78 Questions
What percentage of patients can expect to be free of angina within 1 year with guideline-directed management?
58%
What is the primary reason for recurrence or worsening of anginal symptoms in some patients?
Progression of atherosclerotic disease
What is the purpose of Bayes' theorem?
To determine the probability of an event based on prior knowledge
What is the primary goal of upwards titration of anti-anginal medications?
To resolve worsening anginal symptoms
Which of the following tests is not mentioned in the table?
Holter Monitor
What is the name of the theorem that describes the probability of an event based on prior knowledge of related conditions?
Bayes' theorem
What is the primary benefit of guideline-directed management in patients with ischaemic heart disease?
Reduced anginal symptoms
What is the purpose of revascularisation in patients with ischaemic heart disease?
To resolve worsening anginal symptoms
Which of the following medications is recommended for patients with diabetes and CVD?
All of the above
In patients with diabetes, which of the following is recommended for cardiovascular risk assessment?
Both A and B
What is the primary goal of risk factor control in patients with CKD?
To target specific values
Which of the following medications may require dose adjustments in patients with CKD?
Renally excreted drugs
Which of the following is a recommendation for patients with diabetes and CVD?
Both lifestyle modifications and medication therapy
What is the primary indication for using ACE inhibitors in patients with diabetes?
Cardiovascular event prevention
Which of the following is a recommended medication for patients with diabetes and CVD?
Empagliflozin
What is the recommended age range for considering advanced cardiovascular risk assessment in adults with diabetes?
Age > 40 years
In patients with severe valvular heart disease and low probability of CAD, what imaging modality can be considered as an alternative to coronary angiography before valve intervention?
Coronary CTA
In patients undergoing transcatheter aortic valve implantation, what is the recommended threshold for coronary artery diameter stenosis in proximal segments to consider PCI?
70%
Why is stress testing not recommended for detecting CAD in patients with severe valvular heart disease?
Due to low diagnostic yield and potential risks
In which scenario is Coronary CTA not recommended as an alternative to coronary angiography?
Severe valvular heart disease and high probability of CAD
What is the primary goal of using Coronary CTA in patients with severe valvular heart disease?
To detect CAD
In which patient population is PCI recommended?
Patients undergoing transcatheter aortic valve implantation with coronary artery diameter stenosis >70% in proximal segments
In which patient group is TAVI recommended?
Older patients (≥75 years) or those who are high risk
What is the potential benefit of balloon aortic valvotomy?
Bridge to SAVR or TAVI in hemodynamically unstable patients
What is the primary difference between SAVR and TAVI in terms of patient outcomes?
Survival rates at 3 years
What is the role of SAVR in patients with aortic stenosis?
Recommended in younger patients with low risk for surgery
What is the potential complication of TAVI?
All of the above
What is the primary purpose of using a power injector in coronary angiography?
To inject contrast medium through a cardiac catheter
Which of the following catheters is used for left ventriculography?
Pigtail catheter
In which patient group is balloon aortic valvotomy considered?
Patients with severe aortic stenosis who require urgent high-risk NCS
What is the difference in survival rates between SAVR and TAVI at 3 years?
10.4%
What is the typical diameter range of catheters used in coronary angiography?
4Fr to 8Fr
What is the primary risk associated with SAVR?
Higher risk of cardiogenic shock, severe bleeding, and cardiac tamponade
In patients with large aortic roots, which catheter may be needed?
JL5
What is the purpose of using a JR4 catheter in coronary angiography?
To image the right coronary artery
Why are larger-bore catheters sometimes required in coronary angiography?
To obtain high-quality hemodynamic data
What type of catheter is used to measure wedge pressures?
Catheter with end holes
What is the purpose of using disposable pressure transducers in coronary angiography?
To obtain a precise and continuous measurement of physiological pressures
Which type of medication is recommended in patients with diabetes and CVD?
Glucagon-like peptide-1 receptor agonist
What is the recommended age range for considering advanced cardiovascular risk assessment in asymptomatic adults with diabetes?
> 40 years
What should be controlled to target values in patients with CKD?
Risk factors
Which type of medication may require dose adjustments in patients with CKD?
Renally excreted drugs
What is the recommended treatment for CCS patients with diabetes?
