Cardiology Flashcards
1
Q
Opening
A
Snap - MS
Click - MVP
2
Q
Closure
A
S1
S2
3
Q
Loud S1
A
MS
Short PR (WPW)
Tachycardia
Thyrotoxicosis
4
Q
Soft S1
A
MR
Long PR
inc’d LVEDP
5
Q
S2 inspiration
A
A2 - AV closess first
P2 - PV closes last -> physiologist split
6
Q
S2 expiration
A
both valves close at same time
7
Q
S2 split inc’d
A
closese earlier - MR, VSD
Closes later PS, pulm HTN (loud P2) RBBB
8
Q
Fixed S2 split
A
ASD
9
Q
paradoxical S2 split
A
AS, HTN, LBBB
10
Q
S3
A
inc'd flow chronic MR CHF TR, PDA BENIGN IN KIDS pregnancy
11
Q
Inspiration
A
MORE BLOOD IN R HEART
12
Q
S4
A
Decreased compliance Acute MR HOCM LVH AS Ischemia
13
Q
Pericardial friction rub
A
Superficial scratch sound best heard when pt upright leaning forward and deep breath in pericarditis
14
Q
Pericardial knock
A
constrictive pericarditis - sharp early diastolic sound (early 3rd sound)
15
Q
Physioligc during expiration
A
Single S2
16
Q
HTN/AS/LBBB
A
Paradoxical S2 split
17
Q
ASD
A
Fixed split
18
Q
Calcified AS
A
Single S2 (soft A2)
19
Q
HTN
A
Loud A2
20
Q
Pulm HTN
A
Loud P2
21
Q
Physiologist split
A
A2 before P2
22
Q
Pulsus tardus
A
slowly rising pulse
AS
23
Q
Pulsus bisferients
A
rapid upstroke - bifid/trifid
HCM
24
Q
Pulsus alternans
A
one heart snd normal, one abn severe HF cardiac tamponade SVC obstruction Pulm obstruction
25
Hyperkinetic
High output state
PDA
Thyrotoxicosis
26
Hypokinetic
Low output states
27
Kusmal
deep breath more blood into R heart - taemponade - R septum bulges into LV, dec'd BP on inspiration, JVP bulges
28
Auscultation
R IInd IC space (Aortic Area)
AS
AI
Left II IC Space (Pulm area)
PS, PR, AI, PDA
LLSB (Tricuspid area)
TS, TR
ASD, VSD
HOCM
Apex (Mitral Area)
MS
MR
AR
29
Palpation
Left parasternal area
Hyperdynamic implse (inc'd RV volume (ASD or TR)
Sustained L parasternal heave - RVH, (MS, pHTN, PS)
```
Apical area
Hyperdynamic impulse
Inc'd LV vol (Hyprthyroid, Anemia, preimary MR, AR with nl EF, PDA VSD)
Susptained Apex lift/impulse
LVH (HTN, Dil CM)
IHD, AR with low EF
Bifid/trifid apical impulse - HOCM
```
30
AV Valve Holosystolic murmur
MR, MR, VSD
31
V valves Mid systolic murmur
AS, PS
32
AV Valves Late systolic murmur
MVP - mid systolic click
33
Diastolic mumur
All in-flow to ventricles creates diastolic murmurs
34
AV valves Mid diastolic murmur
MS, TS
35
AV valve - late diastolic murmur, mid systolic plop
Arial Myxoma - > surgery
36
V valves Early diastolic murmur
AR, PR
37
Continuous murmur
PDA
38
Pt with fixed split 2nd heart sound and mid systolic -diastolic rumble dx?
ASD
39
Inspiration
inc'd flow to R side of heart, all R sided murmurs increase
40
Expiration
Inc'd flow to L side of heart - all L sided murmurs increase
41
Inc'd flow INCREASES all murmurs EXCEPT
HOCM/MVP (decrease)
42
Inc'd flow
Sitting, squatting, leg raising
43
Dec'd flow
Standing, Valsalva
44
Handgrip
increases afterload, increases flow to murmurs that flow backward (AI, MR, VSD)
45
What happens to murmur during handgrip or phenylephrine
Handgrip inc'd afterload, LV cavit size inc's so ALL murmurs increase including MR
Except: dec's HOCM, MVP, AS
46
What happens to murmurs with amyl nitrate use
```
Decreaes afterload, so its easy for blood to be pushed into systemic cir, LV cavity decreased
MR dec's
MVP inc's
HOCM inc's
AS inc's
```
47
What happens to murmur post PVC
| PVC=inc'd volume, dec'd afterload
HOCM/AS increase
| MVP dec's
48
What happens to blood that returns to heart during valsalva maneuver
Increases intrathoracic pressure and DEcreases blood return to heart
49
Kussmaul's sign
Neck vins DISTENTION on INSPIRATION
constrictive pericarditis
cardiac tamoponade
RV infarct
50
Application of pressure in the RUQ causes engorged Right jugular vein - rapidly improved upon release of pressure - indicates...
Increased jugular venous pressure
51
inspiration
inc'd R side murmurs
| Dec'd L side murmurs
52
Expiration
inc'd L side murmurs
| Dec's R sided murmurs
53
Standing/valsalva
Inc'd HOCM, MVP
| Dec'd all other murmurs
54
Squatting/Sitting
Dec'd HOCM, MVP
| Inc'd All other murmurs
55
Hand grip
Dec'd HOCM, AS, MVP
| Inc'd MR, MVP
56
Post PVC
Inc'd HOCM, AS
| Dec'd MVP
57
AS
inc'd standing, valsalva, post-PVC
| dec'd with handgrip
58
MR
inc'd standing, valsalva
| Dec'd Post=PVC, handgrip
59
MVP
Dec'd standing, valsalva, post-PVC
| Inc'd with handgrip
60
HOCM
Dec'd Standing, valsalva, handgrip
| Inc'd Post-PVC
61
16yo pw routine checkup - PE reveals a murmur at LSB radiating thru pre-cordium - no change with valsalva or respiration - exam LVH dx?
