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CARDIOLOGY Flashcards

1
Q

How is heart failure classified?

A

Left or right sided
Congestive

Systolic: insufficient contraction (reduced ejection fraction v. Diastolic insufficient relaxation therefore insufficient filling (preserved ejection fraction)

Acute v chronic

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2
Q

What are the causes of left heart failure?

A

Ventricular inflow obstruction (blood can’t flow into ventricles)

Diastolic dysfunction
(not enough blood flows in)

Reduced ventricular contractility (doesn’t contract as well)

Ventricular volume overload
(too much blood flows in)

Ventricular outflow obstruction
(blood can’t flow out)

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3
Q

What causes ventricular inflow obstruction? (blood can’t flow into ventricles)

A

The atrial-ventricular valves not functioning:

Mentral valve or Tricuspid valve stenosis

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4
Q

What causes diastolic dysfunction? (heart doesn’t fill enough)

A

Constrictive pericarditis

Cardiac tamponade

Arrhythmias

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5
Q

What causes reduced ventricular contractility?

A

MI

CAD

Dilated cardiomyopathy

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6
Q

What causes ventricular volume overload? (too much blood flows in)

A

Mitral regurgitation

VSD and ASD

Increased metabolic demand for blood

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7
Q

What causes ventricular outflow obstruction? (Blood can’t flow out)

A

Aortic stenosis

Pulmonary stenosis

Pulmonary hypertension

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8
Q

What are the causes of right heart failure?

A

Left heart failure

Right sided infarct

Congenital heart defect

Pulmonary hypertension and chronic lung disease (e.g. in COPD)

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9
Q

What are the symptoms of left heart failure?

A

Pulmonary (L=lungs) blood backs up in the lungs as it can’t enter the heart, pressure increases and fluid is forced out of the capillaries under pressure causing:
Cyanosis
Tachypnoea
Paroxysmal nocturnal dyspnoea that wakes patient
Bibasal crepitation

Cardiac symptoms are down to the causes
Murmurs
Laterally displaced apex beat

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10
Q

What are the symptoms of right heart failure?

A 
Blood backs up trying to get into the right heart forcing fluid out of the capillaries under pressure resulting in:
Ascites
Peripheral pitting oedema 
Tender hepatomegaly
Parasternal heave 
Riased JVP
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11
Q

What is preload?

A

Volume of blood in the ventricles at the end of diastole = End Diastolic Volume a

This is measured by the pressure it exerts on the ventricle walls

Essentially a measure of the patient’s volume status

Low pre-load = low volume e.g. in shock, hypotension and tamponade

High pre-load = high volume e.g. in heart failure and bradycardia

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12
Q

What is afterload?

A

Pressure the ventricles exert to open the pulmonary/aortic valves which must be greater than the pressure greater by the peripheral vessels (TPR)

After-load is high in: Hypertension (the TPR is higher so more pressure is needed), aortic stenosis (greater pressure is needed to open the valve) and SNS stimulation as that causes increased TPR to redirect blood to needed structures

After-load is low in: Hypotension and sepsis (due to vasodilation)

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13
Q

What is Starling’s law?

A

The more the heart muscle stretches the harder it contracts (to a point)

In heart failure this point is lower

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14
Q

How does heart failure self-perpetuate?

A

Heart failure leads to reduced C.O which leads to reduced BP which activated the RAASystem.

This retains Sodium and Water which increases preload and causes vasoconstriction which increases afterload.

Increased BP increases cardiac work which increases sympathetic activation which leads to increased cardiac contractility

The heart is forced to work harder and thus is damaged and myocytes are lost, this results in worsening of the heart failure

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15
Q

What are is the NYHA classification for heart failure?

A

I - no limitations
II - slight limitation
III - marked limitation
IV - symptoms at rest and no physical activity without discomfort

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16
Q

What are the signs of heart failure on CXR?

A 
Alveolar oedema: 'bat wings'
kerley B lines (interstitial oedema)
Cardiomegaly (s3+4 heart sounds)
Dilatation of apex arteries (blood Diverted to upper lobe)
pleural Effusion
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17
Q

What is BNP?

