIR PPM
Pulmonary vein mapping and isolation
surgical maze
atrial pacing
Implantable atrial defibrillator


CCS Classification --Hurst

Class I: Ordinary physical activity such as walking and climbing stairs does NOT cause angina
only angina with strenous or prolonged exertion
Class II: Slight limitation or ordinary activity
walking on level ground or > 2 flights of stairs
Class III: Marked limitation of ordinary physical activity
less then 2 flight of stairs
Class IV: inability to carry on ANY physical activity without discomfort

This pain should be less then 15 minutes because if greater them its unstable angina


NHYA classification

Class I---No symptoms
Class II- symptoms only with ordinary activity
Class II--symptoms with less then ordinary actitivity
Class IV- symptoms at rest


List 8 contraindications to thrombolytic therapy

Intracranial hemorrhage (any prior)
Known structural cerebral vascular lesion (AVM)
Malignant intracranial neoplasm
Ischemic CVA within 3 months
Suspected aortic dissection
Active bleeding
signficant closed head or facial trauma in last 3 months


What is classification of Calcium channel blockers

predominatly vasodilators
little or no effect on contractility or conduction
reduce vascular permeabilty
less potent vasodilators
inhibit AV node conduction


What is the mechanism of action of nitrates and how do they reduce angina

dilate veins, arteries, and coronaries by relaxing smooth muscle

most anti-ischemic effect from systemic vasodilation that decreases myocardial oxygen demand rather than increase coronary artery blood flow

nitrates cause predomonatly venodilation, lowering preload thus decrease LVEDP, and decrease myocardial demand


What is relationship if Coronary artery calcium and coronary artery stenosis

0 --- No identifiable disease
1 to 99-- mild disease
100 to 399--modeate disease
> 400 severe disease


What are IVUS cut offs

an IVUS mean lumen diameter of < 2.8 mm or MLA < 6mm2 suggets a physiologically significant lesion and identify patients who may benefit from revascularization.

If IVUS MLA is >7.5 to 9 mm, revascularization may be safely deffered.

IVUS MLA between 6 to 7.5mm2 should be interpreted in conjunction with the patients clinical history, stress testing, or FFR>


How do you calculate pulmonary vascular resistance

PVR = PAP - PCWP/Cardiac output


How do you calculate Systemic vascular resistance

SVR = MAP - RAP/cardiac output

RAP = right atrial pressure


What is post pericardiotomy syndrome

non-infectious inflammation of the pericardium after heart surgery

malaise, fever, pericardial rub, chest pain , leukocytosis, non specific ST elevation

occurs 1 to 2 weeks after surgery lasts up to 8.

self limited, NSAID


What are targets for LDL in patients

Low risk pt < 4.5
Moderate risk < 3.5
high risk < 2.5


What are targets for Total Chol:HDL ratio

Low risk < 6.0
moderate < 5.0
High risk < 4.0


What are different agents for elevated LDL, TG< and depressed HDL

Statins: decrease LDL, increase HDL, and decrease total ratio
Resins: decrease LDL and increase HDL
Fibrates: decrease TG and increase HDL
Niacin: increase HDL (mostly) and decrease LDL and decrease TG


What is the evidence of PTCA and what are definitions

Primary PTCA: as initial method of reperfusion
↓ reinfarction and death and intracrancial hemorrhage
However, only in centers able to do 1˚ PTCA
Rescue PTCA: done following recurrent angina or HD instability following thrombolytic Rx
Immediate PTCA: performed in conjunction w/ thrombolytic Rx
ECSG/TAMI/TIMI IIA: does not improve clinical outcome; also ↑ risk of bleeding
Delayed PTCA: occurs during the intervening hospitalization
does not improve clinical outcome in pts w/ no ischemia on stress testing (TOPS)
Elective PTCA: following thrombolytic Rx and med mgt when positive stress test is obtained during same hospitalization or soon thereafter
TIMI IIB: thrombolytic Rx followed by PTCA in pts w/ symptomatic or provokable ischemia is appropriate
Cardiogenic shock: 1˚ PTCA improves survival to 40-60%. In hosp survival 70%. W/in 6h of onset of shock → ↑ 1yr survival


What is IVUS

allows visualization of the coronary arterial wall by using a minature transducer at the end of a flexibile catheter which emits u/s in 10 to 40MHz.

useful in delineating plaque morphology and distribution


Summary of IVUS



Summary of CT angiogram for assessing coronary disease and calcium score



Exercise stress testing



Mibi scan



What is metabolic syndrome

clinical entity associated with increased risk of atherosclerotic coronary artery disease, is components are:

Abdominal obesity
Insulin resistance

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