VSD
62
RCA
inferior
II, III aVF
Posterior V1, V2 (early R wave progression)
RV -> V3R-V4R (no nitrates - IVF + atropine if HR dec)
63
LAD
Anterioseptal V2-4
| Anterior V3-5
64
Cirumflex
Apicolateral V5-6
65
Circumflex branch (OM1) or LAD branch (diag)
High lateral
| I, aVL
66
Pt h/o CP EKG stress reveals depression in lateral leads - nuclear iaging reveals anteroseptal ischemia
High grade LAD stenosis
67
48yo F exertional CP, stress done - stopped in 50 min from CP and ST dep V4-6
High grade LAD stenosis
68
Epidemiology
900,000 deaths/yr
1/3 from CAD
smoking doubles risk
INc'd LDL and total chol risk factor
1% dec LDL = 2-3% ec risk of CAD
Every 1mm dec in BP - 2-3 % dec in r/o MI
Death rates with heart dz MORE in females
69
Risk factors for atherosclerosis
```
Modifiable
HLD
tob
Psychocsocial stressors
DM
HTN
Obesity
Etoh
Physical activity
Diet low in fruits/vegies
```
Unmodifiable:
Age
Male
Family h/o premature CAD (LP (a))
70
Pt no meds - wants advice on dec'ing CAD risk - smoker, HTN, LDL 100 wtd?
Quit smoking
71
ACS
ST elev -> Q wave MI - TPA or PCI
NSTEMI - w+CE - ASA, plavix +- IIb/IIIa
no CE (U/A) - no TPA - hep gtt, ASA, plavix
72
Workup for suspected CAD - middle aged woman pw chest pain, chest discomfort or atypical CP - wtd?
EKG - if normal stress test (exc if can walk)
73
If pt with COPD then
Dobutamine stress (no adneosine, dyprimadole)
74
45yo F vague CP on exertion - EKG normal - exc stress non-sp changes - wtd?
Exc stress with imaging
| If can't walk - or non-sp ST chagnes with LBBB, LAHB, repolariz change then persantine/thallium study
75
Which can under EKG stress?
RBB (not LBBB or paced)
76
Pt with peripheral vascular dz scheduled for bypass surgery - wheezing on exam - HTN controlled to 150.90 from 170/110
Dob stress test (can't use adenosine or dipyridamole with wheezing)
77
Who gets gated pool studies or MUGA scan
IN pt to dtermine LVEF and WMA (dec'd LVEF poor prognostic factor on MUGA
78
When NOT to do stress test
U/A
| AS with sx
79
45yo DM2 with CP, EKG neg - test LEAST likely to be accurate is...
Exercise stress test
80
Obese woman with atypical CP undergoes EST - stops test after 5 min due to fatigue, no CP, HR inc'd by 50%, no EKG chagnes wtd?
Adenosine stress or stress echo
81
When is EST positive
Flat or down sloping ST depressions>1mm & longer than 0.08s
If ST elevated then high grade stenosis
82
When do you stop a stress test
ST dep >2mm
SBP dec >15mm Hg
VT
Chest pain/SOB
83
Poor prognostic factors on stress test
```
>2mm ST depression
Persistant ST dep 5 min post excercise
Fall in BP > 15mmHg
ST elev
Vent ectopy/VT
global ischemic changes
```
84
Who gets cardiac cath/angiogram
Presence of poor prognostic factor on stress test
Post infarct angina
U/A on med tx still with sx or ST dep or troponin +
85
Unstable Angina
New onset severe angina < 2 months
Angina at rest
Recent inc'd freq
Post infarct angina
86
Pt with angina controlled on BB, ASA, nitrates pw inc'd freq and now chest pain lasting > 30 min -> EKG ST dep II, III, aVF - most likley mechanism for CP
Atherosclerotic plque with intermittent rupture and thomobolysis
87
Pt h/o chornic angina controlled on ASA, nitrates with inc freq angina wtd?
Add BB
88
Pt now on ASA, nitrates (with 12 hr nitrate free interval) and BB with inc'd freq angina
Check CBC for anemia
| Check for infxn (in'd HR-> ischemia)
89
Abv pt with low Hg and EKG with ST dep - PRBC tx'd wtd?
Coronary angiogram
90
Pt on ASA, nitrates, BB, statin, Hg normal - no signs infxn or stress with increasing episodes angion a on exertion - angiogram MV dz not amenable to revascularization - wtd?
Ranoxazine (ranexa)
91
Antiplts
ASA - thromboxane
Plavix ADP
GB IIb/IIIa
92
Pt with CP, ST depression present
Welen's syndrome -> persistent twi on EKG - cath lab
| LMWH + GP IIb/IIIa + Plavix + ASA
93
If angina or ST depression perissts with or without troponin (+)
Cardiac cath
94
Pt stopped ASA 2 months ago 2/2 PUD - started on PPI now pw CP wtd?
start ASA
95
45yo M non-smoker, no DM pw new onset CP more than 1/2 hr duration while shoveling snow - no EKG changes in ER wtd?
Admit pt to chest pain unit
| If CE neg, no ekg chages o/n -> stress test
96
65yo M woke up early AM with severe retrosernal CP x 40min, sweating, diaphoresis - EKG ST dep, Twi, started on ASA, IV nitrates BB, LMWH gpIIb/IIIa inhib - anginal pain resolves - 24 hrs later ST dep still persists
Dx: silent ischemia
Cardiac Cath pt
-> if angioplasty/PCI done - would decrease recurrent ischemia at 6 months (not reduce MI freq)
97
Multislice CT helpful to evaluate CP in what group of pts
Exclude dx in LOW risk patients
98
Exertiona dyspnea w/o chest pain in a pt may represent and anginal equivalent in absenseof pulm dz - mc seen in...
DM
Women
Elderly
Post CABG
99
Pathogenesis of SOB
Ischemia-> inc'd LVEDP-> Pulmonary edema
| Dx: Empiric NTG or stress test or radionuclide studies
100
65yo with murmur MR during excercise and disappers post exc - S4 + echo shows mild hypkinesisa and EF 60% etio?
Ischemic
101
46yo M CP lasting 15 min - resolved in ED - HR/BP ok, no ST elev - deep Twi 1-4 - wellen's sign wtd?
Check echo, cath
102
The followin gare true in pts with DM
CAD lesions are proximal
CABG better tha PTCA in pt with CAD
DM patients more likely to have silent ischemia
Among DM - more women athan men die of CAD
DM more prone to CAD than non-DM
103
Pt pw CP, EKG neg - Thalimum stress with reversible ischemia, cath neg dx?
microvascular angina
| Tx: CCB, BB, nitrates
104
Elderly man with h/o syncope - EKG on prsenation normal - feels dizzy after dinner - ST dep in II, III aVF - EKG after 15 min normal dx?
Post prandial ischemia
| tx: cardiac cath
105
Least likely to cuase ST elevation is?
Unstable angina
| Transmural MI, LV aneursym post MI, acute pericarditis, Prinzmetals angina ll aan cause ST elev
106
Young man brought to ER with severe CP - EKG shows ST elev and MI dx - caused by which drug?
