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Cardiology Flashcards

1
Q

Contraindications to exercise stress test

A

Unstable ACS, HF, arrhythmia, AS, dissection
PE, DVT
Active endocarditis, myopericarditis

Uninterpretable baseline: LBBB, WPW, Paced, digoxin, resting STD>1mm

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2
Q

HOCM/MVP Murmur

A
  • Increases with decreased Preload (stand, Valsalva)
  • Decreases with increased preload (squat, leg raise)
  • Decreases with increased afterload (hand grip)

MVP longer murmur earlier click with valsalva

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3
Q

AI/MR Murmur

A
  • Decreases with decreased PL (stand, valsalva)
  • Increases with increased PL (leg raise, squat)
  • Increases with increased AL (hand grip)
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4
Q

AS/MS Murmurs changes w/ maneuvers

A
  • Decreases with decreased PL (stand, valsalva)
  • Increases with increased PL (squat, leg raise)
  • Decreases with increased AL (hand grip)
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5
Q

Reasons to use Plavix (>Ticag) as 2nd anti-plt

A

If ACS:

  • Patient receiving lytics
  • Patient has Afib with CHADS>0 on DOAC
  • Patient has high bleed risk (hx intracranial bleed ever, current non-intracranial bleed, mod-sev liver dz)

Post all elective PCI

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6
Q

Indications/Contraindications for tPA in STEMI

  • door to needle time
  • timing for post-lytic PCI
A

> 120 mins from nearest PCI center

PCI if >12h or cardiogenic shock

Contraindications

  • Bleeding - hemorrhage, ICH ever, stroke <3mo, diathesis, active, anticoag,
  • Trauma: head, dissection, recent OR

*Door to needle time should be <=30 mins FMC
Post TPA PCI should occur w/i 24h

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7
Q

Blood thinners post ACS (no Afib or Afib but CHADS 0)

A

ASA 81 + (Ticag 90 BID or Plavix 75 OD) x 1 yr
After 1 yr:
- If high risk bleed, low thromb risk: ASA alone
- If low risk bleed/high thromb risk: ASA + (Ticag 60 BID or Plavix 75 OD) x 3 years then SAPT

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8
Q

Blood thinners post ACS (Tx PCI) with Afib (CHADS>0)

A
  1. ASA 81 + Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 2.5 BID) x 1 day - 1 month –>
  2. Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 15 OD) x 1 month - 1 year –>
  3. DOAC Lifelong (Apix 5 BID, Dabi 150 BID, Riva 20 OD)
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9
Q

Blood thinners post ACS (No PCI) with Afib (CHADS >0)

A
  1. Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 15 OD) x 1 month - 1 year –>
  2. DOAC Lifelong (Apix 5 BID, Dabi 150 BID, Riva 20 OD)
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10
Q

Blood thinners post- elective PCI with Afib (CHADS >0)

A

If high thrombotic risk:

  1. ASA 81 + Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 2.5 BID) x 1 day - 1 month –>
  2. Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 15 OD) x 1 mo- 1 year –>
  3. DOAC Lifelong (Apix 5 BID, Dabi 150 BID, Riva 20 OD)

If low thrombotic risk:

  1. Plavix 75 + DOAC (Apix 5 BID, Dabi 150 BID, Riva 15 OD) x 1 mo - 1 year –>
  2. DOAC Lifelong (Apix 5 BID, Dabi 150 BID, Riva 20 OD)
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11
Q

Blood thinners post elective PCI (No Afib or Afib CHADS 0)

A

If low bleeding risk:
ASA + Plavix 75 x 6 months (extend up to 3 years if high thrombotic risk) –> ASA lifelong

If high bleeding risk:
1. ASA + Plavix x 1 month if BMS / 3 months DES –> ASA

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12
Q

Indications for ICD in HoCM

A 
Prior VT/VF arrest
Unexplained syncope
Sustained VF >30sec
Family Hx SCD
LV wall >30 mm
NSVT or abN BP response on treadmill w/ other risk factors
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13
Q

HFrEF (EF <40%): Medical Treatment

A

1st line: ARNI ACE/ARB, BB, MRA (ISDN/Nitro if intol to ACE/ARB), SGLT2

  • Add Ivabridine (if SR >70, ie NOT afib, not paced, hosp for HF in last year)
  • Vericiguat if recent HF hospitalization
  • Digoxin if poor AF control

