Cardio - Mechanisms of Disease - Cardiovascular Imaging; EKGs

Question 1

What imaging method acts as a preliminary test to evaluate the size of the heart’s chambers (cardiac silhouette) along with any pulmonary pathology resulting from heart disease?

Answer 1

Cardiac radiography

(NOTE: not useful in making diagnoses of histopathologic disease)

Question 2

Cardiac radiography acts as a preliminary test to evaluate the _______ of the heart’s chambers (cardiac silhouette) along with any _______ pathology resulting from heart disease.

Answer 2

Cardiac radiography acts as a preliminary test to evaluate the size of the heart’s chambers (cardiac silhouette) along with any pulmonary pathology resulting from heart disease.

Question 3

Cardiomegaly is defined as diameter of the heart at its widest point being what size?

Answer 3

> 50% of the cardiothoracic (CT) distance

Question 4

If the pulmonary veins are engorged and visible in the upper part of the chest on CXR, this is called ___________ of vessels.

Answer 4

If the pulmonary veins are engorged and visible in the upper part of the chest on CXR, this is called cephalization of vessels.

Question 5

Why is mitral stenosis associated with a bifid (‘notched’) P wave?

Answer 5

Subsequent left atrial enlargement leads to differential contraction between the left and right atria

Question 6

How should the left atrium appear on CXR?

Answer 6

Concave

(a bulging left atrium indicates mitral stenosis or some other cause of left atrial enlargement)

Question 7

True/False.

Stress testing is for screening like a CXR.

Answer 7

False.

Stress testing is not used for screening like a CXR (used for pts with suspected symptoms of coronary artery disease (CAD) to assess how different areas of the heart are being perfused. This is not a screening test because of its low specificity).

Question 8

If a patient with S/Sy of coronary artery disease has an abnormal EKG, what should happen next?

Answer 8

Scintigraphy with radioisotope

Question 9

If a patient with S/Sy of coronary artery disease has a normal EKG and can exercise, what should happen next?

Answer 9

The Bruce protocol treadmill test

Question 10

If a patient with S/Sy of coronary artery disease has a normal EKG and cannot exercise, ability to tolerate what medication should be assessed?

Answer 10

Adenosine

Question 11

If a patient with S/Sy of coronary artery disease has a normal EKG / cannot exercise / cannot tolerate adenosine, what should be done next?

Answer 11

A stress echo with dobutamine

(or PET scan)

Question 12

What is a positive test stress result on EKG?

Answer 12

ST segment depression (1 mm) during exercise or in the recovery period

(reversibility on scintigraphic study)

Question 13

What is a positive test stress result on scintigraphy?

Answer 13

Reversibility

Question 14

What is a negative test stress result on scintigraphy?

Answer 14

NO reversibility

(the vessel that is not perfused during stress/exercise is still not perfused upon rest → indicative of an old infarction and thus a negative stress test result)

Question 15

What imaging modality can evaluate the heart’s chamber size, wall thickness, wall motion, valves, pericardium, intracardiac tumors, thrombi, and vegetations?

Answer 15

Echocardiography

(using doppler ultrasound)

Question 16

What are the two main viewing perspectives of echocardiography?

Answer 16

Transthoracic (TTE) or Transesophageal (TEE)

Question 17

Which viewing perspective of echocardiography is more commonly used as it is less invasive?

Answer 17

Transthoracic

(as opposed to transesophageal)

Question 18

What echocardiography method is useful in diagnosing cardiac valvular diseases?

Answer 18

Color-flow Doppler

Question 19

A 28 year old man presents with a heart murmur that increases with Valsalva and decreases with squatting. S4 sound is noted at the apex, and he has some DOE (dyspnea on exertion) that’s worse during tennis. Family history is only positive for a cousin who died of sudden cardiac death of unkown cause at 34 years of age.

What is causing the murmur?

Answer 19

Hypertrophic cardiomyopathy

(due to a genetic disorder of sarcomere formation)

Question 20

What is the characteristic finding in patients with hypertrophic cardiomyopathy?

Answer 20

A heart murmur that increases with Valsalva and decreases with squatting

Question 21

What histopathology is characteristic of hypertrophic cardiomyopathy?

Answer 21

Myofibril disarray

Question 22

What causes the murmur in hypertrophic cardiomyopathy?

Answer 22

Narrowing of the outflow tract –> increased turbulence

Question 23

Is the murmur of hypertrophic cardiomyopathy diastolic or systolic?

Answer 23

Systolic

Question 24

Where are 75% of myxomas found?

Answer 24

The left atrium

(attached to the interatrial septum)

Question 25

**True/False**. Mitral stenosis is associated with fluid in the alveolar space.

Answer 25

True.

Question 26

What causes cephalization as seen on CXR?

Answer 26

Pulmonary venous congestion

Question 27

What condition is often observed as the right ventricular wall being compressed, impeding preload?

