Cardiovascular Education

🟣🟢🟡Coronary Artery Dominance: A Key Concept in Angiography

✅Dominance of coronary Artery
🛑Artery which crosses the crux of heart and gives rise to PDA is dominant artery..

✅Understanding dominance is crucial in assessing myocardial perfusion, planning revascularization, and anticipating outcomes in coronary artery disease.

👉👉If Right Coronary Artery (RCA)dominant then it will give rise to PDA and PLV after reaching the CRUX of thr heart

👉👉If LCX artery is dominant then it will give rise to PDA and PLV after reaching the CRUX of the heart

👉👉In codominant(Balanced) RCA will continue as PDA and will not give PLV branch. Instead the entire PLV will be given by LCX..

🟣🟢🟡Prevalence:
🛑Right dominant – ~85%
🛑 Left dominant – ~8%
🛑 Balanced – ~7%

Case discussion!!
please advise which one i really need. High ct calcium score came back at 629. high apo b, high ap(a) chest pain when working hard and chest pain goes away when resting. do i need a ccta or a invasive coronary angiogram......??????????????????????

Asked by a patient so my answer !!

A functional stress test (or invasive angiography) is generally the better next step than CCTA — because a calcium score of 629 is high enough that the calcium "blooms" on a CT angiogram and makes it unreliable (it tends to overestimate blockages and often produces an inconclusive scan that requires a second test anyway).

If the chest pain is mild and stable: a stress test that looks for reduced blood flow — such as a stress PET/nuclear scan, stress echo, or stress MRI — is usually preferred, because these are not thrown off by calcium

If the chest pain is frequent, comes on with little effort, or isn't controlled by medication: going straight to an invasive coronary angiogram (which can also fix a blockage in the same procedure) is reasonable.

CCTA is the least ideal first choice specifically because of the high calcium score
Regardless of which test is chosen, the high ApoB and Lp(a) call for aggressive cholesterol-lowering therapy now, as this lowers risk independent of any procedure.

2026 AHA
Preoperative cardiovascular Risk assessment

Types of pulses

Pulses paradoxus as in cardiac tamponade/severe asthma

Slow rising pulse....AS

Collapsing pulse.....AR..PDA...HYPERKINETIC STATES LIKE ANEMIA FEVER THYROTOXICOSIS EXERCISE PREGNANCY

Pulsus alternansmm..severe LVEF

Pulsus Bisferiens...aortic valve disease

Jerky pulse....HOCM

Keep in mind that...Most emboli are thought to arise from lower extremity proximal veins (iliac, femoral, and popliteal) and more than 50 percent of patients with proximal vein deep venous thrombosis (DVT) have concurrent PE at presentation ... Calf vein DVT rarely embolizes to the lung and two–thirds of calf vein thrombi resolve spontaneously after detection...

BALLOON VS SELF EXPANSION VALVES FOR TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)

Both valve platforms are appropriate for the majority of patients with symptomatic severe aortic stenosis, and randomized trials (SOLVE-TAVI) show the newer-generation balloon-expandable (BEV, SAPIEN 3/Ultra) and self-expanding (SEV, Evolut R/PRO) valves are equivalent for the composite of death, stroke, paravalvular leak, and pacemaker at 30 days....

Device choice is therefore driven by specific anatomic features, hemodynamic goals, and operator/institutional experience rather than a blanket indication for one over the other.

🌸🌸🌸🌸Scenarios favoring a balloon-expandable valve (SAPIEN)

➡️➡️- Dense annular/subannular or LVOT calcification is generally NOT ideal for BEV — but BEV is preferred for a horizontal/severely angulated aorta (aortoventricular angle >70°), particularly for transfemoral access, and a dilated ascending aorta (>43 mm).

➡️➡️➡️- High baseline risk of permanent pacemaker or preexisting conduction disease — BEV carries a consistently lower pacemaker rate.

