General Board Review Flashcards
(229 cards)
2
Q
HTN Tx algorithm
1)
2)
3)
A
1) HCTZ/Chlorthalidone vs loop if CKD
2) ACE/ARB + CCB
3) Spironolactone or eplerenone
3
Q
Vasodilator testing positive response
A
Decrease mPAP by ≥10mmHg
Decrease mPAP to ≤40 mmHg
No worsening in CO
4
Q
PAH Tx suggestion based on WHO symptom class
A
Class 2-3: Endothelin antagonist (bosentan, ambrisentan) + PDE5i (tadalafil, sildenafil)
Class 4: Prostacyclines (epoprostenol, treprostinil, iloprost)
5
Q
Riociguat indications
A
Group I & IV Pulm HTN
6
Q
Treatment of recurrent pericarditis
A
1) CRP-guided NSAIDS Taper + colchicine (repeat initial treatment)
2) Steroid taper over 6-12 months, NSAID taper, colchicine 6 months
3) Immunomodulation - IVIG, anakinra, AZT
4) Radical pericardiectomy
7
Q
NSAID regimen for Pericarditis
- ASA
- Motrin
- Indomethacin
A
ASA 750-1000 mg q8˚ ** ASA only if post-MI pericarditis
Motrin 600 mg q8˚
Indomethacin 50mg q8˚
8
Q
Contraindication to pericardiocentesis
A
Aortic dissection
9
Q
Hemodynamically, rapid Y-descent indicative of …
A
Rapid early diastolic filling
10
Q
Rapid Y-descent seen in …
A
Constrictive and restrictive pericarditis
11
Q
ABI interpretation
A
Non-compressible: >1.4
Normal: 1 - 1.4
Borderline: 0.91 - 0.99
Abnormal: ≤0.9
12
Q
Exercise ABI Positive response
A
ABI decreases by 20%
Ankle pressure decreases by >30 mmHg
13
Q
Vorapaxar
Class:
Effect:
A
Class: Protease activated receptor-1 (PAR-1) antagonist
Effect: reduces thrombotic events in Patients with a history of MI or PAD, without history of TIA/CVA
May reduce ALI
14
Q
Acute Limb Ischemia:
- Viable: (sensory, motor, arterial/venous doppler)
- Threatened
- Irreversible
A
- Viable: Sensory, motor, arterial and venous Doppler intact –> Urgent, tx 6-24˚
- Threatened: mild/moderate sensory loss, no muscle weakness, no arterial Doppler, audible venous Doppler –> Emergency, tx < 6˚
- Irreversible: ø sensation, paralysis/rigor, ø arterial or venous Doppler –> 1˚ amputation
15
Q
AAA Surveillance US timing
A
3 - 3.9: q 3 years
4 - 4.9: q 12 months
5 - 5.4: q 6 months
16
Q
AAA indications for surgery
A
Diameter > 5.5 cm (IIa: 5 - 5.4 cm)
Expansion > 1 cm/yr
Symptomatic
Ruptured or contained rupture
17
Q
Endoleak types 1-5
A
1 - Incomplete seal proximal or distal
2 - from collaterals
3 - fail to anastomose b/w stent components
4 - leak through graft materials
5 - sac expansion w/o clear lesion
18
Q
Marfan syndrome: - Medical management - Hint: Caveat
A
Atenolol + *Losartan*
Even without HTN
19
Q
Indications for aortic repair:
- Turner’s
- Loeys-Dietz
- Marfan (and if pregnant?)
