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Les deux ennemis > Cardiology : PMP, ventricular arrythmias, syncope > Flashcards

Cardiology : PMP, ventricular arrythmias, syncope Flashcards

1
Q

Do you need to have symptoms for an indication of a pacemaker ?

A
  • Sinus node dysfunction IF NEED SX
    brady, pauses, tachy-brady, AF + brady, chronotropic incompetence
    ON GDMT
  • Acquired AV Block do not need sx
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2
Q

How is the y descent in pericardial constriction ?

A

Rapid y descent

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3
Q

How is the y descent in tamponade ?

A

Blunted y descent

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4
Q

How long can you wait to put a pacemaker after myocardial infarction ?

A

Waiting period necessary
5 days post MI if AVB does not resolve

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5
Q

What are indications for a permanent pacemakers post MI ?

A

– Mobitz II AVB
– High grade AVB
– 3rd degree AVB
*** – Alternating BBB

+ class III :
- Transient AVB that resolves
- New BBB or isolated fascicular blok

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6
Q

What are the indications of PMP for acquired AV block ?
Name 5

A

• 2nd degree AVB Mobitz type 2
• 3rd degree AVB
• High grade AVB
• Permanent AF and symptomatic bradycardia
• Symptomatic AVB (spontaneous or from required drug therapy)

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7
Q

What are the three indications for ICD in secondary prevention ?

A
  • Cardiac arrest on VT/VF
  • Sustained VT in the presence of significant structural heart disease
  • Sustained VT > 48h post MI or revascularization

WITH NO REVERSIBLE CAUSE

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8
Q

What is the DDX of brady ?

A

OSA, Lyme, Sarcoid, electrolytes, thyroid, genetic/inherited

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9
Q

What is the definition of an electrical storm ?

A

≥ 3 episodes in 24h

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10
Q

What treatment should you choose in case of an electrocal storm ?

A

Beta blocker, perferably non selective
IV amiodarone

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11
Q

What will a magnet do on a pacemaker ?

A

It will not disable it, it will make it fo on ASYNCHRONOUS MODE, mode often VOO.
Magnet rate is most often 100bpm.
Useful if a patient is undergoing surgery and cautery near the chest may be detected by the device as cardiac activity.

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12
Q

When is an ICD indicated for primary prevention after MI ? after revasc?

A

40 days post MI, 3m post revascularization

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13
Q

When is an ICD indicated for primary prevention in ischemic cardiomyopathy ?

A

ICM, NYHA I, LVEF = 30%
ICM, NYHA II-IV, LVEF = 35 %

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14
Q

When is an ICD indicated for primary prevention in NON ischemic cardiomyopathy ?

A

NICM, NYHA II-III, LVEF = 35 %

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15
Q

When should you consider ICD in hypertrophic CMP ?

A

• Sustained VA or prior cardiac arrest (Class I)
• FMHx of SCD, LV wall thickness >30 mm, unexplained syncope, apical aneurysm, LVEF <50% (Class IIa)
• Extensive LGE on MRI or NSVT on Holter monitoring (Class IIb)

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16
Q

What are the strong recommendations for CRT in CHF ?

A
  • Sinus rythm
  • Symptomatic
  • On GDMT
  • LVEF = 35 %
  • TYPICAL LBBB
  • QRSd >/= 130ms
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17
Q

What are the weak recommendation for CRT indications in CHF ? (may respond)

A

In Sinus rhythm
• Symptoms (NYHA II-II, ambulatory IV)
• On GDMT
• LVEF ≤ 35%
• Non-LBBB **
• QRSd ≥ 150ms **

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18
Q

What is the tx in case of stable, sustained (>30 sec) VT ?

A
  • DC cardioversion vs procainamide
  • Amiodarone
  • Lidocaine
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19
Q

What is the dose of amiodarone in case of sustained VT ?

A

Amiodarone IV 150mg then 900mg/24h infusion

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20
Q

What is the approach in case of polymorphic VT/VF ?

A

– Normal QT : acute ischemia (ACS Tx and amio or lido) vs. no ischemia (amio)
– Prolonged QT : IV Mg, overdrive pacing, non-selective BB, lidocaine if refractory

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21
Q

What is the dose of lidocaine ?

A

100 mg IV push if unstable

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22
Q

What is the dose of procainamide ?

A

10mg/kg IV over 20 min for stable monomorphic VT

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23
Q

What medication should you start after sustained VT/VF ?

A

Beta blocker at maximal doses

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24
Q

What are the three channelopathies which carry risk of sudden cardiac death ?

A

Brugada syndrome
Long QT syndrome
Catecholaminergic polymorphic VT (CPVT)

