2017 AHA / ACC Update on 2014 Valvular Disease Q9

According to the
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Failure” p 262-264

“Concomitant mitral valve repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications”  (Class I)

“Mitral valve surgery ___________ for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR.”   This is a _____ recommendation.

a) is indicated ; Class I
b) is reasonable ; Class IIa
c) may be considered; Class IIb
d) should not be performed ; Class III

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(B)

“Concomitant mitral valve repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications (105).”

“Mitral valve surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR.”

2017 AHA / ACC Update on 2014 Valvular Disease Q8

According to the
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Failure” p 262

“Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished”

“____________________________ when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet”

a) MVR is recommended in preference to mitral valve repair
b) MVR is recommended in preference to mitral valve repair in patients less han 50 years of age
c) Mitral valve repair is recommended in preference to MVR in patients
d) Mitral valve repair is recommended in preference to MVR in patients greater han 70 years of age

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(C)

“Mitral valve repair is recommended in preference to MVR
when surgical treatment is indicated for patients with chronic
severe primary MR limited to the posterior leaflet (83–99).”

“Mitral valve repair is recommended in preference to MVR
when surgical treatment is indicated for patients with chronic
severe primary MR involving the anterior leaflet or both
leaflets when a successful and durable repair can be
accomplished (84,89,95,100–104).”

2017 AHA / ACC Update on 2014 Valvular Disease Q7

Asymptomatic Severe Primary MR

According to the
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Failure” p 262

“Mitral valve surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (_________ and/or left ventricular end-systolic diameter [LVESD] >/=40 mm, stage C2)”

a) LVEF <30%
b) LVEF <45%
c) LVEF 30% to 45%
d) LVEF 30% to 60%

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(D)

“Mitral valve surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30% to 60% and/or left ventricular end-systolic diameter [LVESD] >/=40 mm, stage C2) (76–82).”

2017 AHA / ACC Update on 2014 Valvular Disease Q6

Symptomatic Severe MR

According to the
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Failure

“Mitral valve surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and ____________”

a) LVEF less than 30%
b) LVEF greater than 30%
c) LVEF less than 45%
d) LVEF greater than 45%

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(B)

“Mitral valve surgery is recommended for symptomatic
patients with chronic severe primary MR (stage D) and
LVEF greater than 30% (73–75).”

2017 AHA / ACC Update on 2014 Valvular Disease Q5

According to the
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Failure” p 259

“Surgical AVR or TAVR is recommended for symptomatic patients with severe AS (Stage D) and
____________, depending on patientspecific procedural risks, values, and preferences”

Class of Recommendation = I

a) low risk for surgical AVR
b) low or intermediate risk for surgical AVR
c) intermediate risk for surgical AVR
d) high risk for surgical AVR

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(D)

“Surgical AVR or TAVR is recommended for symptomatic patients with severe AS (Stage D) and high risk for surgical AVR, depending on patientspecific procedural risks, values, and preferences (49–51).”

2017 AHA / ACC Update on 2014 Valvular Disease Q4

According to the
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Failure” p 258

“___________________________  in patients with AF and native aortic valve disease, tricuspid valve disease, or MR and a CHA2DS2-VASc score of 2 or greater”

This is a _______ recommendation.

a) DOAC use is preferable to a VKA ; Class I
b) It is reasonable to use a DOAC as an alternative to a VKA ; Class IIa
c) In select patients, a DOAC may be considered as an alternative to a VKA ; Class IIb
d) A DOAC should not be used as an alternative to a VKA : Class III

DOAC = direct oral anticoagulant
VKA = vitamin K antagonist

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(B)

“It is reasonable to use a DOAC as an alternative to a VKA in patients with AF and native aortic valve disease, tricuspid valve disease, or MR and a CHA2DS2-VASc score of 2 or greater (35–38).”

2017 AHA / ACC Update on 2014 Valvular Disease Q3

According to the
“2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure” p 258

“Anticoagulation is indicated in patients with AF _________________ with native aortic valve disease, tricuspid valve disease, or MR”

Class of Recommendation = I

a) regardless of CHA2DS2-VASc score
b) and a CHA2DS2-VASc score of 1 or greater
c) and a CHA2DS2-VASc score of 2 or greater
d) and a CHA2DS2-VASc score of 3 or greater

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(C)

“Anticoagulation is indicated in patients with AF and a CHA2DS2-VASc score of 2 or greater with native aortic valve disease, tricuspid valve disease, or MR (36–38).”

2017 AHA / ACC Update on 2014 Valvular Disease Q2

According to the
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Failure” p 258

“Anticoagulation with ___________ is indicated for patients with rheumatic mitral stenosis (MS) and AF”

a) a vitamin K antagonist (VKA)
b) a direct oral anticoagulant (DOAC)
c) a vitamin K antagonist (VKA) or a direct oral anticoagulant (DOAC)
d) a vitamin K antagonist (VKA) or a direct oral anticoagulant (DOAC) in addition to low dose aspirin (75-100 mg daily)

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(A)  

“Anticoagulation with a vitamin K antagonist (VKA) is
indicated for patients with rheumatic mitral stenosis
(MS) and AF”

2017 AHA / ACC Update on 2014 Valvular Disease Q1

According to the
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Failure

“The risk of developing IE is higher in patients with underlying VHD.” (IE = infectve endocarditis,
VHD = valvular hear disease)

” … even in patients at high risk of IE, evidence for the efficacy of antibiotic prophylaxis is lacking … led to a revision in the 2007 AHA recommendations for prophylaxis limited to those patients at highest risk of adverse outcomes with IE (11).”

“These included patients with a history of prosthetic valve replacement, patients with prior IE, ______________________. “

a) patients with hypertrophic cardiomyopathy, patients with acquired valvular heart diseases and patients with unrepaired cyanotic heart diseases
b) and patients with acquired valvular heart diseases
c) select patients with congenital heart disease, and cardiac transplant recipients
d) and select patients with congenital heart disease

NOTE: THIS IS A SIMPLIFIED LISTING LACKING SOME DETAILS AND DOES NOT MENTION THAT BOTH 2007 and 2017 DOCUMENTS DISCUSS HISTORY OF PROSTHETIC VALVE REPAIR IN ADDITION TO VALVE REPLACEMENT

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(C)

“These included patients with a history of prosthetic valve replacement, patients with prior IE, select patients with congenital heart disease, and cardiac transplant recipients.”

“Cardiac transplant with valve regurgitation due to a structurally abnormal valve.”

2016 AHA Statin Drug Interactions Q5

2016 AHA Statin Drug Interactions
http://circ.ahajournals.org/content/134/21/e468

According to the 2016 AHA Scientific Statement:
“Recommendations for Management of Clinically Significant Drug-Drug Interactions With Statins and Select Agents Used in Patients With Cardiovascular Disease” p e472:

The combination of individual statins (fluvastatin, lovastatin, rosuvastatin or simvastatin) with warfarin are noted to result in”Increased INR/potential for increased bleeding.”  The “recommendation” for these statin-warfarin combinations is rated as ________.

a) “useful”
b) “reasonable”
c) “may be considered”
d) “potentially harmful” or “should be avoided”

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(A)  

“Simvastatin     Increased INR/potential for increased bleeding   Up to 30% change in INR   Combination is useful”