Cardiac System Flashcards
This deck covers Chapters 68-74 in Rosens, compromising all of cardiology.
1
Q
What is AVRT orthodromic vs antidromic and why do we care?
A
AVRT with Orthodromic Conduction
Anterograde conduction occurs via the AV node with retrograde conduction occurring via the accessory pathway.
Treatment of Orthodromic AVRT
- Like SVT
AVRT with Antidromic Conduction
Anterograde conduction occurs via the accessory pathway with retrograde conduction via the AV node.
Treatment of Antidromic AVRT
- Unstable
- Procainamide
- DC Cardioversion
2
Q
Describe the “runaway PM syndrome”.
A
Runaway Pacemaker Syndrome
- Low battery causes spikes in HR which can cause VF
- May cause failure to capture due to low voltage spikes
- Rare in current age PPMs
Treatment
- Magnet
3
Q
List 6 vascular phenomena seen in IE
A
- Arterial emboli
- Splinter hemorrhages
- Septic pulmonary infarcts
- Mycotic aneurysm
- Conjunctival hemorrhage
- Janeway lesions
4
Q
What is this?
A
Pacemaker-mediated tachycardia (PMT)
- Retrograde p waves sensed w/ ventricular pacing
- Ventricular pacing causes retrograde p waves
- Causes endless loop and rate-related ischemia
- New PPM have programming to terminate PMT
Treatment
- Slow AV conduction
- Adenosine
- Magnet
5
Q
List 8 causes of PVCs/VT
A
- Acute MI
- Previous MI
- Cardiomyopathy
- Myocardial contusion
- Hypokalemia
- Hypomagnesemia
- Hypoxemia
- Hypercapnia
- Acidosis
- Alkalosis
- Methylxanthine toxicity (caffeine)
- Valvular heart disease
- Catecholamine excess
- TCAs
- Idiopathic
- Digitalis toxicity
6
Q
List clinical features that would help you distinguish SVT with aberrancy and VT
A
VT: >50 years, hx of MI, ASD, CHF, VT in the past
SVT: <35, healthy
7
Q
List 8 early complications of MI
A
- Death
- CHF
- Dysrhythmias
- Cardiogenic shock
- LV free wall rupture
- Ruptured interventricular septum
- Papillary muscle rupture
- Pericarditis
- Hyperglycemia
- Stroke
- LV Aneurysm
- Post-PCI pseudoaneurysm
8
Q
List 10 infectious causes of myocarditis
A
-
Viral
- Hep A/B/C
- Herpes 3,4,5,6,7
- Influenza A/B
- Enteroviruses
- Adenovirus
- HIV
-
Bacterial:
- S. pneumoniae
- M. pneumoniae
- C. pneumoniae
- TB
- Lyme
- Diptheria
-
Others:
- Chagas’ – protozoa
- Trichinosis – helminth
9
Q
List the common presentations of ICD malfunction.
A
Increase or changes to shock frequency
- Shocking SVT
- Shocking non-cardiac signals
- Oversensing T waves
- Increased VF/VT (electrolytes, ischemia)
Syncope or dizzy
- VT w/ low shock strength
- SVT w/ hypotension
- Inadequate backup rate
Cardiac Arrest
- ICD malfunction
- VF failing to respond to ICD parameters
10
Q
What is this?
A
Paroxysmal SVT
- Produce retrograde atrial depolarization and a P’ wave
- But these P’ waves are usually buried in the QRS
- Most common = AVNRT (AV node is used for anterograde conduction)
Treatment
- Vagal maneuvers
- Adenosine 6 mg (can repeat 12 mg x 2)
- CCB (Diltiazem 0.25 mg/kg or 20 mg IV)
- UNSTABLE: Electrical 50J
11
Q
What is the CCS classification of stable angina?
A
Class I
- No angina with ordinary activity
Class II
- Slightly limited activity
- Climbing stairs, emotional stress, walking
Class III
- Severely limited activity
- Walking 1-2 blocks, climbing 1 flight of stairs
Class IV
- Can’t do any activity without pain
- Pain at rest
12
Q
According to new guidelines, what are our targets for PCI, thrombolytics, transfer, etc.?
A
- Door to ECG goal: ≤10 min
- Door to lytics: ≤30 min
- Door to balloon goal: ≤90 min
- FMC to balloon goal (transferred): ≤120 min
- Lytics if unable to get PCI within 120 min
Transfer all patients in cardiogenic shock
Primary PCI for patients >12h out with ongoing ischemia
13
Q
What are 4 Class I indications for an ICD?
A
- Cardiac arrest from VF/VT
- Sustained VT
- Syncope with inducible VF/VT
- Nonsustained VT with CAD, MI, EF <35%
14
Q
What is the management of Acute Rheumatic Fever?
