ACCSAP EP Flashcards
what is the most common cause for hospitalization in patients over the age of 65
heart failure
what uses an LV pacing lead to mitigate ventricular conduction delay to improve mechanical function in patients with systolic heart failure
CRT
which area is the last to electrically activate in normal conduction of the heart
lateral RV
when LBBB is present, how is the septum activated
right to left
most significant delay in posterior-lateral free wall of LV
which valvular disorder can be improved with CRT
mitral regurgitation
intraventricular DYSsynchrony results in these 4 things
- decreased CO
- decreased MAP
- decreased LVEF
- decreased ratio of change in pressure to change in time (dP/dt)
which modality is MOST useful to evaluate mechanical dyssynchrony?
EKG
not echo
which type of wide QRS complex derives the most benefit from CRT
LBBB
RBBB and IVCD have variable degrees of LV conduction delay and service less benefit
biventricular pacing improves synchrony which results in more effective
systolic function (improve EF, stroke volume, CO)
name some trials supporting the use of CRT in patients with severe Class III-IV HF
MIRACLE
COMPANION
CARE-HF
name the trials that showed that CRT was not beneficial, and could be harmful in patients with narrow QRS and depressed EF
RethinQ
LESSER-EARTH
EchoCRT
which EKG characteristics if present will likely predict positive response to CRT (2)
LBBB type conduction
QRS >150 msec
list reasons for nonresponse to CRT
suboptimal AV timing arrhythmias (fib or frequent PVCs) suboptimal med rx <90% biV pacing LV lead noncapture
according to guidelines, what is a class I recommendation for receiving CRT
***
NSR
NYHA class II-III or ambulatory IV
LBBB
QRS>150 msec
according to guidelines, what is a class IIa recommendation for receiving CRT
NSR, NYHA II-III or ambulatory IV, LBBB, QRS 120-149 msec
NSR, NYHA III or ambulatory IV, nonLBBB, QRS >150 ms
AFIB and one of the above criteria when near 100% biV pacing is possible (after AVN ablation or with AVN blockers)
New requirement for ventricular pacing when >405 VENTRICULAR PACING IS ANTICIPATED
where is the LV lead of a CRT device placed
coronary sinus branch vessel
what is the name for having two sense-pace electrodes on an RV ICD lead spaced a few mm apart (one at the tip and other at the ring)
true bipolar
what is the name for having one sense-pace electrode on an RV ICD lead at the tip and using the RV coil as the second electrode
integrated bipolar
which trial demonstrated a mortality reduction of 31% and 61% reaction in arrhythmic death with ICDs in ischemic CM, EF =35% patients in the absence of an EP study
MADIT II
which 2 trials established the role of ICD indication in patients with NONischemic cardiomyopathy, EF =35% (found 23% mortality reduction in ICD arm)
SCD-HeFt
DEFINITE
which 2 trials found that there is NO benefit (does not reduce subsequent mortality) with early ICD implantation (within 31 or 40 days) of MI in high risk patients with depressed EF =35-40%
DINAMIT
IRIS
what are the class I indications for ICD implantation for primary prevention
NYHA II-III symptoms
+/- >40 days post MI
LVEF = 35%
If NYHA I symptoms
+/- >40 days post MI
LVEF = 30%
(If LVEF is 35 then it is IIb recommendation)
all patients must have >1 yr life expectancy
in patients with HOCM what are the indications for ICD placement (class IIa)
any one of the below: wall thickness >30 mm NSVT syncope fam hx of SCD
when is it appropriate to implant ICD in patients with prolonged QT(IIa)
syncope or polymorphic VT despite treatment with beta blocker
when is it appropriate to implant ICD in patients with brugada syndrome (IIa)
syncope or documented VT
when is it appropriate to implant ICD in patients with CPVT (IIa)
syncope or documented VT
who are the optimal candidates for subQ ICD placement
ESRD HD patients who do NOT need
CRT or antitachycardia/bradycardia pacing
what are some risks of defibrillator threshold testing (3)
refractory VF
embolism from the LA or LV
PEA
what are the contraindications to defibrillator threshold testing (6)
intracardiac thrombus Afib without adequate anticoagulation high burden of unrevasc CAD severe pHTN HF class III-IV EF <15-20%
what is the suggested slowest treatment zone for VT
no slower than 185 bpm
what are the 2 parameters that are MOST important for tachyarrhythmia related programming
rate detection
duration
employing what type of criterion will help with discriminating a gradually accelerating sinus tach to avoid getting ICD treatment for it
sudden onset criterion
what type of criterion can be employed to distinguish regular, monomorphic VT from AFib
stability criterion
when should tachyarrhythmia discriminators NOT be used ever
complete heart block
…because all rapid ventricular rates are due to VT or VF
what is it called when the ICD detects both the R and the T wave and registers this as a tachyarrhythmia
double counting
when programming the lowest VT zone for secondary prevention, how many bpm should you set it below the clinically relevant sustained VT rate
10-20 bpms
pacing mode nomenclature: what do the first, second, third and fourth letters stand for
1st chamber paced (A,V,D)
2nd chamber sensed (A,V,D,O = none)
3rd response to the sensed events
(Inhibit, Triggered, Dual response to either inhibited or triggered)
3+ shocks in a 24 hour period is called
VT/VF storm
which type of infection requires complete extraction of the ICD/PPM system:
- pocket infection
- lead associated endocarditis
- valvular endocarditis from device seeding
All of the infections require complete extraction
Only difference is antibiotic duration and the timing of re-implantation
RBBB-morphology arrhythmias usually originate from the ___
LV
LBBB morphology arrhythmias usually originate from the ___
RV or interventricular septum
