Cardiology Flashcards
1
Q
Patient comes in with chest pain… best 1st test
A
ECG
2
Q
STEMI on ECG
A
2mm ST elevation
OR
LBBB (wide, flat QRS)
3
Q
Timing of ST elevation…
A
immediately
4
Q
Timing of T wave inversion
A
6 hrs to years
5
Q
Timing of Q waves
A
forever
6
Q
Anterior leads and vessel
A
V1-V4
LAD
7
Q
Lateral leads and vessel
A
I, avL, V4-V6
Circumflex
8
Q
Inferior leads and vessel
A
II, III, avF
RCA
9
Q
R ventricular leads and vessel
A
V4 on R-sided EKG is 100% specific
RCA
10
Q
Emergency reperfusion is…
A
go to cath lab
OR
thrombolytics *if no contraindications
11
Q
Right ventricular infarct
A
Sx: tachycardia, hypotension, clear lungs, JVD
NO pulsus paradoxus
DON”T GIVE NITRO
12
Q
Treatment RV infarct
A
DON”T GIVE NITRO
Vigorous fluid resuscitation
13
Q
Chest pain…2nd best test
A
cardiac enzymes
14
Q
How often check cardiac enzymes?
A
Q8H x3
15
Q
Troponin I rise and peak and nL
A
Rise 3-5 h
Peaks 24-48 h
nL in 7-10 d
16
Q
CKMB rise and peak and nL
A
Rise 4-8 h
Peaks 24 h
nL in 72 h
17
Q
Myoglobin rise and peak and nL
A
Rise 1st
Peaks 2 h
nL by 24 h
18
Q
Chest pain with elevated troponin…tx
A
NSTEMI/STEMI
MONA B PHAST
- morphine
- oxygen
- nitroglycerin (except in RV infarct)
- ASA 325 mg CHEWED
- Beta blocker
- Plavix
Heart imaging
ACEi
Statin
T?
19
Q
Need coronary angiography within… (NSTEMI)
A
48 h to determine need for intervention
20
Q
Standard tx for NSTEMI
A
PCI with stenting
21
Q
CABG if…
A
L main dz 3 vessel dz 2 vessel + T2DM > 70% occulusion pain despite max medical tx post-infarct angina
22
Q
NSTEMI discharge meds
A
ASA Plavix (x9-12 mo if stent placed/x1 mo if bare metal stent) BB ACEi (if CHF or LV dysfxn) Statin Short acting nitro
23
Q
Diagnosis of unstable angina when…
A
No ST-elevation and nL troponins x3
24
Q
Work up for unstable angina
A
STRESS TEST
- Exercise ECG (avoid BB or CCB before)
- Exercise ECHO if old LBBB or baseline ST ele or on digoxin
- Chemical stress test w/ dobutamine or adenosine if pt can’t exercise
or MUGA
- nuclear med test shows perfusion of areas of heart, avoid caffeine or theophylline b4
25
When is stress test positive?
- chest pain reproduced
- ST depression
- hypotension
--> cath lab x coronary angiogram
26
Post-MI complications: MC COD?
arrhythmias = ventricular fibrillation
27
New systolic murmur 5-7 d s/p MI?
papillary muscle rupture
28
Acute severe hypotension s/p MI
ventricular free wall rupture
29
"Step up" in O2 concentration from RA-->RV s/p MI
Ventricular septal rupture
30
Persistent ST elevetaion ~ 1 mo s/p MI + systolic MR murmur?
Ventricular wall aneurysm
31
"Cannon A-waves" s/p MI
AV-dissociation
| Either V-fib or 3rd degree heart block
32
5-10 w s/p MI with pleuritic CP and low grade temp?