- Bicuspid AV
A
Turner: ≥ 2.5 cm/m2 (indexed 2˚ short stature)
Loeys-Dietz: > 4 cm (dangerous: *DIE*tz)
Marfan: ≥ 5 cm, >4 cm if pregnant
Bicuspid AV: ≥ 5.5 cm
20
Q
Indications to anticoagulate for distal LE DVT
A
- Unprovoked + Symptomatic
- Active malignancy
- Close to proximal deep vein
- Prior hx DVT
- +D-Dimer
21
Q
Acute ischemia CVA tx
tPA window:
BP goal if tPA given:
A
tPA window: 3-4.5 hours
BP goal if tPA given: < 185/110
22
Q
tPA contraindications
A
- ICH
- CVA, head trauma, brain/spine surgery within 3 months
- Brain/spine tumor
- Coagulopathy: Platelets < 100K; INR > 1.7
- on OAC/DOAC
- Endocariditis
- Aortic dissection
23
Q
Coronary artery calcium score and statins
A
0: ø statin
1-99: +/- statin
≥100: start a statin
24
Q
Only 2 diets to reduce CV death
A
Mediterranean
DASH Diet
25
Components and interpretation Revised Cardiac Risk Index
- CAD
- HF
- Cr ≥ 2
- Prior TIA/CVA
- DM
≥2 = high risk
High risk surgeries: Vascular, thoracic, transplant
26
Activities ≥ 4 METs
≥ 2 flights of stairs
≥ 4 blocks
Rake leaves or push lawn mower
27
When is it okay to hold DAPT:
• BMS
• DES
BMS: after 30 days
DES: after 3-6 monts (IIb)
≥6 months (I)
28
STEMI, Lytics & transfer
- Sx timing
- Time to PCI
Sx's \< 3 hours onset
Anticipate \> 2 hours to PCI
--\> give lytics and transfer
29
1˚ Lytics strategy in STEMI
- Timing
- Other meds
- Give lytics \< 30 minutes of arrival
- Also anticoagulate minimum 48˚ - 8 days, or until revascularization
• Heparin, lovenox, fondaprinux
30
tPA dose
15 mg IVP Then 0.75 mg/kg over 30 minutes (up to 50 mg) Then 0.5 mg/kg over 60 minutes (up to 35 mg)
31
MI Complications: Dynamic outflow obstruction
- Associated infarct pattern
- Treatment
- Apical infarct/hypokinesis -\> compensatory hyperdynamic basal function -\> LVOT obstruction and hypotension
- Tx: ß-blocker; avoid inotropes and IABP
32
MI Complications:
- New murmur while lying supine --\> ?
- New murmur while bolt upright --\> ?
- Supine: Acute VSD
- Upright: Acute MR
33
MI Complications: Free wall rupture - Presentation - Infarct pattern - Associated complication?
- Old lady, 1st AMI, anterior MI - Anterior free wall MI - Associated PEA
34
Pseudoaneurysm vs True Aneurysm:
Pseudo: narrow neck, contained rupture
True: Wide neck, affects all layers of myocardium
35
AF + Conditions that skip CHADS2-Vasc
Valvular AF: ≥ moderate MS + Mechanical valve
HCM: Warfarin
36
NOAC/Drug interactions
- Verapamil - decrease edoxaban and Pradaxa
- Dronedarone - Pradaxa contraindicated
- HIV Protease inhibitors (-navir's): NOAC's contraindicated
37
AF RFA Complications: Atrioesophageal fistula management
Go to surgery, don't do endoscopy
- Endoscopy uses air --\> further air embolus
38
Cough and hemoptysis s/p AF RFA:
- Dx?
- Management
Pulmonary vein stenosis
- Dx via CT PE/Angiogram
- Tx: Balloon, pulmonary vein stenting
39
AF + WPW
- Management
- DCCV ± procainamide
- INPATIENT ablation
- ø AV nodal blocking agents
40
Sympomatic WPW Management
Risk stratification:
- Exercise stress test (I)
• Low risk: Abrupt loss of pre-excitation
- Hoter (I)
• Intermittent loss of pre-excitation
- EP Study (IIa)
41
WPW Ablation indications
1. Rapid conducting AP
2. Employment precluded
42
ARVC
- Pathology
- EKG findings (3)
- Exercise good/bad?
- Desmosome protein mutation - junctional plakoglobin
- EKG:
1. LBBB
2. TWI V1-V3
3. Epsilon wave
- Exertion/exercise speeds progression
43
Pt with VT & Heart block.
- Dx?
- Dx test?
- Tx
Dx: Sarcoid
Testing: FDG-PET scan
Tx: Immune suppression ± ICD
44
Brugada Syndrome
- Mutation
- ICD indications
- Tx:
- SCN5A LOSS of function (Na channel)
- ICD Indications: Aborted arrest, Syncope + Brugada pattern ECG
- Tx: Quinidine (Ito blocker balances loss of Na channel function); treat fever
45
Bidirectional VT on stress ECG. Dx?
Catecholaminergic Polymporphic VT
- CPVT if increasing PVC's/bigeminy w/ HR \> 120 BPM, stops when resting
46
CPVT:
- Tx:
- \*Nadolol\* ± flecainide ± left cardiac sympathetic denervation
- DO NOT PLACE ICD
47
CPVT pathology
RYR2 mutation --\> Ca release channel
- Leaky ryanodine receptor --\> Diastolic Ca overload
- Mimics digoxin toxicity
48
LQTS: wide QRS adjustment
QTC - (QRS-100)
49
LQTS 1, 2, 3:
- Channel
- Loss/gain function
- Presentation
1: IK**s**, LOSS of function, **S**wimming/activity
2: IK**r**, LOSS of function, **R**eally loud noise, just **R**eproduced
3: INa, **S**C**N**5A GAIN of function, **SN**ooze
50
LQTS Rx
1: ßB with NADOLOL or propranolol
3: PROPRANOLOL ± mexitil/Ranexa
51
AAD elimination
- Renal?