Cocaine
| tx: PCI
107
Cardiac enzymes
Troponin - + 3-6hrs after MI
Peak 10-25hrs
Normal 5-15 days
CPK-MB + 3-8hr
Peak 10-36hrs
Normal 3 days
LDH + 8 to 18hrs
Peaks 2-3 days
Returns to normal 6-10 days
Myoglboin - 0-85= normal
inc'd immediately peaks in 1-4 hrs and normal in 24 hrs
108
Pt with CP, ST elv trop elevated - s/p TPA ST resolve - CP resolved - next blood draw trop more elevated wtd?
Nothing - pt who reperfused have faster peak and higher peak of trop than pt NOT perfused
109
Pt pw CP and ST elev - PTCA done next day has CP best marker?
Myoglobin (peaks 1-4 hrs, normal 24 hrs)
110
65yo M aw PNA to MICU on IV abx - EKG NSR - trop 1.3 wtd?
Echo
Low level trop see in
CHF, critial illness, LVH, coronary vasopalsm, pulm embolism, CKD
111
Pt pw chest pain and low BP - you suspect RV infarct - next dx step?
R EKG - V3R-V4R
112
Acute MI
Q wave MI and non-Q wave MI both similar long term survival
Always admit pt with new onset classic CP - relieved by SL nitro even if pt young or EKG normal
PTCA better than TPA
thrombolytics NOT given for non-Q wave MI - instead give gpIIb/IIIa inhibitors just like for U/A and ST depression
113
INdications for thrombolysis
Chest pain typical for infarction > 30 min with LBBB
ST elev 1mm in two continguous leads
2hrs away from PTCA center and NOT in shock
114
Contraindication for TPA
```
Absolute
Prev hmorrhagic stroke
Other CVA events < 1 yr
IC neoplasm
Active internal bleed
```
```
Relative
CVA> 1 yr
recent internal bleed or major trauma < 2-4 wks
BP>180/110
Pregnancy
Active PUD
```
115
Indications for PTCA (PCI or angioplasty)
```
Acute ST elev MI
ST elevation with CP > 12hrs
MI with shock and Pt is < 75yr
STEMI post CABG pts
If tPA contraindicated
```
116
Plavix
Thienopyridine ADP Plt inhibitor
Pt with MI allergic to ASA -> use plavix
Pt going for PTCA needs plavix
Pt goign for CABG - NO PLAVIX
117
When is CABG better than PTCA
Left Main dz
3 vessel dz with dec'd LVEF
two vessel dz with prox LAD and decreased EF
DM with CAD
118
Pt with CAD s/p PTCA with stent palcement - what meds on d/c
ASA + Plavix
119
60yo pt undergoes CABG - couple months later he is doing fine but has problems keep ing accounts occasionally
Dx: neurocognitive defect
120
Pt with retrosternal CP>1, diaphoretic -> EKG LBBB, ST elev in ant leads - old EKG not availabe to compaire - CK and trop pending wtd?
Cath lab
121
Pt with Chest pain, ST elev ant leads - s/p tPA with BP of 90/60 - 2hrs later ST elev in lateral leads BP drops to 80 pt SOB - no new murmurs - CXR pulm edema wtd?
Cath - IABP-> PIC
| If allergic to ASA then desensitization
122
Elderly pt with IWMI gets tPA - pt becomes hypotensive and HR 38 wtd?
atropine
123
HR 74, BP stable, pt confused, both puils dilated - dx?
ANtichoinergic delierum
124
Pt with 14hrs CP, taken antacids without relief - EKG with ST elevatins in anterior leads - BP 140/80 - given ASA to chew - IV nitrates, IV BB and IV morphine - closest PTCA at least 1 hr away wtd?
Transfer for PTCA
125
60yo pw CP AWMI to small community hospital - nearest PTCA 2 hours away wtd?
TPA then tx for PTCA
126
Pt aw MI - 3 day slater Cp relieved with NTG wtd?
Cath
127
Pt has cath - 2 days later pain in R groin - exam with erythematous and pulsatile mass wtd?
US r/o pseduoaneurysm
128
Pt with MI - 9 days later with persistent CP, worse on deep breath - pericardial friction rub - CXR with effusion - EKG diffuse ST elevation with concatvity upwards
Dressler's syndrome - secondary pericarditis
| Indomethacin, ASA
129
Factors shownto improve survival in MI
```
PTCA
thrombolytic therapy after Q wave MI
BB
ASA
ACE in EF < 35%
```
130
Pt with CP, ST elev in II, III, avF all are true
ACEi improve survival
BB imporove survival
statins improve survival
(CCB DO NOT improve survival)
131
Pt p/w CP - AWMI tx'd in CCU wihtout complciations EF 30%, on D/C what meds
ASA, plavix, BB, ACEi, warfarin 3-6 months, Statin, ICD 40 days later - if high risk for VT then wear lifevest
132
65yo with angina CVABG 2ya HR BP ok, no DM, EF normal wtd to reduce chance of another cardiac event
ACEi (ramipril)
133
Pt had MI, stabilized - few months later stress tes ab - underwent cath - 70% Cx - started on ASA - what will inc survival?
Statin (NOT CABG or PTCA)
134
Complications of MI (arrythmia)
48hrs
VT (scar tissue -> need amiodarone-> ICD
NSVT
135
Complication of MI (ruptures)
Papillary muscle rupture -> Acute MR
Septal rupture -> Acute VSD
Free wall rupture -> Tamponade
136
Ventucular arrythmias during acute MI
Ventricular ectopy or NSVT during AMI should NOT be treated
VT/VFib occuring within 24 hrs of MI are independent risk factors for in house mortality BUT not risk for subsequent mortality from arrhthmia fter d/c
These DO NOT NEED long term antiarrhythmic therapy
137
Pt pw CP - EKG shows MI tx'd with tPA, heparin, nitrates, BB, ACEi - w/in 24 hrs pt has NSVT <30s wtd?
Observe
138
Mechanism of reperfusion arrhythmias?
Triggered activity; change in cardiac frequency due to accumulated Ca+
139
Reperfusion arrythmia
If unstable (dec'd BP, CP) - DCCV
If stable - amiodarone
wtd next - cath
140
Pt with NSVT reverts to SR and is otherwise uneventful - 5 days later pt ready for d/c does pt require long hterm anti arrythmic?
No
141
Pt with VT or VF 48hrs afte rMI - no evidence of reinfarction wtd?
tx VTACH
142
Vtach/VF 48 hrs after MI or more - independent risk factor for mortality after d/c - after acute tx wtd?