A
Treat streptococcus
- Penicillin V 500 mg PO TID x10 days
Treat arthritis
- ASA (or another anti-inflammatory)
- Until symptoms resolve and CRP/ESR normalize
Treat carditis
- Corticosteroids (conflicting evidence)
15
Q
List 8 common precipitating causes of acute HF
A
- Non-compliance
- Fluids
- Sodium intake
- HTN
- MI
- Dysrhythmia
- Infection
- Myocarditis
- Valvular disorder
- PE
- Pregnancy
- Trauma
- Exercise
- Thyroid
- Hypoxia
- Anemia
16
Q
What is the Jones Criteria for the diagnosis of ARF?
A
Positive DX of Rheumatic Fever if:
- Strep + 2 Major or
- Strep + 1 Major + 2 Minor
Proof strep infection
- Culture
- ASOT positive
Major (JONES)
- Joint pain
- cOrditis (carditis)
- Nodules
- Erythema marginatum
- Sydenham chorea
Minor (PEACH F)
- PR prolongation
- ESR elevated
- Arthralgias
- CRP elevated
- History of preceding GAS infection
- Fever
17
Q
List 5 causes of completely irregular (chaotic) rhythms
A
- Atrial fibrillation
- Multifocal atrial tachycardia
- AT/AF with varying conduction
- Extrasystoles
- Wandering pacemaker
- Parasystole
18
Q
What’s the best mode for surgery?
A
VOO
- Asynchronous pacing
- Ventricle paced at a pre-programmed rate
- Sensing not interfered with by cautery
- Monitor for R on T with cautery –> torsades de pointes
19
Q
Describe the 4 stages of pericarditis
A
- Diffuse STE and PR depression (hours/days)
- Flat T wave, ST/PR normalizes (days/weeks)
- TWI (2 weeks)
- Normalization (months)
20
Q
What are the 5 types of MI?
A
- Type 1: Plaque rupture
- Type 2: Supply-Demand
- Type 3: Sudden death
- Type 4: PCI-related
- Type 5: CABG-related
21
Q
List 10 causes of pericarditis
A
- MI
- Viral/Bacterial/Fungal/Lyme
- Surgical
- Idiopathic
- Uremic
- Traumatic
- Rheumatoid arthritis
- SLE
- Amyloid
- Scleroderma
- Radiation
- Tumours
22
Q
List 6 treatments to manage an electrical storm?
A
Rule out reversible causes (electrolyte AbN, myocardial ischemia, TCAs, hyperthyroidism)
- Amiodarone
- B-blockers
- Sedation
- Overdrive pacing
- Emergent catheter ablation
- Hemodynamic support with IABP, LVAD
- Transplantation
23
Q
List 10 secondary causes of HTN
A
- Cushing’s syndrome
- Conn’s syndrome
- OCP use
- Pheochromocytoma
- Hyperthyroidism
- OSA
- Chronic pyelonephritis
- PCKD
- Renal artery stenosis
- Sympathetic drugs
- Licorice Root
- Chronic EtOH abuse
- Atherosclerosis
- Aortic coarctation
24
Q
Describe the 2 Types of Wellen’s Patterns:
A
Type A
- Biphasic, initial positivity
- 25% of cases
Type B
- Deeply, symmetrically inverted
- 75% of cases
The T waves evolve over time from Type A to Type B
25
What is this?
Antidromic AVRT
26
Define Unstable Angina
1. **New onset angina**
* Class II angina onset within last 2 months
2. **Rest angina**
* Rest pain \> 20 min within 1 week of ED presentation
3. **Progressive angina**
* Less precipitation, more often, longer duration
4. **Resistant angina**
* Previously effective anginal meds don't work
27
What is the normal myocardium resting membrane potential (RMP)? How is the RMP maintained?
Normal RMP: -90 mV
Na+/K+ - ATPase
28
What's the diagnosis and management of 3rd Degree AVB
**Pacemakers above His bundle:**
* Narrow complexes at HR 45 – 60
* Will respond to atropine
**Pacemakers below His bundle:**
* Wide complexes at HR 30 – 45
* Will NOT respond to atropine
**Treatment**
* Transcutaneous or transvenous pacing (if unstable)
* Epinephrine 2 – 10 mcg/min
* Dopamine 2 – 10 mcg/kg/min
* AVOID Type I antidysrhythmics (stop escape rhythm)
29
When should you CONSIDER antibiotic prophylaxis for IE in the ED? What do you give for prophylaxis?
**Step 1: High-risk condition for endocarditis?**
* Previous IE
* Prosthetic valve
* Unrepaired cyanotic heart lesion
* Repair that is young (\<6 months)
* Transplanted heart with a valve
**Step 2: High-risk procedure?**
* Gingival manipulation
* I&D of skin
* Incision of the respiratory tract
**Step 3: Prophylaxis?**
* Amoxicillin 2g PO
* Clindamycin 600 mg PO
* Ceftriaxone 1g IV
30
What organisms make up the HACEK group?