- Hepatic
- Renal: sotalol, dofetilide, digoxin, NAPA (procainamide byproduct)
- Hepatic: most other AAD's, amio, lido, mexitil, verapamil, dilt, propafenone
52
Who gets IE PPx (6-7)
- Prosthetic valves
- Transcatheter valves
- Prosthetic materials for valve repair (annuloplasty)
- Prior IE
- Transplant recipients w/ valvulopathy (\> mild dz)
- CHD:
• unrepaired cyanotic lesions
• cyanotic lesion w/ palliative shunt/conduit
• repair ≤6 months w/ prosthetic materials
• repaired lesion w/ residual shunt
- Mitraclip? WATCHMAN?
53
Procedures requiring IE PPx
- Dental
• manipulate gums, roots
• perforation of oral mucosa
• cleaning, extraction, root canal
- Incision into active soft tissue infxn
- Incision/biopsy into respiratory tract
• Bronch WITH BIOPSY \*\*
• Tonsil/adenoidectomy
54
Antibiotics for IE PPx
- Amoxicillin 2g PO
- Ampicillin 2g IM/IV
If allergy -\> Clinda 600mg or Azithromycin 500mg
\* coverage for viridans strep
55
Management of IE + mechanical valve + CVA Sx's
STOP anticoagulation for ≥ 2 weeks
- Prevents hemorrhagic transformation
- If needs valve sx, delay for 4 weeks
56
Reimplantation after IE + CIED
- Eval actual need
- Consider contralateral implant
- Timing:
• 72˚ after device removal
• 14 days if valvular involvement
57
Mitral Stenosis: MVA, Gradient?
- Severe:
- Very Severe:
Severe:
- MVA: ≤ 1.5
- Gradient: ~8-10 mmHg
Very Severe:
- MVA: \< 1
58
Anticoagulation with mechanical valves
- On-X
- Mech AV
On-X + ø risk factors: INR 1.5-2
Mech AV + ø risk factors: INR 2.5
59
Anticoagulation with bioprosthetic valves
- 1st 3 months: INR 2.5
- After 3 mos + ø risk factors: ASA only
- After 3 mos + risk factors: ASA + OAC
60
CVA + Prosthetic valve ... OAC?
- If not on ASA when CVA ocurred --\> add ASA (should have been on aspirin)
- If initial goal INR 2.5 --\> 3
- If initial goal INR 3 --\> 4
61
Bridging in mechanical valves
- Risk factors for thromboembolism?
- AF
- Previous thromboembolism
- Hypercoagulable condition
- LVEF \< 30%
62
Bridging in mechanical valves
- Who gets bridged
- AV mechanical valve w/o risk factors --\> NO BRIDGE
- Everyone else --\> Bridge
63
Bridging in bioprosthetic valves
- ø risk factors --\> ø bridge
- 1st 3 months of +Risk factors --\> BRIDGE
64
Contraindications to pregnancy (7)
- PAH
- Severe Ventricular dysfunction (EF \<30%, NYHA III-IV)
- Prior peripartum CM w/ residual LV dysfxn
- Severe VHD: Sev MS, AS; Severe (re)coarctation
- Sev AO dilation:
• \>45 mm in Marfan
• \>50 mm in Bicuspid AV
• Turner with ASI \> 25 mm2
- Vascular Ehlers-Danlos
- Fontan with any complication
65
Acute pericarditis in pregnancy:
- Management
- \<20 weeks --\> NSAIDs
- \>20 weeks --\> Corticosteroids
66
HTN in pregnancy
- BP based tx
- SBP ≥ 150 or DBP ≥ 95 mmHg: Treat
- ≥170/≥110: Hospitalize and tx
- Gestational HTN + proteinuria + sx's --\> deliver
67
Sinus Venosus ASD associated with...
Anomalous right upper Pulmonary vein
68
Echo shows increased RV, but no ASD... Dx?
Sinus Venosus ASD (can't be visualized on TTE) + anomalous pulmonary veins
69
Primum ASD (AKA partial AV canal defect\_ is a connection between ...
Primum ASD/partial AV canal defect is a connection between RA + LV
70
Primum ASD associated with (2)
Cleft mitral valve
Down's syndrome
71
Primum ASD EKG findings (2)
Left axis deviation
RBBB
72
Primum ASD LV gram
Goose neck deformity
- Apex to AV elongated
- Apex to MV shortened
73
Condition precluding sinus venosus and primum ASD surgical repair
Pulmonary HTN
To close, must have:
- PA pressure \< 50% systemic
- PVR \< 1/3 SVR
74
VSD physical exam and management based on size:
- Small
- Large
Small:
- LOUD NOISE, thrill
- no sx's, no Rx
Large:
- Mitral diastolic flow rumble
- LV enlargement --\> close
75
Pulmonary stenosis - associated with ...