ICD
143
Pt has 2 discharges from ICD in 2 months wtd?
start amiodarone
144
Pt with ICD on amiodarone still getting shocks 4 months later wtd?
RF catheter ablation
145
Pt with MI refractive VT wtd?
O2 and correct electrolytes
| Tx with amiodarone
146
Post MI surgery
elective surgeries at least 6 months post MI (risk of reinfarction highest first 3 months post MI)
147
Middle aged man clutches chest c/o severe CP - EKG diffuse ST elev with concavity up and PR depression wtd?
NSAIDs for pericarditis
| Best med for ppx - colchicine
148
If pt's CXR (pericarditis) shows cardiomegaly or has JVD o rpulsus paradoxis wtd?
echo r/o tamponade/effusion
149
Constrictive pericarditis
Rigid pericardium - impaired cardiac filling
Cl features - gradual onset dypnea, fatigue, ascites, Kussmauls sign +
Sharp early diastolic snd following S2 (early S3)
JVP - > inc'd with prominent x and y descent (Sqrt sign)
EKG normal
CXR - 50% show pericardial calcification
Echo - thickened pericardium =- early diastolic filling of ventricles and pressures >15 adn within 5mm of each other
Swan - RA=RV=PAP=PCWP
tx: pericardial stripping
150
Risk factors for contrictive pericarditis
Post cardiotomy (CABG/AVR)
INfections Viral, TB, fungal
Radiation exposure to chest in past
151
Most sensitive test to measure pericardial thickness
MRI
152
Pt post CABG or AVR 4 yars ago with inc SOB for 3 months +JVD 9cm, hepatomegaly adn pedal edema, EKG and CXR normal - dx?
Pericarditis
153
T/F in pericarditis JVP inc'd on inspiration
T
154
T/F in pericarditis pericardial knock also knowna as sharp early 3rd heard snd can be heard
T
155
T/F in pericarditis Echo can reveal pericardial thikening
T
156
T/F in pericarditis CXR can show pericardial calcification
T
157
T/F in pericarditis Treatment is surgical streipping
T
158
T/F in pericarditis MRI is most sensitive to detect thickness of pericardium
T
159
MCC CHF
Ischemia>dilated CM>HTN, valvular dz, congential HDz
Always r/o ischemia in pt with new onset CHF and sudden decompensation in stable CHF
MC precipitant of decompensation in CHF -> inc'd salt intake
160
CHF Systolic dysfxn
```
dec'd contractility
inc'd LVEDP
dec'd LVEF
Echo - dilated
Tx:
ACEi, BB, ACEi
diuretics (Loop/spironolactone)
Digoxin
Hydralazine + nitrate
ICD/CRT
```
161
CHF Diastolic dysfxn
```
dec'd relaxation
inc'd LVEDP
NORMAL EF
Hypertrophy on echo
Tx:
Candesartan
BB, CCB (long acting)
Diuretics
```
162
BNP
inc'd in CHF
100-250 - significant LV dysfxn with compensated congestion
250-500 - CHF with both systolic and diastolic dysfxn
500-1000 decompenstaed CHF
>1000 - severe CHF
163
Elevated BNP seen in...
LHF 2/2 diastolic dysfxn
LHF 22/ systolic dysfxn
RHF 2/2 COPD
RHF 2/2 PE
164
60yo F eval for 3 month SOB on exertion, no CP, pmhx HTN DM2, HLD - takes meds wtd?
TTE check LV fxn/WM
165
Echo with inf wall hypokinesis and EF 40% best managment?
Cath (not dob stress echo)
166
50yo M pw inc'd SOB 3 days - pmhs HTN, BMI 40, JVP 14, b/l crackles and S3 heard, b/l pitting edema, BNP 160 - management?
IV lasix
167
BNP monitoring shows what?
Dec'd mortality in pt <75yo
168
Pt pw exc intolerance and DOE - exm JVD 10cm, few basal rales, S3+ - pt dx with CHF
CE and trop normal - pt tx'd with diuretics and gts better - TTE shows EF 35% wtd at d/c
ACEi
169
In pt with new onset CHF - Cr up and K inc'd from 4 to 5.6 after starting ACEi wtd?
D/C ACEi
| start hydralazine
170
PT with CHF on lisinpril 5mg and lasix 40mg dialy pw continued fatigue, JVD 12cm, scatter rales, pitting edema - wtd?
Maximize lisinopril - start IV lasix) (no diff between bolus vs infusion)
171
When to start BB in decompensated CHF
ONce volume overload corrected, start low dose BB and titrate up
172
When to f/u patient as outpt after d/c for acute decompensated CHF
F/u Appt in 1 week (not 2)
173
If CHF pt on lasix and lisinopril what to add next?
carvediolol
174
Two months later pt on lasix, KCl supp, lisiopril 10 and coreg 25 bid NYHA III, EF 35% wtd?
D/C K supp and start low dose spironolactone
175
Pt on spironolactone at inc'd risk for what?
HyperK+ (potassium sparing diuretic)
176
Pt on spironolactone pw L only breast enlargement 6 months later
Biospy (if unilateral)
177
CHF pt on lasix, coreg, spironolactone, lipitor prsents 6 months later with BILATERAL breast enlargment
D/C spironolactone ad start Eplerenone
| If can't afford Eplerenone -> start amiloride
178
58yo F pw CHF taking lasix 20, lisinopril 5, liptor 20, coreg 6.125, spironolactone and ASA - JVP 12cm - lung with mid lung crackles, +S3, pedal edema b/l, EKG QRS 0.13 - started on IV lasix - best management?
Optimize medical therapy for CHF (all meds low doses and is overloaded now)
179
1 wk later, pt that was on suboptimal therapy now on lisinopril 30, lipitor 40, coreg 25, spironolactone 25, lasix now up to 60, asa 81 - JVP 10, lungs still with bibasilar cracksl S3+ EKG QRS 0.13 EF 35 % - beset mangement?
Start Metolazone 30min prior to lasix
180
9 months later - pt who was optimized for CHF with lasix, metolazone, coreg, lipiotr sprionlactone and asa for f/u - Echo still 35%, QRS 0.13 -
Start ICD with cardiac resynchroization tx
181
54yo M CHF - echo reveals ejection fraction 35% - what target BP will prevent any coronary event in pt?
BP < 120/80
182
76yo F c/o progressive SOB x 2 months - pmhx HTN, bibasilar crackles S1,S2 no murmurs 1+ pittin gedema - EF 65% with LVH best management?
CANDESARTAN (+diuretics)
183
Apart from HTN which conditions will you get inc'd LV mass?
