Cardiology Flashcards
Sinus arrhythmia (normal sinus pattern but with varying rate) is a sign of increased _____________.
vagal tone
Sinus arrhythmia is normal in ______________.
teenagers; no workup needs to be done unless there is concern that it is potentially symptomatic
PR interval is the distance from _________________.
the start of P to the start of R (or Q if there is a Q wave)
The QT interval is the distance from ________________.
the start of Q to the end of T
The QRS interval is the interval from ________________.
the start of Q to the end of S
How do you calculate the QTc?
QT / (square root of preceding RR)
What does the standardization box mean if the right half is shorter than the left half?
That the precordial leads are 1/2 height and the rest of the leads are normal.
Which type of graft lasts longer, saphenous vein or LIMA?
LIMA
LIMA lasts 10-15 years, SVG only 6-7.
________ makes it hard to estimate ejection fraction.
Atrial fibrillation
The beat-to-beat variation leads to different filling amounts which can make it hard to assess what the true EF is.
Studies have shown that treatment with prednisone increases the recurrence rate of what cardiac condition?
Pericarditis
As such, prednisone is typically reserved for refractory cases of pericarditis (i.e., those that don’t respond to therapy with colchicine and ASA).
ST elevations in leads II, III, and aVF are indicative of ischemia in the ____________.
right coronary descending branch
This pattern suggests posterior ischemia which affects the RV. Do not give NO.
The medical management of NSTEMI includes aspirin, heparin, and _____________.
P2Y-12 inhibitor such as ticagrelor or clopidogrel
The accessory pathway in WPW is the bundle of _______.
Kent
If possible, you should avoid cardioverting someone in atrial fibrillation if the onset might have been longer than ________ hours.
48
Of course, if someone is unstable and not responding to medications then cardiovert regardless of the time.
The initial management of flash pulmonary edema due to hypertension includes which antihypertensive?
Nitroglycerin boluses (up to 2 mg)
Flash pulmonary edema results from increased afterload, increased preload, and pulmonary congestion. Nitroglycerin decreases afterload, decreases preload, and relaxes the pulmonary vasculature.
ST elevation in I, aVL, V5, and V6 is most commonly from occlusion of the _____________.
the circumflex branch of the left coronary
ST elevation in V1 and V2 is commonly from occlusion of which branch of the LAD?
Septal branch
The LAD diagonal branch will cause ST elevations in which leads?
V2-V4
What are the indications of emergent PCI in an NSTEMI?
- Any ventricular arrhythmia
- Any arrhythmia that causes hemodynamic compromise
- Hypotension
- New heart failure
- Ischemic pain with maximal medical therapy
Review the criteria for diagnosing submassive PE.
- RV strain on echo
- Elevated BNP
- Elevated troponin
____________ occurs from a reentrant circuit around the tricuspid annulus.
Atrial flutter
What do the five letters of the AICD pacemakers mean?
1st: chambers paced
2nd: chambers sensed
3rd: inhibition function
4th: programmability
5th: anti-tachycardia functions (aka cardioverter/defibrillator)
What defines cardiogenic shock?
There is not a single discrete set of criteria that are agreed upon, but generally it is at least two markers of shock (decreased UOP, increased Cr, AMS, elevated lactate) in the setting of a known cardiac diagnosis with worsening or an acute cardiac event.
There are RHC criteria that can also define cardiogenic shock.
Normal SvO2 of mixed venous blood (in the R heart) is ______%.
75-80
Central line SvO2 may be a little lower, like 75%.
Normal SaO2 is ______%.
97
Cardiogenic shock generally happens at cardiac indices less than ________.
2.2 L/min/m2
A patient presents post-PCI with SOB and chest pain. Other than ACS, what could be happening?
Post-PCI tamponade from a perforated coronary
Review the etiologies of cardiogenic shock.
Myopathies:
- Decompensated CHF
- Infiltrative disease (like amyloidosis)
- Myocarditis
Ischemia
- MI
Valvular:
- Acute mitral regurgitation
- Acute aortic insufficiency
- Severe aortic stenosis
Pericardial:
- Tamponade
- Constrictive pericarditis
Review the etiologies of cardiogenic shock.