Noonan's Syndrome
76
Pulmonary Stenosis management
Mod-Sev PS + Sx's --\> balloon
Mod-Sev PS + Sx's + unable to balloon or had prior ballon --\> Surgery
77
Coarctation of the aorta, association
Bicuspid AV + Turner symdrome
78
Ebstein Anomaly: CXR
Big heart hanging on string
79
Glenn Shunt
- Shunt
- Indication
* SVC --\> Right or main pulmonary artery
* Single ventricle, hypoplastic left heart
80
Blalock-Taussig Shunt
- Shunt
- Indication
Aorta --\> Right pulmonary artery
• Subclavian A --\> pulmonary A
• ToF, pulmonary atresia, tricuspid atresia, univentricular heart
81
Potts Shunt
- Shunt
- Indication
* Aorta --\> Left pulmonary artery
* ToF
* Not really used anymore
82
Waterston Shunt
- Shunt
- Indication
* Aorta --\> Right pulmonary artery
* ToF
* Not really used anymore
83
Fontan
- Shunt
- Indication
* IVC/SVC/RA --\> pulmonary arteries
* Hypoplastic left heart, tricuspid/mitral atresia
84
Single ventricle shunt/operation order
1. Blalock-Taussig - R subclavian A to pulmonary A 2. Glenn - SVC to PA 3. Fontan - IVC to PA
85
Congenitally corrected transposition of the great arteries (CC-TGA) associations
VSD
PS
Left-sided valvular regurgitation
Systemic Ventricular dysfunction
Complete heart block
86
Triggered VT
- EAD associated with ...
- DAD associated with ...
- EAD: TdP
- DAD: CPVT
• CPVT with Ca overload/Ryanodine mutation
• Mimics digoxin toxicity
87
EKG findings localizing STEMI to LCx
- \*STE II \> III\*
- STE I, V5, V6
88
Pseudoaneurysm, LV aneurysm, VSD:
- Associated infarct/location
- Pseudoaneurysm: RCA/Inferior wall
- LV Aneurysm: Transmural infarct, anterior/apical walls
- VSD: Wrap-around LAD
89
Killip Class grading (I-IV)
I: ø signs of HF
II: Rales, S3, elevated JVP
III: Acute pulmonary edema
IV: Cardiogenic shock, hypotension, and evidence of peripheral vasoconstriction
90
EKG signs of LV aneurysm
persistent ST elevation with Q waves anteriorly, after STEMI
91
Hibernating myocardium: Dobutamine stress echo findings
BIMODAL RESPONSE:
- Low Dob dose demonstrates some improvement in prior hypokinetic or akinetic areas (i.e., Contractile reserve)
- Akinetic at higher Dob dose - Ischemic response
92
Pressor for HCM & shock
Phenylephrine
- Primarily alpha-1 activity --\> increased afterload
93
ARVC
- Inheritance patten
- Protein affected
- Autosomal dominant
- Desmosomal disease; plakoglobin
94
Tafazzin protein mutation associated with ... (2)
DCM
LV noncompaction
95
Risk factors for anthracycline toxicity/CM
- Total lifetime dose of anthracycline
- IV bolus administration
- Higher single doses
- History of mediastinal radiation
- Concommitant use of other cardiotoxic agents: cyclophosphamide, trastuzumab, paclitaxel
- CV disease
- Female
- Extreme age: very old, very young
- Increased length of time since anthracycline completion
96
Indications for ICD in HCM
Class I:
- SCD Hx, VF
- Hemodynamically significant VT
Class IIa:
- \*\*1st degree relative with SCD\*\*
- Max wall thickness \> 30mm
- ≥ 1 recent syncopal episode
97
Indication for ICD in HCM + NSVT
Requires other risk factors:
- Resting LVOT gradient \> 30 mmHg
- Gadolinium enhancement --\> myocardial fibrosis
- LV apical aneurysm
98
Most common cause of death 30 days after heart transplant:
MCC: 1˚ graft failure
99
Most common viral etiology of myocarditis
Parvovirus
100
Fabry disease:
- Inheritance pattern
- Protein deficiency?
- X-linked --\> spotty inheritance in family
- Alpha-galactosidase A deficiency
101
When to worry about creatinine
- Men: \> 2.5 mg/dL
- Women: \> 2 mg/dL
... with a K \> 5
102
Acute HF + High degree AV Block: dx?
Giant cell myocarditis or sarcoid
--\> need biopsy
103
Familial Cardiomyopathy
- How many generations need to be affected?
3 generations
clinical diagnosis; genetic testing not required
104
Doxorubicin toxicity; when to stop doxorubicin?
