Topic summary Gems

Question 1

Three forms of atherosclerotic plaques

Answer 1

Ruptured atheromatous plaque: Large lipid pool, thin fibrous plaque that ruptures with adherent clot
Fibrous plaque: Calcium depoition and burried cap. More stable as has thick cap and small lipid pool
Superficial erosion: Acculuation of proteoglycan with focally denuded endothelium + adherant thrombus

Question 2

Location of lesion by ECG changes: Septal

Answer 2

V1, V2 : LAD

Question 3

Location of lesion by ECG changes: Anterior

Answer 3

V3, V4: LAD

Question 4

Location of lesion by ECG changes: Anteroseptal

Answer 4

V1-4, LAD

Question 5

Location of lesion by ECG changes: Anterolateral

Answer 5

V3,4,5,6 I aVL with reciprocal II, III, aVF Left anterior decendin, left circ or obtuse marginal

Question 6

Location of lesion by ECG changes: Extensive anterior

Answer 6

V1-6 with I and aVL with reciprocal II, III, aVF

Left main CA

Question 7

Location of lesion by ECG changes: inferior

Answer 7

II, III, aVF and reciprocal in I and aVL

Right coronary or R circ.

Question 8

Location of lesion by ECG changes: lateral

Answer 8

I, aVL V5 V6 reciprocal in II, III, aVF

L Circumflex or obtuse marginal

Question 9

Location of lesion by ECG changes: Posterior

Answer 9

V7-9 with reciprocal V1-4 Posterior descending (Branch of RCA or left circuflex)

Question 10

Location of lesion by ECG changes: Right ventricular

Answer 10

II, III, aVF, V1, V3, V4 reciprocal in I and aVL

Right coronary

Question 11

Framingham risk score: highest risk parameter

Answer 11

Age: 13 points as a maximum. With each decade of life the risk of vascular disease doubles.
Highest modifiable risk factor was total cholestrol specifically >280 in young people (20-39), smoker age 20-39 also risk of 8 points. Cholestrols importance decreases with age. E.g by 70-79 over 280 only worth 1 point

Question 12

Smoking impact of MI

Answer 12

Incidence of MI increased x6 in F and x3 in M who smoke at least 20 cigs/day compared to non-smokers

Question 13

Interheart study: highest modifiable risk factor (2004)

Answer 13

Abdominal obesity 61x risk increase, followed by smoker: 44 x

Question 14

High Risk Patients (risk>15% in next 5 years) - treat with full preventative strategy!

Answer 14

• Patients with known coronary artery disease
• Patients with vascular disease (eg. Legs)
• Patients with other high risk conditions
o Age >60 with diabetes
o Diabetes and microalbuminuria
o Moderate or severe CKD
o Familial hypercholesterolaemia
o SBP >180, DBP >110
o Total cholesterol >7.5mmHg

Question 15

Lipid Targets

Answer 15

o TC <4
o LDL <2 in high risk patients
o HDL >1
o TG<1.5

Question 16

Lipid Targets

Answer 16

o TC <4
o LDL <2 in high risk patients
o HDL >1
o TG<1.5

Question 17

Cardiac ladder of change in atherosclerosis

Answer 17

Normal –> perfusion abnormality on cardiac stress nuclear–> diastolic dysfunction on echo –> regional systolic dysfunction on ECHO –> ischemic ECG changes –> Angina pectoris

Question 18

‘Good quality stress test’

Answer 18

adequate workload and 85% max heart rate reached

Contraindications: Recent ACS, uncontrolled arrythmia, severe AS, heart failure (decompensated), PE, dissection

Question 19

Best predictor of outcome in exercise stress testing

Answer 19

<5METs (i.e. poor exercise capacity –> unable to exert to 5 or more metabolic equivalents)

Question 20

Invasive angiography: meaning of fractional flow reserve

Answer 20

Measures pressure drop across a lesion: FFR <0.8 needs stent or alteration, >0.8 normal

Question 21

Proven benefit of survival of CABGs in which 3 groups

Answer 21

left main disease
2 or 3 vessel CAD with prox. LAD
3 vessel CAD with impaired proximal LAD

Question 22

Medication with clear benefit in stable angina

Answer 22

aspirin

Question 23

Types of myocardial infarction

Answer 23

Type 1: spontaneous, likely related to atheroscleprosis
Typce 2: MI secondary to demand ischemia
Type 3: MI resulting in death without biomarkers available
Type 4a: MI related to PCI
Type 4 b: MI related to stent thrombosis
Tpe 5: MI related to CABG

Question 24

Cardiac biomarkers and peak times: first through last

Answer 24

Myoglobin, CK, Troponin, LDH

Question 25

NSTEMI management

Answer 25

• Aspirin to all • DAPT if confirmed intermediate to high risk NSTEACS - continue for 12/12 • Don't give P2Y12 inhibitor if possibility of emergency CABGs • Anticoagulation • Unfractionated heparin or Enoxaparin if confirmed intermediate to high risk NSTEACS • Glycoprotein IIb/IIIa Inhibitors • At time of PCI if high risk clinical and angiographic characteristics Bivalirudin - alternative to glycoprotein IIb/IIIa inhibition and heparin (if likely high risk bleeding)

Question 26

Glycoprotein IIb/IIIa inhibitors

Answer 26

abciximab, eptifibatide, tirofibran last two have lower affinity to the glycoprotein than abciximab

Question 27

Abciximab MOA

Answer 27

By competing with fibrinogen and von Willebrand factor (vWF) for GP IIb/IIIa binding, GP IIb/IIIa antagonists interfere with platelet cross-linking and platelet-derived thrombus formation. Therefore agents blocking the GP IIb/IIIa receptor are very potent platelet inhibitors.