ACE inhibitor
In which patients is ACE inhibitor treatment recommended for event prevention?
Patients with CCS and diabetes
What is recommended in patients with diabetes and CVD?
All of the above
What should be paid special attention to in patients with CKD?
Dose adjustments of renally excreted drugs
What may help when there is tortuosity in proximal vessels?
Ipsilateral arm traction and breath holds
What may provide a useful roadmap for navigating a recurrent radial artery?
A contrast injection
What may help to straighten the access route when accessing the ascending aorta?
Breath holding
What is a factor that increases the incidence of haematoma formation?
Length of time the sheath is left in place
What is another factor that contributes to the incidence of haematoma formation?
Use of a larger gauge sheath
Which of the following is a risk factor that contributes to the incidence of haematoma formation?
Risk factors, e.g. hypertension
What may be used to negotiate tortuosity in proximal vessels?
Gentle ipsilateral arm traction
What is a complication that may occur due to access bleeding?
Haematoma formation
What triggers an autoimmune inflammatory reaction in rheumatic disease?
Prior Streptococcus infection
What is a common symptom of rheumatic disease?
Exertional SoB
What is a result of inflammation in rheumatic disease?
Calcification
What is an uncommon symptom of rheumatic disease?
Bleeding
What is a physical examination finding in rheumatic disease?
S2 diminished and single
What is a possible manifestation of rheumatic disease?
Epistaxis
What is the primary mechanism by which large thick-walled plaques cause chronic intermittent exertional symptoms?
By slowly obstructing the lumen of coronary arteries, thereby decreasing perfusion
What is the significance of the reactive nature of the coronary tree?
It allows for increased coronary flow during exercise
What is the primary factor that influences the development of plaques in the arterial tree?
Turbulent flow at bends and branch points
What is the characteristic of thin-walled 'vulnerable plaques'?
They do not cause meaningful obstruction until the wall is disrupted
Why do therapies that reduce chronic intermittent angina not necessarily reduce ischaemic heart disease mortality?
Because they improve flow but do not stabilise plaque or prevent thrombosis
What is the significance of the non-linear nature of plaque development?
It suggests that plaques may move repeatedly through development, regression, and erosion/rupture
What is the consequence of the complex and varied nature of plaque development?
It suggests that plaque development is more complex and unpredictable than traditional models suggest
What is the primary difference between the response of the coronary tree to exercise and the development of plaques?
The coronary tree responds to exercise by vasodilating, while plaques develop in response to turbulent flow
What is the primary purpose of troponin measurement in patients with acute coronary syndrome?
To guide therapeutic management
Which of the following conditions is associated with spontaneous coronary artery dissection?
Stress induced cardiomyopathy
What is the primary purpose of ECG in patients with acute coronary syndrome?
To guide therapeutic management
Which of the following medications is used to manage patients with acute coronary syndrome?
GTN
What is the primary benefit of using anti-ischemics in patients with acute coronary syndrome?
To improve symptoms of angina
Which of the following biomarkers is used to diagnose acute coronary syndrome?
Troponin
What is the primary purpose of using platelet inhibitors in patients with acute coronary syndrome?
To inhibit platelet aggregation
Which of the following medications is used to manage patients with chronic coronary syndrome?
Statins
What is the primary benefit of using fibrinolytics in patients with acute coronary syndrome?
To dissolve blood clots
What is the primary purpose of using anticoagulants in patients with acute coronary syndrome?
To prevent thrombus formation
Study Notes
Cardiovascular Medicine
- ACE inhibitor treatment is recommended for CCS patients with diabetes to prevent events.
- Sodium-glucose co-transporter 2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) are recommended for patients with diabetes and CVD.
- Glucagon-like peptide-1 receptor agonists (liraglutide or semaglutide) are recommended for patients with diabetes and CVD.
Chronic Kidney Disease (CKD)
- Risk factors should be controlled to target values to manage CKD.
- Special attention should be paid to potential dose adjustments of renally excreted drugs used in CCS.
Angina Management
- Aggressive lifestyle modification and guideline-directed medical therapy can reduce anginal symptoms in patients.
- 58% of patients can expect to be free of angina within 1 year with guideline-directed management.
