Braunwalds Flashcards
the most common finding in SCD which can be the first and last manifestation
Coronary heart disease (CHD)
Where do you see delta waves?
WPW
Where do you see epsilon waves?
ARVC
If P waves are notclearly visible on the regular ECG, atrial activity can occasionally be discerned by placing the right and left arm leads in various anterior chest positions. These leads are AKA
(so-called Lewis leads)
Definition of frequent PVCs
> 10 per hour
Duration of QRS to its peak that makes VT more likely
> = 50 msec
How is tilt table testing done
Patients are placed on a tilt table in the supine position and tilted upright to a maximum of 60 to 80 degrees for 20 to 45 minutes or longer if necessary.
Isoproterenol, administered as a bolus or infusion, may
provoke syncope in patients whose initial upright TTT result shows no abnormalities or, after a few minutes of tilt, may shorten the time needed to produce a positive response on the test
What type of syncope will test positive in tilt table testing?
neurally mediated
syncope
The finding of very long H-V intervals ( _____ msec) identifies patients at increased risk for the development of AV block.
(>80 to 90 msec)
Definition of sinus arrhythmia
phasic variation in sinus cycle
length during which the max sinus cycle length minus the min sinus cycle length exceeds 120 msec or the max sinus cycle length minus the min sinus cycle length divided by the min sinus cycle length exceeds 10%
Type I AV block with a normal QRS complex almost always takes place at the ______
level of the AV node, proximal to the His bundle
An exception is the uncommon patient with type I intrahisian block.
Type II AV block, particularly in association with a BBB, is localized to the ______
His-Purkinje system
Gene responsible for LQTS-3
SCN5A
In adults, rapid rates may be followed by block (called tachycardia-dependent AV block), which is thought to
result from phase ___ block , postrepolarization refractoriness, and concealed conduction in the AV node.
3
T-achycardia ; T-hree
Pause-dependent paroxysmal AV block can also occur; it
results in AV block after a pause or during relative bradycardia. This results from phase __ block
4
P-ause
P-or (4)
Neurally-mediated bradyarrhythmias are characterized most frequently by _______
ventricular asystole
caused by cessation of atrial activity as a result of sinus arrest or SA exit block
A cardioinhibitory response is generally defined as
ventricular asystole exceeding 3 seconds
. A vasodepressor response is usually defined as
a decrease in SBP of 50 mm Hg or more without associated
cardiac slowing or a decrease in SBP exceeding 30 mm Hg when the patient’s symptoms are reproduced
Drug that acutely abolishes cardioinhibitory responses to neurally mediated bradyarrhythmias.
Atropine
Treatment with the Class IC drug _____ and the Class III drug _____ increased mortality in post-infarct patients, possibly due to proarrhythmic effects
Fleicanide and Sotalol
Most likely mechanism of AIVR
Automaticity
Condition/s that may present as monomorphic VT and may appear as RBBB when sinus and LBBB morphology when in VT
Repaired TOF, VSD
Treatment for Idiopathic LV
fascicular reentrant VT
Beta blocker, verapamil
Genes associated with non ischemic cardiomyopathy
40%—LMNA, TTN,
PLM, desmosomal
Treatment for catecholaminergic
polymorphic VT
Beta blocker, fleicanide
The presence of dissociation between ventricular and atrial activity strongly favors VT over SVT, the exception being
junctional ectopic tachycardia with aberrancy
Focal VTs tend to be enhanced by beta-adrenergic stimulation.
T/F
True
Beta-blockers can be helpful
and catheter ablation is usually an option when therapy is warranted.
Considerations for RVOT VTs
ARVC and cardiac sarcoidosis
Treatment for Na blocker toxicity
Hypertonic Na (NaHCO3)
Sustained monomorphic VT may present any time after myocardial infarction, but often more than ____ years after the acute infarction
10
Most patients have LV ejection fraction of less than 40%
ICDs are also recommended for infarct survivors who are at risk for a first episode of VT based on LV ejection fraction of
35% or less with symptoms of heart failure or less than 30% even in the absence of symptoms provided that they are: (1) at least 40 days from acute infarction and (2) are more than 90 days from a revascularization procedure.
Genes assoc with ARVC (autosomal dominant)
Approximately half of the patients have an identifiable mutation involving a esmosomal protein, most commonly plakophilin-2,desmoplakin, and desmoglein, followed by other desmosomal andnon-desmosomal proteins.
Treatment for ARVC
Arrhythmias are commonly provoked by exertion.
Chronic therapywith a beta-blocker is recommended. An ICD is recommended for those who have had sustained arrhythmias, syncope, or RV or LV dysfunction with ejection fraction of 35% or less, and is considered for patients with less severe manifestations of disease because the initial symptomatic event can be sudden death
the most common rhythms identified at sudden death in px with HOCM
Polymorphic VT (PMVT)
and VF
most common locations for idiopathic VT
RVOT and LVOT
mutation assoc with LQTS-1 and 2
Mutation in IK
LQTS with broad symmetric t wave
1
LQTS with notched or humped t wave
2
LQTS with flat ST segment with a peaked T-wave
3
Treatment for LQTS
beta blocker
Chronic beta-blocker
therapy with propranolol or nadolol is often sufficient, particularly for type 1 and 2 LQTS; metoprolol is less effective.
