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).
Which of these is true of the modified sgarbossa criteria?
a) Concordant STE >2mm in contigous leads
b) Concordant STE >1mm in contigous leads
c) Concordant STD >1mm in any lead
d) Concordant STD >1mm in V1-V3
e) Disordant STE >5mm in any lead
D.
Modified criteria:
Concordant STE >1mm in any lead
Concordant STD >1mm in V1-3
Discordant STE >25% or STD >25% of the S wave total size.
Which of the following statements are true?
a) The sympathetic nerve supply to SA node only
b) SA node Beta 1 fibres decrase pacemaking activity (chronotropy)
c) Cardiac Muscle Beta 1 fibres decrease contractility (inotropy)
d) SA node Beta 1 fibre increase inotropy
e) Stilumation of beta 1 and beta 2 receptors in the skeletal and coronary circulation causes vasodilatation.
E.
The sympathetic nerves innervate the SA and AV node, ventricular myocardium and vasculature.
SA node beta 1 fibres increase pacmaking activity (chronotropy - HR)
Cardiac muscle Beta 1 fibres increase contractility (inotropy - SV)
Which of the following is correct regarding ECG leads?
a) All the limb leads are I, II, III, aVL, aVR and aVF
b) V1-V2 is lateral
c) V3-V4 Septal
d) V5-V6 Anterior
e) Right sided leads are V7-V9
A.
The precordial leads are V1-V6 (V1-2 = septal, V3-4 anterior and V5-6 = lateral)
Right sided leads are V3R - V6R
Posterior leads are V7-V9
Lateral = I, aVL, V5 and V6
Inferior II, III, aVF
Anterior V1-V4
Which of the following pressures is correct for the right atrium (mmHg)?
a) 1 - 8
b) 4 - 12
c) 15 - 30
d) 90 - 120
e) 120 - 180
A.
Which of the following pressures is correct for the right ventricle (mmHg)?
a) 1 - 8
b) 4 - 12
c) 15 - 30
d) 90 - 120
e) 120 - 180
A.
Although during systole it increases to 15-30mmHg
Which of the following cardiac index values (L/min/m3) indicates cardiogenic shock?
a) 2
b) 2.5
c) 1.5
d) 2.2
e) 3
C.
A value <1.8 L/min/m3 is considered cardiogenic shock
Which of the following values is within the normal range for a cardiac index?
a) 0.5
b) 1
c) 2
d) 3
e) 4.5
D.
2.6 - 4.2 L/min/m3 is considered normal.
Cardiac index = Cardiac output/body surface area
Which of the following pressures is correct for the pulmonary artery (mmHg)?
a) 1 - 8
b) 4 - 12
c) 15 - 30
d) 90 - 120
e) 120 - 180
B.
4 - 12mmHg or 15 - 30 during systole.
Which of the following pressures is correct for the left atrium/pulmonary capillary wedge pressure (mmHg)?
a) 1 - 8
b) 4 - 12
c) 15 - 30
d) 90 - 120
e) 120 - 180
B.
Which of the following pressures is correct for the left ventricle at end diastole (mmHg)?
a) 1 - 8
b) 4 - 12
c) 15 - 30
d) 90 - 120
e) 120 - 180
B.
What percentage of stenosis is significant on a coronary angiogram?
a) 50%
b) 80%
c) 60%
d) 90%
e) 70%
E.
Which of the following is correct in the CHADS2 score?
a) Cardiac disease
b) Hyperlipidaemia
c) Age >65
d) Diabetes
e) Systolic BP >180
D.
CHADS2 consists of 1 point for congestive heart failure, hypertension, Age >75, diabetes and 2 points for stroke or TIA.
0 = 1.9% stroke risk/yr
1 = 2.8% stroke risk/yr
2-3 = 4-5.9% stroke risk/yr
4-6 = 8.5-18.2% stroke risk/yr
With regards to a STEMI which one of the following statements is true?
a) Thrombolysis should occur within 60 mins (EMS to needle)
b) PCI should occur within 120 mins (EMS to balloon)
c) Thrombolysis is preferred in patients who present <12 hours of symptom onset and PCI can not be administered in the right time frame.
d) Early PCI has an increased rate of recurrent MIs when compared with thrombolysis.
e) Early PCI has an increased rate of intra-cranial haemorrhages when compared with thrombolysis.
C.
Thrombolysis should occur within 30 mins, PCI within 90 mins.
Thrombolysis should be given if <12hrs since pain onset, patient can not get PCI or it is contraindicated. Again the ideal time frame is <30 mins.