DM, Obesity
184
Which pt's have higer incidence of Heart failure wih prserved EF (HFPEF)
Women age > 75 with systolic HTN
185
Poor prognostic factors for CHF
```
S3
Hyponatremia
PCWP >12
PAP >50
Peak O2 uptake < 14ml/Kg
```
186
Drug that improve mortality in CHF
```
ACEi
ARB
Spiroolactone (for NYHA III/IV
Hydralazine+nitrates
BB
```
187
What drugs DO NOT improve survival in CHF
Digoxin (improves fxn capacity and decreases hospitalizations)
CCB
Lasix
188
55yo F brouht to ED onset of severe SSCP x 2 days - inc'd with breathing - recently lost custody of her grandchild - JVP normal HR 120 lungs clear trop 36, EKG 1mm ST elev V1-4 - echo anter and lateral wall hypokinesis with EF 35% ballooning of LV - cath shows NO CORONARY OBSTRUCTIN dx?
Takotsubo's cardiomyopathy
189
Can you use ACEI in asx pt with LV dysfxn?
Yes
190
ACE used for all following
```
Sclerodermal renal crisis
post acute MI
CHF
DM with microalbuminuria
HTN with S4
Viral myocarditis
IgA nephropath
NOT WITH PREGNANCY
```
191
In pt taking ACEi least likely to follow
Serum Ca+
| Do need to f/u BP, K, Cr
192
S/E ACEi
```
Cough 2/2 bradykinin
First dose syncope
Angioedmea/laryngela edema
Dec'd consstriction of efferent arterioles - renal failure in marginal patients
Neutropenia
```
193
What drugs NOT to use in CHF pts
NSAIDs
Glitazones
CCB
Cilostazol
194
Combination of ACEi and ARB shown what?
Less proteinuria
| WORSE renal outcomes
195
70yo F pw pulm edema, two earlier episodes - responds well to IV lasix - HTN hx with 160/95 - LUngs clear, systolic murmur II/VI at apex-> axill a - echo mild LVH EF 60% etio?
CAD
196
65yo F new onset CHF loud S4 soft S3, JVD 12, basal crackes - EKG BBB echo EF 25% - started on iv laxi, iv ace sx improve next test?
cath
| -if 3 vessel dz? -> CABG
197
Joint commision core measures for CHF
```
D/C instructions
Use of ACEi or AR
Document EF
Smoking cessation counseling
Flu shot
```
198
Dilated CM
```
Etio
Etoh/peripartum/doxorubicin
Ischemia
Hemochormatosis
Tx: Similar to systolic dysfuction
In severe CHF inotropic agents such as dobutamine
```
199
Restrictive cardiomyopathy (Diastolic dysfxn)
Secondary to Fibrosis or
Amyloid - thickened septum refractile on echo - normal systolic fxn
Diastolic dysfxn (early restrictive filling)
Hemochormatosis
CHF/arrhythmias
Endomyocardial fibrosis
200
Hypertropic CM
Diastolic dysfxn
Aut dom 30%
4% mortality/yr
Sudden syncope/death after vigorous excercise
Sudden death most frequent in familial form in young patient
CP/dypnea also occurs
Carotid and peripheral pulses with brisk upstroke, BISFERIENTS pulse
Early systoic murmura t LLSB inc'd with dec'd flow (standing, valsalva
(Symmetric hypertrophy=athletes heart)
Etio Asymm hypertrophy of LV = HOCM
Dx: Echo
Tx: BB improve sx
CCB for CP
ICD/Septal myotomy
201
Do HOCM pts need endocardiitis ppx?
NO
202
Poor progrnostic factors in HOCM
```
VT
Age 3cm
Syncope
Failure to inc BP by 20mm upon excerise
Familial form and fhx of sudden death
```
203
T/F about HCM 18yo basketball player with suddne death after vigorous play - autopsy hyperrophied IV septum
T
204
T/F about HCM pt p./w syncope, dypena or CP
T
205
Ventricular Tach on holter monitor inc'd risk of sudden death - these pts need ICD
T
206
T/F about HCM Murmur inc'd on standing, valsalva and decreases with handshake and sitting
T
207
An asyx 18yo wants to join soccer team at PE reveals ejection murmur and brisk carotid upsstorke - echo 16mm thickened upper portion of IV septum - wtd?
No high intensity sports
Can do boweling
tx: sx - CP - BB, long acting CCB
if no response - AV seq pacing or sugical myotomy
If Pt VT or NSVT on holter and fhx sudden death then ICD
208
Aortic Stenossi
MC valvular dz in adults
pw
Sncope - left untreated time to death 3 years
CP - left untreated time to death 3 years
CHF left untreated time to death < 2 years
Signs: Pulsus tardus - systolic crescendo-decrescendo murmura t Right sternal border rad to carotid
Delayed and slow carotid upstroke
209
Signs of severe AS
S4, paradoxical split S2, late peaking murmur Echo with gradient >50, valve <0.5cm sq
210
WTD in asx AS pt
f/u serial echos
211
WTD if progressive deterioration with sx
Replace valve
212
75yo AS gradient 80 and syncope - falls has hip fx after fall
replace valve first
If poor EF then
Balloon valvuloplasty prior to hip surgery
213
If pt has asx AS and hip fx with echo gradient 0.5 then wtd?
Swan during surgery
214
AS pt going for surgical valve replacement wtd prior?
Cath
215
What is seen in pt with AS
LVH
216
AV malformation with GI bleed related to?
AS
217
Aortic Reguritation
Presents w/ dyspnea (backed up blood)
Early diastolic murmur at Left sternal border
Sever cases with AUSTIN FLINT MURMUR (mid diastolic murmur like MS)
218
AR tx:
Tx: Even with severe AR, Asx and EF>50% then according to LV dimentions
ES 55, ED >75 -> Surgery
IF EF<50 with sx then DO SURGERY!
219
Austin flint murmur
AR Jet hits MV open leaflets mid diastolic murmur like MS
220
25yo F with AR EF 60% wants to get pregnant - what to expect?
Normal Vaginal Deivery
221
Best candidate for sildenafil is
Pt with AR adn preserved LVEF (better than AS or pt with angina)
222
Mitral stenosis
Middle aged woman born in china/india with dyspnea, hemoptysis - on exam loud S1, Loud P2, opening snap - mid diastolic rumble (decrescendo at apex - Swan PCWP 18, PAP 80/34, RAP 15 - CXR cardiomegaly - straighteing of left heart border
Dx: Mitral stenosis
COmplciation - dilation of LA -> Afib -> thromboembolism and CHF
Tx: If valve
223
The reason for using diltiazem or BB in mitral stenosis
inc diastolic filing time
224
Pt with III/VI holosystolic murmur at apex->axilla asx or mild diziness echo sev MR BP/HR ok EF 50% LV 72mm diastolic, 51 mm systole wtd?