EF decreases ≥ 10% to absolute EF \< 50%
105
Presentation of Giant Cell Myocarditis
- Rapid progressing, fulminant
- HF + VA's + heart block
106
Ejection click associated with ...
- AS, bicuspid valve with dilated aorta
- PS with dilated PA
107
TEE for re-evaluation of IE indications
- New murmur
- Embolism
- Persistent fever \>3-5 days
- HF
- Abscess
- AV block
108
3 main indications for early surgery for IE
HF
Perivalvular extension
Embolic event
109
Cyanosis of the toes, but not the fingers pathognomonic for...
PDA
110
Coarctation of the aorta: indications for intervention
- Coarct gradient \> 20 mmHg
- High degree of collaterals based on imaging
- systemic hypertension secondary to coarct
- heart failure secondary to coarct
111
Echo finding for coarctation of the aorta
- elevated peak velocity across aortic Isthmus
- diastolic forward flow in the abdominal aorta
112
DVT/PE Dosing for Eliquis
Apixaban 10mg BID x 7 days
and then Apixaban 5mg BID afterwards
113
DVT/PE dosing for Xarelto
Xarelto 15 mg BID x 21 days
and then Xarelto 20mg qD afterwards
114
Management of hypertension in fibromuscular dysplasia
1) anti hypertensive agents 2) renal artery angioplasty (not stenting)
115
Maximum safe dose of contrast calculation
Max Dose = 3.7 x CrCl
116
SYNTAX Score interpretation (PCI vs CABG)
- LM
- 3V Dz
LM + \>/= 33 —\> CABG Wins
3V Dz + \>/= 23 —\> CABG Wins
OVERALL: \>/= 23 -\> CABG preferred
117
Routine aspiration thrombectomy is associated with increased risk of what adverse outcome
Ischemic stroke
118
Platypnea orthodeoxia syndrome: presentation, work up, etiologies
- Shortness of breath with standing, better with lying down
- PFO, ASD, atrial septal aneurysm
- echo with bubble study to evaluate shunt first, right heart after
119
Indications for intervention on asymptomatic AS
- severe AS + EF\<50%
- very severe AS - peak velocity \>5 m/s, mean gradient \>/= 60 mmHg
120
Antiplatelets after Lytics
- Age consideration?
- loading
- Age \>/= 75 -\> no load, just 75 mg
- Age \<75 -\> 300 mg load, followed by 75 mg qD
121
Anticoagulation: Bivalirudin Dosing
- Normal: 0.75 mg/kg bolus, then 1.75 mg/kg/hr
- CrCl \<30: 0.75 mg/kg bolus, then 1mg/kg/hr
- HD: 0.75 mg/kg bolus, then 0.25 mg/kg/hr
122
ASCVD Risk cutoffs
- 5.5-7.4% -\> selected patients for CAC
- \>/= 7.5% -\> w/ risk -\> Statin; w/o risk -\> CAC
123
Five A’s of Smoking Cessation
Ask
Advise
Assess willingness
Assist
Arrange
124
Revised Cardiac Risk Index (RCRI)
- Components
- Interpretation
- high risk (intraperitoneal, intrathoracic, suprainguinal vascular)
- ASCAD
- HF
- CVA risk
- IDDM
- Cr \> 2
—\> \>/=2 :: high risk
125
Presentation for Chagas (3)
Apical aneurysm
CVA
GI dysmotility
126
Conduction disease and then AV block
- Associated genetic disorder?
LMNA, laminopathy
- LMNA gene mutation
- Autosomal dominant
127
Notch 1 gene mutation associations? (2)
Bicuspid AV
Early AV calcification
128
TBX5 (T-box 5) association?
Holt-Oram syndrome
Chromosome 12
ASD, VSD, HCM
129
Fibrillin-1 (FBN1) association?
AD
Marfan syndrome
130
Collagen 3A1 (COL3A1) association?
Ehlers-Danlos
131
Calcineurin inhibitor agents (2)
- Cyclosporine
- Tacorlimus
132
Calcineurin inhibitor - mechanism (other than inhibiting calcineurin)
Inhibits IL-2
133
Cyclosporine Side Effects
HTN, nephrotoxicity
Gingival hyperplasia, hirsutism
134
Tacrolimus Side Effects
HTN, nephrotoxicity
Alopecia, neurotoxicity (headache), PRES, DM
135
Antimetabolite Agents (2)
Azathioprine
Mycophenolate mofetil
136
Azathiprine side effects
Myelosuppression
137
Mycophenolate mofetil Side Effect
Myelosuppression
GI upset\*
138
Which antimetabolite requires serum level checks?