Answer 27

Pericardial Effusion

Question 28

A 57-year-old veteran with a below the- knee amputation (BKA), T2DM, and asthma presents with substernal chest discomfort while using his wheelchair. The symptoms started about one month ago. He has no symptoms at rest. You decide to evaluate him for coronary artery disease. The most appropriate test to order in this patient would be: ## Footnote a) Treadmill stress test using standard Bruce protocol b) Treadmill stress test with radionuclide augmentation c) Pharmacologic stress test using adenosine d) Dobutamine stress echo

Answer 28

d) Dobutamine stress echo (he should not receive adenosine due to his risk of bronchospasm)

Question 29

A 51-year-old very active man has been experiencing some mild substernal chest discomfort with exertion. His EKG shows LVH. What test should be performed next to evaluate this problem? a) A standard treadmill test b) A treadmill test using radionuclide augmentation (nuclear stress test) c) Pharmacologic stress test using adenosine d) A coronary angiogram

Answer 29

b) A treadmill test using radionuclide augmentation (nuclear stress test)

Question 30

A 26-year-old woman was noted to have a II/VI systolic murmur at the left sternal border associated with some mild dyspnea on exertion. Which study should be performed in order to diagnose her condition? a) An exercise stress test with radionuclide b) A transthoracic echocardiogram (TTE) c) A transesophageal echocardiogram (TEE) d) A dobutamine stress echocardiogram

Answer 30

b) A transthoracic echocardiogram (TTE) (coronary artery disease is not indicated here)

Question 31

P waves should be upright in which leads?

Answer 31

Leads II, III, and aVF.

Question 32

A wide QRS complex (\>3 mm) is indicative of what?

Answer 32

A bundle branch block

Question 33

The QT interval should be \_\_\_\_% the RR interval.

Answer 33

The QT interval should be **_\<50_**% the RR interval.

Question 34

What bundle branch block is associated with wide splitting?

Answer 34

Right BBB

Question 35

What bundle branch block is associated with paradoxical splitting?

Answer 35

Left BBB

Question 36

How does left bundle branch block manifest on EKG?

Answer 36

| (prolonged at leads V1 and V6)

Question 37

How does right bundle branch block manifest on EKG?

Answer 37

(QRS is prolonged at leads V1 and V6.)

Question 38

What are the main effects of hyperkalemia on EKG?

Answer 38

Wide QRS + peaked T waves

Question 39

**True/False**. Hypercalcemia is an important cause of QT prolongation.

Answer 39

**False**. ***Hypo***calcemia is an important cause of QT prolongation.

Question 40

What two EKG findings are shown here?

Answer 40

a) Ventricular tachycardia b) Ventricular fibrillation

Question 41

Answer 41

**Hypocalcemia** | (slowed heart rate)

Question 42

Answer 42

Hyperkalemia

Question 43

Name three risk factors for atrial fibrillation.

Answer 43

Previous MI; heart failure; hypertension

Question 44

Cocaine, exercising, ischemia, and fever can all cause what EKG finding?

Answer 44

Sinus tachycardia

Question 45

Athleticism, beta-blockers, and old age/sick sinus syndrome can all cause what EKG finding?

Answer 45

Sinus bradycardia

Question 46

Why might an EKG show very low voltage complexes?

Answer 46

Due to pericardial fluid or other obstructive substances

Question 47

How can you determine a patient's expected sinus node maximum firing rate?

Answer 47

220 – age

Question 48

Very tall QRS complexes are indicative of what?

Answer 48

Left ventricular hypertrophy

Question 49

Bradycardia: HR is \< ___ beats per min Tachycardia: HR is ≥ ___ beats per min

Answer 49

Bradycardia: HR is \< **_60_** beats per min Tachycardia: HR is ≥ **_100_** beats per min

Question 50

A 34 year old patient has a maximum sinus node firing rate of ______ BPM.

Answer 50

A 34 year old patient has a maximum sinus node firing rate of **_186_** BPM. ## Footnote ***(220 - age)***

Question 51

Regular sinus rhythm is defined as what?

Answer 51

Upright P wave followed by QRS complex

Question 52

Left atrial enlargement presents as what on EKG?

Answer 52

Notched P wave

Question 53

Right atrial abnormalities present how on EKG?

Answer 53

Large, tall P waves

Question 54

How does bi-atrial enlargement present on EKG?

Answer 54

(1) Tall or peaked P wave (indicating RAA) **AND** (2) negative deflection (indicating LAA)

Question 55

How does hypokalemia present on EKG?

Answer 55

Flat T waves

Question 56

How does hyperkalemia present on EKG?

Answer 56

Tall, peaked T waves

Question 57

How do T waves present on EKG during ischemia?

Answer 57

Inverted

Question 58

How do subendocardial injuries present on EKG?

Answer 58

Depressed ST segment

Question 59

How do epicardial injuries present on EKG?

Answer 59

Elevated ST segment

Question 60

How do transmural injuries present on EKG?

Answer 60

Elevated ST segment

Question 61

Atrial fibrillation, atrial flutter, and supravetricular tachycardia are all examples of what?

Answer 61

Supraventricular rhythyms

Question 62

How does acute pericarditis present on EKG?

Answer 62

Diffuse **ST elevation** | (as well as PR segment depression)

Question 63

**True/False**. A new left-bundle-branch-block in the setting of chest pain is a surrogate for STEMI.

Answer 63

True.

Question 64

Hypocalcemia leads to a(n) __________ QT interval. Hypercalcemia leads to a(n) __________ QT interval.

Answer 64

Hypocalcemia leads to an **_increased_** QT interval. Hypercalcemia leads to a **_decreased_** QT interval.