A

Brain Naturitic Peptide is produced by the LV myocardium in response to strain

> 400 pg/ml

  • LV Hypertrophy
  • Ischaemia
  • Tachycardia
  • RV overload
  • Hypoxaemia-P.E

Also by: sepsis, GFR <60, COPD, Diabetes, >70 y/o, Cirrhosis

< 100 pg/ml

  • Obesity
  • Diuretics
    • Aldosterone antagonists
  • ACEi/A2RB
  • B blockers
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18
Q

How is heart failure treated?

A

ACEi* (Ramipril) + B-Blocker* (start low, go slow) (Bisoprolol, Carvedilol, Nebrilol)

Aldosterone Antagonist* (Spironolactone)/ A2RB (Candestartan, Losartan)/ Hydralazine + Nitrate* (Isosorbide mononitrate) which are Vasodilators

Cardiac resynchronisation therapy (pacing) or a Cardiac Glycoside (Digoxin) especially in AF

Diuretics can be used if in fluid overload (Furosemide or Spiron)

Flu and pneumococcal vaccine

*shown to improve mortality

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19
Q

What is Acute Coronary Syndrome?

A

Acute presentation of ischaemic heart disease (CAD): Reduced blood flow to the heart muscle due to vessel disease

STEMI
NSTEMI
Unstable angina

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20
Q

What are the risk factors for ACS?

A

Modifiable:

  • Obesity and physical inactivity
  • Hypertension
  • Hypercholesterolaemia
  • Smoking
  • DM
  • Alcohol excess

Unmodifiable:

  • Age
  • Male sex
  • Genetic
  • Ethnicity
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21
Q

What are the signs and symptoms of ACS?

A 
Crushing, central chest pain radiating up neck and down left arm *diabetics and the elderly may not have chest pain
Dyspnoea 
Palpitations
Sweating
Nausea and vomiting 
Syncope

Pale and clammy
Often normal pulse (sometimes tachy), BP and O2 stats

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22
Q

What cardiac enzymes are measured?

A

Troponin (T or I) is the most sensitive and begins to raise from 3-12 hours after onset of pain with a peak at 24-48 hours and decline over 5-10 days

CK-MB rises after 3-12 of pain onset and returns to baseline 48-72 hours

LDH

Myoglobin levels rise within 1-4 hours which is sensitive but not specific to ACS

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23
Q

How are MIs localised on ECG?

A 
Inferior- II, III, avF-RCA**branchsupplies AVN so can cause complete heart block 
Septal- V1+V2-LAD
Anterior- V3+V4-LAD
Lateral- I, aVL, V5+V6-lCfx
Posterior- Tall R in V1+V2-lCfx+ RCA

Tall T wave
ST elevation (**in aVR is highly suggestive of 3 vessel or Left main stem disease)
T wave inversion 
Pathological Q (40ms wide >2mm deep)
**New LBBB in context of chest pain
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24
Q

How is ACS managed initially?