- Atherosclerotic disease progression may lead to recurrence or worsening of anginal symptoms, requiring upward titration of anti-anginal medications or revascularization.
Diagnostic Tests
- Coronary CTA may be considered as an alternative to coronary angiography before valve intervention in patients with severe valvular heart disease and low probability of CAD.
- PCI should be considered in patients undergoing transcatheter aortic valve implantation and coronary artery diameter stenosis >70% in proximal segments.
- Stress testing is not routinely recommended in severe valvular heart disease due to low diagnostic yield and potential risks.
Cardiac Catheterization
- The Judkins Left 4 and Judkins Right 4 catheters are commonly used to image the left and right coronary arteries.
- The pigtail catheter is used for left ventriculography.
- Catheter diameter is measured in French gauge (Fr), with common sizes ranging from 4Fr (0.053") to 8 Fr (0.105").
Interventional Cardiology
- TAVI is recommended in older patients (>75 years) or those who are high risk (STS-PROM/EuroSCORE II >8%) or unsuitable for surgery.
- Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in hemodynamically unstable patients and those with severe aortic stenosis who require urgent high-risk NCS.
Surgical Aortic Valve Replacement (SAVR)
- SAVR is recommended in younger patients who are low risk for surgery.
- At 3 years, survival was 83.4% after SAVR and 72.0% after TAVI (P=0.0015).
- SAVR was associated with higher risk of cardiogenic shock, severe bleeding, and atrial fibrillation compared to TAVI.
Manage a Patient with Acute Coronary Syndrome
- In CCS patients with diabetes, ACE inhibitor treatment is recommended for event prevention.
- Sodium-glucose co-transporter 2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) are recommended in patients with diabetes and CVD.
- Glucagon-like peptide-1 receptor agonists (liraglutide or semaglutide) are recommended in patients with diabetes and CVD.
Manage a Patient with Chronic Coronary Syndrome
- Atherosclerosis is the development of lipid-rich plaques in the arterial wall, resulting from an inflammatory process.
- Plaques tend to occur at bends, branch points, and other areas of turbulent flow in the arterial tree.
- Large thick-walled plaques can slowly obstruct the lumen of coronary arteries, causing decreased perfusion and chronic intermittent exertional symptoms.
- Thin-walled 'vulnerable plaques' may not cause meaningful obstruction until the wall is disrupted, leading to sudden myocardial infarction.
- The coronary tree is a reactive network of vessels that respond to stimuli such as exercise and stress.
ECG and Biomarkers
- ECG is used to diagnose acute coronary syndrome.
- Troponin is a biomarker used to diagnose acute coronary syndrome.
- Other biomarkers, such as troponin, can be used to diagnose acute coronary syndrome.
Imaging Techniques
- Echocardiography is used to diagnose acute coronary syndrome.
- Other imaging techniques, such as coronary CTA, can be used to diagnose acute coronary syndrome.
Medication
- Analgesics, such as GTN, IV opioids, and morphine, are used to manage acute coronary syndrome.
- Anti-ischemics, such as beta-blockers, are used to manage acute coronary syndrome.
- Anticoagulants, such as UFH, enoxaparin, and bivalirudin, are used to manage acute coronary syndrome.
- Fibrinolytics, such as streptokinase, are used to manage acute coronary syndrome.
- Platelet inhibitors, such as aspirin, P2Y12 receptor inhibitors, and GP iib/iiia receptor inhibitors, are used to manage acute coronary syndrome.
- Statins are used to manage chronic coronary syndrome.
Complications
- Access bleeding and haematomas are complications of coronary angiography.
- Recurrent radial artery spasm is a complication of coronary angiography.
Risk Factors
- Atherosclerosis is a risk factor for chronic coronary syndrome.
- Diabetes is a risk factor for chronic coronary syndrome.
- Hypertension is a risk factor for chronic coronary syndrome.
- Dyslipidemia is a risk factor for chronic coronary syndrome.
- Smoking is a risk factor for chronic coronary syndrome.
- Family history is a risk factor for chronic coronary syndrome.
- Age > 40 years is a risk factor for chronic coronary syndrome.
This quiz explores the management of cardiovascular disease, including the use of ACE inhibitors and sodium-glucose co-transporter 2 inhibitors for preventing events in patients with diabetes.
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