Valvular Heart Disease
Definition of severe aortic stenosis (1/3)
Small valve area (≤1.0 cm2)
High peak velocity (>4 m/s)
High mean gradient (>40 mm Hg)
(1.0)x4=40
Diagnosis associated with Echo showing apical dyskinesis or ballooning with preservation of basal wall motion
Takotsubo cardiomyopathy AKA stress-induced cardiomyopathy AKA apical ballooning syndrome
Indication for placement of implantable cardioverter-defibrillator in HFrEF patients
Refractory heart failure symptoms despite GDMT with EF <35%
Reduces mortality in patients
First-line medical therapy for stable angina (3)
Aspirin, beta-blocker and statin
MKSAP 12
Consider ASA desensitization or clopidogrel in patients with ASA intolerance
HR goal 55-60
Diabetic medication associated with reducing CV risk in patients with heart failure
Sodium-glucose cotransporter 2 (SGLT2) inhibitors
MKSAP 10, 79, 93 and 117
Reduces CV events/death, including heart failure–related mortality and hospitalizations
Dapagliflozin and empagliflozin are also effective in patients without diabetes
SGLT2s and GLP1 agonists are both recommended for diabetics with ASCVD or established kidney disease due to their cardiovascular benefits
Indications for AV replacement 2/2 severe aortic stenosis (1/3)
Presence of symptoms (exertional dyspnea, syncope, angina)
LVEF <50% in an asymptomatic patient
Concomitant cardiac surgical procedure for other indications
MKSAP 8
Rx of Takotsubo cardiomyopathy
Goal directed medical therapy
MKSAP 61
All patients need to have CAD excluded with cardiac cath
Has favorable prognosis and most patients recover cardiac function over several months
Indication for cardiac resynchronization therapy in heart failure patients (4 parts to this answer)
Refractory heart failure symptoms despite GDMT with EF <35%, QRS >150 ms and LBBB in NSR
CRT is associated with improved LVEF, reduced symptoms, and improved survival rates.
Of note, any patients who meet the indication for CRT also meet indications for ICD therapy.
MKSAP 77
Management of persistent angina despite maximally tolerated medical therapy
Coronary angiography to assess if patient is candidate for PCI or CABG
MKSAP 41 and 112
Helps improve symptom status and quality of life
Rx of Symptomatic PVCs
β-blocker or calcium channel blocker therapy v. reassurance if asymptomatic
MKSAP 17 and 55
Rx if symptomatic (palpitations, HF or exertional sx) or frequent (>10% of all beats or 10,000 PVCs per day) - goal is to prevent CM
Catheter ablation should be considered in patients with continued frequent PVCs despite medical therapy, patients who cannot tolerate medical therapy, and patients who develop PVC-induced cardiomyopathy.
PVC burden can be influenced by stress, alcohol or caffeine intake, sleep disturbances, thyroid disorders or anemia.
Indications for transcatheter aortic valve implantation (TAVI) (1/3)
Patients >80 years old
Life expectancy <10 years
Patients with high or prohibitive surgical risk if predicted post-procedure survival is >12 months with an acceptable quality of life.
MKSAP 8
Balloon aortic valvuloplasty is now rarely used - may be used to bridge unstable patients to therapy with TAVI or SAVR
Diagnosis associated with Echo showing bi-atrial enlargement and severe diastolic dysfunction in the setting of normal ventricular size, wall thickness, and systolic function
Restrictive cardiomyopathy
Indications for use of ivabradine in heart failure patients (3 parts to this answer)
LVEF <35%
NSR with HR >70/min
On maximally tolerated doses of a β-blocker
Reduces heart failure–associated hospitalizations and the combined end point of mortality and heart failure hospitalization
Medical management of persistent angina despite optimal first-line medical management (3 medication classes)
CCB
Ranolazine
Nitrates
Test used to diagnose cardiac amyloidosis
Cardiac magnetic resonance imaging with gadolinium contrast
MKSAP 7 and 85
Low voltage ECG with Echo showing increased wall thickness suggests an infiltrative cardiomyopathy
After cMRI need to then distinguish between AL (monoclonal light-chains) amyloidosis and ATTR amyloidosis (abnormal 99m-technetium pyrophosphate scan). Cardiac amyloidosis is unlikely in the absence of a monoclonal plasma cell dyscrasia and negative 99m-technetium pyrophosphate scintigraphy findings.
