Cards Test 1 Combo Flashcards
1
Q
Arrhythmia commonly found in COPD/lung disease patients
A
Multifocal Atrial Tachycardia
2
Q
continuous rapid-firing of multiple atrial automaticity foci
A
atrial fibrillation
3
Q
What should you think if you have a ventricular rate of exactly 150bpm?
A
atrial flutter
4
Q
Which BBB can be fairly common in healthy hearts?
A
Right BBB
5
Q
Which leads are useful in assessing atrial enlargement?
A
V1 and II
6
Q
Why is V1 useful in assessing atrial enlargement?
A
it’s perpendicular to the flow of electricity through the atria, and thus produces a nice biphasic P wave that’s useful to look at when left atrial enlargement is suspected
7
Q
Why is lead II useful in assessing atrial enlargement?
A
Lead II is parallel to the flow of electricity in the atria, and will thus be enlarged if atria are enlarged
8
Q
Evidence of RAE on EKG?
A
-P wave > 2.5mm in leads II or the first part of the diphasic P wave in V1
9
Q
Evidence of LAE on EKG?
A
- terminal portion of the diphasic P wave in V1 should drop at least 1 mm below the isoelectric line
- or the terminal portion should be at least 0.04sec in width
10
Q
Why is LAE sometimes called P mitrale?
A
-because mitral valve disease is the most common cause
11
Q
Why is RAE sometimes called P pulmonale?
A
-because it’s often caused by severe lung disease
12
Q
Evidence of right ventricular hypertrophy on EKG?
A
-large R wave in V1 (normally the S wave is larger)
13
Q
Evidence of left ventricular hypertrophy on EKG?
A
-S wave in V1 + R wave in V5 > 35mm
14
Q
Only in what type of patient is it safe to diagnose RVH? Why?
A
- patient with lung disease
- because lung disease with it’s associated RV afterload increase should be the only real reason for RVH
15
Q
Triad of myocardial infarction
A
- ischemia
- injury
- necrosis
16
Q
Evidence of ischemia on EKG
A
- ST depression
- T wave inversion
17
Q
What is ST elevation on EKG?
A
infarction
18
Q
Evidence of infarction on EKG?
A
-ST elevation
19
Q
What is ST depression on EKG?
A
ischemia
20
Q
What are the three stages through which an EKG evolves during an acute myocardial infarction?
A
- T wave peaking followed by T wave inversion
- ST segment elevation
- Appearance of new Q waves
21
Q
In what lead(s) is T wave inversion normal
A
-V1
22
Q
In which leads would T wave inversion be present in a patient with Wellens Syndrome?
A
V2 and V3
23
Q
What is the worst “kind” of ST depression?
A
- downsloping
- horizontal is also bad
24
Q
What makes a Q wave significant?
A
- at least 0.04 seconds (1 small square) wide
- or 1/4 of the entire QRS amplitude
25
What do significant Q waves indicate?
irreversible myocardial cell death
26
How does hypocalcemia manifest on EKG? Why?
- prolonged QT interval
| - because this is where ventricular contraction occurs, and not enough calcium prolongs ventricular contraction
27
What arrhythmia may be triggered by hypocalcemia?
-Torsades de pointes
28
possible causes of hypocalcemia
- primary/secondary hypoparathyroidism
- vitamin D deficiency
- chronic kidney disease
29
How does hypercalcemia manifest on EKG? Why?
- shortened QT interval
| - b/c a lot of calcium allows for very quick ventricular contraction
30
Possible causes of hypercalcemia
- malignancy
- chronic kidney disease
- adrenal insuffiency
31
How does hypokalemia manifest on EKG? Why?
- Early: T wave flattening
- ST segment starts to depress and can invert the T wave
- U wave in severe cases
- Remember that K+ is involved in phase 3 repolarization, which manifests on the T wave of EKG
32
causes of hypokalemia
- diuretics
| - vomiting/diarrhea
33
How does hyperkalemia manifest on EKG? Why?
- peaked T waves
- P waves may be flattened or absent
- Severe: QRS widens and fuses with T wave
- remember that K+ is involved in phase 3 repolarization, which manifests on the T wave of EKG
34
Causes of hyperkalemia
- ACE inhibitors
- K+ sparing diuretics
- renal failure
- hypoaldosteronism
35
Normal PR interval
0.12-0.20
36
what should you think if there's a lengthened PR interval?