```
Surgery for mitral regurgitation: Repair>Replacement
Asx - LV systomic dysfxn (EF<60)
Pulm HTN
afib
Symptoms
```
225
Pt h/o aortic aneurysm schedule for surgery gtting stress test - recent EKG, PFTs CXR normal - during stress test has ST dep in lat leads and 2/6 systolic murmur at apex - 5 min later no murmur dx?
Ischemic MR
226
ASD
Secundum defect 70% (no need for abx ppx)
Fixed S2 (pulm valve clsoes later than aortic valve
Parasternal impulse, prom a and v wave - mid systolic murmur at Left sternal border
EKG with RV strain and partial RBBB
227
When closure
If L-> R shunt >1.7:1
228
What if pt ASD asx and L-> shunt >2:1
Surgery
229
What if R-> L shunt (Eisenmenger's syndrome)
NO SURGERY - denotes onset of pulm HTN
230
Atrial septal aneursym management
No ASA, No warfarin, no need to resect
231
PFO
incomplete fusion of septum primum
Bubble study for dx - 1 bubble /beat in LA
(Hepatopulm syndrome 1 bubble every 4th beat)
232
Secundum ASD
Incomplete covering of foramen ovale by septum primum
| Ideal candidate for percutanous closure
233
Primum ASD
Septum primum does not connect to endocardial cushion
234
VSD
```
common in children
systoic murmur at LLSB -> precordium
Split 2nd heart sound (not fixed)
No endocarditis ppx unless w/in 6 months of surgery
If L-> shunt >1.7:1 then Do surgery
```
235
PDA
Crescendo-descrecendo continuous murmur left parasternal area (Lt 3rd ICS) - Soft S3
Surgery helps at all ages
No abx pps needed
236
35yo Asx man for routine physical - brisk carotid upstrokes and ejection click followed by stystolic ejection murmur at base of heart, also II/VI diastolic murmur at LSB wtd?
Echo -
mild dilation of LV wtd?
nifedipine/ACEi revent further dilation and systolic dysfxn
237
Coarctation of Aorta
Aw bicuspid AV
Delayed femoral-brachial pulse or absent femoral puulse
Early systolic murmur
Persistent HTN after surgical correction
BP higher in upper than LE
CXR rib notching 22/2 collateral vessels ("3" sign)
No need for abx ppx
238
Marfan's syndrome
```
Decrased strength and dilation of aorta with aortic regurgitation and dissection
Monitor yearly echos
If >4.5cm - Echo q6month
5.5cm or greater - repair
Prevention of dissection - BB
```
239
Pt with marfan's has echo q6month - current echo 5.3cm - pt wants to wait
explain pt should consider repair now and the possibility of dissection in mean time
240
Eisenmenger's syndrome
R-> L shunt
| Cl ft - Cyanosis of mucous membranes
241
HTN
Systolic BP>disastolic BP as CVD risk factor
242
HTN screenings
Pt normal BP after age 18
| Screen for HTN q2yr
243
What systoic BP aim for in elderly
SBP < 150
244
Diastolic HF more common in...
Women > 75 with systolic HTN
245
Isolated systolic HTN in elderly tx?
Thiazide diuretic 12.5-25 daily
246
Mild to mod HTN
Thiazide/chorothalaidone
247
HTN with LVH (S4+)
ACEi
248
HTN with renal insuff
ACEi
249
HTN with ischemic HDz
BB, CCB
250
HTN with DM/proteinuria
ACEi
251
HTN with CHF
ACEi, Diuretics, Carveilol
252
HTN post MI
BB, ACEi
253
HTN with gout
Losartan (ARB)
254
HTN with pregnancy
Labetolol, Methyldopa, hydralazine
| NO ACEi
255
Thiazide s/e
```
Hyper Ca+
Hyper uricemia
Hypo K+
Hyponatremia
Inc'd dig and lithium levels
```
256
Does Angiotensin II blocker induce cough?
NO
257
Pt on HCTZ 25 daily BP still high wtd?
Restric fluid and salt
258
Pt HTN on HCTZ 25 daily - BP 160-148 Exam S4+ wtd?
add ACEi
259
Ma huang (ephedra) causes
HTN
260
18yo F 170/105 wtd?
Urine tox first
261
21yo Pt CP, cocaine + 160/100 wtdD?
benzo, nitrate, ASA
| Prevent CP - no cocaine, CCB
262
Thoracic aneuysm
```
CP rad-> back
Acute AR murmur
Widened mediastinum
Surgery if >6cm and asx
OR symptoms at any size
or dissections
```
263
Abdominal aneurysm
Interscapular pain
Surgery >5cm and asx
or Sx's at any size
Dissecting AAA treat medically first with BB and nitroprusside if pain persists then surgery
264
68yo M ddmittened for urgent repair of 7.5cm AAA pt with DM and inc'd cholesterol - fhx MI at 57 next step?
No further testing
265
AAA screening
Anytime smoker age 65-75 - AAA US screening noce in MEN ONLY
| No screening in women
266
73yo chrnoic smoker with family hx AAA has neg abd US for AAA wtd?
No additional US needed
267
73yo ex soker no fhx of AAA has small aneursym on US wtd?
Repeat US in 6 months
268
60yo M h/o CAD severe CP-<> back 190/100 HR 90 decresenco murmur dx?
Aortic dissection
Dx: TEE - or CT scan wo contrast if no TEE available
then tx with BB, IV nitropruside THEN surgery
269
A loose fitting/large fitting BP cuff will ...
UNDERestimate BP
270
Small/tight cuff will...
