Hu Said: Cardiology Board Review Series

In this episode, we explore ischemia with non-obstructive coronary arteries (INOCA). How is the diagnosis of microvascular angina (MVA) and vasospastic angina (VSA) made? What cutoffs in the index of microvascular resistance (IMR) and coronary flow reserve (CFR) are used to diagnose MVA and VSA? Which medication for treating MVA will worsen VSA? What factors increase risk of spontaneous coronary a...

In this episode, we explore flow reserve measurements used to determine lesion significance in coronary artery disease. What is the difference between hyperemic and non-hyperemic wire-derived ratios? Which different segments of diastole are instantaneous wave-free ratio (IFR), diastolic pressure ratio (DPR), and diastolic hyperemia-free ratio (DFR) measured at? What are the cutoffs for fractional...

In this episode, we review the anatomy of normal coronary arteries and provide a systematic framework for thinking about coronary artery anomalies. How do you define proximal vs mid vs distal RCA, LAD, and LCX? What are the normal lengths of the RCA, LAD, and LCX? Which coronary artery anomalies have no clinical significance, and which are associated with sudden cardiac death? Which types of anoma...

In this episode, we explore the complications that can arise following myocardial infarction (MI). What is the Bezold-Jarisch reflex, and which territory of myocardial infarction (MI) predisposes to it? Where are LV aneurysms most likely to occur post-MI, and how can they be distinguished from LV pseudoaneurysms on echocardiography? Does accelerated idioventricular rhythm (AIVR) post-reperfusion c...

In this episode, we explore the use of fibrinolysis in managing STEMI when PCI is not immediately available. What is the difference between streptokinase, alteplase, reteplase, and tenecteplase? What is the mandated door-to-needle time for receiving fibrinolytic? What is the window for onset of symptoms for which fibrinolysis is acceptable? What loading dose of antiplatelet should you use when giv...

In this episode, we explore key aspects of percutaneous coronary intervention (PCI) from the generalist’s perspective. What are the comparative risks of death, stroke, and major vascular complications in diagnostic catheterization versus PCI? What are the relative advantages and disadvantages of radial access over femoral access? What are the mandated durations for first medical contact to PCI, ED...

In this episode, we explore key aspects of coronary artery bypass grafting (CABG) revascularization. What are the 10-year patency rates of internal mammary artery (IMA) grafts compared to saphenous venous grafts (SVGs), and what accounts for this difference? Is CABG or PCI a better option for revascularizing patients with left main disease? What about triple-vessel disease with reduced ejection fr...

In this episode, we review preventive and adjunctive therapies in the management of coronary artery disease (CAD). Who qualifies for cardiac rehabilitation (CR)? What are the four phases of CR? What is the difference between the DASH and Mediterranean diets? In which situations are pharmacologic therapies such as GLP-1 receptor agonists appropriate for weight loss in patients with CAD? How can exp...

In this episode, we review long-term medication therapy for CAD, including medications used post-myocardial infarction (MI) and medications used for anginal symptom relief in unrevascularizable CAD. What pathways do colchicine interrupt in the development of CAD? Is dual-antiplatelet therapy (DAPT) primarily for prevention of in-stent thrombosis or in-stent restenosis? How many months should you c...

In this episode, we explore the role of antiplatelets and anticoagulants in managing acute coronary syndromes (ACS) and during percutaneous coronary intervention (PCI). How many days off clopidogrel, prasugrel, ticagrelor, and cangrelor is advised prior to proceeding to CABG? In patients not undergoing CABG, how does one decide which P2Y12 inhibitor to use? How do glycoprotein IIb/IIIa inhibitors...

In this episode, we explore the concepts in myocardial hibernation and stunning. What is the difference between myocardial stunning, hibernation, and scar? What is considered viable and what is not? What cellular adaptations occur in the process of hibernation? What pattern of rest perfusion, stress perfusion, and FDG metabolism on FDG PET imaging would indicate hibernation instead of scar? What w...

In this episode, we review anatomic testing for coronary artery disease. When can you draw upon coronary artery calcium (CAC) scoring to guide statin therapy? When can you use coronary CT angiography (CCTA) with CT-FFR? What are pitfalls of each? Should you choose anatomic testing or functional stress tests for your patients? Tune in for answers to these questions. Difficulty Level: Easy You are l...

In this episode, we review the essentials of stress testing, including indications and contraindications of exercise and pharmacologic stress agents, features and pitfalls of imaging-based stress, and a systematic framework for reporting stress test results. What are normal and abnormal ECG changes in response to stress? What baseline abnormalities render exercise ECG uninterpretable? When should...