If going NYHA 4 symptoms –> palliative care, add ISDN/Nitro, adv HF therapy

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14
Q

HFrEF: Indications for primary prevention ICD +/- CRT

A

EF <=35% after 3 mo post-revasc/OMT/40d post- MI:

  • NYHA 1: ICD ONLY IF ischemic CM + EF <=30%
  • NYHA 2-3: ICD +/- CRT* (*if sinus rhythm, + LBBB >130 msec, or any BBB >150 msec)
  • NYHA 4: ICD +/- CRT* (only if ambulatory, expected to improve, or candidate for adv tx)
  • expected life expectancy >1y and reasonable QoL
  • weak rec: CRT in frail elderly, permanent AF, chronic RV pacing + symptomatic HFrEF
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15
Q

HFeEF: Indications for secondary prev ICD

A

VT/VF Arrest or Sustained VT (>=30 secs or hemodynamically significant) with structural heart disease or >48 hrs post MI /revasc
No reversible cause found

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16
Q

HFpEF: Medical Treatment

A 
Manage HTN (ACE/ARB = 1st line) 
Diuretics for symptoms
MRA if elevated BNP
Consider candesartan
**no recommendation for ARNI

-empa ?mort benefit

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17
Q

Diagnosis Pericarditis

A

2/4 of:

1) Typical CP (pleuritic, worse when supine)
2) Pericardial Rub
3) ECG: Diffuse STE +/- PR depression w/o reciprocal ST depression
4) New or worsening pericardial effusion on echo

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18
Q

Tx Pericarditis (1st, recurrent, pregnancy)

A

1st episode: NSAID x2weeks + Colchicine x 3 months
Recurrence: NSAID x2weeks + colchicine x6 months
Post MI: High dose ASA (650mg QID) + Colchicine

AI or refractory NSAID: Pred + Colchicine
Pregnancy: No ASA, NSAID, Colchicine.
Breastfeeding: No ASA

Advanced: IVIG, anakinra, azathioprine, pericardioectomy

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19
Q

Tx Thoracic Aortic Dissection

A

Type A - Surgical
Type B (does not involve ascending aorta) - IV labetalol (target HR <60-65, sBP <120), IV nitroprusside if BP refractory to labetalol, consult vascular surg
(can also use CCB or ACEi)

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20
Q

When to operate: Thoracic Ao aneurysm

*how often to screen

A

5.5 cm - degenerative/bicuspid valve
5 cm - Marfan’s, rapid growth
4.5 cm - all other congenital disorders (turner, ehlers-danlos, etc)

*F/U: q6-12mo (dep on rate of change), q6m if genetic aortopathy; MRI if <50yo bc serial radiation

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21
Q

When to operate: AAA

*how often f/u

A

5.5 cm for all
5 cm if: Female, +FHX, Hx CTD, Rapid growth >0.5 cm/year
*F/U: q6-12 mon if <4.5 cm, q3-6 mo >4.5 cm

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22
Q

Monitoring Bicuspid AoV

A

Annual H&P
Repeat echo only if evidence of stenosis, aortic dilatation or new symptoms
- If stenosis: q3-5years mild, q1-2 years moderate, q6-12 mo if severe and not candidate for replacement
- If aortic root dilation: q6-12 mo

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23
Q

AS: Indications for valve replacement

A

1) Severe Symptomatic AS (AVA <1cm, MG >40mmHg, peak veloc >4m/s) (D1)
2) Severe AS w/ LVEF <50% (C2)
3) Symptomatic Low-flow low-gradient AS (AVA <1cm, MG <40/V <4, LVEF <50%) with symptoms if MG>40/V>4 with dobutamine stress test (D2)
4) Symptomatic Low-flow low-grad AS with EF<50% OR if AS most likely cause of sx
5) Severe AS without symptoms if symptoms develop on exercise stress (C1)
6) Sevee AS without symptoms going for other CV surgery

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24
Q

AI: Indications for valve repair/replacement

A

1) Severe Symptomatic AI
2) Severe AI with LVEF <55% if no other cause for reduced LVEF
3) Severe asymptomatic AI going for other CV Surgery