Specific therapeutic strategies for the type of LQTS are
emerging, including potassium supplementation for type 2 and sodium channel blockers for type 3
Syndromes assoc with LQTS
(Timothy Syndrome, AndersenTawil Syndrome) and a recessive form accompanied by congenital deafness (Jervell Lange-Nielsen Syndrome)
Mutations assoc with Short QTc
It is rare and caused by mutations that result in gain of function in repolarizing potassium channels (IKr and IKs) or loss of function in the L-type calcium current channel
Most patients present with arrhythmias before 40 years of age. There is a male predominance. An ICD is recommended for patients who have had symptomatic arrhythmias. Quinidine may be helpful in diminishing episodes of VT
For Brugada syndrome, ____ the only established therapy to protect against SCD and is recommended for patients with a history of cardiac arrest or syncope consistent with an arrhythmia who have a type-1 ECG
ICD
Definition of early repolarization pattern
An ER pattern is defined as a J-point elevation (or a J-wave producing slurring of the terminal QRS) ≥1 mm in at
least 2 contiguous inferior and/or lateral leads of the 12-lead ECG and a QRS duration less than 120 milliseconds in leads without J waves
Bidirectional VT is also seen in ______ (3)
digoxin toxicity, myocarditis, and Anderson-Tawil syndrome
Definition of lone AF
Lone atrial fibrillation refers to AF that occurs in patients younger than 60 years who do not have hypertension or any evidence of structural heart disease
Percentage of asymptomatic AF
25%
AF burden in persistent AF
100%
Aside from prior stroke, the highest RR for stroke among best-established risk factors for stroke in patients with nonvalvular AF is ______
DM
(relative risk [RR], 1.7), hypertension (RR, 1.6), heart
failure (RR, 1.4), and age 70 or older (RR, 1.4 per decade)
reversal agent of dabigatran
idarucizumab
reversal agent for Factor X inhibitors
andexanet alfa
Onset of DOACs, half life of DOAC
1.5-2h
12hrs
The most common oral agents for acute conversion of AF are
propafenone (300 to 600 mg) and flecainide (100 to 200 mg)
Definition of early persistent AF
<6 months
optimal metric for rate control is a resting heart rate
<80 beats/min
all the available drugs except amiodarone have similar
efficacy and are associated with a _____ reduction in the odds of
recurrent AF during 1 year of treatment
40% to 60%
amiodarone was 60% to 70% more effective in suppressing AF
The risk of developing AF increases ___ with every 5-point increase in BMI.
29%
The goal of weight loss ideally
should be a BMI of
≤27 kg/m
Most common site of focal trigger that initiate AF
pulmonary vein
Most feared complication of AF ablation
atrial esophageal fistula
The only proven benefit of AF ablation
improvement in QoL
incidence of AF after open heart surgery can be significantly reduced by prophylactic
Amiodarone, Sotalol, Btea blockers
electrolyte imbalance common after open heart surgery and can heigten the risk of AF
Hypomagnesemia
AF that occurs after cardiac surgery often resolves within _____
3 months
______ and _____ are contraindicated in patients with WPW syndrome and AF
Digitalis and calcium channel antagonists
These agents selectively block
conduction in the AV node and can result in acceleration of conduction through the accessory pathway.
The most appropriate rate-control drugs in patients with systolic heart failure are _____ and ______
beta blockers and digitalis.
the only two rhythm-control drugs that are not associated with an increased risk of death in patients with heart failure
Amiodarone and dofetilide
AF occurs in ___% of px with HOCM
25%
Adequate HR cntrol of px with AF during moderate exercise
90-115
interpret HUT result
POTS
interpret HUT result
Cardioinhibitory
interpret HUT result
Vasodepressor
interpret HUT result
Mixed
interpret HUT result
Autonomic failure
interpret HUT result
normal
Only indication for treatment of PAC
if sufficiently symptomatic
Least common mechanism of PSVT
FAT
Narrowest anatomic segment of the circuit travelled by typical atrial flutter
Cavo-Tricuspid Isthmus
Antiarrhythmics that should not be used in px with atrial flutter
Class 1 C due to risk of slowing atrial rate and facilitating 1:1 Av conduction
Cut off for classifying Short RP tachycardias
RP <70 msec vs > 70 msec
Pseudo RBBB in v1 and pseudo S in inferior leads indicate _____ with accuracy of 100%
typical AVNRT
Most common mechanism for SVT in adults late after surgical repair of CHD
Macroreentrant AT
Medications that will inc pacing threshold
Amiodarone
Class 1C
Medications that will lower pacing threshold
Glucocorticoids
Isoproterenol and Epinephrine
Tachycardia detection duration should be programmed to at least _____ seconds or at ____ interval
6-12
30
For primary prevention in adult patients, the slowest tachycardia detection rate should be programmed to
185 to 200 beats/min.
Antitachycardia pacing (ATP) should be programmed for all VT/ventricular fibrillation (VF) zones up to _____ beats/min in all patients with structural heart disease.
230
In which type of surgeries should you apply magnet in px with Pacemaker/ICD
Apply magnet or reprogram if surgical site above umbilicus.
Guidelines for ICD patients recommend that patients refrain from driving for ___ months after each shock for VT/VF and for __ months after ICD implant for secondary prevention.
6
6