A 
Morphine
O2 (if <94%)
Nitrates (Glycerol trinitrate) sublignusally
Aspirin 300mg
Pasugrel (clopidogrel or ticagrelor)
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25
How are STEMIs managed?
Purcutaneous Coronary intervention angioplasty +/- stent within 2 hours via radial or femoral catheter Can drive 1 week after angioplasty and 4 weeks without one ``` Then: Statin Lifelong Aspirin + 1 mo of clopidogrel (lifelong if aspirin contraindicated) or tricagrelor ACEi Beta Blocker to reduce heart rate ```
26
What is thrombolysis?
When PCI is not available for STEMI (Also in stroke and PE) Convert plasminogen to plasmin which degrades fibrin and breaks up clots e.g. Alteplase Tenecteplase Streptokinase
27
When is thrombolysis contraindicated?
Can cause a bleed so... - Active bleeding - Recent haemorrhage - Recent trauma/surgery - Coagulation/bleeding disorders - Stroke < 3months - Intercranial neoplasm - recent head injury - Aortic dissection - Severe HTN - Pregnancy
28
How are NSTEMIs managed?
Antithrombin treatment: FONDAPURINUX (Enoxaparin)If no risk of bleeding and no angiography in 24 hours UNFRACTIONATED HEPARIN if angiography in 24 hours or high creatinine Lifelong aspirin + 300mg of clipidogrel for 12 months IV glycoprotein IIb/IIa receptor antagonists EPTIFIBATIDE or TIROFIBAN if high risk of CVS events + angiography within 96 hours
29
What is Angina?
MI caused by atheroma brought on by exertion and relieved by rest
30
What are the 4 types of Angina?
Stable: caused by exertion, relieved at rest Unstable: increased frequency or severity on minimal exertion Decubitus: precipitated by lying flat Variant: prinzmetal's- coronary artery spasm
31
What precipitates angina?
``` 4 Es Exercise Eating Emotion Exposure to cold ```
32
How is Angina managed?
- Lifestyle changes - Statin - Aspirin - B-B or CCB then combine (but not Verapapamil with BBlocker) - Nitrates Symptoms: spray subligually every 1/2 hour Prophylaxis: Regualr oral nitrate e.g. isosorbide mononitrate (can develop tolerence so take every 8 hours not 12 hours in standard release) - Ivabradine - PCI or CABG
33
What are the ECG changes that indicate thrombolysis or PCI?
ST elevation >2mm in 2 or more consecutibe anterior leads (V1-V6) or ST elevation > 1mm in >1 consecutive inferior leads (II, III, aVF, aVL) or New LBBB
34
What is coarctation of the aorta?
Stenosis in the aortic arch distal to the left subclavian artery Hypertension proximally (upper limbs): - Dizziness - Headache - Neuro symptoms ``` Hypotension distally (lower limbs) - Caudication ``` Collateral arteries between the pre-coarctation and post-coarctation aorta (e.g. intercostal and internal mammary arteries) enlarge and communicate between the aortic segments proximal and distal to the coarctation. Enlarged intercostal arteries notch the inferior margins of te ribs detectable on XRAY.
35
What is an Atrial Myxoma?
Benign tumour of the heart 75% are in the left atrium Surgery is curative
36
What are the features of Atrial Myxoma?
Mid diastolic murmur with 'tumour plop' in early diastole ``` Systemic: - Dypnoea - Fatigue - Weight loss - Fever - Clubbing Embolic (e.g. TIA) Atrial Fibrillation ```
37
What is an Atrial Myxoma?
Benign tumour of the heart 75% are in the left atrium Surgery is curative
38
What are the features of Atrial Myxoma?
Mid diastolic murmur with 'tumour plop' in early diastole ``` Systemic: - Dypnoea - Fatigue - Weight loss - Fever - Clubbing Embolic (e.g. TIA) Atrial Fibrillation ```
39
What is Pulsus Paradoxus?
Systemic blood pressure falls by >10mmHg during INSPIRATION so the pulse is faint or absent when breathing in CARDIAC TAMPONADE Severe Asthma
40
What presents with Slow Rising/ Plateu pulse?
Prominant in carotids and brachials AORTIC STENOSIS LVF
41
What presents with Collapsing Pulse?
Waterhammer-Corrigan's Lift arn up vertically-hold muscular forarm, should feel tapping over muscles AORTIC REGURGITATION PDA Hyperkinetic e.g. exercise, fever, thyrotoxic, pregnancy
42
What presents with Pulsus Alternans?
Regular alternation of the arterial pulse SEVERE LVF
43
What presents with Bisferiens Pulse?