Myopathies:
- Decompensated CHF
- Infiltrative disease (like amyloidosis, sarcoidosis, hemochromatosis)
- Myocarditis
Ischemia
- MI
Valvular:
- Acute mitral regurgitation
- Acute aortic insufficiency
- Severe aortic stenosis
Pericardial:
- Tamponade
- Constrictive pericarditis
You’re worried about cardiogenic shock in the ED. What workup should you do to help differentiate this?
- EKG
- CMP, CBC, trop, lactate, ABG, BNP
- Central line SvO2
- POCUS, CXR
Rule out other causes of shock PRN.
Which pressor should not be used in cardiogenic shock?
Vasopressin
What is Impella?
It is a mechanical circulatory support (MCS) device that is inserted into a peripheral artery and passed into the LV. It sucks blood into itself from the LV and dumps it into the aorta.
It can provide more improvement to cardiac output than IABPs.
The two afterload agents that you should start in cardiogenic shock are ___________.
nitroprusside and hydralazine
Other than widened mediastinum, what are some other radiographic findings of aortic dissection?
Rightward displacement of the trache
Downward displacement of the left mainstem bronchus
Review the four classes of aortic transection.
I: intimal tear
II: transmural hematoma
III: pseudoaneurysm
IV: rupture
In aortic dissections, keep HR _____________.
60-80
What will CT show in cardiac contusion?
Nothing usually.
POCUS can sometimes show WMAs, but those are non-specific for contusion.
Cardiac contusion is a clinical diagnosis based on mechanism of injury combined with elevated troponin, chest pain, and/or unexplained tachycardia.
What is pulsus paradoxus?
Decreased BP with inspiration
The decreased intrathoracic pressure pulls more blood/fluid into the pericardial space and thus decreases RV preload further.
The mediastinal should not be wider than _______ cm.
8
What things should you assess in an LVAD patient with a decompensation?
- Is the LVAD on and working? Listen to the hum of the device in the chest and check the box.
- Is there evidence of clot? Look at the device and see if there is increased resistance.
- Is there evidence of infection? Check for redness/erythema and cultures.
Review the causes of sinus tachycardia.
Decreased oxygen-carrying:
- Anemia
- Hypoxia (PE, PNA, CHF)
Decreased volume
Cardiac dysfunction:
- ACS
- Tamponade
- Valvular disease
Increased demand:
- Fever
- Sepsis
- Acidosis
Medication:
- EtOH or drug withdrawal
- Sympathomimetic drugs
- Anticholinergic drugs
Psych:
- Anxiety
- Pain
Misc:
- Hyperthyroidism
Review the management of stable and unstable SVT.
Stable:
- First line: vagal maneuvers
- Second line: adenosine 6 mg IV or IO
Unstable:
- Synchronized cardioversion (120 - 200 J)
Review the causes of AF.
PIRATES
- PE
- Ischemia
- Respiratory distress
- Anemia
- Thyroid dysfunction
- EtOH
- Sepsis
When would you cardiovert a stable AF patient?
If the onset is known and is less than 48 hours or if you confirm that they don’t have a clot on TEE.
Low voltage cardioversion is often successful in which arrhythmia?
A flutter
Often as low as 25 J can work.
True or false: defibrillate stable torsades de pointes refractory to magnesium.
False
Perform synchronized cardioversion.
Review the etiologies of ventricular tachycardia.
Ischemia
CHF
Trauma
Hypothermia
Electrolyte disturbances
QT-prolonging drugs
True or false: synchronized cardiovert pulseless V tach.
False
Defibrillate pulseless VT. Cardiovert unstable VT.
What is the dose of procainamide for stable VT?
100 mg IV over 2 minutes
What infections can cause AV node blockade?
Myocarditis
Lyme disease
If the rhythm is regular, then you know the type of heart block must be _______________.
either 1st or 3rd degree block
What is Levine’s sign?
Clenched fist over sternum — an old sign for MI
What is the mortality from STEMI at 45 minutes vs 200 minutes?
3% vs 9%
“Chest pain plus” should make you think of…
Aortic pathology
Ask about pain elsewhere in the body (neck, throat, arms, back, abdomen, legs), paresthesias, numbness, and weakness elsewhere.
