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[Educational objective] Tx for COMPLETE (100%) occlusion of the carotid artery / asymptomatic patient - Answer- risks of CEA outweigh its benefits b/c absence of sx indicates the presence of adequate collateral blood flow. Medical therapy only. (Stroke. 2011 Aug;42(8):e464-540. doi: 10.1161/STR.0b013e3182112cc2. Epub 2011 Jan 31. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease.) What % stenosis in carotid artery atherosclerosis is needed for any management. - Answer- >50% stenosis needs management which includes medical therapy in ALL patients and evaluation for carotid endarterectomy (CEA) for SELECT patients. (Stroke. 2011 Aug;42(8):e464-540. doi: 10.1161/STR.0b013e3182112cc2. Epub 2011 Jan 31. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease.) medical therapy management of carotid artery atherosclerosis (ie stenosis >50%) - Answer- aspirin, statin, antihypertensives, diabetes management, smoking cessation (Stroke. 2011 Aug;42(8):e464-540. doi: 10.1161/STR.0b013e3182112cc2. Epub 2011 Jan 31. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease.) Define symptomatic in carotid artery atherosclerosis - Answer- TIA or ischemic stroke in the distribution (ie on the correct side) of the affected vessel within the past 6 months (Stroke. 2011 Aug;42(8):e464-540. doi: 10.1161/STR.0b013e3182112cc2. Epub 2011 Jan 31.
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS
guideline on the management of patients with extracranial carotid and vertebral artery disease.) CEA is recommended - Answer- In patients who have: -a life expectancy >5 years AND -are symptomatic from a high-grade lesion, eg, 70%-99% (symptomatic = ie, transient ischemic attack or ischemic stroke in the distribution of the affected vessel within the past 6 months) (Stroke. 2011 Aug;42(8):e464-540. doi: 10.1161/STR.0b013e3182112cc2. Epub 2011 Jan 31. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease.) Patients unlikely to benefit from CEA - Answer- -those who have significant comorbidities, ie, poor surgical candidates; -those who have had an ipsilateral stroke with persistent disabling neurologic deficits; -those with COMPLETE "100%" OCCLUSION of the internal carotid artery. (Stroke. 2011 Aug;42(8):e464-540. doi: 10.1161/STR.0b013e3182112cc2. Epub 2011 Jan 31. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease.) Patients not benefiting from Carotid Endarterectomy (CEA): - Answer- Patients not benefiting from Carotid Endarterectomy (CEA):
- significant comorbidities;
- complete (100%) occlusion of the internal carotid artery;
- hx ipsilateral stroke with persistent disabling sequelae. Most common location of AAA - Answer- Infrarenal Size needed to be considered an AAA - Answer- 3 cm or larger Six risk factors for AAA. Which one is worst? - Answer- Smoking... is worst 60 years or older Male White Atherosclerotic disease Family history of AAA
[Educational objective]: Normal aging sees what changes in the heart? - Answer- Increase in left atrial size/volume. Left ventricular wall thickening and increased mass. QId: 10812 (1088067) [Educational objective]: Does resting left ventricular ejection fraction change as someone ages? - Answer- No - resting left ventricular fraction does NOT change over time in a healthy older person. QId: 10812 (1088067) [Educational objective]: Does maximum heart rate change overtime as a healthy person ages? - Answer- Yes - maximum heart rate decreases over one's lifetime. It can be calculated as (220 - age). QId: 10812 (1088067) [Educational objective]: What is the calculation to determine someone's maximum heart rate at a given age. - Answer- (220 - age) QId: 10812 (1088067) [Educational objective]: What is pulse pressure? - Answer- The difference in systolic and diastolic blood pressure. QId: 10812 (1088067) [Educational objective]: Describe pulse pressure in association with patient aging. - Answer- Pulse pressure increases with normal aging due to increased stiffening of the large arteries with progressive atherosclerosis. QId: 10812 (1088067) [Educational objective]: What are the imaging intervals for follow up echo's (i.e. TEE) in aortic stenosis? - Answer- Mild aortic stenosis: TEE every 3-5 years. Moderate aortic stenosis: TEE every 1-2 years. Asymptomatic severe aortic stenosis: TEE Q6-12 months, unless left ventricular EF less than 50%, then AVR. If symptomatic severe aortic stenosis: then consider AVR.
