Cardiovascular Flashcards
Which of the following from the history has the greatest predictive value for acute coronary syndrome?
a) Pain at rest but not on exertion
b) No radiation
c) Diaphoresis
d) History of hypertension
e) History of dyslipidaemia
C.
Diaphoresis, vomiting, worse on exertion and radiation of pain are 4 of the most predictive features on history that the patient has ACS in the context of chest pain. Radiation to both arms is a greater risk than just the right side followed by the left side.
Defining sinus rhythm on an ECG. The ‘p’ wave should be inverted in which of the following leads?
a) aVL
b) aVR
c) I
d) II
e) III
B.
In all other limb leads the ‘p’ wave should be upright and only inverted in aVR. If this is not the case then the patient does not have a sinus rhythm. Its either ectopic or if PR interval is <120ms think junctional rhythm.
In an inferior MI, which lead is the first to change?
a) aVL
b) aVR
c) I
d) II
e) III
A.
aVL shows ST depression and T wave inversion prior to the same changes in aVR and ST elevation in leads I, II and III.
1/3rd of inferior MI’s can involve the right ventricle. What would classify as a right sided infarction on ECG?
a) 0.5mm STE in lead V3-V6
b) 1mm STE in leads V3-V6
c) 1mm STD in leads V3-V6
d) 1mm STE in leads V7-V9
e) 0.5mm STE in leads V7-V9
E.
Only 0.5mm of STE in the right sided leads (V7-V9)
Which of these signs would help you distinguish from STEMI and hyperkalaemia?
a) Leftward axis
b) Rightward axis
c) ST elevation
d) ST depression
e) Tall T waves
B.
Hyperkalaemia acts as a sodium channel blocker causing changes similar to STEMI but most of the time hyperkalaemia will have a rightward axis when most STEMIs do not (not a 100% but helpful). STEMI and hyperkaalemia can have all the other signs.
Which of these signs if pathognomonic of pericarditis?
a) Tender on palpitation
b) Shortness of breath
c) Relieved leaning forward
d) Radiates to the trapezius ridge
e) Pleuritic in nature
D.
This sign is said to be pathognomonic of pericarditis due to inflammation to the phrenic nerve which runs along the pericardium. Pain relieved by sitting forward and that is pleuritic in nature are ‘typical’ of pericarditis but not as specific.
Which of these ECG signs would indicate pericarditis instead of a STEMI?
a) PR depression in leads V2-V6
b) PR elevation in aVR
c) ST elevation throughout
d) Horizontal ST segments
e) None of the above
E.
Unfortunately all the classic signs a, b and c can all occur in a STEMI. Look for factors that rule in STEMI first! Factors which favour STEMI include: Reciprocal ST depression in any leads (except aVR & V1) STE in lead III > STE in lead II Horizontal or convex upward ST-segment morphology (pericarditis has a concave ST elevation) R-T sign or “checkmark sign” Q-waves that you know are new
Which of these causes a short QT interval?
a) Hypocalcaemia
b) Digoxin toxicity
c) Hyperkalaemia
d) Citalopram overdose
e) Raised ICP
B.
Short QT interval DDx: hypercalcemia, digoxin toxicity, short QT-syndrome The others cause a prolonged QT interval.
Which of these ECG changes would you find in hypercalcaemia?
a) Prolonged QT interval
b) Tachycardia
c) Narrow QRS
d) Short PR interval
e) Short QT interval
E.
Prolonged PR interval Bradycardia, AV blocks QRS interval widening, bundle branch blocks ST segment changes (can mimic ACS) Differentiate by eliciting a good HPI and looking for short QT interval
Which of these is seen on an ECG with hypokalaemia?
a) Wide QRS
b) Peaked T waves
c) U waves
d) Short QT interval
e) Wellens’ waves
C.
ECG Findings in Severe Hypokalemia: Prolonged QT-interval U-waves (Can be very large) Flattening of T waves then ST segment down-sloping/depression “reverse Wellens’ waves” Ventricular ectopy
Which of these causes a wide QRS on the ECG?
a) Pre-excitation
b) Atrial fibrillation
c) Atrial flutter
d) SVT
e) Junctional tachycardia
A. - all the others are supra-ventricular rhythms which based on their own cause narrow QRS complexes.
Causes of QRS Prolongation: Bundle branch blocks (LBBB or RBBB) Paced beats Pre-excitation (e.g. WPW) Ventricular ectopy Metabolic (Hyperkalemia or severe acidosis) Na+ channel blocking drugs (e.g. TCA’s) Non-specific intraventricular conduction delay (e.g. LVH, cardiomyopathy)
Which of these cause a rightward axis on the ECG?
a) Inferior MI
b) Dextrocardia
c) LBBB
d) LVH
e) WPW
B. The others causes a leftward axis.
Differential Diagnosis for Rightward Axis:
Right ventricular hypertrophy
Pulmonary hypertension (e.g. PE, COPD)
Lateral MI (due to Q wave in I)
Ventricular ectopy
Dextrocardia
Hyperkalemia
Na+ channel blocking drugs (e.g. TCA’s)
Left posterior fascicular block
Misplaced leads
Normal in young kids
Which of these cause a leftward axis on the ECG?
a) RVH
b) Pulmonary HTN
c) Hyperkalaemia
d) Inferior MI
e) Left posterior fascicular block
D. The others cause a rightward axis.
Differential diagnosis for leftward axis:
Left ventricular hypertrophy
Left bundle branch block
Inferior MI
Ventricular pacing /ectopy
Wolff-Parkinson-White Syndrome
Primum ASD – rSR’ pattern
Left anterior fascicular block – diagnosis of exclusion Horizontally orientated heart – short, squat patient
Which of the following statement is correct in relation to heart blocks?
a) In Mobitz I, the PR interval is constant.
b) In premature Atrial Complexes the P-waves are regular.
c) In complete heart block the PR-interval is regular.
d) In Mobitz II there is progressive PR interval lengthening.
e) A premature atrial complex can mimic a Mobitz II.
