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TRP 2021 Written Answers

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TRP 2021 Written Answers TRP Written Exam 2021 Booklet 1 - Answers Q1a. PH 1. PAH: 1.1 idiopathic; 1.2 heritable; 1.3 drug/toxin- induced; associated with 1.4.2. HIV or 1.4.3. portal hypertension 2. Left Heart Disease: 2.1 DCM, 2.2 restrictive CM; 2.3 severe AI or MR 3. Lung Disease or Hypoxia: 3.2 interstitial lung disease 4. Obstruction: 4.1 CTEPH; 4.2.5 Parasites 5. Unclear or Multifactorial Mechanisms: 5.1 sickle cell disease; 5.2 sarcoidosis Q1b. PVR PVR = mean PAP - mean PCWP Cardiac Output = Wood units (or x 80 dynes-sec-cm-5) Normal < 1.25 units or < 100 dynes-sec-cm-5 Q1c. PAH Treatments 1. Prostanoids (IV, inhaled, oral) 2. Prostacyclin agonists (e.g. selexipag) 3. Endothelin receptor antagonists 4. PDE5 inhibitors 5. DHP CCB in patients who have positive vasodilator testing 6. Soluble guanylate cyclase stimulator (e.g. riociguat) Q2. Aspirin: irreversible inhibition of platelet cyclo- oxygenase activity leading to decreased thromboxane A2 production Carvedilol: B1, B2 and a1 antagonist with anti- inflammatory properties Fondaparinux: activation of ATIII to (indirectly) and selectively inhibit Factor Xa Q2. Clopidogrel and ticagrelor are both P2Y12 adenosine receptor antagonists. Clopidogrel is a pro-drug that requires metabolism to active drug via cyp2C19; ticagrelor is active drug. Clopidogrel is irreversible; ticagrelor is reversible. Q3. Mechanical MVR Warfarin for an INR target of 3.0. ASA 75-100 mg daily only if antiplatelet therapy is indicated (vascular dz). Change in 2020 guideline In patients with mechanical valves and appropriately anticoagulated with warfarin define the approximate annual risk of a) Thromboembolism 1-4% b) Major bleeding 1-2% Q3. Pre-op Ok for OR; no need for further testing Hold warfarin; when INR < 2, start LMWH; hold LMWH > 12 hours pre-op (Refer to anticoagulation clinic gets half marks) Endocarditis prophylaxis required: amoxicillin 2 g PO 1 hour pre-op Q4. Hibernating myocardium: non-contractile myocardium due to chronic ischemia, which will recover function with revascularization. Stunned myocardium: non-contractile myocardium immediately post revascularization, which will recover function with time. Q5. Sampling Site Oxygen Saturation High SVC 67 Low SVC 67 High RA 78 Mid RA 92 Low RA 81 Hi IVC 71 Low IVC 71 RV Inflow 90 Mid RV 87 RV Outflow 88 PA 88 Aorta 98 Pulmonary vein 98 Q5. Sampling Site Oxygen Saturation High SVC 67 Low SVC 67 High RA 78 Mid RA 92 Low RA 81 Hi IVC 71 Low IVC 71 RV Inflow 90 Mid RV 87 RV Outflow 88 PA 88 Aorta 98 Pulmonary vein 98 Q5. Secundum ASD Qp/Qs: calculate Mixed Venous O2 (Flamm) MV = (3SVC + IVC) / 4 = [3(67)+1(71)] / 4 = 68 Qp = Ao – MV = 98-68 = 30 = 3:1 = closure Qs PV – PA 98-88 10 Q6. 1. MV 2 leaflets, TV 3 leaflets 2. Septal attachment of a leaflet of the TV (no septal attachment of MV) 3. MV 2 pap muscles/TV >= 3 pap muscles 4. No continuity of TV & PV due to the infundibular septum/ MV & AV continuous 5. Higher insertion of the MV on the ventricular septum (more atrial insertion) 6. TV is associated with anatomic RV/MV is associated with anatomic LV Q7. 