How should you treat SVT in a pregnant woman?
Same as in non-pregnant women
The data on adenosine affecting fetuses is just case report level but suggests that it does not hurt them. Shocking by is unclear but if the mother is unstable then the baby is unstable and you should not wait.
What are the two life-saving interventions in flash pulmonary edema?
- BiPAP
- Nitrates
Why do nitrates help flash pulmonary edema?
Flash pulmonary edema happens because of a positive feedback cycle in the adrenergic system. When cardiac output decreases in someone with CHF, the adrenergic system ramps up to try to increase CO. With a failing heart, sometimes the adrenergic system has more affect on the systemic vascular resistance and not the heart. This increases afterload without increasing contractility. Increased afterload also increases preload which overflows the heart and leads to worse pulmonary congestion. Fluid then begins to accumulate in the lungs and that stimulates more adrenaline which perpetuates the problem further.
Nitroglycerin decreases afterload quickly reduces both afterload and preload, correcting both problems.
What dose of NO is given in flash pulmonary edema?
You can give 0.4 mg every 5 minutes orally. You can also give a drip at a rate of 40-400 mcg/minute
The three most common causes of CHF in the US are what?
Ischemia
HTN
Valvular disorders
When a person presents in a CHF exacerbation, what dose of Lasix should you start in the ED?
If they are on Lasix already, then do IV at the same dose they take orally (so effectively twice the dose). If they are not on Lasix and have no renal dysfunction then you can start low, at 20 mg IV.
What is the EMRAP approach to ECGs?
1) Is it too fast or too slow? If so then go to tachycardia and bradycardia algorithms.
2) If it’s a normal rate, are there any emergency features?
- ST elevation or depression
- QRS widening
- T wave rising or flipping
The formal name for benign ST elevation is ___________.
benign early repolarization
When you see peaked T waves, you next should look for ____________.
bradycardia and widening of QRS
One feature of peaked T waves that is worrisome is that they are ______________.
pointy, symmetric, and big relative to the QRS complex
STEMI is usually _________ at the top of the wave.
rounded (whereas hyperkalemia is very pointy and benign early repolarization is mildly pointy)
What is the de Winter T wave?
It is a tall, peaked T wave that looks like hyperkalemia but is actually from a developing STEMI. The telltale findings are slight ST segment depression and that the waves will quickly change to more rounded, tombstone-like waves on subsequent ECGs.
What are ECG signs that ST segment elevation is benign?
- Notching between the R wave and the ST complex
- J waves
- Concave upward sloping of the ST complex
- Slurring of the wave between the R wave and the T wave
- Lack of reciprocal depression
- Nonvascular territory
- Absence of Q waves and T-wave inversion
Review the EMRAP approach to ECGs in the setting of syncope.
Active things:
- Arrhythmia
- Ischemia
- PE
Latent things:
- Structural: LVH, ARVD
- Electrical: WPW, Brugada, QT prolongation
- Just don’t forget that aortic stenosis can also cause syncope, it just won’t appear on an ECG.
What are signs of ARVD (say, in the ECG of a person who came in with syncope)?
RBBB
Epsilon wave (an extra notch after the J wave)
T wave inversions in V1-V3
What is the pathophysiology of Brugada syndrome?
It is a sodium channelopathy.
Describe the Brugada morphology.
It is an RSR’ complex with J point elevation and a gently downsloping R wave into an inverted T wave (called “sharkfin”),
The classic strain pattern is ____________.
asymmetric T wave inversion (sloping down gently, rising quickly)
Needle-like Q waves is a sign of what disorder?
HOCM
There are four ECG signs of PE: ____________.
RAD, S1Q3T3, deep symmetric T waves in the precordial leads, and tachycardia
Particularly if any of the above are acute (i.e., you have an old ECG)
True or false: The QT interval goes to the beginning of T.
False
It is from the beginning of Q to the end of T.
What is overdrive pacing?
Pacing someone at a faster rate to make the heart always be refractory and unable to develop arrhythmia (used in TDP).
Athlete’s heart presents with what two things on ecg?