Dressler syndrome
(Autoimmune pericarditis)
Tx w/ NSAIDs and ASA
33
A young healthy patient comes in with chest pain... Ddx
pericardidtis
costrochondriasis/MSK
myocarditis
Prinzmetal angina
34
A young healthy patient comes in with chest pain...and worse with inspiration/pleuritic, better when learning forward, friction rub, deiffuse ST elevation
pericarditis
35
A young healthy patient comes in with chest pain...and worse with palpation of chest wall
Costochondriasis or MSK-opathy
36
A young healthy patient comes in with chest pain...and vague cp and hx of viral infection and murrmur
myocarditis
37
A young healthy patient comes in with chest pain...that occurs at rest, worse at night, few CAD RFs, migraine HA, with transient ST elevation during episodes
Prinzmetal angina (CA vasospasm)
38
Dx and tx Prinzmetal angina
Dx: ergonovine stimulation test
Tx: CCB or nitrates
39
Progressive prolongation of PR interval followed by dropped beat
*** type heart block
40
Cannon-a waves on physical exam
| "Regular P-P interval and regular R-R interval
*** type heart block
41
Varying PR interval with 3 or more morphologically distinct p waves in the same lead
*** type heart block
42
*** type heart block (df p waves in same lead) management
Screen in an old person with chronic lung dz (COPD) in pending respiratory failure
43
Three or more consecutive beats with QRS <120 ms at a rate of > 120 bpm
***
44
Short PR interval followed by QRS > 120 ms with a slurred initial deflection representing early ventricular activation via the bundle of Kent
WPW
45
Regluar rhythm with a ventricular rate of 125-150 bpm and atrial rate of 250-300 bpm
atrial flutter
46
prologned QT interval leading to undulating rotation of the QRS complex around the EKG baseline in a patient with low MG and low K
Torsades de pointe
47
Torsades when...
hypomagnesemia
hypokalemia
Li OD
TCA OD
48
regular rhythm w/ a rate between 150-220 bpm and sudden onset of palpitations and dizziness
***
49
Renal failure patient/crush injury/burn victim with 'eaked t-waves, widened QRS, short QT, and prologed PR
***
50
Alternate beat variation in direction, amplitude, and duration of the QRS complex in a patient with pulsus paradoxus, hypotesnion, distant heart sounds, JVD
***
51
Undulating baseline, no p waves, irregular RR interval in hyperthyroid pt, old pt with SOB/dizzi/palp with CHF or valve dz
atrial fibrillation
52
SEM crescendo/decrescendo, loud with squatting, softer with valsalva, + palsus parvus et tardus
ASS
53
SEM louder with valsalva, soften with squatting or handgrip
HOCM
54
Late systolic murmur with click louder with valsalva and handgrip, soften with squatting
MVP
55
Holosystolic murmur radiates to axilla with LAE
MRS
56
Holosystolic murmur with late diastolic rumble in kids
VSD
57
Continuous machine-like murmur
PDA
58
Wide fixed and split S2
ASD
59
Rumbling diastolic murmur with an opening snap, LAE, and afib
MSD
60
Blowing diastolic murmur with widened pulse pressure and eponym parade
ARD
61
Patient comes in with dyspnea... heart or lungs???
Don't miss PE
PNA
CHF
ACS
62
Dyspnea...suspect PE when...