Mycophenolate mofetil (Celcept)
139
Proliferation signal inhibitor agents (2)
Sirolimus
Everolimus
140
Proliferation Signal Inhbitor side effects (6)
Edema/effusions
Interstitial pneumonitis
Hyper triglyceride is
Impaired wound healing
Mouth ulcer
GI upset
141
“Standard” Anti-rejection regimen
Tacrolimus + Mycophenolate Mofetil
142
Anti-rejection regimen of neurological issues (Seizure, HA) from tacrolimus
Cyclosporine/MMF
143
Anti-rejection regimen if rejection, CAV, CMV
Tacrolimus + PSI
144
Anti-rejection regimen if CKD or cancer issues
MMF + PSI
145
Genetic mutation associated with Alcoholic Cardiomyopathy
Titian (TTN)
146
Peripartum CM pathophysiology association
\*PROLACTIN\*
147
Non-invasive risk stratification - Low:
- CAC score?
- CCTA findings
CAC \< 100
CCTA with \<50% stenosis lesions
148
Non-invasive Risk Stratification - High
- Stress ischemia: %
- ST depression
- Inducible WMA in how many territories?
- CAC
- Stress ischemia ≥ 10% or ≥ 2 coronary areas
- ST depression \> 2 @ low work or persisting into recovery
- Inducible WMA in 2 coronary territories
- CAC \> 400 Agatston Unitis
149
Aortic Stenosis:
- Timing of Follow up echo
- Mild AS: q5 years
- Mod AS: q2 years
- Sev AS: q1 year
150
Indication for surgery for asymptomatic Severe AS (4)
- øsx + Severe AS + EF \<50%
- øsx + Severe AS + getting another cardiac surgery
- øsx + Severe AS + abnormal ETT (drops pressure or EF)
- øsx + VERY Severe AS (Vm ≥ 5m/s, Gradient ≥ 60 mmHg) + low surgical risk
151
Bicuspid AV:
- Indications to replace AORTA (3)
- ≥ 5.5 cm (I)
- \>5 cm + risk factors for dissection (Fam Hx, rapid progression)
- \>4.5 with severe AS or Severe AI
152
Severe AI:
- Vena contracts width
- Pressure Half Time
- Vena contracta: \>0.6
- PHT \< 250
153
AI
- Indications for surgery
Symptoms + …
- EF = 55 % (I)
- LV dilatation: ESD \> 50mm (IIa); EDD \> 65mm (IIb)
154
AI:
- Echo follow up after initial diagnosis
- Echo monitoring by classification (mild, mod, sev)
- Recheck echo in 3 months to establish chronicity; then yearly
- Mild: q3-5 years
- Mod: q1-2 years
- Sev: q6-12 MONTHS
155
Bicuspid AV Associations:
- Chest pain + BAV = …
- HTN + BAV = …
- Chest pain + BAV = Aortopathy/dissection
- HTN + BAV = Coarct
156
Severe MS grading:
- Mean gradient
- PASP
- Valve area
- Mean gradient \> 10 mmHg
- PASP \> 50 mmHg
- Valve area \< 1cm2
157
Wilkins score includes what 4 items
1. Leaflet thickening
2. Leaflet mobility
3. Leaflet calcification
4. Subvalvular thickening
158
Wilkins Score:
- Balloon valvuloplasty cutoffs?
* ≤ 8 —\> Valvuloplasty
* ≥ 8 —\> MVR
• can’t do balloon valvulopasty if \> moderate MR
159
Mitral stenosis: MVR indication (3)
* Symptomatic
* +LAA thrombus despite OAC
* Unfavorable anatomy for balloon commissurotomy
160
Severe Mitral regurgitation
- ERO
- RVol
- Jet area
- Regurgitatant fraction
- ERO: ≥ 40
- RVol: ≥ 60
- Jet area ≥ 0.5
- Regurgitatant fraction \>55%
161
Indications for surgery for **ASYMPTOMATIC** MR
- Rule of thumb
60/50/40 rule
- EF drop ≤ 60% (Sx - I)
- PA pressure \> 50 mmHg (Repair - IIa)
- ESD ≥ 40 mm (Sx - I)
… AF (MV repair IIa)
162
Valvular obstruction vs patient-prosthetic mismatch
- EOA
- Acceleration time
Obstruction
- Acceleration time \> 100 ms
PPM
- iEOA \< 0.65
- AT ≤ 100 ms
163
Indications for Re-Evaluation of infective endocarditis
- Change in clinical symptoms (new murmur, embolism, fever \>3-5 days, HF, concerns for abscess, AV block
- Patients at high risk of complications - large veg or staph/fungal/enterococcus infections
164
Valve thrombosis: thrombolysis vs surgery vs heparin
Thrombolysis
• Right sided valves
• If patient at higher surgical risk
Surgery
• Functional class 3-4 (I)
• Large thrombus
• Unclear if pannus
```
Heparin
• Small clot with class 1-2 symptoms, consider heparin -\> lysis -\> surgery
```
165
Timothy Syndrome:
* Presentation
* EKG findings
* Channel affected
* LQT number?