Bradycardia and PR prolongation
A “mid-diastolic rumble” is typical of which cardiac pathology?
Mitral stenosis
Patients who develop atrial fibrillation after ______________ are likely to convert to sinus in a couple days.
cardiac surgery
That being said, if someone develops post-operative atrial fibrillation then they are more likely to have other underlying disease and are at high risk of recurrence.
True or false: chest pain that radiates to the right side is less worrisome than non-radiating chest pain.
False
Any kind of radiating pain is more worrisome than non-radiating pain. It doesn’t matter where the pain radiates to.
Rhythmol is what drug?
Propafenone
What is a suction event in a person with an LVAD?
The LVAD sucks blood out of the LV. If the person is dehydrated then the pump can suck the LV wall. This presents often with pump failure (so cardiogenic shock) and tachyarrhythmias.
Why is echo helpful in an LVAD patient with crisis?
You need to know if they are hypovolemic, have RV failure, or if the pump has signs of failure:
- Hypovolemic: small LV and RV
- Possible pump failure: big LV and RV
- RV failure: small LV, big RV
Which gene is most commonly mutated in HOCM?
Beta myosin heavy chain
What are the doses of cardioversion for pediatric SVT?
0.5-1.0 J/kg
Remember “2, 4, 6, 8, that’s how we defebrillate” and then just like in adults, the dose for cardioversion is 1/2 that of defibrillation.
In addition to rib notching, you can also see __________ on CXRs of those with aortic coarctation.
the “3 sign”
This is when you notice a notch in the aorta that make the arch look like a 3.
Review the ECG and significance of the de Winter pattern.
The de Winter pattern happens in occlusions of the proximal LAD. It presents with ST elevations in aVR and tall T waves with or without ST depression in V2-V4.
It is a STEMI equivalent.
True or false: cardiovert pulseless VT.
False
Defibrillate w/ 200 J.
True or false: cardiovert TDP.
False
Defibrillate w/ 200 J.
The bottom line is
What three conditions do you need to defibrillate?
VF, pulseless VT, and TDP
What doses of shock should you give stable VT?
Synchronized cardioversion 100 J followed by 200 J
What is the gtt equivalency of nitroglycerin paste?
0.5 inch: 5 mcg/min IV
1.0 inch: 10-39 mcg/min IV
1.5 inch: 40-59 mcg/min IV
2.0 inch: 60-100 mcg/min IV
If a person with SCAPE fails NO tablets and needs a drip, how should you start?
Bolus of 1000-2000 mcg followed by gtt starting at 400 mcg/min titrated to BP and symptoms. The max NO gtt rate is 800 mcg/min
Once you start a NO gtt for SCAPE, remember to do what?
Frequently reassess their BP. People in SCAPE are likely to have their BP normalize quickly (such as in minutes to hours). When their SBP gets to the ~140s-150s, cut the NO in half and reassess soon.
A person presents with SCAPE. You start PPV and then ask what critical question?
Are you a PDE inhibitor?
Nitroglycerin is one of the key medicines in SCAPE, but it cannot be given if they are on Viagara, Cialis, or a PAH med.
If a person with SCAPE has refractory HTN on max NO drip, then check their _______ and start _________.
PPV; clevidipine
Transient hypotension is common in the treatment of SCAPE. If this happens, do what?
Stop all of their HTN meds (NO gtt or paste most commonly) and then consider a fluid bolus. Remember that people are usually euvolemic when they start to develop SCAPE so it won’t likely make it worse.
The key with SCAPE is that it is _______-onset.
rapid/sudden
One subtle finding of early MI is loss of the ______ wave.
S
If there should be an S wave (such as V3) and there is not, then be considered for early ischemia.
What are the first-line antihypertensive agents for the following demographics?
- Those with CKD
- Black people
- All others
- CKD: ACEi
- Black: CCB or thiazide
- All others: Thiazide
Pericarditis pain classically improves when ___________.
sitting forward
Review the differential diagnosis for bradycardia.