Early PCI has lower mortality, intra-cranial haemorrhages or recurrent MIs when comapred to thrombolysis.
Which of the following is an absolute contraindication to thrombolysis?
a) Uncontrolled HTN
b) Ischaemic stroke >3 months
c) Recent internal bleeding (<2-4 weeks)
d) Pregnancy
e) Known malignant intracranial neoplasm
E.
The absolute contraindications are:
Prior intracranial haemorrhage
Known structural cerebral vascular leasion
Known malignant intracranial neoplasm
Significant closed head or facial trauma <3 months
Ischaemic stroke < 3months
Active bleeding
Suspected aortic dissection
Which of the following is a relative contraindication to thrombolysis?
a) Prior intracranial haemorrhage
b) Known structural cerebral vascular lesion
c) Ischaemic stroke <3 months
d) Noncompressible vascular punctures
e) Active bleeding
D.
The relative contraindications are:
Uncontrolled HTN (sBP>180, dBP>110)
Current anticoagulation
Noncompressible vascular punctures
Ischaemic stroke >3 months
Recent internal bleeding (<4 weeks)
Prolonged CPR or major surgery (<3 weeks)
Pregnancy
Active peptic ulver disease
Which of the following typically causes heart failure with preserved ejection fraction (diastolic heart failure).
a) Restrictive cardiomyopathy
b) Diabetes
c) Alcohol
d) Dilated cardiomyopathy
e) Myocarditis
A.
While there is some overlap in aetiologies between the two, broadly speaking the causes are:
HFpEF:
Ischaemia, severe hypertrophy from HTN, aortic stenosis or HCM. Restricitve cardiomyopathy from amyloid. MI
HFrEF:
Ischaemia, HTN, alcohol (and other toxins), myocarditis, dilated cardiomyopathy.
What are the five most common causes of heart failure?
CAD (60-70%)
HTN
Idiopathic (often dilated cardiomyopathy)
Valvular (e.g. AS, AR and MR)
Alcohol (dilated cardiomyopathy).
Also the most common cause of right heart failure is left heart failure.
What are the precipitants of Heart failure?
HEART FAILED mneumonic
Hypertension
Endocarditis / environmental (heat wave)
Anaemia
Rheumatic heart disease and there valvular disease
Thyrotoxicicosis
Failure to take meds (very common)
Arrhythmia (common)
Infection / Ischaemia / Infarction (common)
Lung problems (PE, pneumonia, COPD)
Endocrine (pheochromocytoma, hyperaldosteronism)
Dietary indiscretions (common)
What are the pharmacological treatments for heart failure?
Renin-angiotensin-aldosterone blockade (ACE-I or angiotensin II blockers. Latest evidence suggests ARB + neprilysin inhibitor ARNI to be better than an ACE-i alone)
Beta Blockers - carvediolol improves class IV HF
Aldosterone intagonists - spironolactone (can cause hyperkaelaemia)
Diuretics
Digoxin
Antiarryhythmia drugs (amiodarone if already on beta blockers and digoxin)
Anticoagulants
What is the most common cause of dilated cardiomyopathy?
a) alcohol
b) idiopathic
c) SLE
d) Chagas disease
e) Cocaine
B.
Approximately 50% of DCM is idiopathic, presumed viral.
Other causes include, alcohol, genetic, uncontrolled tachycardia.
Collagen disease (SLE, PAN, dermatomyositis, progressive sclerosis).
Infectious (Coxsackie B, HIV, Chagas, Lyme, Rickettsial disease, acute rheumatic fever, toxoplasmosis).
Neuromuscular disease (Duchenne, myotonic dystrophy, Friedrich’s ataxia.
Metabolic: uraemia, nutritional deficiency (thiamine, selenium, carnitine).
Endocrine (hyper and hypothyroidism, DM, pheochromocytoma)
Peripartum
Toxic; cocaine, heroin, organic solvents
Drugs; chemotherapy (doxorubicin, cyclophosphamide), anti-retrovirals, chloroquine, clozapine, TCA.
Radiation
In bold are also the causes for myocaritis which can lead to DCM. Additional causes for myocarditis apart from idiopathic are, bacterial (s.aureus, c.perfringens, c.diphtheriae, mycoplasma), fungi, hypersensitivity/eosinophilic (antibiotics, diuretics, lithium, clozapine, insect or snake bites), collagen vascular disease (SLE, RA, sarcoidosis, autoimmune) and giant cell myocarditis.
Which of the following abnormalities would you expect with a dilated cardiomyopathy?
a) Low BNP
b) Low Creatine
c) High LFTs
d) High bicarbonate
e) High Sodium
C.
