EKG Block 2: The Possible Algorithm Thunder Dome Flashcards
What are the cardinal Sxs of CVDz?
CDC PFCS Chest pain/discomfort Dyspnea Cough Palpiatation Fatigue/Weakness Claudication Syncope/Dizzy
What is the cardinal manifestation of myocardial ischemia from CAD?
Chest pain
Define Dyspnea
Uncomfortable awareness of breathing
What are parts of the blood testing used for standard evaluation?
CBC
Thyroid indices
Lipid levels
Other than troponin, what other lab/blood result is useful in evaluating PTs for potential HF?
Pro- B type natriuretic peptide level
BMP <300 nearly excludes Dx
In the setting of acute chest pain, what imaging modality if effective in diagnosing coronary artery disease?
Multi-slice CT
When are stress tests/pharmacologic stress testing useful?
Ischemia
Abnormal perfusion- radionuclide studies
Abnormal transient wall motion
Radionuclide studies can be used to assess what types of heart function issues?
Left ventricle function
Myocardial ischemia
Determine if ischemic myocardium is variable
What can cardiac catherterization be used to measure?
Gradients across stenotic cardiac valves
Severity of intracardiac shunts
Intracardiac pressure
What can coronary angiography be used to provide diagnostically?
Definitive Dx of coronary artery disease
Necessary to prelude coronary revascularization with percutaneous interventions or coronary artery bypass grafts
Define Palpitations
Sensation of irregular/abnormal heart beats most commonly from ectopic premature atrial beats, ventricular contractions and tachyarrythmias
What is the next clinical step when a PT complains of palpitations?
Hx can lead to Dx
Pt taps out rhythm with fingers
Pre/Syncopes can be manifestations of what four things?
Tachy/brady arrhythmias
Neurocardiogenic syncopes
Unrelated to arrhythmias
What can cause neurocardiogenic syncope?
Vasovagal/reflex- most common Situational micturition- defecate, swallow, cough Carotid sinus syncope Neuralgia Psych d/o Meds Exercise
What can cause arrythmogenic syncope?
Bradys: sinus node dz, 2/3 AV blocks, pacemaker malfunction, drug induced
Tachys: V-tach, Torsades, SVT
What are the “other” causes of syncopes?
Neurologic/psych dz- migraine, TIAs OHOTN Dec CO Neuralgias Psych D/os Meds Exercise
Diagnostic considerations that need to be taken for neurocardiogenic syncope?
Sxs after prolonged motionless standing
Well trained athlete after exertion w/out heart dz
Situational syncope after micturition
Diagnostic considerations that need to be taken for organic heart disease syncope?
No prodrome, brief LOC
Syncope w/ exertion
FamHx of sudden death
Diagnostic considerations that need to be taken for neurological syncope?
Confusion >5min post-seizure
TIA
Migraine
Diagnostic considerations that need to be taken for other vascular reasons of syncope
Carotid sinus
OHOTN
Subclavian steal
Aortic dissection
What are the 3 class categories for PTs with heart palpitations?
1- palpitations, syncope, dizziness
2- SoB, chest pain, fatigue,
3- Sxs not reasonably expected to be caused by arrhythmias
When is long term monitoring suggested for PTs?
When is exercise testing used?
Holter, Loop, Telementry or Loop Recorders
Assess arrhythmia and chronotorpic incompetence in bradyarrhythmias
When can formal invasive electrophysiologic testing useful diagnostically?
When/why is electrophysiologic testing used?
Supra/Ventricular wide-complex tachy
Mechanisms of tachyarrhythmias and prior to ablations
What are the three Classes of electrophysiology studies?
1- PT w/ palpitations and tachy arrhythmias and ECG fail to document cause of palpitations or palpitations after a syncope
2- clinically significant palpitations, sporadics/unrecordable Sxs
Studies used to determine mechanism of arrhythmia, direct/provide therapy or assess prognosis
3- PTs w/ palpitations and have extracardiac causes
WHat are the three classes of use for an ECG?
1- arrhythmic w/ evidence of heart dz
2- arrhythmias associated with but w/out evidence of heart dz
3- palpoatations w/out evidence of arrhythmias or minor arrhythmia w/out evidence of heart dz
What is the most useful test for analyzing valve and ventricular functions and can quantify stenotic/regurgitated lesions?
ECG
When are handheld US performed by generalists?
Assess left ventricular function, cardiomegaly and pericardial effusion
What is the preferred test/image modality to evaluate probable aortic dissection and idntify clots in cardiac chambers?
Transesophageal echocardiography
What is the most common form of angina?
What S/Sxs does it present with?