OVER estimate BP
271
Porcine valve
No A/C
272
Prosthetic valve
Needs A/C
273
Valvuloplasty
Tricuspid stenosis, pulm stenosis, mitral stenosis
| Temporary in Aortic stenosis
274
TEE needed for...
prostethic valve endocarditis
Desceding aortic aneurysm
Left atrial thrombus
PFO
275
Afib
atria fibrillating, no p waves
some imprulse conducted and cnotract ventricles - irregularly irregular ventricular response
Narrow QRS except with abberant conduction
276
New onset afib
w/in 48hrs
277
Paroxysmal afib
terminates spontaneously
278
Chronic
always in afib
279
Slow ventricular response in afib
BB
CCB
Digoxin
280
Convert to NSR
```
Amiodarone
Ibutilide (prolongs QT)
Quinidine
Procainagmide
Dofetilide (prolonges QT)
Electrical cardioversion
Dronedarone (ony med shown to decrease hospitazation -> avoid in pt with EF<35%)
```
281
Risk factors for afib
```
High risk
-Prev stroke
TIA or Embolism
Mitral stenosis
Prosthetic heart valve
```
```
Moderate Risk factors
Heart failure
HTN
Age>75
LVEF<35%
DM
```
```
Weaker risk factors
Female
Age 65-74
CAD
Thyrotoxicosis
```
282
Afib tx
No risk factors - ASA 81
one mod risk factor ASA81 daily or wafarin INR 2-3
Any high risk factor or >1 mod risk factor - warfarin INR 2-3
283
CHAD Vasc
Vasc dz 1 point
Age 65-75 1 point
Sc=female=1 point
284
Heart dz with one major contraindication to warfarin
tx with ASA
285
Afib with wide compplex tachy
```
WPW
tx with procainamide
NO DIG
NO BB
NO CCB -> vfib
```
286
62yo pw palpiations EKG afib HR 100/min - started on BB - echo with no vavluar abnormalies and normal wall thickeness - BP 140/84 wtd?
ASA 81 (no risk factors)
287
76yo pt HTN pw palpitations - HR 110 HR 110, started on BB
Warfarin (one mod risk factor - HTN)
288
65yo afib h/o TIA in past
Warfarin (one high risk factor)
| start on 5mg daily
289
Pt chronic afib on warfarin going for MINOR surgery
continue warfarin
290
Pt with chronic afib on warfarin going for major surgery wtd?
If CHAD score 2 or less -> D/C warfarin 5 days prior no bridge
If CHAD score 3 or higher -> D/C warfarin 5 day sprior and bridge with:
1. LMWH twice daily and last dose 24 hrs prior to surgery OR
2. LMWH once daily last dose 1/2 morning of procedure
291
On day of surgery pt INR 1.6 wtd?
Clear for surgery
292
Rate control and A/C in afib compared to DCCV show to ?
Decrease stroke
| Decrease hospitalizations
293
Pt with chronic afib refractory to med tx or can't tolerate meds wtd?
AVJ ablation with PPM
| needs AC? - YES - atria still fibrillating
294
Young adult recurrent afib refractory to medical tx or can't tolerate meds
Afib ablation - pulm vein isolation
295
Elderly pt pw weakness on L side body - EKG shows afib IV heparin started weakness resolves - carotid dopper hows L ICA >70% best tx?
warfarin + heparin bridge
296
Afib rate control goal
<110 (resting)
297
48yo M pw acute onset periumbilical pain - afib with RVR 130 bpm wtd?
arteriography r/o sequella afib emboli
298
Pt wtih afib tx'ing with diltirazem - rate control - echo structurally normal heart - pt comes back with inc'd sx palpitations - holter shows many episodes of afib where he had sx wtd?
Add BB
299
What drug will bring afib into NSR
ibutilide
300
Aflutter
macro re-entrant circuit - EPS for RFA
Atrial flutter rate 250-300
Usually 2:1 block HR 125-175
Etio Cardiac or pulm dz - can have WPW
First slow AV conduction BB, dilt then cardiovert with amiodarone/quinidine
Low energy DCCV or atrial pacing can also be done
Recurrent flutter - EPS/RFA
301
32yo F MS sudden palpitation - 150/min and regular - carotid massage slowed rate but then returned to 150 when stopped - dx?
Aflutter
302
MCC SVT
AVNRT 70%
Tx: carotid massage
Adenosine 6->
If wheezing then CCB
303
Orthodromic reentrant tachycarida
accessory pathway
EPS/RFA
down AVN, up accessory pathway - narrow complex
Tx: AVN blockers, vagal maneurvers
304
Antidromic re-entrant tachycardia
Accessory pathway
Down accessory pathway, up AVN
Wide complex
Treat like VT with procainamide or cardioversion
305
22yo palpitations pounding sensation in neck for several years - now worse - gets slightly dizzy at times - sx occur without warning while restig - when she breathes slowly and deeply palpiations resolve on own - EKG normal dx?
Paroxysmal SVT
306
WPW
Impulse via accessory pathway reach ventricle earlier than AV node -> delta wave, shortened PR on EKG
WPW can pw Afib, aflutter and vfib
DO EPS if aw any arrhythmia or unexplained syncope
Never tx wide complex tachy with BB, CCB or digoxin
307
Pt has SVT and respods to carotid sinus massage - pt asks how to prevent future episodes
teach vagal maneuvers
308
25yo palpitations, gradual onset - during episodes sinus tach 140 notes - asx EKG normal - echo normal - pt dx with inappropriate sinus tach wtd?
start BB
309
Youn athlete on routine physical found to have EKG with WPW, asx - can he play basketball?
YES
310
Pt pw palpitaitons, EKG Afib or SVT - after BB feels bette rand repeat EKG shows shortened PR - wtd?
EPS/ablation of errant tract
311
Pt pw wide complex tachycardia HR 200 QRS 0.14 pt has h/o WPW - unable to decide if is SVT with aberration or VTach - you woudl tx this patient with ?
Procainamide
312
Multifocal Atrial Tachycardia
```
Three or more distinct morphological types of "p" waves
Seen in COPD, result of theophylline use
Tx: Oxygen, Mg, inhaled bronchodilators
2nd: CCB
NO DIGOXIN
```
313
PVCs
3 or more PVCs = NSVT
| 30 S of NSVT = sustained VT
314
Pt with muultiple PVCs wtd?
Look for organic heart dz - echo, stress, gated pool studies
If heart dz negative, asx - NO TX
If heart dz neg but symptoms -> BB
If heard dz postiive with LOW LVEF -> ICD
Sustained VTach - ICD
315
45yo healthy man who excercises everyday and asymptomatic, is going for elective major surgery - EKG reveals multiple PVCs wtd?
