Day 2

Question 1

Review the etiologies of bundle block.

Answer 1

• Iatrogenic (ablation, cardiac surgery)
• Endocarditis
• Ischemia
• Age-related degeneration/sclerosis
• Sarcoidosis
• Chagas disease

Question 2

Define maven.

Answer 2

(n.) A person who is an expert in some field

Example: “She is a grammar maven.”

Question 3

________ causes left-axis deviation.

Answer 3

Left anterior fascicle block

Question 4

You see Q waves in aVL, II, and III. There is left-axis deviation. What is the cause?

Answer 4

IMI with LAFB (“the pupu platter”)

Question 5

What is the “small-f flitter sign”?

Answer 5

Inverted P wave in aVL, suggestive of COPD

Question 6

An axis greater than 120º is one of two things: ____________.

Answer 6

• Left posterior fascicle block
• Right ventricular hypertrophy

RVH is much more common.

Question 7

LPFB causes _______-axis deviation.

Answer 7

right

Question 8

Why does an RBBB lead to the RSR’ formation?

Answer 8

The wave passes to the left ventricle first and then the right ventricle.

Question 9

In RBBB, there is abnormal QRS and abnormal __________.

Answer 9

T waves: they are generally inverted; if they are normal, then that is worrisome

Question 10

A QRS greater than ________ is diagnostic of complete RBBB (if other features are present).

Answer 10

120 mS

If the QRS is > 120 mS, then the diagnosis is incomplete RBBB.

Question 11

With a RBBB, you need to subtract the ________ to evaluate the axis.

Answer 11

terminal S wave (the post-block section of the QRS)

Question 12

Describe the rule of III vs. II.

Answer 12

• If the R wave in III is greater than in II: axis >90º
• If the R wave in III is the same as in II: ~90º
• If the R wave in III is less than in II: <90º

Question 13

If the R is greater than R’ in a RBBB (that is, the first R is larger than the second R), then it is likely a ______________.

Answer 13

superimposed posterior infarction

Question 14

Interpolated PVCs are PVCs that _____________.

Answer 14

don’t interrupt the rhythm

Question 15

In LBBB, list the axis orientations in order of best to worst prognosis.

Answer 15

• Normal
• LAD
• RAD

Question 16

What is the “small f Flitter” sign?

Answer 16

Inverted P wave in aVL indicates vertical heart with likely COPD

Question 17

When you assess axis in a person with a BBB, you need to ______________.

Answer 17

consider only the pre-BBB section of the QRS complex

So if lead I has an upright R and then an inverted, wide S, only consider the R because the S is an artifact of the RBBB.

Question 18

Rate-related BBB occurs with ___________.

Answer 18

tachycardia

Question 19

The more common type of bifascicular block is _____________.

Answer 19

LAFB and RBBB

LPFB and RBBB is the less common type.

Question 20

When the R is greater than the R’ in V1-V3, you must consider ______________.

Answer 20

RBBB with older posterior MI

Question 21

List the three ways you can diagnose an old MI in someone with a LBBB.

Answer 21

• Cabrera sign: a Q wave with a notch on the right side
• Chapman sign: an R wave with a notch on the right side
• Q waves in I and aVL: old anteroseptal

Chapman and Cabrera just tell you that there was an MI somewhere.

Question 22

What are the criteria for diagnosing an acute MI in LBBB?

Answer 22

Sgarbossa criteria:
• > 1 mm of ST elevation that is concordant with the QRS complex
•> 5 mm of ST elevation that is discordant with the QRS complex
•ST depression in V1-V3