(References: -2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. -Asymptomatic aortic stenosis in the elderly: a clinical review.) QId: 10239 (1088067) [Educational objective]: Defining parameters for aortic stenosis mild, moderate, and severe: - Answer- AS mild: mean gradient across the valve < 20 mm Hg (normal < 5 mm Hg) moderate: mean gradient 20-39 mm Hg severe: mean gradient > 40 mm Hg AND aortic valve area (LESS THAN) < 1 cm² (References: -2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. -Asymptomatic aortic stenosis in the elderly: a clinical review.) QId: 10239 (1088067) [Educational objective]: In the context of MI, when should nitrates be avoided and why? - Answer- Do not give nitrates in RVMI due to decreasing RV preload causing worsening of hypotension (References: -Acute right ventricular infarction. -2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.) QId: 11125 (1088067) [Educational objective]: In the context of MI, what symptoms make you think of right ventricular MI (RVMI).. - Answer- Hypotension or shock, right jugular venous distention, and clear lung fields. Hypotension maybe acutely worsened by giving nitroglycerin. (References: -Acute right ventricular infarction.
-2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.) QId: 11125 (1088067) RVMI tx: - Answer- -Similar to those with acute STEMI: -dual oral antiplatelet: aspirin + clopidogrel -statin -anticoagulant -Reperfusion with PCI asap -Extreme caution with using nitrates or diuretics - (drugs that lower preload), calcium channel blockers (drugs that decrease contractility), and drugs that slow heart rate - (beta blockers) (References: -Acute right ventricular infarction. -2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.) QId: 11125 (1088067) Acute myocardial infarction (MI) of only right ventricle is uncommon. More often, right ventricular MI (RVMI) is associated with [ ] and occurs in 30 to 50 percent of such cases
- Answer- acute STEMI of inferior wall of the left ventricle (References: -Acute right ventricular infarction. -2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.) QId: 11125 (1088067) clinical evidence of hypoperfusion (low cardiac output), is .... - Answer- .... sinus tachycardia, low urine output, and cool extremities. (References: -Acute right ventricular infarction. -2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.) QId: 11125 (1088067)
3 signs of evidence of low cardiac output are ... - Answer- hypotension, hypoperfusion, and a low or normal jugular venous [JVP] pressure (References: -Acute right ventricular infarction. -2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.) QId: 11125 (1088067) In treating RVMI [....] should be given to patients with evidence of low cardiac output (hypotension, hypoperfusion, and a low or normal jugular venous [JVP] pressure) who do not have pulmonary congestion or evidence of right heart failure [33]. This is done to enhance preload and thus improve forward flow out of the right ventricle - Answer- Intravenous fluid (usually isotonic saline) (References: -Acute right ventricular infarction. -2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.) QId: 11125 (1088067) In treating RVMI Intravenous fluid (usually isotonic saline) should be given to patients with evidence of low cardiac output (hypotension, hypoperfusion, and a low or normal jugular venous [JVP] pressure) who do not have [....]. This is done to enhance preload and thus improve forward flow out of the right ventricle - Answer- pulmonary congestion or evidence of right heart failure (References: -Acute right ventricular infarction. -2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.) QId: 11125 (1088067) Acute pericarditis is diagnosed by the presence of at least [...] of the following criteria: - Answer- at least two of the following criteria: •Typical chest pain (sharp and pleuritic,worse with lying flat and improved by sitting up and leaning forward). •Pericardial friction rub •Suggestive changes on the electrocardiogram (typically widespread ST segment elevation)
(J Vasc Interv Radiol. 2010 Feb;21(2):175-7, quiz 178. doi: 10.1016/j.jvir.2009.12.381. Statin prescription is essential in peripheral vascular disease.) QId: 9705 (1088067) Educational Objective What patients are considered Clinically significant ASCVD: - Answer- -Acute coronary syndrome -Stable angina -Arterial revascularization (eg, CABG) -Stroke or TIA -PAD (J Vasc Interv Radiol. 2010 Feb;21(2):175-7, quiz 178. doi: 10.1016/j.jvir.2009.12.381. Statin prescription is essential in peripheral vascular disease.) QId: 9705 (1088067) Educational Objective ALL patients with clinically significant atherosclerotic cardiovascular disease should be given what... - Answer- Statin: Age <75: High-intensity statin Age >75: Moderate-intensity statin (J Vasc Interv Radiol. 2010 Feb;21(2):175-7, quiz 178. doi: 10.1016/j.jvir.2009.12.381. Statin prescription is essential in peripheral vascular disease.) QId: 9705 (1088067) Educational Objective 3 things needed in tx for patients with peripheral arterial disease. - Answer- -A supervised graded exercise program -Antiplatelet agents (eg, aspirin, clopidogrel) -Lipid-lowering therapy with statins (J Vasc Interv Radiol. 2010 Feb;21(2):175-7, quiz 178. doi: 10.1016/j.jvir.2009.12.381. Statin prescription is essential in peripheral vascular disease.) QId: 9705 (1088067) Guidelines for statin therapy - Define High-intensity and Moderate-intensity statins. - Answer- High-intensity statins: atorvastatin 40-80 mg, rosuvastatin 20-40 mg ..... Moderate-intensity statins: atorvastatin 10-20 mg, rosuvastatin 5-10 mg,