Rx for patients with chronic, secondary mitral regurgitation
Guideline-directed medical therapy - to hopefully improve ventricular dysfunction and decrease severity of MR
+/- cardiac resynchronization therapy if indicated
MKSAP 26
Benefits of valve repair or replacement in patients with secondary mitral regurgitation are less certain but surgery is reasonable for those undergoing CABG
TEER has been approved for patients with refractory symptoms despite optimal GDMT for heart failure.
Indications for ICD implantation in a patient with hypertrophic cardiomyopathy (2/6)
Episode of cardiac arrest or sustained VT (primary prevention)
One or more risk factors for sudden cardiac death (secondary prevention):
- SCD in first degree relative <50 yo
- LV hypertrophy > 30 mm
- Episode of syncope suspected to be arrhythmic in nature
- LV apical aneurysm
- LV ejection fraction less than 50%
MKSAP 103
Treatment used to bridge to heart transplant in patients with advanced heart failure
Left ventricular assist device (LVADs) - used as a bridge or as "destination" therapy in patients with advanced heart failure who are poor surgical candidates (>65-70 yo, cancer in past 5 years)
Survival at 1 year is near the survival after heart transplant.
Always should consider palliative conversations
Therapy includes anticoagulation to prevent pump thrombus formation (stroke is major complication)
MKSAP 106 and 22
Diagnosis for patient with worsening heart failure and holosystolic murmur over LSB after recent STEMI
Acquired ventricular septal defect from septal wall rupture
Complicates inferior or anterior STEMI usually 5 days later
Rx: afterload reduction with medical therapy and IABP support but should consider surgical closure
Postinfarct VSDs have high mortality rates (50%)
Rx of atrial myxomas
Urgent surgical excision - to prevent embolic phenomenon
MKSAP 80
Echo will show a large left atrial mass with attachment by a stalk to the interatrial septum vs. a cardiac angiosarcoma which typically arises in the RIGHT atrium and is a/w pericardial effusion (MKSAP 14)
Indications for surgical repair of chronic, severe, primary mitral regurgitation (2/3)
Symptomatic patients
Asymptomatic patients with LVEF <60% or LVESD >40 mm
MKSAP 63
Surgical repair is preferred over replacement in all patients. For patients who are not surgical candidates, transcatheter mitral valve repair with a clip device (transcatheter edge-to-edge repair [TEER]) improves coaptation of the mitral valve leaflets, leading to increased valve closure and a reduction in regurgitation.
How to differentiate constrictive pericarditis from restrictive cardiomyopathy (1/3)
Pericardial calcification on CXR or CT
Pericardial thickening on CT or CMR imaging
BNP <100 (v >400 in RCM)
H/o previous cardiac surgery, pericarditis, or chest irradiation
Differentiating between the two disorders is essential because surgical pericardiectomy may relieve symptoms and prolong life in patients with constriction.
A hallmark feature of constrictive pericarditis is ventricular interdependence, whereby total cardiac volume is limited by the rigid pericardium. With ventricular interdependence, increased filling of the right or left ventricle can occur only with reciprocal decreased filling of the other ventricle. Ventricular interdependence may be demonstrated by Doppler echocardiography, CMR imaging, or invasive hemodynamic evaluation in patients with constriction; however, it is not present in patients with RCM.
Rx of cardiogenic shock (2/5 treatment modalities)
Reperfusion
IV inotropes and vasopressors (norepi)
Mechanical support (intra-aortic balloon pumps, percutaneous ventricular assist devices, and extracorporeal membrane oxygenators)
Transplantation or permanent device placement (LVAD)
Palliative or hospice care.
MKSAP 98
DAILY DOUBLE
Initial medical management of ACS (5/7 meds)
Most common cause of chronic, primary MR v. secondary MR (2 answers)
Mitral valve prolapse v. ventricular dysfunction (Left ventricular systolic dysfunction)
Ventricular dysfunction causes mitral regurgitation through papillary muscle displacement and tethering of the mitral leaflets, which impairs coaptation but the mitral valve apparatus is normal in patients with chronic secondary mitral regurgitation