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25
Which pattern is worrying in case of Brugada syndrome ? What are the EKG characteristics?
TYPE 1 : dome V1-V2 followed by negative T wave In that case : EP study for risk stratification ICD indicated if syncope presumed from ventricular arrhythmia with type 1 EKG
26
How many Brugada syndrome is there ?
Type 1 clinically relevant pattern Type 2-3 only matter if they turn into type 1
27
What can provoke a Brugada type 1 ?
Fever, ischemia, hypo/hyperK, hypothermia, post cardioversion RX like sodium channel blockers : fleicanide, propafenone not exclusive
28
What is the pathophysiology of Brugada ?
Mutation in sodium channels Autosomal dominance mutation
29
What is the pathophysiology of catecholaminergic polymorphic VT (CPVT)?
Mutation in the ryanodine receptor
30
What is DDX of long QT ?
Long QT syndrome, bundle branch block, electrolytes, medications, congenital
31
In case of long QT syndrome, which medication should you give ?
Beta blockade is recommended if QTc is 470ms or more to reduce risk of ventricular arrhythmias
32
What is the pathophysiology of torsades de pointes ?
Occurs in the setting of QT prolongation is triggered by an “R-on-T” event, in which a premature ventricular contraction hits the T-wave, producing polymorphic VT.
33
What is the management of long QT ?
- Discontinue offending drug - Correction of e+ (Mg = 1 and K > 4) - Increase the patient’s heart rate with temporary pacing - Isoproterenol - Lidocaine
34
Does increasing the patient’s heart rate increase or shortens the QT interval ?
Shortens the QT interval and makes it less likely for a PVC to hit the QT
35
Why are beta blocker useful to prevent torsades de pointes ?
Supress ventricular ectopy, reducing the R on T likelihood,reduce the risk of cardiac arrest
36
What are the driving restrictions in case of VT/VF ?
3 MONTHS 1 week if structurally normal heart and well controlled No driving if commercial
37
What are the driving restrictions in case of sinus node dysfunction / AV block ?
If no impaired LOC : OK to drive If unpaired LOC : No driving unless PPM If 2nd degree type II, alternating BBB, 3rd degree AVB : no driving peu importe Same for commercial
38
What are the driving restrictions in case of a pacemaker ?
1 week post implant IF impaired LOC / high grade AV block Same for commercial
39
What are the driving recommendations for commercial drivers in case of an ICD ?
No driving
40
What are the driving recommendations for private car in case of an ICD for primary and secondary prophylaxis ?
Primary prophylaxis : 1 w post implant Secondary prophylaxis : 3 months if impaired LOC, if not 1 week
41
What are the driving recommendations in case of ICD shock or therapy for private driving?
If impaired LOC or disabling : 3 months, if not 1 week No restriction if inappropriate ICD therapies
42
What are the driving restrictions in case of electrical storm ?
3-6 months after event for private car No driving if commercial
43
When should you do cardiac testing in case of syncope ?
If high clinical suspicion of ischemic, structural or valvular heart disease Stress testing should be performed for patients who present with syncope that occurs before, during, or after exertion
44
When should brain imaging be performed in case of syncope ?
Only for whom intracranial disease is highly suspected or suspicion of head trauma
45
Holter monitors to catch symptoms of what frequency ?
Daily symptoms But there is extended holters for weekly / monthly symptoms
46
What is the treatment of orthostatic hypotension ?
Increased H20 and Na Compression garments Head up tilt sleeping Fludrocortisone Midodrine
47
What is the treatment of vasovagal syncope ?
Increased H2O and Na If recurrent and refractory : fludrocortisone or midodrine > BB if age > 42 Cardiac pacing
48
When is cardiac pacing indicated for vasovagal syncope ?
- Patients ≥ 40 with highly symptomatic VVS - Documented symptomatic asystole > 3s - Documented asymptomatic asystole > 6s - Tilt-table induced asystole > 3s or HR < 40 bpm for > 10s
49
What are the driving recommendations in case of syncope for private car ?
OK to drive if single / recurrent vasovagal syncope 1 week if reversible cause / avoidable trigger / single unexplained syncope 3 months if recurrent unexplained syncope
50
What are the driving recommendations in case of syncope for commercial driver ?
OK to drive if single / recurrent vasovagal syncope 1 month if reversible cause / avoidable trigger 12 months if single or unexplained recurrent syncope
51
What is the definition of POTS ?
Orthostatic tachycardia without orthostatic hypotention Sustained increase in HR > 30bpm supine within 10 min of standing with no drop in BP
52
What is the treatment of POTS ?
Non pharm : exercise training, Na 10g/d, H2O 3-4 L/d, compression stockings waist high Pharm : midodrine, fludrocortisone
53
Should you screen athletes with ECG ?
No recomment against routine screening ECG Only do ECG if Hx et PE concerning
54
DDX of Tall R wave in R1 ?
i) RVH/strain ii) RBBB iii) WPW iv) Posterior MI v) Dextrocardia vi) Muscular dystrophy vii) Hypertrophic cardiomyopathy
55
Posterior STEMI on ECG ?
Anterior ST depression Do a 15 lead to look for posterior ST elevation
56
Multiple pulmonary nodules on chest XRAY : DDX ?
- Malignancy, multiple lung metastases - Septic pulmonary emboli (ex Staph aureus, if recent cardiac procedure be worried about endocarditis on right side) - TB - Fungal but usually under 0.5cm - GPA/Wegener - Pneumoconiose (silicosis usually smaller and upper lobe predominant)
57
What features on CT would suggest this nodule is malignant ? - Doubling time of <1 month compared to previous imaging - Popcorn calcification - Size <1cm - CT enhancement >20 Houndsfeld Units - Smooth border
- CT enhancement >20 Houndsfeld Unit
58
DDX solitary pulmonary nodule : size
>4cm much more likely a bronchogenic carcinoma <1cm makes malignancy less likely
59
DDX solitary pulmonary nodule : rate of growth
Requesting a prior Xray is key - doubling of size (in 2-dimension this corresponds to an increase by 25%) in <1 month suggests infection, in >18mos suggests benign
60
DDX solitary pulmonary nodule : calcification
Malignant calcification is usually eccentric or stippled. Benign calcification includes popcorn type, laminar, concentric.
61
Solitary pulmonary nodule : enhancement on CT ?
CT densitometry - >20 Houndsfeld units post contrast suggests malignant, whereas <15 suggests benign.
62

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