1. Bicuspid AV 2. Marfan Syndrome (fibrillin-1) 3. Vascular EDS (collagen III) 4. Loeys-Dietz (TGF-B receptor for most) 5. Familial Thoracic Aortic Aneurysm 6. Aneurysm-Osteoarthritis Syndrome 7. Turner Syndrome Q8. Aneurysm: Contour abnormality in both systole and diastole True: Full thickness infarcted myocardium forms wall (3 layers) Wide neck of mouth of aneursym Low risk for rupture Pseudo: Contained perforation of the heart (by pericardium) Narrow neck of mouth of aneurysm High risk of rupture Q9. Friederich’s ataxia: HCM, conduction abnormality Tuberous sclerosis: rhabdomyoma, cardiomyopathy Hereditary hemorrhagic telangiectasia: pulmonary AV fistula, high output heart failure Q10. 1. LQTS1: alpha subunit of the IKS potassium channel (loss of function); broad-based T wave; exertion, especially swimming 2. LQTS2: alpha subunit of the IKR potassium channel (loss of function); bifid T wave; loud noise 3. LQTS3: Sodium channel (gain of function); long ST segment; sleep Q11. Class I recommendations for surgery for NVE (ACC/AHA 2020) 1. Valve dysfunction with heart failure; 2. Left sided endocarditis caused by S aureus, fungal or other highly resistant organisms; 3. Evidence of heart block, annular or aortic abscess, sinus or destructive penetrating lesions 4. Evidence of and persistent infection after a prolonged period (>5 days) of appropriate antibiotic therapy, as indicated by presence of persistent fever or bacteremia. 6. (Recurrent emboli is 2a so would be wrong answer to this question). Q 12. SGLT -2 • a) Inhibition of Sodium-glucose co-transporter 2 in the proximal collecting tubule to prevent reabsorption of glucose. • b) Dapagliflozin vs placebo in patients with HFrEF with or without diabetes. Dapagliflozin significantly reduced the risk of worsening heart failure or death from cardiovascular causes in both diabetics and non-diabetics. Q13. Brugada Syndrome Type 1 ECG: coved ST segments, with ST-segment elevation >2 mm, followed by a negative T-wave Type 2 ECG: J-point elevation >2 mm, gradual ST segment descent, +/- biphasic T wave (saddleback appearance) Provocative agents: procainamide, flecainide, ajmaline Type 3 ECG: no relevance Q14. Hypertriglyceridemia 1. Genetics 2. DM 3. Alcohol 4. Hypothyroidism 5. CRF/nephrotic syndrome 6. Oral contraceptive pill/strogen 7. Steroids 8. Beta blocker 9. Diuretics 10. Obesity Q15. RA 15 mean RV 45/5/15 PA 45/30/37 PCWP 15/20/17 PA sat 61% Ao sat 95% CO 4 L/min Transplant Pulmonary Vascular Resistance (PVR) = TPG/cardiac output = 20/4 = 5 Wood units Trans-Pulmonary Gradient (TPG) = mean PAP - mean PCWP = 37-17 = 20 Diastolic Pulmonary vascular Pressure Gradient (DPG) = diastolic PAP – mean PCWP = 13 (better if < 7) Pretransplant desire a PVR < 3 and a TPG < 14 Patient is not currently an acceptable transplant candidate Q16. Resistant HTN: on at least 3 anti-hypertensives, including a diuretic. In what conditions is the 4th Korotkoff sound is recommended as the diastolic BP? Pregnancy Severe AI Can’t hear the 5th Q17. Updated 2018 Q17. Modified WHO classification of maternal cardiovascular risk: principles Risk class and risk of pregnancy by medical condition I No detectable increased risk of maternal mortality and no/mild increase in morbidity. II Small increased risk of maternal mortality or moderate increase in morbidity. III Significantly increased risk of maternal mortality or severe morbidity. Expert counselling required. If pregnancy is decided upon, intensive specialist cardiac and obstetric monitoring needed throughout pregnancy, childbirth, and the puerperium. IV