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25
Q

Rheumatic MS: Indications for valve repair/replacement

A 
Percutaneous Mitral balloon Commisurotomy (PBMC): 
Severe MS (dw: MVA <=1.5 cm, PAP >50, dBP 1/2t >=150) + NYHA 3-4 + no contraindications (>= mod MR, LA thrombus)  + fav anatomy

MV surgery (commisurotomy +/- repair/replacement):

  • Failed or contraindication for PBMC + acceptable surgical risk
  • Severe MS going for other CV surgery
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26
Q

MS: Indications for anticoagulation and targets

A
  1. Afib
  2. TIA/Stroke
  3. LA Thrombus

VKA –> Target INR 2.5-3.5

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27
Q

MR (primary): Indications for MVR

A
  1. Severe primary symptomatic MR
  2. Severe primary asympatomatic MR with LVEF <60% or LVESD >=40mm Hg

For secondary: must be on OMT, including CRT & revascularization

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28
Q

TR: Indications for TVR

A

Severe TR going for other left sided valve surgery

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29
Q

Anti-coagulation post valve-replacement

mech vs bioprosthetic targets and agent

A

Mechanical = Lifelong VKA

  • Modern AVR - INR 2-3
  • Mitral or ball in cage AVR - INR 2.5-3.5

Bioprosthetic
First 3-6mo: Surgical: VKA (INR 2-3) + ASA;
vs/ TAVR: DAPT (Plavix) or VKA (INR 2-3) +ASA
- Then ASA for life

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30
Q

A.fib: Who gets anticoagulation, exclusion, and when to use VKA

A
  1. > = 65
  2. <65, but 1 of: CHADS (CHF, HTN, DM, Stroke
  3. Mitral stenosis
    * *Exclusion: No anticoagulation for ESRD with eGFR <15

VKA: if mechanical valve, rheumatic MS, mod/severe non rheumatic MS

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31
Q

DOAC Doses for Afib

A
  1. Apix 5 BID (2.5 BID if 2 of: Age>=80, Cr >=133, Wt <60kg) - ok till eGFR 15
  2. Rivaroxaban 20 OD (15 OD if CrCl <50) - ok till eGFR 15
  3. Dabi 150 BID (110 BID if CrCl <50 or age >75) - ok till eGFR 30
  4. Edoxaban 60 OD (30 OD if CrCl <50 or weight <60kg) - ok till eGFR 30
    * See other CAD slides for doses if being combined with anti-plt
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32
Q

Afib: Who gets immediate cardioversion

A

Electrical cardioversion (w 4 weeks AC post) if:

1) Hemodynamically unstable
2) NVAF <12 hrs and no prior stroke
3) NVAF 12-48 hrs and CHADS2 0-1 (age >75 not 65 as per CHADS65)

*All others, start rate control and 3 weeks of anticoagulation and reassess for cardioversion as outpatient

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33
Q

Persistent Afib: Who gets rhythm control > rate and how?

A

Who:

  1. Afib <1 year
  2. High symptom burden/QoL impact
  3. Multiple recurrence or difficulty achieving rate control
  4. CHF secondary to afib

How:

  1. Anticoagulate x 3 weeks (unless meeting criteria for immed cardioversion)
  2. Electrical or chemical cardioversion
  3. Initiate maintenance anti-arrhythmic if Sx improve with cardioversion
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34
Q

Paroxysmal Afib: Treatment Algorithm

A

Low Symptom burden: Observe vs pill in pocket

High symptom burden: Maintenance anti-arrhythmic +/- catheter ablation

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35
Q

A.fib: Which maintenance AADs to use

A 
If HFrEF (<40%): Amiodarone
If HF (>40%): Amio or sotalol (caution if LVH or torsades risk)
CAD: Amio, sotalol, dronaderone
WPW: Procainamide, Ibutilide ; avoid AV nodal blocker
No HF or CAD: Sotalol, dronaderone, flecainide, propafenone
36
Q

Indications for PPM

A
  • Symptomatic: tachy brady, sinus pause/brady, to increase GDMT, chronotropic incompetence
  • Mobitz II 2nd degree AVB, 3rd deg AVB +/- symptoms
  • Alternating LBBB/RBBB
  • Permanent Afib with symptomatic bradycardia (either spont or tx induced)
37
Q