* Presentation: syndactyly, developmental disorder; cardiac and facial abn's
* EKG: 2:1 AV block, prolonged QT
* Channel affected: L-type Ca
* LQT number?: LQT 8
166
Normal heart rate recovery with stress test
12 BPM within first minute
167
Anderson-Tawil
* Presentation
* Channel Affected:
* LQT #?
* Presentation: wide-set eyes, low set ears, hypoK periodic paralysis
* Channel Affected: IK1
* LQT**7**
168
Jervell & Lange-Nielson Syndrome
* Presentation
* Associations
* Lab abnormality
* Presentation: B/L sensorineural hearing loss
* Associations: Iron deficiency anemia; LQT
* Lab abnormality: Elevated Gastrin
169
Asymptomatic MR indications for surgery (60/50/40 rule)
170
Severe MR measurements
* RVol ≥ 60
* Reg Fraction \>50%
* Jet area \> 5 mm
* ERO ≥ 40
(60/50/5/40)
171
Indications for angioplasty for renal artery stenosis (2)
1. Severe bilateral dz \> 75% stenosis
2. Unilateral dz in solitary kidney
172
* Alveolar capillary engorgement and tortuosity = ? ...
* Association with ?
- Pulmonary capillary hemangiomatosis
- Asoociated with **Pulmonary Veno-Occlusive dz**
173
How to Dx Pulmonary Veno-Occlusive disease
Lung biopsy
174
Pulmonary veno-occlusive disease:
* CXR findings:
* CT findings:
* RHC findings:
* DLCO
* CXR findings: Pleural effusions
* CT findings: Ground glass and nodules
* RHC findings: Inconsistent wedge, wedge normal to elevated
* DLCO: reduced
175
Severe Apnea Hypopnea Index
Severe: \>30
176
Genetic CM Genes
HCM (2)
MYH7
MYBPC3
177
Genetic CM Genes
ARVC, Naxos
DES
DSP
PKP2
178
Genetic CM Genes
LV noncompaction (1)
TAZ
179
Genetic CM Genes
DCM (3)
TTN
LMNA
SCN5A
180
Late Gadolinium Enhancement Patterns
DCM
Mid-wall stripe
181
Late Gadolinium Enhancement Patterns
HCM
Septal enhancement
182
Late Gadolinium Enhancement Patterns
Myocarditis
Epicardial, patchy
183
LMNA CM rhythm features
sinus bradycardia with 1˚ AV block, degrading to AF, AT, VT
Arrhythmia precedes decreased EF
184
LMNA CM management
ICD even if normal EF
185
Anthracycline agents
* **Rubicins**: Doxorubicin (adriamycin), Epirubicin, Doxorubicin, dauno
* Mitoxantrone
186
Tyrosine Kinase Inhibitor agents
* -Tinib's: axitinib, dasatinib, erlotinib, imatinib, nilotinib, sunitinib
187
When to start cardioprotective meds in Chemo-related CM (4)
* EF \<50%
* EF drop \<10%
* Abnormal GLS (\>15% drop)
* Abnormal troponin
188
Metastatic melanoma tx'd with T-Cell checkpoint inhibitors associated with ...
Fulminant myocarditis
Arrhythmia is an early sign
189
Associations
ASD + Cleft MV =
ASD + Cleft MV = Primum ASD
190
Associations
ASD + PAPVR =
ASD + PAPVR = Sinus venosus defect
191
Associations
Big RV + increased PV velocity + normal looking PV =
Big RV + increased PV velocity + normal looking PV = ASD or PAPVR
192
Two equations for CO
CO = SV x HR
CO = CSA x VTI x HR
193
SVR equation
(MAP-CVP)/CO • 80
194
PVR equation
(PAmean - PCWP) / CO
195
Pericardial effusion tapped, RA pressures do not normalize ... Dx?
Constrictive/Effusive Pericarditis
196
Congenital absence of pericardium, features (4)
* **Laterally displaced** apex/apical impulse
* RBBB, RAD
* CXR with **leftward displacement of cardiac silhouette**
* TTE with **teardrop-shaped heart**
197
s-FLT1 association?