AV block
37
what should you think if there's a shortened PR interval?
accessory pathway
38
What is the normal duration of the QRS complex?
- Less than or equal to 0.12 seconds
39
What should you think if the QRS complex is widened?
-BBB
40
Where would you see an R, R' if there's a RBBB?
-lead V1
41
Where should you see an R,R' if there's an LBBB?
-Lead V5
42
What would you think if there was an R, R' in lead V1?
RBBB
43
What should you think if there's an R,R' in lead V5?
LBBB
44
What is the normal QTc (QT interval) for males?
<450
45
What is the normal QTc (QT interval) for females?
<460
46
What are the three mechanisms of tachyarrhythmias?
- Enhanced automaticity
- Reentry
- Triggered Activity
47
What will be the response of a ventricular tachyarrhythmia to a vagal maneuver? Why?
- little to no effect at all
| - because there's little to no parasympathetic innervation in ventricular cells
48
On what ion does nodal tissue primarily rely for initiating depolarization?
calcium
49
For a reentry to exist, what must be true about the Purkinge fiber with two conduction pathways to ventricular muscle?
- there must be a limb with slow conduction
| - each limb must have a different refractory period
50
spontaneous depolarizations requiring a preceding impulse (a triggering beat)
after-depolarizations
51
After-depolarization that occurs before membrane repolarization is complete
early after-depolarization
52
Which after-depolarization may be the mechanism responsible for arrhythmogenesis related to the prolonged QT syndrome?
early after-depolarizations
53
Which type of after-depolarization is often triggered by electrolyte disturbances?
early after-depolarizations
54
After-depolarization that occurs after membrane repolarization is complete
delayed after-depolarization
55
what can cause delayed after-depolarizations?
an abnormal intracellular calcium load high enough to cause spontaneous depolarization
56
During what phase of repolarization do early after-depolarizations "strike"?
Phase 2 or 3
57
During what phase of the myocardial action potential do delayed after-depolarizations arise?
Phase 4
58
How can you calculate the upper rate range for sinus tachycardia?
220 - patient's age
59
What do we call it when patients have a rapid rise in HR with mild exertion?
-Inappropriate chronotropic response (part of inappropriate sinus tachycardia)
60
What would the resting HR be of a patient with inappropriate sinus tachycardia?
>100bpm
61
What is the most common mechanism of PSVT?
-reentry involving AV node, atrium, or an accessory pathway
62
Will junctional tachycardias terminate with vagal maneuvers?
no
63
Accessory pathway between the atria and ventricles?
Bundle of Kent
64
In what instances is WPW especially dangerous?
If patient has A fib or flutter
65
DOC for WPW
IV procainamide
66
What type of drug is best for treating WPW?
Na+ blocker
67
What drug do we need to make sure patients with WPW syndrome don't take?? Why?
- Digoxin
| - because it shortens the refractory period and may accelerate ventricular response in a setting of Afib
68
Most common cardiac arrhythmia necessitating hospitalization in the US
Afib
69
Which arrhythmia is associated with post-op status? On what post-op day does it most often occur?
- Afib
| - POD #3
70
What signs of Afib might you witness as a result of the loss of atrial contractile force (and therefore decreased cardiac output)?
- pulmonary rales
- S3
- peripheral edema (pitting)
- JVD
71
What is the focus of Afib treatment?
- rate control
- anticoagulation
- restoration of sinus rhythm
72
What drugs are good for the initial rate control of Afib an a hemodynamically stable patient?
- IV diltiazem
| - IV metoprolol
73
What drug is commonly used for long-term anticoagulation?
Warfarin
74
What INR do we want to achieve in our Afib patients before cardioverting?
2.0-3.0
75
What is the most commonly used drug for Afib cardioversion?
IV Ibutilide
76
How long must you maintain target INR before cardioverting Afib?
3-4 weeks
77
Where is the reentry circuit that's commonly associated with Aflutter located?
usually along the tricuspid valve annulus
78
What kind of medical therapy is often implemented in a patient with Aflutter?
- slow ventricular rate by drugs that increase AV block
- restore sinus rhythm (slow conduction or prolong refractory period of the atria - Class IA, IC, or III)
- DCCV if above fails
79
Which ventricular arrhythmia is more common among young, healthy individuals?
PVCs
80
What do we call it when there are more than three PVCs in a row?
ventricular tachycardia
81
If a patient says they feel a "flip-flop" of their heart, what are they more than likely describing?