Indications for PPM Post-MI

A

Mobitz-T2, 3rd AVB, alternating BBB, symptomatic persisting >5d post-MI
- Consider in new BBB or isolated fascicular block, or transient AVB that resolves

*consider pacing in post-cardiac surgery, post-TAVI, asystolic syncope during tilt testing, cardioinhibitory carotid sinus syndrome

38
Q

Syncope: High risk features warranting further Ix (beyond Hx/Px/ECG/basic BW)

A
  • Symptoms suggestive of cardiac syncope (Symptoms just before during or just after exertion or without prodrome)
  • Hx CVD (valve, CADm arrythmia)
  • Concomitant trauma
  • FHX SCD <50 years
  • Abn VS or cardiac exam
  • Elevated trop/BNP
  • High risk ECG: Sinus node dysfxn (brady <50, pause >3sec), blocks (QRS >120, bifascicular block, Mobitz 2, 3rd degree), ventricular pre-excitation, SVT, AF, NSVT, QTc <340/>460, Brugada, LVH, current or past ischemia)
39
Q

Right sided murmurs increase with:

A

Inspiration

40
Q

Left sided murmurs increase with:

A

Expiration

41
Q

VSD

A

Holosystolic murmur @ LLSB with thrill
Radiates to RLSB
Maneuvers = same as MR –> Decreases with reduced preload (standing, valsalva), Increases with increased PL (squat, leg raise), Increases with increased AL (handgrip)

42
Q

Systolic Murmurs

A

Pansystolic: MR (Apex rad to axilla), TR (LLSB), VSD (LLSB to RLSB), MVP (LLSB rad to LUSB or back)

SEM: AS (RUSB rad to clavicle/carotid, parvus), Aortic sclerosis (RUSB, no carotid radiation, no parvus), HoCM (apex/LLSB radiates to axilla/base)

43
Q

Diastolic Murmurs

A

Low pitched rumble: MS (at apex, hear opening snap after S2)

High pitched: AI (RUSB) +/-Austin Flint (functional MS without opening snap)

44
Q

Continuous murmurs

A 
PDA
Aortopulmonary window
Coarctation
AVMs
Ruptured sinus of valsalva to atrium
Internal Mammary artery
Venous hum in jugular
Arterial stenosis (ie. subclavian) `
45
Q

ASD

A

Wide fixed split S1 + S2, loud S1 and P2
Diastolic rumble due to flow over TV
SEM over LUSB due to flow over PV

46
Q

Loud S1

A

MS, TS
ASD, PDA (due to pressure equalization)
Short PR (less time for leaflet to drift together)
Exercise (ventricular contraction)

47
Q

Quiet S1

A

Calcific MS
MR
Valves close early (long PR, AI, LBBB)

48
Q

Variable S1

A

A.fib
AV dissociation (complete heart block, VT)
Severe Tamponade

49
Q

Wide split S1

A

RBBB
ASD
Ebstein’s anomaly

50
Q

Loud S2

A

A2: HTN, CoA, Aneurysm
P2: pHTN, ASD

51
Q

Quiet S2

A

A2: AI, severe calcific AS
P2: Low pulm artery Pressure, PS

52
Q

Wide split S2

A

RBBB, LV PPM

53
Q

Wide fixed S2

A

ASD, RV failure

54
Q

Paradoxically split S2

A

LBBB, WPW, Fixed LVOT, AS, HOCM

55
Q

Differentiating Tamponade, Pericarditis, Restrictive CM

A

Tamponade: + Pulsus, - Kussmaul, Blunted Y-dec, high JVP, (quiet S1/2), + ventric interdependence

Constrictive: - Pulsus, + Kussmaul, Prominent Y-dec, high JVP, (peric knock), + Ventricular interdependence

Restrictive: - Pulsus, + Kussmaul, Prom Y-dec, high JVP, (manifestations amyloid /sarcoid), no ventricular interdependence

56
Q

Driving guidelines post ACS/CABG

A

ACS/CABG with WMA: 1 month private, 3 months commercial

ACS (no WMA) tx with PCI: 48 hrs private, 7 days commercial
ACS (no WMA) tx WITHOUT PCI: 7 days private, 30 days commercial

If ICD: 1 mo (if primary prev)/6 months (secondary) if private, NO commerc
PPM: 7d private, 1mo w/ N ECG commerc