Fastidious gram neg. bacilli that are difficult to isolate
* **H**aemophilus species
* **A**ggregatibacter (prev. Actinobacillus)
* **C**ardiobacterium hominis
* **E**ikenella corrodens
* **K**ingella kingae
31
What is the new 2018 definition of MI?
Elevated troponin plus one of:
* Symptoms of ischemia
* New ECG changes
* Pathologic Q waves
* Imaging evidence of myocardial injury
* Coronary thrombus by angiography
32
List 8 causes of PM malfunction in 4 categories
**Failure to Capture**
* Leads disconnect or break
* Exit block
* Battery dies
**Failure to sense**
* Leads move
* Leads fracture
* Poor contact
**Oversensing**
* Oversensing extracardiac signals (shivering)
* T wave sensing
**Inapproprate Rate**
* Low battery
* Pacer mediated tachycardia
33
What is the LOWN classification of PVC and which are concerning for developing a malignant arrhythmia?
* 0: none
* 1: \<30/hr
* 2: \>30/hr
* 3. Multifocal
* 4a. Two consecutive
* 4b. Three consecutive
* 5. R on T
Class 3-5 are concerning for arrhythmia
34
Provide 5 DDX for ST depression
1. MI
2. Reciprocal changes
3. PE
4. Demand ischemia
5. Digoxin effect
6. Hyper/hypokalemia
7. ICH
8. Myocarditis
9. Rate-related depression
10. Pneumothorax
11. Repolarization abnormality
12. LVH with strain
13. BBB
14. Paced rhythm
35
What is this ECG?
**Multifocal Atrial Tachycardia**
* At least THREE distinctly different P waves with varying P’-R, R-R and P’-P intervals
* Irregular rhythm
**Causes of MAT (same as for PAT)**
* PACs (MCC)
* PVC (rare)
* Electrolyte or acid-base disturbance
* Drug toxicity
* Fever
* Pulmonary disease & hypoxemia
**Treatment Options for MAT (or PAT, NPAT)**
* Treat underlying cause
* BB or CCB
* MgSO4 2–4 g IV
* Overdrive pacing
* Synchronized cardioversion (50 – 100J)
36
Define the Vancouver Chest Pain rule? Any good?
1. Is there an **abnormal ECG**, **positive troponin** at 2 hrs, or **prior ACS** or **nitrate** use?
* If Yes to any = No early discharge
2. Does **palpation** reproduce the pain?
* Yes = early discharge and don’t move to step 3
3. **Age ≥50**, or does the pain **radiate to neck, jaw, or left arm**?
* If Yes to any = No early discharge
* If No to all = Early discharge with FU for stress testing
The rule was validated in 2014 on 1635 patients. Sensitivity is 99.1%, Specificity is 16.1%.
37
Explain pause- vs. tachycardia-dependent torsades de pointes
**Acquired QT prolongation (pause-dependent)**
* Majority of adult cases are acquired
* Precipitated by a SLOW HR
* **Treatment**
* Increase HR
* Overdrive pacing or drugs for HR 100-120
* IV MgSO4
**Congenital QT prolongation (tachycardia-dependent)**
* Eg. Romano-Ward, Jervell and Lange–Nielsen, Timothy
* Precipitated by catecholamine excess
* Typical story: patient presents with syncope after exertion
* **Treatment**
* Slow HR
* Can use BBs
38
What is the mechanism of action of nitroglycerin?
* Gets converted in body to NO
* NO activates guanylate cyclase
* Leads to accumulation of cGMP:
* Sequesters Ca2+ in SR
* Results in relaxation of vascular smooth muscle
39
List 8 ABSOLUTE contraindications to fibrinolytics in ACS
**Absolute CI**
1. Any prior ICH
2. Known structural cerebral vascular lesion (eg, AVM)
3. Known malignant intracranial neoplasm (primary or mets)
4. Ischemic stroke within 3 mo EXCEPT acute within 4.5 h
5. Suspected aortic dissection
6. Active bleeding or bleeding diathesis (excluding menses)
7. Significant closed-head or facial trauma within 3 mo
8. Intracranial or intraspinal surgery within 2 mo
9. Severe uncontrolled hypertension (unresponsive to tx)
10. For streptokinase, prior treatment within last 6 mo
40
What are the 2014 STEMI criteria (ECS/ACCF/AHA)?
New ST segment elevation in 2+ contiguous leads \>1mm in all leads other than V2-V3.
* For V2-V3:
* ≥1.5mm in Women
* ≥2mm in Men \>40years
* ≥2.5mm in Men \<40 years
41
Describe the ECG characteristics of an RBBB. List 5 causes of RBBB.