The onset of a normal beat after the compensatory pause that follows a PVC
82
What is the most common cause of ventricular tachycardia?
CAD
83
Why is it important to distinguish monomorphic VT from SVT with aberrant ventricular conduction?
They each require different immediate and long-term treatments
84
When in doubt as to whether an arrhythmia is SVT with aberrant conduction or VT, which should you assume until proven otherwise?
VT
85
prior structural heart disease - more likely VT or SVT?
VT
86
vagal maneuvers affect the rhythm - SVT or VT?
SVT
87
No relationship of the QRS to P wave - more likely SVT or VT?
VT
88
QRS complexes in V1-V6 all have similar appearance - more likely SVT or VT?
VT
89
When trying to determine if an arrhythmia is SVT with aberrant conduction or VT, in what circumstances is VT more likely?
-prior structural heart disease
90
What is the most common cause of polymorphic VT?
-Acute MI
91
What is the ultimate cause of Long QT Syndrome?
- sodium and potassium chanelopathies
| - this causes a prolongation of ventricular repolarizationd
92
What's the primary symptoms of Long QT Syndrome?
syncope
93
What's the hallmark arrhythmia of Long QT syndrome?
Torsades de Pointes
94
What ion imbalances may be associated with Torsades?
- hypokalemia
| - hypomagnesemia
95
What is the most common type of congenital Long QT syndrome?
LQT1
96
What are common initiators of arrhythmias in LQT2 patients?
- auditory stimuli
| - emotional stress
97
What factors can precipitate syncope and sudden death in LQT1 patients?
- Physical exertion
| - sympathetic stimulation
98
What type of drug would you give to a patient with LQTS patient with a history of syncope or one with a definite prolonged QT interval?
Beta blocker
99
What would you do with a LQTS patient already on a beta blocker who experiences recurrent syncope?
prophylactic implant of an ICD
100
What diagnosis should you think of if a patient presents with a history of:
- Unexplained syncope
- Unexplained cardiac death of a family member <30
- Congenital deafness
Long QT Syndrome
101
What is the only effective therapy for ventricular fibrillation?
non-synchronized electrical defibrillation
102
What are the two mechanisms of bradycardias?
- disorders of impulse formation
| - conduction blocks
103
What are the most common extrinsic causes of sinus bradycardia?
medications
104
What is the most common indication for a pacemaker?
Sick Sinus Syndrome
105
What's a good drug to give in a patient with severely depressed heart rate?
-IV atropine (anticholinergic)
106
What type of pacing would you use in a patient when the AV node and vetnricular conduction systems function normally?
Atrial pacing (atria are paced)
107
What type of pacing would you use in a patient with complete AV block?
P wave-triggered pacing (ventricles paced)
108
What type of pacing would you use in a patient with SA node dysfunction combined with AV node dysfunction?
A-V sequential pacing (atria and ventricles are paced)
109
If a junction escape rhythm did produce a P wave, in what leads would be inverted?
II, III, AVF (the inferior leads)
110
What is the most common cause of 1' AV block?
Drugs that slow conduction through the AV node (Beta blocker and calcium channel blockers)
111
Which type of 2' block is more serious?
Mobitz Type II
112
Does a patient with a Wenckebach block need a pacemaker?
no
113
Does a patient with a Mobitz block need a pacemaker?
Yes
114
How are patients with Mobitz II block likely to present?
dizziness, lightneadedness, or syncope
115
What is the most common cause of Mobitz II block?
Acute MI (anterior or inferior)
116
Describe bradycardia management if perfusion is poor
- Prepare for transcutaneous pacing
- Administer IV Atropine
- Begin pacing if Atropine ineffective
- Consider epi or dopamine while waiting for pacer or if pacing is ineffective
117
What are the two types of temporary pacing?
- Transcutaneous
| - Transvenous
118
What should be included in your differential diagnosis for bradycardia?
- SSS
- Escape Rhythm
- Afib/flutter
- AV blocks
119
What should be included in your differential diagnosis for tachycardia?
- Sinus tach
- SVT
- Afib/flutter
- MAT
- Vtach
- Vfib
120
What should be included in your differential diagnosis for an irregular rhythm?
- sinus arrhythmia if all P waves are the same
- Wandering pacemaker if P waves are different
- MAT if P waves are different
- Atrial fibrillation if no P waves
- Atrial flutter if there are flutter waves
- AV blocks
121
What should you think if you don't see proper R wave progression?
-Something has happened to the anterior and/or lateral wall of the LV