57
Q

Driving guidelines VT/VF

A

No ICD: 6 months private, NO driving commercial

58
Q

Driving guidelines CHF

A

NYHA 1-2: no restrictions private, NO commercial driving if LVEF <=35%
NYHA 3: no restrictions private, NO commercial driving
NYHA 4, LVAD, Inotropes: No driving

59
Q

Cocaine Associated Chest Pain : Tx

A

1) ASA Load + Benzos
2) NTG/Nitroprusside for HTN / persistent CP
3) If STEMI/NSTEMI - Tx as usual but avoid BB acutely

60
Q

ECG Features Suggestive of VT

A

Complete axis deviation (QRS + in aVR, - in I, II and aVF)
QRS >160 msec
RSr’ (left bunny ear higher) in V1 - most specific
AV dissociation
Capture / Fusion beats
Concordance across all precordial leads
Absence of LBBB or RBBB Morphology
Brugada sign (distance from QR to S >100 msec)
Josephson’s sign - notched S wave

61
Q

RE-LY Trial
Dabigatran 150 was associated with (a) efficacy and (b) bleeding risk compared to warfarin

Dabigatran 110 was associated with (c) efficacy and (d) bleeding risk compared to warfarin

A

a) superior
b) equivalent
c) equivalent
d) decreased

62
Q

Left atrial mobile mass arising from intact septum

A

Atrial Myxoma

63
Q

Treatment recurrent pericarditis

A

1) NSAID 2wks + Colchicine x6 months
2) If recurs again - add prednisone (0.2-0.5 mg/kg) then slow taper
3) If still recurrent: Anakinra (anti-IL1), Aza, IVIG
4) If recurrent despite the above, pericardectomy

64
Q

Mitral Valve Prolapse

A

Pan-systolic murmur at apex with radiation to base or back with mid-systolic clic

Maneuvers = identical to HoCM
No change with inspiration/expiration
Increased PL: murmur quieter + shorter, click later
Dec PL: murmur louder + longer, click earlier
Inc AL: Murmur quieter + shorter, click later

65
Q

ECG Features in HoCM

A

Left atrial enlargement
LVH with ST/T wave abn from repolarization
Deep, narrow, dagger like Q waves in lateral>inf leads
Giant precordial Twave inversions
WPW
Arrhythmias (afib, SVT, PACs, PVCs, VT)

66
Q

Max HR for TST

A

85% of max HR (220-age)

67
Q

Consider CABG if:

A 
L main dz (>50%)
Proximal LAD stenosis
3-vessel disease
2- or 3-vessel disease with LVEF <40%
Multivessel dz with diabetes/LV dysfcn/CHF
68
Q

Antiplatelet dose

A

Loading: ASA 160, Ticag 180, Plavix 300-600
Maintenance: ASA 81, Ticat 90 q12h, Plavix 75

69
Q

RF for bleed in DAPT/stent

A

Drugs: OAC, NSAID, prednisone
Patient: Age >75, frail, Low BW (<60kg), bleed within past year, previous stroke/intracranial bleed, HTN
Labs: Hgb <110, CKD (CrCL <40), abnormal LFT, labile INR

70
Q

Preop Antiplatelets

  • Holding
  • Neuraxial anesthesia
A

Plavix and Ticag 5-7d preop; 7d if neuraxial anesthesia
Prasugel 7-10d
Continue ASA periop if possible

71
Q

Syncope Drive

A

Vasovagal: can drive private/commerc if not provoked sitting

Recurrent unexplained: 3mo syncope free private, 12mo syncope free commerc

72
Q

Cardiac Amyloid Tx

A

Restrictive CM: Diuretics
*Avoid: BB, CCB, ACE/ARB, dig
OAC for afib (regardless of CHADS; similar to HOCM)

ATTR : tafamidis or inotersen or patisiran +/- liver transplant
AL: chemotherapy +/- autologous stem cell transplant
ICD - consult EP

73
Q

When to workup HFrEF for advanced therapy

A

NYHA 2-4 +1 of:

  • EF < 25%, worsening RHF/PH, end organ dysfcn
  • Need pressors, refractory to diuresis or have to stop meds
  • Repeat hospitalizations, 1y mortality, can’t do ADLs, cachexia, hypoNa
  • 6MWT distance < 300m
74
Q