- Metabolic: hyperkalemia, hypoglycemia
- Iatrogenic: CCBs, beta-blockers, digoxin
- Ischemia: RCA MIs
- Sick sinus syndrome
- Hypothermia
- Neurogenic shock
- Increased vagal tone (athletes, people in pain, vagal maneuvers like BM/micturition/cough)
The dose of amiodarone for stable VT is _____________.
150 mg over 10 minutes
What is marantic endocarditis?
A non-infectious, thrombotic endocarditis seen in those with malignancy
What is the CHESS rule for high-risk syncope?
It comes from the San Francisco syncope guidelines. Any feature below makes syncope high risk:
- CHF (structural heart disease)
- Hgb low
- ECG abnormal
- SOB
- SBP < 90 mm Hg
Review the Sgarbossa criteria for STEMI in an LBBB.
Concordant ST elevation > 1 mm in positive QRS leads
Concordant ST depression > 1 mm in leads V1-V3
Discordant ST elevation > 5 mm
Why isn’t NO given to children with CHF?
It is more common to cause severe hypotension in children.
In a RBBB, the _________ part of the RSR’ complex is always wider.
second (i.e., the R’)
IABP cannot be used in patients with which type of valvular pathology?
Aortic insufficiency
IABPs put additional afterload to help perfuse the coronaries. That only works if the aortic valve can close. If it cannot close then blood will push back into the heart and skip the coronaries.
In LBBB, the V1 wave will be ___________ (positive or negative).
negative
How can you know if an EKG wave is positive if it is unclear?
Look to the left of the EKG and trace out where the baseline is – this is the isoelectric axis.
Slurred S wave w/ hyperacute T waves = _____________.
hyperkalemia
When all the waves look “slurry”, think _________.
hyperkalemia
The nodal tissues are sensitive to which electrolyte?
Calcium (hence CCBs)
The ventricular tissues are sensitive to which electrolytes?
Potassium and magnesium
Review the causes of atrial fibrillation.
- Structural heart disease: valvular stenosis/insufficiency, CHF, age-related fibrosis of the atria
- Pulmonary stress: PE, pulmonary HTN, PNA
- Damage to myocytes: ischemia, myocarditis
- Toxins: alcohol intoxication, alcohol withdrawal, cocaine
- Metabolic problems: potassium and magnesium derangements
- Catecholaminergic stress: sepsis, hyperthyroidism
Atrial fibrillation can be cardioverted only if two criteria are met: _______________.
present less than 48 hours or anticoagulated for at least 3 weeks
What kind of shock is given to those in atrial fibrillation?
Synchronized 50-100 J
Review the two ways of dosing diltiazem (Cardizem) for atrial fibrillation.
- Weight-based: 0.25 mg/kg first dose -> 0.35 mg/kg second dose
- Non weight-based: 20 mg first dose -> 25 mg second dose
Review the causes of bradycardia.
- Electrophysiologic disorders: SSS, heart block
- Ischemia (RCA or LAD lesions)
- Hyperkalemia (CKD or hyperk drugs)
- Toxins (BCCDO: beta-blockers, CCBs, clonidine, digoxin, organophosphates)
- Hypothermia
- Hypothyroidism
- CNS causes (bleed, tumor)
- Vagal stimulation (pain, micturition, bowel movement)
An epsilon wave – which appears as a small positive wave between the S and ST waves – is pathognomonic for what condition?
ARVD (arrhythmogenic right ventricular dysplasia)
What is the De Winter pattern?
The De Winter pattern is a STEMI equivalent that happens in the case of a proximal LAD lesion. It presents with ST-segment depression followed by peaked T waves in the precordial leads.
What drug should be given to neonates with ductal-dependent cardiac anomalies?
Alprostadil 0.1 mcg/kg/min
What is the most sensitive pattern for ARVD?
T-wave inversions in V1-V3 in the absence of RBBB
Epsilon waves are the most specific but are seen in only 25%.
The triad of EKG findings for WPW are _______________.
delta waves, wide QRS, short PR
Review the differences in orthodromic and antidromic WPW.
Orthodromic passes through the AV node in the normal way (top to bottom) and then circulates from the ventricles to the atria through the bundle of Kent. Antidromic does the opposite.
True or false: first-degree heart block in the absence of other evidence of heart disease has not been shown to lead to a higher risk of adverse outcomes.