* QRS \> 120 msec
* RSR’ pattern in V1-3 (‘M-shaped’ QRS complex)
* OR broad monophasic R wave or qR complex
* Wide, slurred S wave in the lateral leads (I, aVL, V5-6)
**Causes**
1. RVH (cor pulmonale)
2. PE
3. Ischemic heart disease
4. Myocarditis
5. Rheumatic heart disease
42
Which organs are typically affected and which conditions can arise during a hypertensive emergency?
* Brain
* Heart
* Kidney
* Aorta
* Eyes
43
What other scoring methods are used to risk stratify potential ACS patients?
**PURSUIT**: Does not include troponin assays as part of score and the majority of the score is dependent on patient age.
**TIMI**: Simple to use, but has a poor predictive power (i.e. c-statistic 0.65)
**GRACE**: Very complex to use and a large portion of the score is dependent on the patient age. Also, patients not divided into different risk groups
**FRISC**: Like TIMI, is simple to use but has a poor predictive power (i.e. c-statistic 0.70)
44
According to the 2018 CCS Guidelines for Atrial Fibrillation, list 3 populations that could be safely cardioverted in the ED
1. Unstable Afib
2. NVAF \<12 hours and no recent TIA/CVA
3. NVAF \<48 hours and CHADS2 \<2
4. On anticoagulation for \>3 weeks
45
What is the NYHA classification for chronic HF?
**Class I**
* Asymptomatic at normal exercise
**Class II**
* Symptomatic at normal exercise
**Class III**
* Symptomatic with less than ordinary exercise
**Class IV**
* Symptomatic at rest
46
In WPW with AFib and RVR, what drugs should you avoid?
**ABCDs**
* Adenosine
* BBs
* CCBs
* Digoxin
47
Name 4 auscultation findings of HOCM
1. S4 gallop
2. Harsh crescendo-decrescendo systolic murmur (LUSB)
3. Murmur is louder with Valsalva (decreased preload)
4. Murmur is quieter with squatting (increased preload)
48
Outline the HEART score for risk stratifying possible ACS patients in the ED
**HEART**
* **H**istory: Not / Mod / Suspicious
* **E**CG: Normal / Non-specific / ST-D
* **A**ge: \<45 / 45-64 / \>65
* **R**F: 0 / 1-2 / 3+
* **T**roponin: Normal / 1-3x normal / \>3x normal
**Interpret**
* 0-3 Low risk (outpatient)
* 4-6 Moderate risk
* 7+ Admit
49
Describe the Vaughn Williams classification for antiarrhythmics
**Class I**
* **A**: Na (int): Procainamide, Quinidine (QT-prolonging)
* **B**: Na (fast): Lidocaine, phenytoin
* **C**: Na (slow): Flecainide (QT-prolonging) propafenone
**Class II**
* Beta-blockers
**Class III**
* K+ Channel: amiodarone/sotalol (QT-prolonging)
**Class IV**
* Ca2+: Verapamil/Diltiazem
50
Provide 12 DDX for STE
1. Ischemia
2. AMI
3. Hyperkalemia
4. BER
5. LVH
6. LBBB
7. Pericarditis
8. Normal variant
9. Brugada
10. Post-electrical cardioversion
11. Brain bleed
12. LV aneurysm
13. Ventricular paced rhythm
14. Pulmonary embolism
51
What is this ECG?
**2:1 Atrial Tachycardia**
* Regular narrow complex tachycardia
* Ventricular rate \> 100
* From a non-sinus focus above AV node
* Each QRS preceded by P’ wave that is morphologically different from sinus P wave
* If P’ wave is inverted, a low atrial source is likely
52
What is this?
AV dissociation
## Footnote
**Ventricular Tachycardia**
53
BP targets for:
* Ischemic Stroke: Given tPA
* Ischemic Stroke: No tPA
* Post/During tPA
* ICH
* SAH
* Ischemic Stroke: Given tPA: \<185/110
* Ischemic Stroke: No tPA: \<220/120
* Post/During tPA: \<180/105
* ICH: ~140 (MAP \<130)
* Interact-2/ATACH : No difference if lowered
* SAH: \<140
54
List indications for biventricular pacing (i.e. indications for CRT)
**All of the above:**
1. NYHA III/IV HF despite optimal Rx therapy
2. EF \<35%
3. Sinus with QRS \>120ms
4. LBBB
Biventricular pacing “resynchronizes” the ventricles by simultaneously pacing the left and right ventricles, eliminating the delay in LV free wall contraction and improving systolic function
55
What are the Brugada Criteria for VT? (4)
**Step 1**
RS complex in precordial leads?
* If none = VT
* If any = move to step 2
**Step 2**
Measure RS interval:
* If \> 100 ms -\> VT is diagnosed.