Double pulse x2 systolic beats MIXED AORTIC VALVE DISEASE
44
What presents with a Jerky Pulse?
HOCM
45
Where is Right Ventricular hypertrophy detected?
4th intercostal space in left parasternal area (right ventricular heave)
46
What is Transfusion Haemosiderosis?
Deposition of iron in heart (and endocrine organs) can lead to heart failure
47
What is Cardiomyopathy?
Muscle becomes hard and thick and is sometimes replaced by scar tissue
48
What are the Primary Cardiomyopathies?
Predominantly affect the heart Genetic: A.D - Hypertrophic Obstructive (HOCM) - Arrhythmic Right Ventricular Dysplasia (ARVD) Mixed Cardiomyopathies: Genetic predispositon to cardiomyopathy which is triggered by a secondary process - Dilated Cardiomyopathy - Restrictive Cardiomyopathy Acquired Cardiomyopathies: - Peripartum - Takotsubo
49
What is Hypertrophic Obstruction Cardiomyopathy?
``` Defects in the genes encoding for CONTRACTILE PROTEINS - B-myosin heavy chain - myosin-binding C protein - cardiac troponin T 1/500 ```
50
What are the features of Hypertrophic Obstruction Cardiomyopathy?
``` Asymptomatic but: - Dyspnoea - Angina - Syncope - Sudden death Arrhythmias -> ventricular Heart failure: preserved ejection fraction ``` ``` Jerky pulse Large 'a' waves on JVP Double apex beat Ejection systolic murmur: increased during valsalva manouver and decreased when squatting 4th heart sound ```
51
What are the features of Hypertrophic Obstruction Cardiomyopathy on ECG?
- LV hypertrophy - Progressive T wave inversion - Deep Q waves - AF occasionally
52
What are the features of Hypertrophic Obstruction Cardiomyopathy on ECHO?
MR SAM ASH MR - Mitral Regurgitation SAM - Systolic Anterior Motion of Anterior ASH - Asymmetrical Septal Hypertrophy
53
What is Arrhythmic Right Ventricular Dysplasia?
RV myocardium replaced by fatty and fibrofatty tissue | ~50% have a desmosome gene mutation
54
What are the features of Arrhythmic Right Ventricular Dysplasia on ECG?
ECG: V1-V3 - T wave inversion - Epsilon wave - terminal notch in QRS
55
What is Dilated Cardiomyopathy?
Dilated heart leads to systolic (with or without diastolic) dysfunction leads to enlarged heart with or without thickening 1/3 have genetic predisposition no congenital, ischaemic or valve disease
56
What are the features of Dilated Cardiomyopathy?
Reduced ejection fraction Arrhythmias Emboli Mitral Regurgitation
57
What is Restrictive Cardiomyopathy?
Walls of heart are rigid (not thickened) - restricted from stretching and filling
58
What are the features of Restrictive Cardiomyopathy?
``` Tiredness Leg swelling Shortness of Breath Chest pain Fainting ```
59
What are the Complications of Restrictive Cardiomyopathy?
Heart failure Valve disease Irregular heart beat
60
What is Loeffer Endocarditis?
Restrictive cardiomyopathy affects the endocardium | WBC proliferation - specifically eosiniphils
61
What is Peripartum cardiomyopathy?
Last month of pregnancy until 5 months post-partum Older women, greater parity and multiple gestation
62
What is Takotsubo?
'Stress-induced' e.g. traumatic events leading to chest pain (can mimic Anterior MI) and heart failure which is temporary Transient, apical ballooning of the myocardium Supportive treatment
63
What are the Secondary Cardiomyopathies?
pathological myocardial involvement due to a generalised systemic disorder e.g. ``` Amyloidosis SLE Haemachromatosis Sarcoidosis Myotonic dystrophy DM Thyrotoxicosis Acromegaly Alcohol Thiamine-VitB1-Wet Beri Beri Coxsackie B Chagas ```
64
What are the Early Diastolic Murmurs?
``` Aortic Stenosis Pulmonary Stenosis HOCM (loudest standing and during vagal, quietist squatting) ASD Fallot's ```
65
What are the Pan Systolic Murmurs?
Mitral Regurgitation Tricuspid regurgitaton VSD 'harsh'
66
What are the Late Systolic Murmurs?
Mitral Valve Prolapse | Coarctation of the Aorta
67
What are the Early Diastolic Murmurs?
Aortic Regurgitation Pulmonary Regurgitiation Graham-Steel
68
What are the Pan Diastolic Murmurs?
``` Mitral Stenosis (L lateral) Austin-Flint ```
69
What is a Graham-Steel Murmur?
Mitral Stenosis + Pulmonary HTN + Pulmonary Regurgitation | Mitral stenosis causes pulmonary HTN causes Pulmonary regurg
