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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
Q

Which pattern is worrying in case of Brugada syndrome ? What are the EKG characteristics?

A

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
Q

How many Brugada syndrome is there ?

A

Type 1 clinically relevant pattern
Type 2-3 only matter if they turn into type 1

27
Q

What can provoke a Brugada type 1 ?

A

Fever, ischemia, hypo/hyperK, hypothermia, post cardioversion
RX like sodium channel blockers : fleicanide, propafenone

not exclusive

28
Q

What is the pathophysiology of Brugada ?

A

Mutation in sodium channels
Autosomal dominance mutation

29
Q

What is the pathophysiology of catecholaminergic polymorphic VT (CPVT)?

A

Mutation in the ryanodine receptor

30
Q

What is DDX of long QT ?

A

Long QT syndrome, bundle branch block, electrolytes, medications, congenital

31
Q

In case of long QT syndrome, which medication should you give ?

A

Beta blockade is recommended if QTc is 470ms or more to reduce risk of ventricular arrhythmias

32
Q

What is the pathophysiology of torsades de pointes ?

A

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
Q

What is the management of long QT ?

A
  • Discontinue offending drug
  • Correction of e+ (Mg = 1 and K > 4)
  • Increase the patient’s heart rate with temporary pacing
  • Isoproterenol
  • Lidocaine
34
Q

Does increasing the patient’s heart rate increase or shortens the QT interval ?

A

Shortens the QT interval and makes it less likely for a PVC to hit the QT

35
Q

Why are beta blocker useful to prevent torsades de pointes ?

A

Supress ventricular ectopy, reducing the R on T likelihood,reduce the risk of cardiac arrest

36
Q

What are the driving restrictions in case of VT/VF ?

A

3 MONTHS
1 week if structurally normal heart and well controlled
No driving if commercial

37
Q

What are the driving restrictions in case of sinus node dysfunction / AV block ?

A

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
Q

What are the driving restrictions in case of a pacemaker ?

A

1 week post implant IF impaired LOC / high grade AV block
Same for commercial

39
Q

What are the driving recommendations for commercial drivers in case of an ICD ?

A

No driving

40
Q

What are the driving recommendations for private car in case of an ICD for primary and secondary prophylaxis ?

A

Primary prophylaxis : 1 w post implant
Secondary prophylaxis : 3 months if impaired LOC, if not 1 week

41
Q

What are the driving recommendations in case of ICD shock or therapy for private driving?

A

If impaired LOC or disabling : 3 months, if not 1 week
No restriction if inappropriate ICD therapies

42
Q

What are the driving restrictions in case of electrical storm ?

A

3-6 months after event for private car
No driving if commercial

43
Q

When should you do cardiac testing in case of syncope ?

A

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
Q

When should brain imaging be performed in case of syncope ?

A

Only for whom intracranial disease is highly suspected or suspicion of head trauma

45
Q

Holter monitors to catch symptoms of what frequency ?

A

Daily symptoms
But there is extended holters for weekly / monthly symptoms

46
Q

What is the treatment of orthostatic hypotension ?

A

Increased H20 and Na
Compression garments
Head up tilt sleeping
Fludrocortisone
Midodrine

47
Q

What is the treatment of vasovagal syncope ?

A

Increased H2O and Na
If recurrent and refractory : fludrocortisone or midodrine > BB if age > 42
Cardiac pacing

48
Q

When is cardiac pacing indicated for vasovagal syncope ?

A
  • 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
Q

What are the driving recommendations in case of syncope for private car ?

A

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
Q

What are the driving recommendations in case of syncope for commercial driver ?

A

OK to drive if single / recurrent vasovagal syncope
1 month if reversible cause / avoidable trigger
12 months if single or unexplained recurrent syncope

51
Q

What is the definition of POTS ?

A

Orthostatic tachycardia without orthostatic hypotention
Sustained increase in HR > 30bpm supine within 10 min of standing with no drop in BP

52
Q

What is the treatment of POTS ?

A

Non pharm : exercise training, Na 10g/d, H2O 3-4 L/d, compression stockings waist high
Pharm : midodrine, fludrocortisone

53
Q

Should you screen athletes with ECG ?

A

No recomment against routine screening ECG
Only do ECG if Hx et PE concerning

54
Q

DDX of Tall R wave in R1 ?

A

i) RVH/strain ii) RBBB iii) WPW
iv) Posterior MI v) Dextrocardia vi) Muscular dystrophy vii) Hypertrophic cardiomyopathy

55
Q

Posterior STEMI on ECG ?

A

Anterior ST depression
Do a 15 lead to look for posterior ST elevation

56
Q

Multiple pulmonary nodules on chest XRAY : DDX ?

A
  • 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
Q

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

A
  • CT enhancement >20 Houndsfeld Unit
58
Q

DDX solitary pulmonary nodule : size

A

> 4cm much more likely a bronchogenic carcinoma
<1cm makes malignancy less likely

59
Q

DDX solitary pulmonary nodule : rate of growth

A

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
Q

DDX solitary pulmonary nodule : calcification

A

Malignant calcification is usually eccentric or stippled. Benign calcification includes popcorn type, laminar, concentric.

61
Q

Solitary pulmonary nodule : enhancement on CT ?

A

CT densitometry - >20 Houndsfeld units post contrast suggests malignant, whereas <15 suggests benign.

62
Q
A

Les deux ennemis (7 decks)

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