* If \< 100 ms -\> move on to step 3
**Step 3**
Look for AV dissociation
* If AV dissociation --\> VT
* If no AV dissociation --\> go to step 4
**Step 4**
If positive R wave in V1, VT if:
* Smooth monophasic R wave
* Taller left rabbit ear (Marriott's sign)
* A qR complex (small Q wave, tall R wave) in V1
In V6, VT if:
* QS complex — a negative complex with no R wave
* R/S ratio \< 1 — small R wave, deep S wave
56
List 9 ECG differences between VT and SVT
1. Absence of typical RBBB or LBBB morphology
2. Extreme axis deviation ("northwest axis")
3. Very broad complexes (\>160ms)
4. AV dissociation (P and QRS complexes at different rates)
5. Capture beats
6. Fusion beats
7. Precordial concordance
8. Brugada's sign - The distance from the onset of the QRS complex to the nadir of the S-wave is \> 100ms
9. Josephson's sign - Notching near the nadir of the S-wave
10. RSR' complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller
57
List the Sgarbossa criteria
Sgarbossa Criteria for AMI in patient with old LBBB
* Concordant STE \>1mm OR 25.6 (5 pts)
* Concordant STD \>1mm in V1, V2 or V3. OR 6.0 (3 pts)
* Discordant STE \>5mm OR 4.3 (2 pts)
Modified rule got rid of last criteria (5mm disc) and replaced with:
* Discordant STE ≥ 25% of the depth of the preceding S-wave.
58
List 3 immunologic phenomena seen in IE
1. Osler’s nodes (are painful Osler -ouch!)
2. Rheumatoid factor
3. Roth’s spots (retinal hemorrhage)
59
What is the best pacemaker mode for floating a pacer?
**VVI**
* Ventricular pacing and sensing
* Pacemaker will pace at pre-programmed rate unless sensed beat
* If sensed then pacing inhibited
* Asynchronous pacing
60
List 8 adverse effects of digitalis
1. GI
2. Fatigue
3. Drowsy
4. Visual
5. Colour Disturbance
6. Headache
7. Depression
8. Heart block
9. Ectopy
10. Ventricular tachycardia
11. Psychosis
61
List 8 causes of atrial fibrillation
1. HTN
2. CHF
3. Valvular Disease including RF or MR
4. Pericarditis
5. Fever
6. Viral illness
7. Hyperthyroid
8. PE
9. Cardiac surgery
10. Alcohol
11. Idiopathic
12. Electrolyte abnormalities
13. Pneumonia
14. Sepsis
62
What is “Pacemaker Syndrome”?
Clinical consequences of AV dyssynchrony with PPM
Iatrogenic disease - often underdiagnosed.
**Symptoms due to:**
* Decreased cardiac output
* Cannon A waves (atria contract against closed AV valve)
* Loss of atrial contribution to ventricular filling (Atrial kick)
* Vasodilation (due to ANP production)
* VA conduction – retrograde - dyssynchrony
63
What are the Duke Criteria for diagnosing IE?
**Definite:**
* 2 Major
* 1 Major and 3 Minor
* 5 minor
**Possible**
* 1 Major and 1 minor
* 3 minor
**BE FEVIER**
Major (2):
* **B**lood C+S positive x2
* 1+ BCx Coxiella Burnetti
* **E**cho evidence
MINOR (6):
* **F**ever
* **E**cho findings (not in major) - removed in Modified Duke
* **V**ascular phenomena
* **I**mmunologic phenomena
* **E**vidence: single positive C+S
* **R**isk factors: IVDU, a predisposing heart condition
64
What is this?