70
When is S3 heard?
Ventricle filling Normal in young and women <50 Pathological causes: - LVF e.g. in dilated cardiomyopathy - Contstrictive pericarditis - pericardial knock - Mitral Regurgitation
71
When is S4 heard?
Atrial contraction against a stiff ventricle - HOCM (double apicle impusle due to palpable S4) - Aortic Stenosis - HTN
72
What are the features of an Aortic Stenosis murmur?
Best heard RSE and radiate to carotids and apex on EXPIRATION Syncope Angina Dyspnoea (exertional) Associated with: - Slow rising pulse - Narrow pulse pressure - Heaving apex beat - Soft or absent S2 - May have LVF w/ S3
73
What are the causes of an Aortic Stenosis murmur?
- Senile calcification - Congenital bicuspid valve e.g. in Turner's - Rheumatic - HOCM
74
What is the differentiating feature of an Aortic Sclerosis murmur?
Doesn't radiate
75
What are the features of an Aortic Regurgitation murmur?
Early diastolic RSE or LSE sitting forward - Fatigue - SOB - Syncope - Exertional Dyspnoea - Orthopnea - Paroxysmal Nocturnal Dyspnoea Associated with: - Collapsing pulse - Wide pulse pressure - Displaced apex - Quinke's sign: pulsation in nails - Corrigan's sign visible carotid pulsation
76
What are the causes of an Aortic Regurgitation murmur?
Acute: - IE - Aortic dissection Chronic: - CT disorders - Ank Spon - RA - Congenital - HTN
77
What are the features of a Mitral Regurgitation murmur?
Best heard in apex and radiates to left axilla Expiration - Dyspnoea - Fatigue - Palpitations Associated with: - AF - Displaced thrusting apex due to volume overload - Soft S1 - LVF S3 - Pulmonary HTN
78
What are the causes of a Mitral Regurgitation murmur?
``` Papillary muscle dysfunction e.g. after an MI Dilated cardiomyopathy Rheumatic Infective Endocarditis Congenital CT ```
79
What are the causes of JVP 'A' wave changes?
Atrial Contraction Large in: Tricuspid Stenosis Pulmonary Stenosis Cannon in: contraction against a closed Tricuspid Complete heart block VT/Ectopics Nodal Rhythm Absent in: AF
80
What is the JVP 'C' wave?
Closure of the Tricuspid valve
81
What are the causes of prominant JVP 'X' and 'Y' wave?
Fall in atrial pressure in ventricular systole - Constrictive pericarditis - Restrictive cardiomyopathy
82
What is the cause of an absent 'Y' wave?
Cardiac Tamponade
83
What is the cause of a giant JVP 'V' wave?
Filling of atria when tricuspid valve closed | Tricuspid regurgitation
84
What are the causes of a raised JVP?
Constrictive pericarditis: Kussmaul's: paradoxically raised in JVP during inspiration Left ventricular free wall rupture (with pulsus paradoxus and reduced heart sounds) Raised non-pulsatile JVP in SVC obstruction
85
What is Anaphylaxis?
Severe lifethreatening and generalised type 1 IgE mediated hypersensitivity reaction
86
What are the features of Anaphylaxis?
SERUM TRYPTASE HIGH FOR 12 HOURS Capillary leak: - Urticaria - Erythema Oedema: - Larynx - Lids - Tongue - Lips Cyanosis Wheeze Laryngeal obstruction
87
How is Anaphylaxis managed?
Secure airway, 100% O2 Adrenaline: 500mcg (0.5ml 1:1000) every 5 minutes into the ANTEROLATERAL MIDDLE 1/3 THIGH IM Hydrocortisone 200mg CLORPHENAMINE 10mg (continue 4mg/6hours if still itchy) 0.9% Saline 500ml over 5min up to 2 litres
88
What is Pericardial Effusion and when does it occur?
Accumulation of fluid in the pericardial sack as a result of Heart Failure ``` Vascular: Nephrotic syndrome Idiopathic Trauma AI: Dressler's syndrome Met: Uraemia I Neoplasm D ```
89
What are the features of Pericardial Effusion?
- Dyspnoea - Raised JVP - Bronchial breathing
90
What are the features on ECHO, CXR and ECG?
Enlarged 'water-bottle heart' Echo-free zone surrounding Low QRS Pericardiocentesis to determine bacterial cause
91
What is Cardiac Tamponade and what can cause it?
Accumulation of pericardial fluid causing a rise in intercardial pressure, heart doesn't fill, cardiac output falls - Biopsy - Transeptal rupture - Warfarin - Aortic dissection
92
What are the features of Cardiac Tamponade?
- Dyspnoea - Tachycardia - HoTn - Pulses Paradoxus (abnormally large fall in systolic BP + pulse wave amplitude during INSPIRATION) ABSENT Y WAVE on JVP Beck's triad: - Low arterial BP - Distended neck veins - Muffled heart sounds