Medical therapy for valves

A

AS: ACE/ARB after TAVI (NO afterload reduction otherwise), tx HTN/DLPD as normal
AR: ACE/ARB or ARNI for symptoms or LV systolic dysfcn + prohibitive surgical risk, tx HTN as normal
MS: VKA if afib, stroke, LA thrombus
MR/TR: Tx HF as normal. NO vasodilators if normal EF and asymptomatic primary MR

75
Q

TAVI indications

A

> 80yo or younger pt w/ <10y life expectancy
intermed/high/prohibitive surgical risk
Reasonable QoL with life expectancy >1y

*bioprosthetic valve req IE ppx

76
Q

Causes of pericarditis

A
  • Vascular – post MI or CV Sx
  • Infectious - Coxsackie, echovirus, adenovirus, flu, parvo, TB, fungal
  • Autoimmune – RA, SLE …
  • Metabolic - uremia, dialysis, hypothyroidism
  • Iatrogenic – Radiation, Meds (hydralazine, dilantin, INH, procainamide, minoxidil)
  • Neoplastic - mesothelioma, breast/lung/melanoma mets, leukemia, lymphoma
77
Q

Reasons to admit pericarditis

A
  • Fever T>38C
  • Hemodynamic instability
  • Myopericarditis (Troponin elevation)
  • Significant effusion (>20mm) or cardiac tamponade
  • Immunocompromised
  • Trauma
  • Oral anticoagulation therapy
  • Subacute onset
  • Lack of improvement after 7d appropriate therapy
78
Q

OAC for AF in liver dz, Ca, CHD, frail, preg, thyroid

A

Liver: Not if CP-C or signif coagulopathy
Cancer: DOAC>VKA, individualize
Congenital heart dz: OAC for HCM
Frail elderly: OAC
2ndary AF: no OAC EXCEPT risk for recurrence, or acute thyrotoxicosis (until euthyroid)
Pregnancy: No DOAC. Give LMWH/warfarin (T2-T3)

79
Q

VT management

a) Storm
b) polymorphic +/- prolong QT

A

Storm (>3 in 24h): NSBB (eg propranolol), IV amio, sedation
Polymorphic:
-Normal QT - ischemia (ACS tx, amio/lido), vs no ischemia (amio);
-Prolonged QT: IV Mg, NSBB, overdrive pacing +/-lidocaine if refractory

Stable: cardiovert vs procainamide. 2nd line: amio, lidocaine

80
Q

Cardiac pacing for vasovagal syncope

A
  • Patients >/= 40 with ++sx
  • Symptomatic asystole > 3s or asymptomatic asystole >6s
  • Tilt-induced asystole > 3s or HR < 40 bpm for > 10s
81
Q

Different PVD ulcer characteristics

A

Arterial ulcer = punched out, on toes, feet
Venous stasis ulcer = medial calf
Diabetic ulcer = plantar foot, heel

82
Q

PVD Tx

A

NonPharm: Exercise, self foot examination, wound care

Pharm:
ASA/Plavix, ASA+Riva2.5BID for stable CAD/PAD
ACEi + statin in all
Smoking cessation
Cilostazol (PDE3i) - CONTRAINDICATED in CHF
Anticoag for acute limb ischemia

Revasc only if critical limb ischemia

83
Q

Precordial TWI DDx

A 
Wellens - proximal LAD occlusion
Brugada
Increased ICP 
PE
RBBB, RVH
HOCM, LVH
84
Q

BP and bruit differences in Coarctation vs Takayasu

A

Coarctation: lower in LE, higher in UE. NO subclavian bruit
Takayasu: higher in LE, lower in UE, subclavian bruits

85
Q

High risk features on exercise stress test

A

Duke Treadmill Score -11 or less
STE or STD >=2mm or >1mm with <5 METS/ >=5 leads/ persisting >3 min into recovery
VT/VF
Abnormal BP response (fail to increases BP >120, drop >10, drop below BL)

86
Q

Tall R wave in V1 DDX

A 
Hypertrophic cardiomyopathy
RBBB /RVH/strain 
WPW
Posterior MI  (STE Leads 7-9)
Dextrocardia 
Muscular/myotonic dystrophy

RCE (18 decks)

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