Brugada sign (Red)
Josephson’s Sign (Blue)
65
List 8 adverse effects of amiodarone
1. Bradycardia
2. Hypotension
3. QT prolongation
4. GI
5. Photosensitivity
6. Hyperthyroid
7. Pulmonary fibrosis
8. Decreased contractility
66
Outline your 1st and 2nd line antihypertensive agents for the following conditions:
1. ACS
2. CHF
3. AoD
4. CVA
5. ICH
6. Hypertensive encephalopathy
7. AKI
8. Preeclampsia/Eclampsia
9. Sympathetic Crisis
1. ACS - Nitro
2. CHF - Nitro
3. AoD - Esomolol + Nitroprusside/Labetalol
4. CVA - Labetalol
5. ICH - Labetalol
6. Hypertensive encephalopathy - Labetalol
7. AKI - Nicardipine
8. Preeclampsia/Eclampsia - Labetalol/Hydralazine
9. Sympathetic Crisis - Benzos
67
Explain the 5 letter PPM Code
**Pilsener, Stout, IPA**
* **P**acing (A, V, Dual)
* **S**ensing (A, V, Dual)
* **I**nhibitor Functioning (Trigger, Inhibit, Dual)
* **P**rogrammability (Rate adaptive, Simple)
* **A**nti-tachycardia (Pacing, Shock, Dual)
68
Describe the ECG characteristics of an LBBB. List 5 causes of LBBB
* QRS \> 120 msec
* Dominant S wave in V1
* Broad monophasic R wave in lat leads (I, aVL, V5-V6)
* No Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
* Prolonged R wave peak time \> 60ms in left precordial leads (V5-6)
* Appropriate discordance
* LAD
**Causes**
1. Anterior MI
2. Aortic stenosis
3. HTN
4. Dilated cardiomyopathy
5. Hyperkalemia
69
Describe the ECG changes in the following types of MI (Leads/Vessel/Reciprocal changes):
* Anterior
* Lateral
* Inferior
* RV MI
* Posterior
**Anterior MI**
* V1-V4
* LAD
* Inferior
**Lateral MI**
* I, aVL, V5, V6
* LCx
* Inferior
**Inferior MI**
* II, III, aVF
* RCA
* Lateral
**RV MI**
* V4R
* RCA
* Lateral
**Posterior MI**
* V7, V8 and V9
* PDA (branch off of RCA or LCx)
* V1-V2
70
Draw the phases of the myocardial action potential, including ion flow at each stage
71
List 3 causes of acute mitral regurgitation, describe the pathophysiology, and management
**Cause**
* MI
* Trauma
* IE
**Pathophysiology**
* Associated with low LA compliance
* Sharply elevated LA pressure --\> acute CHF
**Clinical Features**
* Fulminant pulmonary edema
* Harsh midsystolic murmur radiating to the BASE
**Management**
* Aggressive afterload reduction (vasodilators)
* Inotropes
* Intubate, if required
* Emergency Echo + Cardiac cath
* IABP as a bridge to surgery
72
Provide 12 DDX for T wave inversion
1. Brugada
2. CVA
3. Hypokalemia
4. GI disorders
5. Normal variant
6. Persistent juvenile T wave inversion
7. Hyperventilation
8. Post-MI changes
9. ACS
10. LVH
11. BBB
12. Paced rhythm
13. Myocarditis
14. Pericarditis
15. PE
16. Pneumothorax
17. WPW
18. Wellen’s Syndrome
73
List 5 contraindications to labetalol use
1. CHF (use nitro)
2. Heart block
3. Asthma
4. Cocaine toxicity
* Increases risk of seizures and death
* Unopposed alpha
5. Pheochromocytoma
* May lead to paradoxical hypertension
* Unopposed alpha
74
How do you distinguish PACs with abnormal conduction from PVCs?
**PAC**
* No pause
* p waves
* Looks like RBBB
* Normal axis,
* QRS not wide
**PVC**
* Pause
* Wide
* Abnormal axis
* No p waves
* LBBB or similar looking
75
**Tachy Brady Syndrome**. List 5 risk factors and treatment
* Runs of tachycardia interspersed with long sinus pauses
* Extremely low sinus rate
* Sinus beats followed by paroxysms of junctional tachycardia
**Risk Factors**
* Fibrosis (elderly)
* Ischemia
* Inflammatory diseases
* Cardiomyopathy
* Connective tissue diseases
* Drugs (BB, CCBs, Digitalis, Quinidine)
**Treatment:**
* Rate stimulation (Atropine or Pacing)
* Rate control (BB, CCB, or Digoxin)
* Cardiology referral for PPM + meds for Afib
76
What is this?
Junctional Afib (Digoxin)
77
What's the formula for?
* Cardiac Output
* Blood pressure
* MAP
* CO = SV x HR
* BP = CO x SVR
* MAP = 2/3(DBP) + 1/3(SBP)
78
What are the 3 key ECG features for WPW syndrome?
1. Short PR (\<120 msec)
2. QRS \> 100 msec
3. Slurred upstroke of QRS complex (delta wave)
79
Describe the mechanism of Enhanced Automaticity
Spontaneous phase 4 depolarization in non-pacemaker cells (abnormal automaticity)
* Example: VT within 1st 24 hours after MI
An increase in the slope of depolarization in cells that normally undergo phase 4 depolarization (enhanced automaticity)
* Example: catecholamine excess stimulating a non-SA-nodal pacemaker source to become the dominant pacemaker e.g. idioventricular rhythm after MI
80
List 8 types of cardiomyopathies
1. Arrhythmogenic right ventricular
2. Dilated
3. Hypertrophic
4. Ion-channel disorder
5. Inflammatory
6. Mitochondrial
7. Peripartum
8. Restrictive
9. Takotsubo
10. Tachycardia-induced
81
What's an electrical storm? List 4 causes.
**3**+ episodes of sustained VT in 24h
**Causes:**
* Drug toxicity
* Electrolyte disturbances (hypoK and hypoMg)
* CHF
* Acute myocardial ischemia
* QT prolongation
* Thyrotoxicosis
82
Provide 5 DDX for hyperacute T waves.