93
What is Acute Pericarditis and what causes it?
Inflammation of the pericardium due to: - MI - CT diseases - Viruses e.g. Coxsackie, HIV, EBV, Flu, Varicella - Bacteria e.g. TP, Pnuemonia, Rheumatic, Staph and strep - Fungi - Drugs
94
What are the features of Acute Pericarditis?
Central chest pain - Worse on inspiration - Worse lying flat - Better sitting forward - Pleuritic: central, sharp, stabbing - Dyspnoea, Tachypnoea - Hear PERICARDIAL FRICTION RUB - Fever - Tachycardia
95
What are the diagnositic tests for Acute pericarditis?
WIDESPREAD SADDLE ST ELEVATION with PR depression Cardiomegaly if effusion 1/3 have raised troponin
96
What is Constrictive Pericarditis?
Heart encased in stiff pericardium, cause usually unknown ?TB
97
What are the features of Constrictive Pericarditis?
- RHF signs: ascites, oedema, hepatosplenomegaly - Soft apex beat - Pericardial knock: LOUD S3 KUSSMAUL'S SIGN: Paradoxical rise in the JVP on inspiration or JVP fails to fall JVP: PROMINENT X+Y CXR: PERICARDIAL CALCIFICATION
98
How is Acute Heart Failure managed?
- oxygen - diuretics (furosemide-higher doses in renal failure) - opiates (diamorphine) - vasodilators - inotropic agents - CPAP - ultrafiltration - mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices
99
What is Bradycardia and how does it present?
HR <60bpm - Dizziness - Syncope - Palpitations
100
What are the causes of Bradycardia?
SA Node Bradycardia (Sick Sinus Syndrome) due to fibrosis - SA Arrest - SA Block (1', 2', 3') - Tachy-brady syndrome AV Node block - 1', 2', 3' RBBB LBBB Bi and Trifasicular blocks
101
What is SA Node Arrest?
SAN fails to depolarise so atria and ventricles don't depolarise: NO QRS
102
What is SA Node Block?
Depolarises but not conducted to the atria ``` 1'-no changes 2' - Type I Wenckeback - Type 2 3' absent P ways ```
103
What is Tachy-Brady syndrome?
SA Node dysfunction leads to SVT Tachyarrhythmia Run of tachycardia followed by a run of bradycardia Tachycardia can either be ESCAPE RHYTHMS or EXISTING TACHY (e.g. AF with SAN remodeling)
104
What are the causes of AV Node Block?
``` AI Infective: endocarditis Acute MI: INFERIOR RCA Surgical: after ablation/valve surgery AI: Ankylosing Spondylitis Degenerative: - fibrosis - calcification of nearby valves Drugs: Digoxin, B Blockers, Ca channel blockers, anti-arrhythmics ```
105
What is 1' AV Node block?
Delayed conduction betwen the A+V through or around the AVN - Asymptomatic (pace if symptomatic) - P-R >5small squares (0.2s) but at a constant interval - Narrow QRS - Block within node - Broad QRS - Block in bundle of HIS
106
What is 2' AV Node block?
Partial conduction Some make it through MOBITZ TYPE 1 WENKEBACK P-R lengthens until no WRS Black usually within node Likely to progress MOBITZ TYPE 2 No elongation in P-R but QRS dropped occasionally e.g. every 3rd dropped = 3:1 block PACE
107
What is 3' AV Node block?
``` Complete heart block Complete dissociation of atrial and ventricular depolarisation No P-QRS relationship Narrow=Node Broad= Bundle of His ``` PACE
108
What is BBB?
Slowed conduction through ventricular system and higher If one bundle is blocked impulse is transmitted to the other ventricle by non-specialised vascular tissue in between
109
What are the causes of RBBB?
- Ischaemia - P.E - Rheumatic heart disease - Myocarditis - Congenital heart defects - Cardiomyopathy - Cor Pulmonale
110
What are the features of RBBB?
Wide QRS (>3sq, 0.12s) Secondary R wave (Ri) in V1 and V2 ST changes are COMMON so hard to comment on ischaemia SLURRED S in I/V5/V6 MORROW
111
What are the causes of LBBB?
- Cardiomyopathy - HTN - Coronary Artery Disease (acute anterior MI)
112
What are the features of LBBB?
Wide WRS R' in Absent Q in V5/V6 WILLIAM
113
What are the fascicular blocks?
Bifasicular block: - RBBB +R/L HEMIBLOCK (RBBB +R/L axis deviation) Trifasicular block: BIFASICULAR + 1' HB
114
What are the hemiblocks?
Anterior MC : Left axis deviation Posterior: Right axis deviation

FINALS (13 decks)

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