Extremely high risk of maternal mortality or severe morbidity; pregnancy contraindicated. If pregnancy occurs termination should be discussed. If pregnancy continues, care as for class III. Modified from Thorne et al. WHO Class IV Pulmonary arterial hypertension of any cause Severe systemic ventricular dysfunction (LVEF <30%, NYHA III–IV) Previous peripartum cardiomyopathy with any residual impairment of left ventricular function Severe mitral stenosis, severe symptomatic aortic stenosis Native severe coarctation Marfan syndrome with aorta dilated > 45 mm Aortic dilatation >50 mm in aortic disease associated with bicuspid valve, Turners ASI>25 mm/m2 BSA • Pregnancy not recommended (extras) – Vascular ED – Fontan with any complication Q18. Cardiotoxicity of anthracyclines: cardiomyopathy/LV systolic dysfunction To limit this cardiotoxicity: 1. Use another drug 2. Limit the dose/use continuous infusions 3. Avoid concomitant use of trastuzumab (anti-HER2, Herceptin) 4. Add dexrazoxane (if 300mg/m2 of doxorubicin is used) 5. Close monitoring 6. Avoid/treat other cardiac stresses (e.g. HTN) 7. Early treatment/prophylactic treatment with ACE/BB/?statin Q19. A continuous murmur is heard through S2. Continuous murmurs result when there is a continuous pressure gradient during systole and diastole. They can be classified as 1) aorto pulmonary connections; 2) arterio-venous; 3) abnormal arterial flow; and 4) abnormal venous flow Causes: 1. PDA 9. Venous hum 2. A-P window 10. Mammary souffle 3. Aortic-RV/RA/LA fistula 11. ALCAPA 4. BT shunt, Potts, 12. Periphl pulm stenosis Waterston 13. Pulmonary AV fistula 5. Coronary AV fistula 14. Severe T of F, truncus 6. Coarctation arteriosus, tricuspid atresia, TAVR 7. COTA collaterals 15. Lutembacher Syndrome 8. Bronchial collaterals Q20. 1. Beta blockers 2. Sotalol 3. Amiodarone 4. Steroids 5. Colchicine 6. Magnesium 7. (Bi)-atrial pacing 8. Omega 3 fatty acids/Vit A and E 9. Botulinum toxin into fat 10.Statins probably not! Q21. Pulmonary vein 1 (100% saturated) IVC 2 (renal shunt) SVC 3 Coronary Sinus 4 (heart extracts maximally at rest) Q22. Ebstein’s Anomaly Apical displacement of the TV leading to atrialization of the RV ECG findings 1. WPW (may have multiple pathways) 2. Right atrial enlargement (Himalyan p waves) 3. First degree AV block 4. Atypical RBBB 5. T wave inversion V1-V4 and inferior leads Cyanotic with exercise? Shunt right to left with exercise across either ASD or PFO Q23. Absolute contraindications to lytics (STEMI ACC AHA 2013) 1. Any prior ICH 2. Known structural cerebral vascular lesion (e.g., arteriovenous malformation) 3. Known malignant intracranial neoplasm (primary or metastatic) 4. Ischemic stroke within 3 mo, EXCEPT acute ischemic stroke within 4.5 h 5. Suspected aortic dissection 6. Active bleeding or bleeding diathesis (excluding menses) 7. Significant closed-head or facial trauma within 3 mo 8. Intracranial or intraspinal surgery within 2 mo 9. Severe uncontrolled hypertension (unresponsive to emergency therapy) 10.For streptokinase, prior treatment within the previous 6 mo Q24. Allopurinol: inhibits xanthine oxidase, a main source of reactive oxygen species—less oxygen wastage, and less endothelial injury. Ranolazine: inhibits the late sodium current (INa), which decreases calcium overload and improves diastolic function.
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