True
In those with heart disease, however, first-degree heart block has been shown to lead to more advanced forms of heart block.
How do initial HTN meds differ by race?
Black people benefit from thiazides or CCBs, whereas other people show benefit from ACE, CCBs, or thiazides. People with CKD should take ACEi.
Running a magnet over an AICD does what?
Stops shocks (if a patient is being shocked inappropriately)
ST elevation in II, III, and aVF indicate ________ infarction.
inferior
What kind of endocarditis is seen in SLE patients?
Sterile thrombi
Called Libman-Sacks endocarditis.
The circumflex originates off of which coronary artery?
Left main
The left main originates off of the aorta and then bifurcates into the LAD (the anterior interventricular artery) and the circumflex.
STEMI in which leads is most associated with papillary muscle rupture?
II, III, and aVF
Inferior wall STEMIs cause reciprocal depressions in which leads?
I and aVL
How can you differentiate between Dressler syndrome and infarct pericarditis?
Infarct pericarditis is localized and occurs within a couple of days of the MI. Dressler syndrome is generalized pericarditis and presents 2-10 weeks later.
What condition can cause slow atrial fibrillation?
Myxedema coma
What three diagnoses do you need to exclude to diagnose takatsubo cardiomyopathy?
- Ischemic CAD
- Myocarditis
- Pheochromocytoma
ST has to be more elevated in which leads to count as STEMI (per AHA)?
V2 and V3 (1.5 mm in women, 2.0 mm)
__________ is the reciprocal for the inferior leads.
aVL
You see a STEMI. What EKG feature is suggestive of poor long-term prognosis?
Q waves
True or false: Complete heart block is irregular ventricular rate.
False
CHB is regular.
Which arteries supply the AV node?
RCA (80%)
Circumflex (20%)
Describe the De Winter pattern.
ST depression with hyperacute, symmetrical T waves
The De Winter pattern can be caused by the occlusion of which vessel?
LAD
The initial push bolus effect of amiodarone is what?
AV node blockade
A patient with STEMI has significant ectopy. What drug can you give them?
Lidocaine
You should only cardiovert stable AF if the patient is anticoagulated or symptoms have reliably been present for less than ________.
48 hours
If a patient is unstable you can cardiovert, but there is a risk of stroke.
For evaluating a neonate with suspected PDA-dependent anomaly, a pre-/post-ductal difference greater than ___% is suggestive of anomaly.
10
What are the pathophysiological mechaniisms of SVT?
- PAC or PVC triggering depolarization abnormalities
- Irritability of heart tissue (catecholamines, dehydration) causing an ectopic focus
What is the difference between atrial tachycardia and MFAT?
Atrial tachycardia will be narrow, regular, and have P waves (which differentiates it from AVRT/AVNRT) that are morphologically different (in II, III, and aVF). MFAT will be narrow, irregular, and have several morphologies of P waves.
What is the big differentiating factor between orthodromic and antidromic WPW AVRT?
Antidromic is wide, regular (like VT)
Why should you have patients cough when they’re having non-perfusing rhythms?
It temporarily increases afterload that helps perfuse the coronaries and the brain.
An oversensing pacer will show what on tele?
No pacer spikes. It thinks your heart is pumping so it doesn’t fire.
Which SVT is most sensitive to cardioversion?
Atrial flutter (sometimes as low as 25-50 J)
True or false: young patients often require higher doses of adenosine for DVT.
True
Maybe even up to 18 mg.
What are features that suggest VT (as opposed to SVT with aberrancy)?
H/o structural heart disease
NW axis
Concordance
Starts with PVCs
Capture beat
Unusual morphology (I.e., not BBB)
AV dissociation (P ways not corresponding to QRS complexes)
What drug prevents VT (rather than aborting it)?
Amiodarone
It works over hours, whereas lidocaine and procainamide work over minutes.
Other than magnesium and holding QT drugs, what can you do to prevent Torsades?
Rate control
QT prolongs more at lower heart rates. Keeping them faster (with isoproterenol or pacing) can keep them out of Torsades. HR goal 100.
What are the six concerning features of EKG for cardiac syncope (in a young person)?