simvastatin 20-40 mg, pravastatin 40-80 mg, lovastatin 40 mg. (J Vasc Interv Radiol. 2010 Feb;21(2):175-7, quiz 178. doi: 10.1016/j.jvir.2009.12.381. Statin prescription is essential in peripheral vascular disease.) QId: 9705 (1088067) Guidelines for statin therapy / Indications for tx- Is LDL >190 mg/dL indication for tx - Answer- YES, with High-intensity statin (J Vasc Interv Radiol. 2010 Feb;21(2):175-7, quiz 178. doi: 10.1016/j.jvir.2009.12.381. Statin prescription is essential in peripheral vascular disease.) QId: 9705 (1088067) Guidelines for statin therapy / Indications for tx- Age 40-75 with diabetes - choosing tx: - Answer- 10-year ASCVD risk >7.5%: High- intensity statin. 10-year ASCVD risk <7.5%: Moderate-intensity statin (J Vasc Interv Radiol. 2010 Feb;21(2):175-7, quiz 178. doi: 10.1016/j.jvir.2009.12.381. Statin prescription is essential in peripheral vascular disease.) QId: 9705 (1088067) Guidelines for statin therapy / Indications for tx- Estimated 10-year ASCVD risk >7.5% - choosing tx: - Answer- Moderate- to high- intensity statin (J Vasc Interv Radiol. 2010 Feb;21(2):175-7, quiz 178. doi: 10.1016/j.jvir.2009.12.381. Statin prescription is essential in peripheral vascular disease.) QId: 9705 (1088067) A patient with intermittent claudication and abnormal ankle-brachial index has what dx - Answer- peripheral arterial disease in the lower extremity. (J Vasc Interv Radiol. 2010 Feb;21(2):175-7, quiz 178. doi: 10.1016/j.jvir.2009.12.381. Statin prescription is essential in peripheral vascular disease.) QId: 9705 (1088067) [Educational objective]:
[Educational objective]: Vasovagal or neurocardiogenic syncope is commonly triggered by..... - Answer- prolonged standing, emotional distress, or painful stimuli. QId: 10671 (1088067) [Educational objective]: Vasovagal or neurocardiogenic syncope sx.... - Answer- a prodrome of nausea, pallor, diaphoresis, abdominal discomfort, and/or a generalized sense of warmth, then syncope QId: 10671 (1088067) [Educational objective]: What antihypertensive meds are problematic in diabetes / prediabetes.... - Answer- Thiazide diuretics and Beta blockers (not carvedilol) can cause hyperglycemia and are associated with an increased risk of diabetes. QId: 10573 (1088067) [Educational objective]: Describe sx of ischemic chest pain vs. sx of non-cardiac chest pain.... - Answer- ischemic chest pain is usually described as chest tightness, heaviness, squeezing, crushing, burning, heartburn, achiness, band-like, or pressure sensation. In contrast, chest pain described as sharp, stabbing, positional, and/or pleuritic is generally non- cardiac in etiology. QId: 10225 (1088067)
- Answer- [Educational objective]: after cardiac stent placement, what blood thinners are used, why, and for how long.... - Answer- Dual antiplatelet therapy with
1.) aspirin and 2.) thienopyridine agents (clopidogrel, prasugrel, or ticagrelor) is recommended after ALL cardiac stents to -prevent stent thrombosis and -decrease the risk of subsequent myocardial infarction. Recommend uninterrupted dual therapy for -at least 1 month after bare-metal stent (BMS) implantation and -at least 12 months after drug-eluting stent (DES) implantation. After that time, aspirin should be CONTINUED INDEFINITELY in these patients. QId: 10199 (1088067) [Educational objective]: For emergent surgery (ie non elective surgery), and separately for elective surgery - Discuss management of blood thinners for a post cardiac stent placement patient who needs surgery - - Answer- EMERGENCY ie NON ELECTIVE SURGERY - DO NOT STOP ASPIRIN AND CLOPIDOGREL Except neurosurgery may need to discontinue -ELECTIVE SURGERY should be POSTPONED .... Patients requiring EMERGENCY ie NON ELECTIVE SURGERY during the initial stent placement period (1 month for BMS; 12 months for DES) should have BOTH aspirin and clopidogrel/prasugrel CONTINUED throughout the perioperative period to minimize perioperative cardiovascular complications. However, in surgeries such as neurosurgery where perioperative bleeding may cause significant morbidity -then both drugs may need to be discontinued. Whenever possible, ELECTIVE SURGERY should be POSTPONED until the minimum recommended duration of dual antiplatelet therapy can be completed. QId: 10199 (1088067)