1. Ischemia
2. AMI
3. Hyperkalemia
4. BER
5. LVH
6. LBBB
7. Pericarditis
83
Name 6 reasons why a patient with IE may require surgery
1. CHF
2. Fungal
3. Annular abscess
4. Heart block
5. Recurrent emboli despite ABx
6. Stroke
7. Persistent bacteremia
8. \>1 cm vegetation with embolic disease
84
List 3 causes of chronic mitral regurgitation, describe the pathophysiology, and management
**Causes**
1. Dilated CM (enlargement of mitral annular ring)
2. RHD
3. MVP
4. Connective tissue disorders (Ehlers-Danlos, Marfan)
**Pathophysiology**
* Associated with high LA compliance
* Near norm LA pressure with reduced forward output
* Decompensate with volume
**Clinical Features**
* Signs of chronic systolic HF
* Holosystolic murmur at apex and radiates to AXILLA
**Treatment**
* Standard CHF management
* Consider valve replacement w EF \<60%
85
What is this?
Bidirectional VT (digoxin)
86
List 8 acquired and 2 congenital causes of prolonged QT
**Acquired**
1. Hypothyroidism
2. Hypomagnesemia
3. Hypokalemia
4. Hypocalcemia
5. Brain bleed
6. MI
7. PASTA CACA
* Propranolol
* Amiodarone
* Sotalol
* TCAs
* Antimalarials
* Cocaine
* Antiemetics/Antibiotics
* Carbamazepine
* Antidysrhythmics
**Congenital**
1. Jervell and Lange Nielsen
2. Romano-Ward
3. Timothy
4. Mitral valve prolapse
5. Sporadic
87
Describe the 3 components of the re-entry mechanism:
For re-entry to occur, 3 conditions must be met:
1. Two paths (or a circuit) must be available
2. They must have unequal responsiveness
3. One path must be slower
88
What are the Class I indications for PPM in adults?
* 3rd degree AVB or Advanced 2nd-degree AVB w/
* Asystole \>3s
* Asystole \>5s with afib
* AV nodal ablation
* Ventricular dysrhythmia
* Symptomatic bradycardia
* HR \<40
* Neuromuscular disease
* 2nd-degree AVB with symptomatic bradycardia
* 3rd-degree AVB w/ HR \>40 and LV dysfunction
* Bi/Trifasicular block w/ intermittent 3rd-degree AVB
* Exercise-induced 2nd/3rd degree AVB
89
List shocks that an ICD triggers for:
Appropriate Shocks
* Ventricular fibrillation
* Monomorphic VT
* Polymorphic VT
90
Explain the Frank-Starling mechanism. Provide 5 examples of factors that increase & decrease contractility
As preload (LV EDV) is increased, SV increases:
* Increased force of contraction
* Maximizes # of actin-myosin interactions
* Eventually, sarcomere overstretched, leading to lower SV
**Increase contractility:**
1. Sympathetic drive
2. Inotropes
3. Digitalis
4. Catecholamines
5. Increase HR (minimal)
6. Post-extra-systolic potentiation
**Decrease contractility:**
1. Parasympathetic drive
2. Intrinsic depression
* (MI, CHF, cardiomyopathy)
3. Drugs & EtOH
* (CCB, BB, barbiturates, procainamide)
4. Hypoxia
5. Hypercarbia
6. Acidosis
91
What is Poiseuille’s Law? What is Laplace’s Law?
**Poiseuille’s**
* Flow is directly proportional to 4th power of the radius
**Laplace**
* T = Pr
* Tension is directly proportional to r (cavity size)
92
What are 5 diseases associated with WPW?
1. Idiopathic
2. Tricuspid Atresia
3. TGA
4. Ebstein's
5. Endocardial Fibroelastosis
6. Mitral Valve Prolapse
7. HOCM
93
What is the Ashman phenomenon?
* Aberrant ventricular conduction of an atrial extrasystole after a long setup cycle (originates above AVN)
* May occur in any irregular atrial arrhythmia
* Classically seen in AF
* In normal patients, the RBB is the last part of the infranodal system to repolarize completely
* Thus, aberrantly conducted impulses in the Ashman phenomenon assume a RBBB appearance on ECG
94
Describe the following murmurs:
* Mitral Stenosis
* Mitral Regurgitation
* Mitral Valve Prolapse
* Aortic Stenosis
* Aortic Regurgitation
* Tricuspid Regurgitation
* Hypertrophic Cardiomyopathy
95
What is this?
**Atrial Flutter**
* Regular atrial depolarization rate of 250 – 300 atrial complexes per minute
* Rate of 300 bpm is classic
* Abnormal atrial depolarizations in a “sawtooth” appearance (flutter waves)
* Best seen in leads II, III, aVF, V1, V2
**Treatment**
* STABLE
* Control ventricular response rate:
* CCB or BB
* Digoxin (2nd line)
* MgSO4 2-4 g IV (3rd line)
* Cardioversion:
* Procainamide or amiodarone
* UNSTABLE
* Synchronized CV (50 J)
96
In general terms, what is the main treatment goal in a hypertensive emergency?