```
hx of cancer
s/p surgery
butt sitting
pregnant
plane ride
```
63
Tx PE
D-dimer
CT chest
HEPARIN
64
When give O2
<90% oxygen saturation
65
Signs/sx of pneumonia...get
CXR
66
Dyspnea with murmur...get
ECHO to check EF
67
Dyspnea with hx CHF...get
ECHO to check EF
68
Tx acute pulmonary edema
LMN
Lasix
Morphine
Nitrates
69
Dsypnea in young pt with sxs of CHF with prior viral infection
Think myocarditis (coxsackie B)
70
Dyspnea in young pt with no cardiomegaly on CXR
Consider primary pulmonary HTN
| *Right heart cath can tell CHF from pulmonary HTN (check PAP pulmonary artery pressure, LA pressure)*
71
Systolic CHF
decreased EF (<55%)
heart can't pump
ischemic, dilated
72
Causes systolic CHF
```
viral
EtOH
cocaine
Chagas
idiopathic
```
73
Alcoholic dilated cardiomyopathy prognosis and tx
REVERSIBLE
| if stop the booze
74
Diastolic CHF
normal EF
| heart can't fill
75
Causes diastolic CHF
HTN
amyloidosis
hemachromatosis
76
Hemachromatosis restrictive cardiomyopathy prognosis and tx
REVERSIBLE
| with phlebotomy
77
CHF tx
```
ACEi
BB
Dig
Furosemide
Spironolactone
```
78
Why ACEi in CHF
improves survival
| prevents remodeling by aldosterone
79
Why BB in CHF
improves survival
| prevents remodeling by epi/norepi
80
Why digoxin in CHF
decreases sxs
decreases hospitalizations
does NOT improve survival
81
Why furosemide in CHF
decreases sxs (SOB, crackles, edema)
82
Why spironolactone in CHF
improves survival in NYHA class III and IV
83
normal P wave
120-200 ms
| 3-5 small boxes
84
increased PR in:
first degree AV blcok
hyperthyroidism
CAD
85
shortened PR in:
WPW
ectopic atrial rhythm
occasional junctional rhythm
86
normal QRS
< 100 ms
87
prolonged QRS length
> 120 ms
| > 3 small boxes
88
QRS complex represents...
ventricular depolarization
from inside out
from endocardium to epicardium
89
MC causes of wide QRS
MC: conduction defects (bundle branch blocks)
LVH
hyperkalmeia
ventricular or paced rhythms
90
"poor r wave progression" signifies...
```
anterior/anteroseptal MI
LVH
fascicular blocks/partBBB
infiltrative or dilated cardiomyopathy
WPW
COPD
clockwise rotation of heart
```
91
early R wave progression
should be smaller than S wave
and more S wave in V6 than R wave
posterior MI
RVH
RBBB
WPW
92
large R waves in V1 and V2
RVH
93
nL QT interval
= time in ventricular systole
shorter as HRH goes up
nL: 300-400 ms
slightly longer for females
94
QTc corrects for... and equation
heart rate
QTC = QT + 0.00175 (HR - 60)
95
prolonged QT caused by...
```
hypoCA, hypo K, hypMg
type IA and type II AAD
TCAs
antipsychotics
macrolides
quinolone abx
methadone
c long QT dyndrome
```
96
short QT caused by...
```
(uncommon)
hyperCA, hyperK
acidosis
increased vagal tone
congenital channel assoc with sudden death*HOCM?
```
97
ST elevation ddx
```
acute injury/MI
pericarditis
ventricular aneurysm
prinzmental angina
myocarditis
Brugada's syndrome (STE with RBBB)
```
98
ST depression ddx
MI
ventricular hypertophym BBB
paced or ventricular beats
digoxin
99
digitalis intoxication
slow HR
nausea
ST depression
100
inverted T waves...
ischemia
101
T wave inversion nL in...
aVR, sometimes V1 and V2
102
deeply inverted T waves thought to be cause by...
autonomic changes induced by increased ICP!
| cerebral bleed
103
Tall, hyperacute T waves ddx
hyperkalemia (K > 6)
early MI
CVA
usually localized to V2-5, not diffuse
104
66 yo taking Lasix, ate too many prunes, and got diarrhea
U wave - hypokalemia
***may cause an artifactual increase in QT interval
105
five small boxes = __ s
five small boxes = one big box = 0.2 s
count 5 big boxes = 1s
count 30 big boxes = 6s
multiple that amount in 30 box times 10 = rate
106
Take __ into account when determining axis
age
as people age, axis tends to shift leftward
107
RAD is axis > x
| LAD is axis of x
RAD is > 105 *
| LAD is -30 to -90
108
causes of RAD
COPD
RVH
RBBB
dextrocardia
109
causes LAD
```
MC: LVH
LBBB
pregnancy, ascites, swing apex leftward/elevates diaphragm
inferior MI
advanced age
```
110
conduction defects can be...
atrioventricular
AND
intraventricular
111
sick sinus syndrome
AKA tachy-brady syndrome
long pauses/bradycardia with SVT/afib/aflutter
cardazem may cause
fix with rate control
112
AV conduction defects are...
