In this episode, we go over the practical use and management of intra-aortic balloon pumps (IABP) in the cardiac intensive care unit. How does the IABP assist during systole and diastole, and what are the hemodynamic benefits of its inflation and deflation? What physiologic effects does the balloon pump have on cardiac output, coronary perfusion, left ventricular wall stress, pulmonary capillary wedge pressure, heart rate, and urine output? Why is helium used? What are key indications and contraindications for balloon pump placement? Where do you want the IABP to be located on monitoring chest X-ray? What level of diastolic augmentation and assisted end-diastolic pressure do you want to see for the IABP to be effective? When should you use ECG trigger, pressure trigger, pacemaker trigger, and asynchronous mode? How do you recognize and troubleshoot early or late inflation and deflation? What steps should be taken if balloon perforation is suspected? What are best practices for weaning a patient off the balloon pump? Tune in for answers to these questions.

Difficulty Level: Intermediate

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In this episode, we review the use of inotropes in acute decompensated heart failure and cardiogenic shock? What are the effects of activating alpha-1 receptors, beta-1 receptors, and beta-2 receptors? What are the effects of inhibiting phosphodiesterase-5? What is the vasoconstriction-vs-inotropy-plot and where does each inotrope and vasopressor sit on the plot with respect to the intropy=0 vertical line or the vasoconstriction=0 horizontal line? In a patient with pulmonary hypertension with >3 Woods units of pulmonary vascular resistance, is dobutamine or milrinone a more appropriate choice? In a patient with acute kidney injury, is dobutamine or milrinone a more appropriate choice? What are the main contraindications for each inotrope? Tune in for answers to these questions.

Difficulty Level: Intermediate

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In this episode, we review central venous pressure (CVP) waveform interpretation. What is signified by the a, c, and v waves, and the x and y descents? What do giant a peaks signify? What do cannon a waves signify? What does absent a peak signify? What does a prominent v peak or merged CV peak signify? What does a diminished v peak signify? What does a merged ACV peak signify? What does a rapid y descent signify? What does a rapid x descent signify? Tune in for answers to these questions.

Difficulty Level: Intermediate

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In this episode, we review pulmonary artery (Swan-Ganz) catheterization. What are indications and contraindications to pulmonary artery catheter placement? What variables make up the oxygen content equation and oxygen delivery equation? What is the difference between mixed venous oxygen saturation (SvO2) and central venous oxygen saturation (ScvO2)? What conditions cause elevated or depressed SvO2? What conditions cause elevated and depressed pulmonary vascular resistance (PVR) and systemic vascular resistance (SVR)? What are the drawbacks and advantages of Fick cardiac output versus thermodilution cardiac output? What is the pulmonary artery pressure index (PAPi) and cardiac power output (CPO), and how can PAPi and CPO be used to make decisions in cardiogenic shock? Is left ventricular end-diastolic pressure (LVEDP) synonymous with as wedge pressure? Tune in for answers to these questions.

Difficulty Level: Intermediate

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In this episode, we review the assessment of right ventricular (RV) size and function. What is the normal range of RV basal diameter, mid diameter, and longitudinal diameter? What are the relative advantages and drawbacks of tricuspid annular plane systolic excursion (TAPSE), tissue Doppler peak systolic velocity S’ at the tricuspid annulus, RV fractional area change (RV FAC), and RV index of myocardial performance (RIMP)? How are they calculated? Tune in for answers to these questions.

Difficulty Level: Advanced

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In this episode, we review diastolic function and diastolic dysfunction. What are the four phases of diastole? What are the characteristics of normal diastolic filling patterns, and how do they change in mild, moderate, and severe diastolic dysfunction? How do the E and A waves on Doppler of mitral inflow evolve with increasing stages of diastolic dysfunction? How do E and A waves vary with age, preload, and heart rate? What does the L wave (mid-diastolic flow across the mitral valve) represent? How do the E/e' ratio on TDI of the basal segment of the lateral and septal walls evolve with increasing stages of diastolic dysfunction? When is it invalid to use E/e’ for estimating diastolic dysfunction? On PW Doppler of the pulmonary veins, why is S>D in mild diastolic dysfunction? Why does atrial reversal flow in the pulmonary vein increase in moderate and severe diastolic dysfunction? How can diastolic dysfunction be assessed in patients with atrial fibrillation? What additional findings are seen during a diastolic stress test? Tune in for answers to these questions.

In this episode, we review the very common issue of diuretic resistance and cardiorenal syndromes. What are the key actions of diuretics along different segments of the nephron? How do factors like hypoalbuminemia, renal perfusion pressure, and competing anions reduce loop diuretic efficacy? What role does chronic RAAS activation play in creating sodium avidity in the distal tubules and collecting ducts? How can sequential nephron blockade help overcome diuretic resistance? What are the five types of cardiorenal syndrome? Why is it that BUN:Cr ratio is >20:1 in pre-renal acute kidney injury? What are situations in which fractional excretion of sodium (FENa) can be <1% even if there is no volume depletion? Tune in for answers to these questions.

Difficulty Level: Easy

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In this episode, we review the role of biomarkers and lab abnormalities in congestive heart failure. What are ANP, BNP, CNP, and DNP? What effect does BNP have on glomerular filtration rate, urinary sodium excretion, adrenal aldosterone secretion, and peripheral vascular tone? What is the relationship between BNP and NTproBNP? What are some factors that increase BNP and NTproBNP? What are some factors that decrease BNP and NTproBNP? How should NTproBNP thresholds be adjusted in older adults and patients with obesity? Why does hyponatremia occur in acute decompensated heart failure? Tune in for answers to these questions.

Difficulty Level: Easy

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In this episode, we review the presentation and management of acute heart failure decompensation (ADHF). Why is venous dilation with IV nitroglycerin beneficial in patients with ADHF? What are the four quadrants of the Forrester-Stevenson classification? What is the relative conversion between oral and IV loop diuretics? When is a right heart catheterization indicated? What is the difference between transferrin, total iron binding capacity (TIBC), ferritin, and transferrin saturation? How are absolute iron deficiency and functional iron deficiency defined? What is the role of oral versus intravenous iron in heart failure? What are the clinical criteria for diagnosis of cardiogenic shock, and the invasive hemodynamic criteria for diagnosis of cardiogenic shock? What cutoffs in pulmonary artery pulse index (PAPi), central venous pressure to wedge ratio characterize right ventricular shock? What are the A-B-C-D-E stages of shock? What are the INTERMACS 1 through 7 profiles of shock? Tune in for answers to these questions.

Difficulty Level: Easy

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In this episode, we review chronic heart failure with reduced, mildly reduced, improved, and preserved ejection fraction (HFrEF, HFmrEF, HFimpEF, HFpEF). What are the stages of HF, and what therapies should be given to patients with pre-heart failure? What does adverse myocardial remodeling involve? While core GDMT for HFrEF is well-known, what constitutes core GDMT for HFpEF and HFmrEF? When should you use adjunctive GDMT such as ivabradine, vericiguat, digoxin, polyunsaturated fatty acids, and potassium binders? Tune in for answers to these questions.

Difficulty Level: Easy

You are listening to Hu Said: Cardiology Board Review Series (2024-2025 Season)

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