All other labs are:
High BNP and Creatine
Low bicarbonate and Sodium
In regards to HOCM which of these will make the harsh systolic murmur quieter?
a) Squating.
b) Standing.
c) Squeezing hands then letting them go.
d) Valsalva.
e) Nitrate administration.
A.
Dynamic maneuvres:
Quieter with increase in preload (eg, squatting) or increase in afterload (eg, handgrip).
Louder with any decrease in preload (eg, Valsalva maneuver, nitrate administration, diuretic administration, standing) or with any decrease in afterload (eg, vasodilator administration)
Which of the following drugs should be avoided in HOCM?
a) Beta blockers
b) Disopyramide
c) Verapamil
d) phenylephrine
e) ACE-i
E.
Treatment for HOCM consists of Beta-blockers, disopyramide, verapamil (started only in monitored setting) and phenlephrine (in the setting of cardiogenic shock).
Drugs to avoid (as they increase the LVOT gradient) include:
Nitrates, diuretics and ACE-i.
Which of these aeitologies causes restrictive carditis?
a) alcohol
b) Carcinoid syndrome
c) SLE
d) Chagas disease
e) Cocaine
B.
A, C, D and E cause dilated cardiomyopathy
Causes of restricitve cardiomyopathy include:
Infiltrative: Amyloidosis, sarcoidosis
Non-Infiltrative: Scleroderma, idiopathic myocardial fibrosis
Stroage diseases: Haemachromotosis, Fabry’s disease, Gaucher’s disease, glycogen storage diseases.
Endomyocardial: Endomyocardial fibrosis, Loeffler’s endocarditis or eosinophilic endomyocardial disease. Radiation heart disease and carcinoid syndrome.
Which of these aetiologies causes acute pericarditis?
a) Hyperthyroidism
b) Bowel Cancer
c) Dissecting aneurysm
d) Colchicine
e) Endomyocardial Fibrosis
C.
Other causes:
Idiopathic is the most common (presumed viral)
Infectious: Viral (Coxsackie A or B, echovirus), bacterial (Strep pneumoniae and staph aureus) and TB. Fungal (histoplasmosis and blastomycosis.
Post MI: Acute (direct extension of myocardial inflammation 1-7d post-MI), Dressler’s syndrome (autoimmune reaction, 2-8 weeks post MI)
Post cardiac surgery or trauma
Metabolic: Uraemia, hypothyroidism
Neoplasm: Hodgkin’s, breast, lung, renal cell carcinoma, melanoma.
Collagen vascular disease: SLE, polyarteritis, rheumatoid arthritis, scleroderma.
Vascular: Dissecting aneurysm
Other: Drugs (hydralazine), radiation, infiltrative disease (sarcoid).
Which of these causes a transudative pericardial effusion?
a) Uraemia
b) Post-CABG
c) Dissecting aneurysm
d) Hypothyroidism
e) SLE
D.
The transudate causes are:
CHF / Hypoalbuminaemia/hypoproteinaemia / Hypothyroidism.
The exudative (serosanginous) causes are the same for acute pericarditis:
Idiopathic is the most common (presumed viral)
Infectious: Viral (Coxsackie A or B, echovirus), bacterial (Strep pneumoniae and staph aureus) and TB. Fungal (histoplasmosis and blastomycosis.
Post MI: Acute (direct extension of myocardial inflammation 1-7d post-MI), Dressler’s syndrome (autoimmune reaction, 2-8 weeks post MI)
Post cardiac surgery or trauma
Metabolic: Uraemia, hypothyroidism
Neoplasm: Hodgkin’s, breast, lung, renal cell carcinoma, melanoma.
Collagen vascular disease: SLE, polyarteritis, rheumatoid arthritis, scleroderma.
Vascular: Dissecting aneurysm
Other: Drugs (hydralazine), radiation, infiltrative disease (sarcoid).
Which of the following is in Beck’s triad?
a) Tachycardia
b) Pulsus paradoxus
c) Decreased JVP
d) Friction rub
e) Hypotension
E.
Beck’s triad: Hypotension, increased JVP and muffled heart sounds.
Classic Quartlet of Tamponade: Hypotension, Increased JVP, Tachycardia, Pulsus paradoxus.
Which aetiology below causes pulsus paradoxus?
a) Acute pericarditis
b) Asthma
c) Pneumothorax
d) Severe HTN
e) Dressler’s syndrome
B.