WPW delta waves
Long QT
ARVD
HOCM
Brugada
Lown-Ganong-Levine (short PR)
How can you tell a defibrillator vs a pacer on an X-ray?
Defibrillators have coils over the tips which look thicker and dense on XR.
What does putting a magnet over an ICD do? What does it do for a pacer?
ICD: stops inappropriate shocks
PM: causes the device to pace asynchronously (which corrects for if the device is not pacing)
What is electrical storm?
3 or more times of shocking VT/VF without cardioversion
Why should you be careful with fluid resuscitation in those with massive PE?
Their RV is failing because of obstruction, not hypovolemia.
The D-sign on POCUS occurs during which of the cardiac phases?
Diastole
Give thrombolytics to STEMI if the anticipated time to catheterization is going to be ________.
over 120 minutes
What is the dose of alteplase for STEMI?
15 mg bolus followed by two weight-based drips:
1) 0.75 mg/kg over 30 minutes
2) 0.5 mg/kg over 60 minutes
The most common etiology of AIVR is what?
Reperfusion of the myocardium
The recommended door to balloon time for STEMI is ____ minutes.
90
Goal INR for mechanical heart valve?
2.5 - 3.5
Review the types of IA, IB, and IC antiarrythmics.
IA: quinidine, procainamide
IB: lidocaine, mexilitene, and phenytoin
IC: propafenone, flecainide
The most common cause of viral myocarditis is _______________.
Parvovirus B19
The two kinds of capture for pacing are what?
Electrical capture (every pacer spike is followed by a widened QRS) and mechanical capture (patient’s pulse matches the rate of the pacer)
Compare epinephrine and atropine for bradycardia.
Atropine does not work on AV nodal blocks, so it frequently does not work. Epinephrine works on the whole heart and is generally better, but it does have more systemic effects.
Which bradycardic patients do not respond well to pacing and epi?
Those with an extra-cardiac causee of bradycardia – hyperkalemiia, hypoglycemia, hypothermia, toxidrome, and hypothyroidism.
What is the push dose of epinephrine for bradycardia?
20-50 mcg
What are the proper positions for pacer pads?
Anterior posterior or apex and base
Which has a worse prognosis in bradycardia, narrow or wide QRS?
Wide
These are usually infranodal and require a paceeer.
The De Winter pattern suggests disease in which vessel?
LAD
What is the treatment for AIVR?
Usually just observation – it is a hemodynamically stable rhythm. Amiodarone can result in dysrhythmias.
Pneumomediastinum is most commonly seen in pediatric patients with _____________.
asthma
What are the three risk categories of HEART score?
0-3: low risk (0.9 - 1.7 % chance of MACE in 30 days), likely safe for DC from an ACS standpoint
4-6: moderate risk (12 - 16% chance of MACE in 30 days), discuss admission for observation and testing
7-10: high risk (50 - 60% chance of MACE in 30 days), offer admission and potential urgent catheterization
What is the weight-based dosing of IV nitroglycerin for flash pulmonary edema?
1 - 5 mcg/kg/min
Where do leads V7-V9 go?
All on the back
V8 is right below the tip of the scapula
True or false: a remote history of smoking contributes to risk in the HEART score.
False
Only smoking in the past 3 months.
True or false: squatting worsens the murmur of HOCM.
False
Squatting increases venous return (like leg raise), so it decreases the HOCM murmur. AS worsens with squatting.
The only lead that looks directly at the RV is ______.
V1
Review the EMRAP method of emergency EKGs.
1st: Rate – is it too fast or too slow? If so then address this first!
2nd: Scary features – ST elevation/depression, wide QRS, or peaked Ts.
Full dose aspirin given early in the course of MI has been shown to lead to a _____% reduction in 30-day mortality.
23
The bundle of His is _____________ (proximal or distal) to the LBB.
proximal
It goes SA node -> AV node -> bundle of His -> LBB -> Purkinje fibers.
True or false: sporadic capture beats make a rhythm more likely to be SVT with aberrancy rather than VT.
False
A sporadic capture beat in a run of wide complex tachycardia is more concerning for VT (because it shows that the QRS complex is normal when not in the VT rhythm).