Clear for surgery
316
Ventricular tachycardia
```
3 or more consequential PVC
Diff dx:
SVT with aberrancy
WPW
LBBB
```
317
VT more likely if
```
QRS>0.14
LADev
Fusion beats
Capture beats
Prsense of organic heard dz
Cannon A
Concordance of QRS in precordial leads
Rate>100
```
318
30yo AA pt to ER with palpitations - found to be in arrhythmia adn hypotensive - defib twice and IV med is started - exam cervial axillary and epitrocheal LN ++
Dx: Sarcoidosis
319
Prolonged QT interval
```
Quinidine Disopyramide
Methadone
Azithro
Procainagmide
Hypokalmeia, hypo Mg+
Pentamidine
Erythromycin
Phenothiazine
TCA, moxifloxacin
Ariprazole
```
320
Torsade de points
tx: D/C offending drug
Overdrive pacing
Mg SO4
321
MCC sudden cardiac death
ishemia
322
What dec'd short term mortality in pt with vfib
Defibrillation
323
What is most effective timing of defib
CPR then defib
324
Pt with Vfib collapse in ER - defib x 2 but short while later vfib twice more wtd next?
epinephrine
check electrolytes
amiodarone
325
Best managment in pt with fhx sudden cardiac death
ICD
326
Indications for ICD
```
Sudden cardiac death VT or Vfib
EF<35% with CHF irrespectie of etio
NICM - 3 monthas fter med therapy
ICM - 40 days after MI
HOCM with NSVT and fhx SCD
```
327
21yo F wakened by alarm clock and minutes later has syncope - EKG prolongued QT and TWi - hx might be helpful is?
fhx sudden cardiac death
328
60yo F c/o recurrent excercise idued palpitations with near syncoep - pt fhx near syncope in mother and daughter - EKG QTc 460, EF 55% next step?
BB therapy (sotolol)
329
42yo Asian man with sudden cardiac arrest - EKG Vfib - defib'd successfull - EKG now ST elev in V1-3 and asx - pt fhx father dying at age 40 dx?
Brugada syndorme
| tx: ICD
330
Pt with h/o dizziness passing out for few sesonds - h/o palpitations
Holter montior (continuous loop recorder)
331
Pt with palpitations 2-15 minutes - NO SYNCOPE
Event monitor - press button to start
332
First deg AVB
```
conduction impulse to ventricles delayed
PR>0.2
intranodal block with benign process
NO NEED FOR PPM
(if suspecting endocarditis -> may have new 1st deg AVB)
```
333
2nd deg AVB type I (mobitz I/wenkebach)
prolonguing PR till dropped QRS
| no need for PPM unless very low HR or HD problems
334
Pt with inf wall MI had PCI now stable - 3 days later tele shows 2nd deg AVB type I 50bpm no sx - wtd?
Close monitoring as outpt
reduce BB dose
Block in AVN
335
2nd deg AV block type II
PR prolonged but constant with sudden drop QRS
If 2/2 IWMI/RV MI usually transient and doesn't required PPM (may need atropine or TVP)
If 2/2 AWMI - more extensive damage - may need PPM
Infranodal block
336
3rd deg AVB
atria and ventricles beathing at own rate - cannon A waves on JVP
PPM needed
Acute MI with new bifasciular block -> high risk for progression to CHB
337
Indications for PPM
```
2nd deg Mobitz II
3rd deg AVB
Pause dep VT
sinus nodes dysfxn - HR3s, Mobitz II AVB with bifasciular block, post op AVB
CHF with prolonged QRS - use bivi ppm
```
338
75yo M intermittent palpitations denies SOB or syncope - pt on BB and ACEi for HTN - EKG NSR 66bpm - holter with HR 35-106 during day
PPM (need for tachy brady to tx palpitaitons)
339
80yo for regular checkup found to have HR 45 - holter shows rate max 55, drops to 38 during night at one point - no sx
reassurance NO PPM
340
65yo F SOB on exertion CHF EF 22% on nitrates, BB, ACEi, spironolactone and dogxoin QRS>0.12 what else to decrease sx?
BIVICD
341
Junctional rhythm
```
Junctional tachycardia
Vrate 70-130
p wave may be inverted - buried beneath QRS or following QRS
Etio:
Dig toxicity
IWMI
Myocarditis
Post cardiac surgery
```
342
Sinus bradycardia
HR<60
Hypothermia
Hypothyroid
343
Sick Sinus syndrome
SA node problem causing bradycardia, block, arrest or tachy-brady syndrome
No need for EPS -> directly to PPM
Tx: PPM if:
1. Symptomatic
2. Tx of tachyarrhythmias causing significant bradycardia
344
Digoxin
inc'd vagal tone
Wt loss
anemia
AVN block -> Jnc rhthym -> regularized afib -> dig tox
345
Digoxin effect
```
Scooped ST segment
No tx (not dig toxicity)
```
346
Anti arrhythmic drugs
ClassI decrease upslope of action potential
Ia: Disopyramide, Quinidine, Procainamide (Double quarter Pounder)
Ib: Lidocaine, Tocainide, Mexiletine, Phenytoin (Letuce Tomato, mayo)
Ic: Flecanide, Propafenone (Fries Please)
Class II: decreases synpathetic activity
Beta Blockeers
Class III: prolongs action potential
Amiodarone, Sotolol, Bretylium
Class IV: CCB
Others: Adenosine: slows AV conduction
Digoxin
347
Toxicity of Antiarrhythmics
Quinidine -> prolongues QT, dec'd plts
Procainamide -> Drug induced lupus (anti-histone)
Lidocaine -> seizures
Amiodarone -> Pulm fibrosis, hypo/hyperthyroid, COrneal deposits
348
LAenlargement EKG
M shaped pwave (MS)
349
RAEnlargment
Tall p wave
350
RVH
R wave V1, RADev
351
RBBB
R, R' V1-2
352
LBBB
R R' I, aVL, V6
353
Digoxin: Normal level <1ng/mL
Toxcity - anorexia/wt loss
Regularized afib - weight loss
EKG Jnc Tachycardia, PAT with block, PVCs
354
Predisposing factors for dig toxicity
Low K
Low Mg
Low Renal Fxn
Low O2
355
Drugs tha tincrease Digoxin level
```
Quinidine
Amiodarone
Verapamil
Spironolactone
Chlorthalidone/HCTZ
```
356
Treament of Digoxin toxicity
```
Correct electrolytes
BB
Lidocine/phenytoin
Digoxin binding antibodies - if pt with life threatening arrythmia
NO QUINIDINE, NO PROCAINAMIDE
```
357
Pt with afib started on Digoxin - regularized afib on EKG wtd?
D/C Digoxin
358
Elderly pt with Cr 1.3 on lisinopril, glizpiide mirtazapien and digoxin 0.25/day with gradual wt loss wtd?
lower digoxin dose
359
Pt on digoxin and amiodarone is added wtd?
Decrease digoxin dose
360
78yo M SOB with Cr 1.5 on digoxin and warfarin - EKG HR 96 looks regular with regular with retrograde pwave
Dig toxcity - check electrolytes
| pAT with block