Causes:
Constricitve pericardiits (rare)
Severe obstructive pulmonary disease (asthma)
Tension pneumothorax
PE
Cardiogenic shock
Cardiac tamponade
Which of these signs is seen in cardiac tamponde but not in constrictive pericarditis?
a) Hypotension
b) Kussmaul’s sign
c) Pericardial knock
d) Pulsus paradoxus
e) Prominent ‘x’ decent on the JVP
E.
Constrictive pericarditis:
Prominent ‘y’ decent / Kussmaul’s sign (paradoxical rise in JVP on inspiration) / rarely pulsus paradoxus / pericardial knock / variable hypotension
Cardiac Tamponade:
Prominent ‘x’ decent, pulsus paradoxus and hypotension.
Regarding the Vaughan-Williams Classification of antiarrhythmics, which of the following statements is true?
a) Procainamide is a class 1a drug
b) Flecanide is a postassium channel blocker
c) Class II drugs are calcium channel blockers
d) Metoprolol is a class IV drug
e) Sotalol is a class II drug
A.
Class 1 drugs are sodium blockers and class 3 are potassium blockers (like sotalol).
Class 2 are beta blockers (propranolol and metoprolol) and class 4 are calcium channel blockers (verapamil and diltiazem).
Class 1 is broken down further into:
1a Moderate Na block = Quinidine, procainamide and disopyramide
1b Mild Na block and shortens phase 3 repolariasation in the cardiac cycle = lidocaine and mexiletine.
1c = Marked Na blockade = propafenone, flecanide and encainide.
Which of the following is a life threatening cause of chest pain?
a) Pericarditis
b) Pulmonary Embolism
c) Flail chest
d) Sternal Fracture
e) Oesophageal chemical burn
B.
While all can pose from mortality risk the big life threats to exlude in ED are:
PE
Oesophageal Rupture
Tamponade
MI/angina
Aortic dissection
Pneumothorax
(Mnemonic PET MAP - esophageal rupture!)
Which of the following signs might you see on chest xray in a patient with an aortic dissection?
a) Triple calcium sign
b) Pleural effusion R>L
c) Right apical cap
d) Deviated NGT
e) Mediastinum >5cm
D.
Other Xray findings:
Widened mediastinum: >8.0-8.8 cm at the level of the aortic knob on portable anteroposterior chest radiographs (although this upper limit of normal varies). (56-63%)
Double aortic contour
Irregular aortic contour (48%)
Inward displacement of atherosclerotic calcification (>1 cm from the aortic margin)
Pleural effusion L>R
Tracheal shift
Left apical cap
Deviated NGT (normal in 11-16%)
Aortic knuckle double calcium sign >5 mm (14% - in Rosens, other papers talk about >10mm - increase specificity but reduced sensitivity). Seen where the innrer calcium is >10mm from the outer soft tissue marking of the aorta.
Which of these are a common cause of atrial fibrillation?
a) Fever
b) Age
c) Hypotension
d) Digoxin overdose
e) Pulmonary embolism
E.
C (sea) PIRATES
CHF, cardiomyopathy
Pulmonary Embolism
Ischaemic heart disease
Anaemia
Thyroid
ETOH, Elevated BP
Sick Sinus, Stress (surgery or sepsis)
Which of the following will precipitate heart failure?
a) Taking NSAIDs
b) Low salt intake
c) Hypothyroidism
d) Starting CPAP at night
e) Exercise
A.
FAILURE:
Forgot medication (or change to medication or starting NSAIDs)
Arrhythmias / Anaemia
Ishcaemia / Infarction / Infection
Lifestly (high salt intake)
Upregulation of cardiac output (pregnancy, hyperthyroidism)
Renal failure
Embolism (pulmonary)
Other causes include iatrogenic fluid overload and hypertensive crisis.
Which of the following statements are correct:
a) Ventricular escape rhythms are typically 30 - 60 bpm
b) Ventricular tachycardia is a rate over 140
c) Accelerated ventricular escape ryhythm is 40 - 120 bpm
d) Accelerated ventricular escape ryhythm is 60 - 120 bpm
e) Ventricular escape rhythms are typically 40 - 100 bpm
C.
Rate = 20-40: Ventricular escape rhythm (idioventricular rhythm)
Rate = 40-120: Accelerated ventricular escape rhythm (accelerated idioventricular rhythm, AIVR)
Rate > 120: Ventricular tachycardia
Caveat: VT can have slower rates if patient is on an antiarrhythmic (e.g oral Flecanide or Amiodarone)
Other mimics of VT (rate often <120)
Hyperkalemia
Sodium channel blocker toxicity