➡️➡️- Extensive coronary artery disease with likely future PCI — the short cobalt-chromium frame facilitates coronary reaccess.

➡️➡️- Transapical access — historically the balloon-expandable platform has been the option when transfemoral access is precluded by peripheral vascular disease/aortic calcification.

➡️➡️- Lower rates of major/life-threatening bleeding and paravalvular regurgitation are additional relative advantages.

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🌸🌸🌸🌸🌸🌸🌸Scenarios favoring a self-expanding valve (Evolut)

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- Severe annular/LVOT calcification with risk of annular rupture (nitinol frame conforms rather than forcing radial expansion).
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- Small or extremely oval-shaped annulus, and small ileofemoral access (Evolut requires a slightly smaller minimum vessel diameter, ~5.0 mm).
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- Goal of optimal hemodynamics / avoiding prosthesis-patient mismatch (PPM) — the supra-annular design produces larger effective or***ce area and lower gradients.
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- Intolerance to rapid pacing (e.g., low EF).
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- Valve-in-valve TAVR in a prior small surgical bioprosthesis (supra-annular designs).
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- Repositionable/recapturable — an advantage for low coronary ostia and precise deployment.
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Small aortic annulus — the most clearly differentiated indication. In the SMART randomized trial (716 patients, 87% women, annulus area ≤430 mm²), SEV and BEV were noninferior for the 1-year composite of death/stroke/HF hospitalization (9.4% vs 10.6%), but SEV was superior for bioprosthetic valve dysfunction (9.4% vs 41.6%) with far less moderate/severe PPM (~11% vs ~35%). Whether these hemodynamic advantages translate to better long-term clinical outcomes remains unproven; PARTNER long-term data have not shown a mortality difference attributable to PPM in small annuli] The following JACC review central illustration summarizes small-annulus and other expanding contemporary indications:

For patients suitable for either device, the choice ultimately reduces to individual anatomy, hemodynamic priorities, and operator/institutional experience via the Heart Valve Team.

Drugs useful in cardiac resuscitation

When to stop CPR....!!

⏯⏯Determining when to stop resuscitation efforts in cardiac arrest patients is difficult, and little high-quality evidence exists to guide decision-making..

⏯⏯Physician survey data and clinical practice guidelines suggest that factors influencing the decision to stop resuscitative efforts include

🛑Duration of resuscitative effort >30 minutes without a sustained perfusing rhythm
🛑Unwitnessed collapse with an initial ECG rhythm of asystole
🛑Prolonged interval between time of collapse and initiation of cardiopulmonary resuscitation (CPR)
🛑Patient age, severe comorbid disease, or prior functional dependence

👉👉More objective endpoints of resuscitation have been proposed.
Of these, the best predictor of outcome may be the end-tidal carbon dioxide (EtCO2) level following 20 minutes of resuscitation .

👉👉 EtCO2 values are a function of carbon dioxide (CO2) production and venous return to the right heart and pulmonary circulation.

👉👉A very low EtCO2 (20 minutes) is a sign of absent circulation and a strong predictor of acute mortality . It is crucial to note that low EtCO2 levels may also be caused by a misplaced endotracheal tube, and this possibility needs to be excluded as soon as the low CO2 level is identified and before the decision is made to terminate resuscitative efforts....

Also note that....Resuscitation in the emergency department does not appear to be superior to field resuscitation by emergency medical services (EMS) personnel. Therefore, EMS personnel should not transport all victims of sudden cardiac arrest to the hospital if further resuscitation is deemed futile ....

⏯⏯One simple and potentially useful set of criteria for determining the futility of resuscitation following out-of-hospital cardiac arrest is the following:
🛑🛑Arrest not witnessed by EMS personnel
🛑🛑Non-shockable initial cardiac arrhythmia (eg, asystole, pulseless electrical activity [PEA])
🛑🛑No return of spontaneous circulation (ROSC) prior to administration of third 1 mg dose of epinephrine