Peripartum CM
198
Surveillance Echo for AS based on severity
Generally Mild: 3-5 years Mod: 1-2 years Sev: 6 mos - 1 year
199
Surveillance echo for MS by severity
Mild, \>1.5: 3-5 years Mod, 1-1.4: 1-2 years Sev: 6 mos - 1 year
200
4F-PCC dosing
Based on INR & body weight
* INR 2-4: 25 U/kg
* INR 4-6: 35 U/kg
* INR \>6: 50 U/kg
* Max dose 5000 U at 100 Kg body weight
-or-
1000U for any bleed
1500U for intracranial bleed
201
Indications for ICD in ToF
* LV systolic or diastolic dysfunction
* NSVT
* QRS duration ≥180 msec
* Extensive RV scarring
* Inducible sustained VA at EPS
202
Parameters for MitraClip suitability
LVEF: 20-50%
LVESD: ≤ 70 mm
PASP: ≤ 70 mm Hg
203
Cardiac Power Output: - Equation - Abnormal?/interpretation
MAP x CO / 451
\< 0.6 is bad, needs MCS
204
PA Pulsatility Index (PAPi): - Formula - Interpretation/Abnormal?
(sPAP - dPAP) / RAP
~ \< 0.9, consider RV support
205
Mixed Venous Oxygen Saturation and interpretation
\> 65 % (normal/high): Isolated distributive shock
\< 65% (low): cardiogenic component
206
Fick Equation with fudge factor
O2 consumption / arteriovenous O2 difference = (125 mL O2/min/m2) / [13.6 x hemoglobin x (O2 saturation – O2 mixed venous saturation)]
\* the O2 saturations are as percentages; e.g., 94% = 0.94
207
Definition of Chronotropic Incompetence on exercise stress test
\< 70-80% age predicted maximal HR achieved with exercise
Mostly 80%?
208
Dx?
Pericardial cyst
209
Indications for LV aneurysm repair (3)
* HF
* VA’s refractory to antiarrhythmics and ablation
* Recurrent thromboembolism despite OAC
210
Diagnosis?
LV Pseudoaneurysm
211
Diagnosis
SAM associated with Stress CM
212
MI complicated by LVOT obstruction or SAM and MR: - Management
IV fluids Decrease HR and allow for LV filling with ßB … even if rales and mild hypotension
213
Preferred stress modality in patients with LBBB or RV pacing
Vasodilator stress rMPI or stress echocardiography
Even if they are able to exercise
214
Aortic Intramural Hematoma:
* CT findings
* Management
* High attenuation, no contrast enhancement
* Similar management to aortic dissection
215
Describe INTERMACS Classes
1. Critical cardiogenic shock, crash and burn; increasing lactic
2. Progressive decline; sliding on inotropes
3. Stable, but inotrope dependent; dependent stability
4. Resting symptoms
5. Exertion intolerant
6. Exertion limited; no fluid overload, comfortable at rest, fatigues quickly with activity; “walking wounded”
7. Advanced NYHA III
216
Echo findings for prosthetic valve stenosis (4)
1. Elevated transvalvular velocity and gradient
2. Prolonged (\>100 msec) acceleration time
3. Reduced effective orifice area (\<1 cm2)
4. Reduced dimensionless index (\<0.3)
217
If concerns for HIT, which anticoagulant can be used if undergoing PCI?
Bivalirudin
218
Which anticoagulant is associated with catheter thrombosis?
Fondaparinux
219
Appropriate follow-up stress in asymptomatic SIHD patient timeline:
* After PCI
* After CABG
* PCI - after 2 years
* CABG - after 5 years
220
Gold standard for diagnosis of coronary artery spasm
“Spontaneous pain with ST elevation on EKG in the absence of underlying obstructive CAD”
* provocative tests not necessary
221
Characteristics of patient who would benefit from CCTA: (3)
1. Ongoing sx's + prior normal testing
2. Prior inconclusive testing results
3. Unable to do stress nuke or stress echo
**CCTA not beneficial if high pre-test prob CAD or established CAD**
222
Loading dose of ASA + Plavix if \>75 years old
ASA 162 mg
Plavix 75 mg
223
What's the optimal activity goal for primary prevention of ASCVD?
**Moderate intensity** **aerobic** exercise for **30-60 minutes**, at least **3-4 days/week**
224
AV block in the setting of STEMI:
* When can you observe
Can observe if inferior MI, otherwise a-sx
Consider other stuff if LAD territory
225
Indications to PCI spontaneous coronary artery dissection?
* medically refractory ischemia
* left main involvement
* hemodynamic instability
… otherwise, observe, ßB, and antiplatelet agents
226
What's the optimal activity goal for secondary prevention of ASCVD?
Moderate intensity aerobic exercise, 30-60 minutes, 5-7 days/week
227
Which statin is not metabolized via cytochrome P450 and is therefore good with transplant patients on immunosuppressants?
**P**ravastatin
good for **P**450… and trans**P**lant
228
NIHSS threshold for intervention?
≥6
for tPA or thrombectomy
229
Carotid US:
* Velocities and corresponding stenosis
≥50% = ≥ 180 cm/s
≥70% = ≥ 230 cm/s