AV heart blocks
113
fixed, prolonged PR interval
first degree AV block
prolonged PR > 0.2 s
no tx required
114
PR interval lengthens weith each successive beat
type I second degree AV block (Wenckeback)
due to gradulally deteriorating conduction through AV until impulse is dropped
115
causes and tx type I 2nd degree AV block
meds
degeneration of AV node
ischemia (especially inferior MI, RCA)
usually none, stop offending med, packemaker if high grade
116
random drop of a QRS on ECG
type II 2nd degree AV block
may progress to 3rd degree AV block
117
causes and tx type II 2nd degree AV block
ischemia, usually anterior MI, LAD
requires packmaker (bc may progress, unless low grade and HR is adequate)
118
high grade AV block
PR interval dose lengthen before QRS is dropped
119
p waves march out independently of QRS, regular P-P and regular R-R
3rd degree (complete) heart block
lack of conduction between atria and ventricles
may develop escape beats (junctional or ventricular)
120
Escape rhythm... junctional vs. ventricular
if block is high in AV node:
if block is low in AV node:
junctional escape rhythm
ventricular escape rhythm
121
junctional escape rhythm char.
narrow QRS
block high in AV node
rate 40-60
122
ventricular escape rhythm char
wide QRS
block low in AV node
rate 20-40
123
Intra-ventricular conduction defects include...
RBBB
LBBB
fascicular blocks (partial, not covered)
124
BBB changes are..
when the R waves are separated because the ventricles depolarize separately
125
RBBB characteristics
conduction across septum from left, axis shift to right
QRS > 120 ms in V5-V6
RSR' in V1 "rabbit ears"
large R' in V1
secondary ST&T changes in V1-V3
126
RBBB causes and tx
occasionally normal
almost any right sided heart dz, pul HTN, PE
usually not ischemic
none
127
LBBB characteristics
depolarization proceeds from right to left, axis shift to left
"tree stump" wide QRS in I and V5-V6
no Q in I, aVL, V5-6 (lose septal depolarization)
broad, deep QS in V1
128
LBBB causes
```
degenerative
HRN
acute MI
valvular anomalies
NOT in normal heart
```
129
right atrial overload ECG features
tall, peaked, wide P waves in I + II* + V1*
> 2.5 mm tall
biphasic P wave in V1
130
causes right atrial overload
pulmonary HTN
RV infarct
right sided valvular abnL
left sided valvular abnL
131
left atrial overload ECG features
wide, notched P wave in I + II* + V1*
> 3 small boxes
NOT tall and pointy
biphase P wave in V1 that is 1 mm deep and 0.04 s in duraction
132
causes left atrial overload
```
mitral valve dz
LVH
HTN
aortic valve dz
cardiomyopathy
```
133
RVH ECG features
RAD
classic changes when hypertrophy is advanced
ECG is less sensitive for RVH
reversal of normal precordial:
tall R wave in V1-V2
deep S in I + aVL + V5-V6
134
RVH criteria
R > S in V1
R in V1 at least 7 mm
R in V1 + S in V6 at least 11mm
135
LVH criteria (voltage plus...)
R in V5/V6 at least 30 mm
S in V1/V2 at least 30 mm
S in V1/V2 + R in V5/V6 > 35 mm
R in aVL > 11 mm
```
PLUS
- strain pattern in lateral leads
- LAO
OR
- LAD
```
136
most specific sign of LVH on ECG
R in aVL > 11 mm
137
positive lead I
positive lead II
negative aVF
axis?
-15 degrees