Question 28

Algorithm for statin therapy

Answer 28

Is the LDL >4.9 mmol ? yes no (FH or not) If no to >4.9 then evaluate risk. If >10% risk-statin, if 5-10% assessment further with CAC or lipoprotein-a level, if <5%, no statin If >10% and commenced - recheck at 6 weeks. Hi intesity statin for >20% risk + LDL remaining >2.5 Moderate if 10-20

Question 29

Statins are contraindicated in which patient group?

Answer 29

pregnant women

Question 30

Secondary prevention post NSTEMI

Answer 30

• Statin - initiate and continue indefinitely • Beta Blocker - initiate in patients with reduced LV function <40% ACEI/ARB - initiate in those with CCF, LV dysfunction, DM, anterior MI or co-existant hypertension

Question 31

STEMI: Patient presents within 60 minutes of pain

Answer 31

Access to cath within 60 mins: percutaneous cornoary intervention, if not Fibrinolysis

Question 32

STEMI with symptom onset 1-3 hours before presentation

Answer 32

within 90mins available: PCI if not Fibrinolysis

Question 33

STEMI with symptom onset 3-12 hours:

Answer 33

PCI avaialable withint 90 mins onsite or 2 hours offsite: PCI if yes, Lysis if no

Question 34

Inidcation for rescue PCI

Answer 34

Fibrinolysis and no reperfusion iwthin 90 mins --> PCI within 12 hours.

Question 35

STEMI >24 hours of symptoms

Answer 35

No benefit of intervention

Question 36

Best outcome PCI candidates

Answer 36

present within 3 hours and 1 year mortality RR increases by 7.5 % every 30 minute delay

Question 37

Contraindications to fibrinolysis

Answer 37

♣ active bleeding, ♣ significant closed head or facial trauma within 3/12, ♣ suspected aortic dissection, any prior ICH, ♣ ischaemic stroke w/in 3/12, ♣ known structural cerebral vascular lesion, ♣ known intracranial neoplasm ♣ Active bleeding or bleeding diathesis

Question 38

Indications for implantable cardiac device post STEMI

Answer 38

Use if: • LVEF ≤ 30% at least 40d post MI LVEF ≤ 35%, cardiomyopathy (ischaemic/non-ischaemic), NYHA II/III, at least 40d post MI

Question 39

Management of cardiogenic shock in STEMI

Answer 39

Most have extensive disease: L main or triple vessel. Treat as previously explained: however avoid bBlockers or any negative ionotrope. Arrythmia treated wtih amiodarone. Nor-adrenaline is useful as vasopressor support.

Question 40

Timing of in stent thrombus and risk of DAPT

Answer 40

o BMS - Highest risk of stent thrombosis within 6 weeks post stent insertion DES - High risk of stent thrombosis ongoing for 1 year post stent insertion

Question 41

Causes of Pericarditis

Answer 41

``` Infectious Idiopathic Malignancy Autoimmune Metabolic (Uraemia) ``` MIAMI

Question 42

Diagnostic criteria for pericarditis

Answer 42

Typical chest pain Pericardial rub ST changes on ECG New pericardial effusion 2 criteria needed

Question 43

Management of pericarditis

Answer 43

Depends on the cause (malignancy, bacterial etc.) High risk patients (Fever, tamponade, immunosuppression) - admit Low risk--> home Avoid strenuous exercise Colchicine + NSAIDs Colchicine can reduce recurrence

Question 44

Constrictive pericarditis: causes, physiology and presentation

Answer 44

Idiopathic, viral, post surgical, post radiation Ventricular interdependance: negative intrathoracic pressure generated by inspiration doesn't augment filling pressures to right heart Early diastolic filling: Filling restricted due to pericardial fibrosis - fast filling first 1/3 of diastole, then slows X and Y descent are prominent on JVP Kussmal's sign: paradoxical increase in JVP during inspiration Pulsus paradoxus Echo is diagnostic

Question 45

Cardiac Tamponade: Presentation, Physiology

Answer 45

Becks triad: hypotension, soft heart sounds and JVP distension Increased ventricular interdependance: Shifting of interventricular septum toward L during inspiration and R in expiration due to changes in intrathoracic pressure Progressive decrease in venous return: Cardiac volume reduced due to compressive effusion: therefor as the ventricle contracts and creates a potential space, diastolic filling occurs. Total venous return falls. Prominant X descent and absent Y descent