E.
Blocked Premature Atrial Complexes: P-waves are irregular, the non-conducted P-waves come early. Usually a benign cause (ex. mild electrolyte abnormalities). May mimic Mobitz II, often misdiagnosed by the ECG machine!
Mobitz I (Wenckebach): P-waves are regular (P-P interval is constant). Progressive PR-interval lengthening before a non conducted beat.
Mobitz II: P-waves are regular (P-P interval is constant). Some impulses fail to conduct to the ventricles WITHOUT progressive PR-interval lengthening.
AV Dissociation, 3rd degree AV Block: P-waves are regular (P-P interval is constant). PR-interval is randomly changing.
Which of the following causes a prolonged QT?
a) Hypercalcaemia
b) Digoxin
c) Hypomagnesaemia
d) Short QT syndrome
e) Oleander ingestion
C. The others cause a short QT. Oleander causes a digitalis toxicity.
Prolonged QT differential:
Hypokalaemia
Hypomagnesaemia
Hypocalcaemia
Hypothermia
Myocardial ischemia
Post-cardiac arrest
Raised intracranial pressure
Congenital long QT syndrome
DRUGS (e.g. citalopram)
Which of the following would cause syncope or a seizure presentation and should be checked for on an ECG?
a) Sinus rhythm
b) WPW
c) First degree heart block
d) Premature atrial complexes
e) Premature ventricular complexes
Differential for syncope on ECG:
Ischemia (Acute Coronary Syndrome, Cardiomyopathy, etc.)
Dysrhythmias (Tachycardia, Bradycardia, AV-blocks)
WPW/Pre-excitation syndromes
Long & Short QT syndromes
Hypertrophic cardiomyopathy
Brugada syndrome
Arrhythmogenic RV dysplasia
Which statement is true regarding inverted U waves on the ECG?
a) Usually occurs in the inferior leads.
b) Associated with RCA disease.
c) Only significant if the patient has chest pain.
d) Occurs in lateral leads.
e) Can be ignored.
D.
Regarding inverted U-waves:
Usually occurs in lateral leads
Associated with LAD or LMCA disease
May occur during pain or painless state
Should not be ignored!
Which of the following will cause ‘low voltage’ on an ECG?
a) Amyloid
b) Anorexia
c) Pneumonia
d) Hyperthyroidism
e) Myocardial infarction
A.
Low Voltage QRS Differential:
“Low Power”
Myxedema (severe hypothyroidism)
Infiltrative diseases (Amyloid, Sarcoid, etc.)
End stage cardiomyopathy
Conduction blockage:
Fluid/Effusion (pericardial or pleural)
Fat (obesity)
Air (COPD)
Which of the following statments is true regarding pericardial effusion signs on an ECG?
a) Defined as a QRS amplitude <10 mm in the limb leads.
b) Defined as a QRS amplitude in I+II+III <10 mm.
c) Defined as a QRS amplitude in V1+V2+V3 <30 mm.
d) Defined as a QRS amplitudes in all the chest leads <7.5 mm.
e) Pulsus alternans is seen in 50% of cases.
C.
Low Voltage Definition:
Specific Definition
QRS amplitudes in limb leads all < 5 mm OR in all chest leads < 10mm
Sensitive Definition
QRS amplitudes in I+II+III < 15 mm OR V1+V2+V3 < 30 mm
Pulsus alternans is seen in 30% of cases.
Which of the following on ECG would indicate an acute pulmonary embolism?
a) T wave inversion in the anteroseptal leads.
b) Sinus bradycardia
c) LBBB
d) SIQIITIII
e) Premature atrial complexes
A.
ECG findings in Pulmonary Embolism:
Sinus Tachycardia (only in 30-50%)
SIQIII or SIQIIITIII, a.k.a. Rightward Axis (not sensitive or specific)
New RBBB or incomplete RBBB
Superventricular tachydysrhythmias
Ventricular dysrhythmias
ST-segment elevations or depressions
New TWI’s, especially in anteroseptal +/- inferior leads = Acute Pulmonary Hypertension = PE until proven otherwise!
Which of the following causes a prolonged PR interval?
a) Junctional rhythm
b) WPW
c) Lown Ganong Levine syndrome
d) Enhanced AV nodal conduction
e) Hyperkalaemia
E.
Differential for short PR interval:
Junctional rhythm
Pre-excitation syndromes
WPW (Wolff-Parkinson-White syndrome)
LGL (Lown-Ganong-Levine syndrome)
Normal variant (EAVNC – enhanced AV nodal conduction)
In relation to Lown Ganong Levine syndrome which of the following is true?
a) It is associated with an accessory pathway
b) It causes paroxysmal tachycardia
c) It is associated with ventricular arrythmias.
d) If symptomatic needs ablation
e) Associated with VF and death
B.
All the other statements are what was previously thought about LGL but the latest evidence has debunked these concepts. LGL presents with a history of paroxysms of tachycardia and has a short PR interval without a delta wave (normal QRS).