How can you tell the difference between oversensing and slow backup pacing?
Oversensing will show too few ventricular paces, whereas backup shows low but sufficient pacing.
Syncope in AFib/AFlut is usually caused by ____________.
conversion pauses
What is the formula for max sinus heart rate?
220 - age
What is the half-life of amiodarone?
59 days
It is given as a bolus and drip because of it’s quick lipophilic redistribution.
Why is amiodarone so toxic?
It is lipophilic and has a high binding of tissues.
What is this murmur?
L sternal border 3rd intercostal, diastolic high pitched
Aortic regurgitation (look for the widened pulse pressure!)
What features make chest pain high risk for ACS?
- Patient reported similarity to prior ischemic episode (odds ratio ~3.5)
- Exertional chest pain (odds ratio ~2.8)
- Radiation of chest pain to both arms or right arm (odds ratio ~2.5)
If you are at a facility that does not have PCI, what is the maximum assessment-to-intervention time for transfer (after which you should give tPA)?
120 minutes
List three ECG findings of hypertrophic cardiomyopathy.
- Left axis deviation
- Left atrial enlargement (two-humped P wave in II)
- Q waves in the inferior leads (aVF, II, III)
What is the pathognomonic arrhythmia of digoxin overdose?
Bidirectional VT
Look for a wide QRS tachycardia that alternates axis every other beat.
Review the order of EKG changes in hyperkalemia.
1) Peaked T
2) Flattened P
3) Widened QRS + bradycardia
4) Sine wave
Antidromic WPW looks like what other dysrhythmia?
VT
Review the original and modified Sgarbossa criteria.
Original:
- Concordant ST elevation (i.e., positive QRS complex, ST segement elevated compared to PR)
- Concordant ST depression (i.e., negative QRS complex, ST segment depressed compared to PR)
- Greater than 5 mm discordant ST elevation in any lead (i.e., negative QRS complex with ST > 5 mm higher than PR segment).
Modified:
- Concordant ST elevation > 1 mm in any lead
- Concordant ST depression > 1 mm in V1-V3
- ST elevation to QRS height ratio > 0.25 (meaning you measure the height of the QRS complex from the PR and compare that to the ST segment to PR)
True or false: carcinoid syndrome is the most common cause of tricuspid stenosis.
False
The most common cause is rheumatic heart disease.
The AHA says that lytics should be given to STEMI transfer patients if the door-to-balloon time is expected to be greater than what?
120 minutes
How does runaway pacemaker present on EKG?
Multiple pacer spikes that don’t conduct
Review the Sgarbossa criteria.
Concordant ST elevation > 1 mm (ST and QRS go up)
ST depression in V1-V3 > 1 mm
Discordant ST elevation (QRS down, ST up) > 5 mm
What patient factor leads to decreased levels of BNP?
Obesity
What is the pathogenesis of ARVC?
Desmosome abnormality that leads to fibrofatty infiltration of the myocardium
Which medication class may increase mortality in myocarditis?
NSAIDs
What degree of ST depression is needed for clinical significance?
0.5 mm
Type II heart block is often seen with a prolonged _______.
QRS (from BBB)
Review the system for pacemaker nomenclature.
Chamber Paced - Chamber Sensed - Response to sensing
Think “Pacers Should Respond” for chamber Paced, chamber Sensed, and Response.
So a VVI (the most basic pacer) means that the ventricle is paced and sensed. When it senses a depolarization it Inhibits the pacer.
What is the mnemonic for classes of antiarrhythmics?
Simply Block the Proper Channel
I: sodium channels
II: beta blockers
III: potassium
IV: calcium channel blockers
What are the three EKG changes seen in digoxin toxicity from most to least common?
PVCs > bradydysrhythmias > bidirectional VT
What agent should you use to treat AFRVR in those with active ACS?
Amiodarone
What are the first, second, and third drugs for pericarditis?
NSAIDs
Colchicine
Prednisone
What EKG finding is typical post heart transplant?
Two morphologically distinct P waves
The donor heart is usually inserted with its sinoatrial node near the native sinoatrial node, resulting in two distinct P waves.