In this episode, we review the presentation of acute coronary syndromes (ACS) and the Fourth Universal Definition of Myocardial Infarction (MI). What is the difference between myocardial injury, ischemia, and infarction? Why is the term "Type 2 NSTEMI" no longer appropriate? Why is the term "atypical angina" deprecated? What does the GRACE score and TIMI score contain? Tune in for answers to these...

In this episode, we review ECG changes in acute coronary syndromes (ACS). What constitutes a significant vs a non-significant Q wave? Can the shape of the curve of the ST elevation or depression offer clues about whether the ST change is ischemic or non-ischemic? What types of infarctions would you not see reciprocal changes on in the standard ECG? How do you define Sgarbossa's criteria, Wellen's...

In this episode, we review apolipoproteins, Lp(a), and familial dyslipidemias. What roles do apolipoproteins like ApoB48, ApoB100 and ApoA-I play in lipid transport and cardiovascular risk? Why is measuring Lp(a) in nmol/L more informative than mg/dL? Who should ApoB and Lp(a) level testing be sent on? How do conditions like familial hypercholesterolemia differ from dysbetalipoproteinemia or famil...

In this episode, we review ASCVD risk estimation and lipid-lowering therapies. What low-density lipoprotein cholesterol (LDL-C) level should be targeted for patients who have had an ASCVD event versus those who have not, and how do these target LDL-C levels vary based on the presence of risk factors, diabetes status, and estimated 10-year ASCVD risk? What equation recently replaced the pooled coho...

In this episode, we discuss common complications of pacemaker (PPM) and implantable cardioverter-defibrillator (ICD) implantation, along with considerations at the end of life. What are the risks of pacemaker pocket hematoma, pneumothorax, lead dislodgement, diaphragmatic stimulation, and muscular stimulation post-implantation, and how are these managed? What is twiddler's syndrome? What is the di...

In this episode, we clarify key terms related to pacemakers (PPMs) and implantable cardioverter-defibrillators (ICDs). What do the common two-letter labels AR, VR, AS, VS, AP, VP, FD, TD, TP, CD, RV, and RT mean on EGM of an ICD? What is the relationship between the lower rate limit and the lower rate interval? What is the relationship between the post-ventricular atrial refractory period (PVARP)...

In this episode, we explore the concept of ventricular dyssynchrony and cardiac resynchronization therapy (CRT). What are the eleven scenarios in which CRT is recommended, according to the 2022 heart failure guidelines? What benefits to patients receive when CRT is appropriately used? What factors could contribute to nonresponse to CRT? How can echocardiography be used to find the atrioventricular...

In this episode, we review the key aspects of ICD therapies. What are typical thresholds for a VT monitor zone, regular VT zone, fast VT zone, and VF zone? How is the number of intervals to detect (NID) defined deterministically vs probabilistically for VT vs VF detection? What is a typical rate and interval decrement for anti-tachycardia pacing (ATP)? What is the difference between a burst and a...

In this episode, we explore the fundamentals of permanent pacemaker (PPM) and implantable cardioverter-defibrillator (ICD) interrogation. What are the most common pacing modes, and when are they used? What is rate-adaptive pacing, mode switching, and managed ventricular pacing? What mode do you induce when you place a magnet? How do you perform a sensing test and a threshold test? What are the tim...

In this episode, we review QT prolongation and QT shortening. What is the QT interval, and how is it corrected (QTc) for heart rate variations? Which arrhythmogenic syndromes are associated with mutations in KCNQ1, KCNH2, and SCN5A? How do the T waves of long QT syndrome types 1, 2, and 3 differ? Which long QT syndrome is suggested by arrhythmia triggered from swimming? Which long QT syndrome is s...

In this episode, we review arrhythmogenic right ventricular cardiomyopathy (ARVC) and catecholaminergic polymorphic VT (CPVT). Other than epsilon waves at the end of QRS complexes, what other features on ECG characterize ARVC? What are the echocardiographic and cardiac MRI findings of ARVC? Is diltiazem used in atrial fibrillation in patients with ARVC? What right ventricular ejection fraction mak...

In this episode, we review Brugada Syndrome, syndrome of syncope and/or sudden death in healthy patients associated with mutations in SCN5A. How is Brugada pattern different from Brugada syndrome? How do you recognize the three main types, and how do they differ in management? Who should receive an implantable cardiac defibrillator, and who should receive antiarrhythmics such as quinidine? Tune in...