* 10% reduction in MAP within 1 hour AND
* \<25% within 24 hours
* Agent of choice:
* Nitroprusside or Labetalol
97
What 4 agents inhibit or reverse ventricular remodeling in HF (i.e. decrease mortality)?
1. BBs
2. ACEIs
3. ARBs
4. Aldosterone antagonists (e.g. spironolactone)
* Bonus: ICD/CRT
98
Outline the TIMI score for UA/NSTEMI
**AMERICA**
* **A**ge (greater than 65 years)
* **M**arkers (raised serum cardiac markers)
* **E**CG (ST-segment depression at presentation)
* **R**isk factors (at least three for coronary artery disease)
* **I**schaemia (at least two anginal events in last 24 hours)
* **C**oronary stenosis (prior stenosis of 50% or more)
* **A**spirin (use in previous 7 days)
Score of 0/1 — 4.7 % Score of 2 — 8.3 % Score of 3 — 13.2 % Score of 4 — 19.9 % Score of 5 — 26.2 % Score of 6/7 — 40.9%
99
Name 4 adverse effects of sodium nitroprusside
1. Hypotension
2. Coronary steal syndrome
* Normal vessels dilate + divert flow from more diseased vessels (DON’T use in MI)
3. CN toxicity (or thiocyanate)
4. Methemoglobinemia
100
List 8 RELATIVE contraindications to fibrinolytic therapy
**Relative CI**
1. History of chronic, severe, poorly controlled HTN
2. Significant HTN on presentation (SBP \>180 or DBP \>110)
3. History of prior ischemic stroke \>3 mo
4. Dementia
5. Known intracranial pathology not in absolute CI
6. Traumatic or prolonged (\>10 min) CPR
7. Major surgery (\<3 wk)
8. Recent (within 2 to 4 wk) internal bleeding
9. Noncompressible vascular punctures
10. Pregnancy
11. Active peptic ulcer
12. Oral anticoagulant
101
What is this?
**Brugada**
Inherited Na channelopathy
**Type 1**
* Coved STE with a gradual descent to TWI
**Type 2**
* T wave is positive or biphasic
* The terminal portion of ST is elevated (saddleback)
**Type 3**
* T wave is positive
* The terminal portion of ST elevated
102
Explain the mechanism of Triggered Dysrhythmias
Triggered dysrhythmias are the result of after-depolarizations:
**Delayed after-depolarizations**
* Enhanced by faster HR
* Associated with intracellular Ca2+ overload
* Example: digitalis toxicity
**Early after-depolarizations**
* Enhanced by slower HRs
* Classic example: torsades des pointes
103
What is this?
**Wellen's**
* Pattern of deeply inverted or biphasic T waves in V2-3
* Highly specific for critical stenosis of LAD
* May be pain-free in ED and have normal/minimally elevated cardiac enzymes, but are at extremely high risk for extensive anterior wall MI within days-weeks
* Cardio consult in ED
**Diagnostic criteria:**
1. Deeply-inverted or biphasic T waves in V2-3
* May extend to V1-6
2. Isoelectric or min-elevated ST segment (\< 1mm)
3. No precordial Q waves
4. Preserved precordial R wave progression
5. Recent history of angina
6. ECG pattern present in a pain-free state
7. Normal or slightly elevated serum cardiac markers
104
What are 3 common causes of dysrhythmia formation?
1. Enhanced Automaticity
2. Re-entry
3. Triggered Mechanisms
105
List 3 methods that can be used to differentiate VT from SVT with aberrancy
**Wellen's Criteria**
* Uses multiple unordered clinical data points to help estimate the likelihood of VT or SVT
**Brugada Criteria**
* Uses 4 steps to identify VT (if absent, Dx = SVT)
**Griffith Approach**
* Identifies classic BBB patterns to first identify SVT
* Then seeks AV dissociation to find VT in the remainder
* Brugada & Griffith approaches perform similarly
106
What is the normal MAP for an LVAD patient? What is hypertension? What is hypotension?
Hypotension = \<60 mmHg
Normal = 60-90 mmHg
Hypertension = \>90 mmHg
107
How do you take a blood pressure on a patient with an LVAD?
Arterial line
or
Manual - as sound returns by doppler/auscultation = MAP
108
According to the 2018 CCS Guidelines for Atrial Fibrillation, list 4 populations that should be anticoagulated for 3 weeks before cardioverted
1. Valvular Afib
2. NVAF \<12 hours and recent TIA/CVA
3. NVAF 12-48 hours and CHADS2 \>/= 2
4. NVAF \>48 hours