Stable agina pectoris- classic angina
Short lasting burning, heavy, squeezing feeling in chest
Describe Unstable Angina
Chest pain occurring with increased frequency, duration and intensity that can be precipitated by progressive less effort
What are the parts of gatering an angina history?
S/Sx- in PTs own words Allergies Meds- SHOP Past MedHx Last PO intake Events- what were you doing when this event started?
What acronym are we using for gathering an aninga history?
OPQRST
What are the anginal equivalents that PTs can present with that are not EXACTLY angina?
Dyspnea, Fatigue, Lightheaded, Dizzy, Belching
What position preference do angina PTs prefer?
What makes the feel better?
Rest, sit, or stop walking when angina occurs
Resolves w/in minutes of rest or taking Nitro
What does typical chest pain quality have?
What are the atypical quality traits of angina that are more common in women, elder, DM, CVD PTs?
Levine Sign
Mild epigastric burning
Numbness
Where does angina radiation commonly present?
L side of neck/jaw L shoulder Ulnar surface of L arm R arm is less common Epigastric w/ or w/out chest pain
When does angina pain start to become concerning?
Angina pectoris is brief-mi
Concerning for ACS when more than 15-20min and especially at rest or nocturnal
Describe what non-cardiac etiologies of chest pain can present as?
Pleuritic- reproduced w/ movement/palpitations of chest wall
Sharp/constant x many hrs
Localized pain w/ tip of finger
What is the preferred test for PTs with suspected angina or moderate probablitlity of CAD?
Treadmill ECG
Q waves are a specific indicator for ?
Previous MI
When are Nuclear Cardiology imaging used?
Single Photon Emission on PTs who have an abnormal ECG
When is a Stress Echo done on PTs?
ID new wall motion abnormalities and structure of the heart
Define Prinzmetal Angina?
Caused by occlusive spasm on a coronary artery that would not otherwise obstruct blood flow
Prinzmetal Angina is associated with what 3 things?
Raynauds phenomenon
Migraine HA
Smoking
When do PTs with variant angina have pain?
How does the pain present?
Rest, possibly w/ exercise
Cyclic or recurring
How is Variant Angina diagnosed and managed?
Documented Transient ST elevation during chest pain w/out corresponding CAD
CCBs
Define Wellens Syndrome
Syndrome indicating critical high-grade occlusion of the proximal LAD or L main
What is the pathophysiology behind Wellens Syndrome
Unstable angina or unstable thrombus that may cause intermittent Sxs, nonspecific ECG findings, and little/no cardiac marker elevations
What is the end results of Wellens Syndrome that is not identified and properly treated?
Mean time from onset to extensive anterior wall MI is 8.5days
Difference between Type A and B Wellens Syndrome
A= 25%, biphasic T waves in anterior leads
Pseudo normal ST segment w/ pain
Causes AMI in 9 days if no PCI/CABG is done
B- 75%, V3 deeper than V2, 1mm ST elevation in chest leads
ECG characteristics of Wellends Syndrome Type A
Biphasic T waves in V2 and V3 that are symmetrical
No Q waves in precordial leads
Precordial R waves remain unchanged
ECG characteristics of Wellens Syndrome Type B
Deep symmetrical T waves
Characteristics of LMCA occlusion
70% risk of cardiogenic shock or dying
ONLY Tx- rapid PCI or emergent CABG
Not only in STEMI PTs, any ACS w/ LMCA occlusion
What ECG changes occur in aVR during a Left Main Occlusion?
ST elevation in aVR during ACS highly indicative
ST elevation in aVR greater than V1, elevation in aVL and aVR >1.5mm
What’s the dilema with Dx MI w/ LBBB?
1/2 of PTs don’t have chest pain and thus less likely to receive appropriate care (aspririn, BBs)
How to ID a posterior wall STEMI?
ST elevation in aVR in presence of ischemia- highly specific for acute occlusion on LMCA
Where to look to try and locate a Posterior Wall STEMI?
V1-3 reciprocal marks
Posterior Wall MIs are suggested by what ECG changes?
Horizontal ST depressions
Tall, broad R waves
Upright T waves
Dominant R waves in V2
PT presenting w/ ischemic Sxs, horizontal ST depression in V1-3 raises suspicion for ?
Post MI
Posterior wall STEMIs use leads V7-9 to locate, where are they placed?
7- posterior axillary line
8- tip of L scapula
9- left paraspinal region
What effect does cocaine cause on the heart?
Inhibits NorEpi, Sympathomimetic effect Tachy HTN Vasospasm Chest pain ACS
What can cocaine cause in the heart and what may be seen?
Cause: MI/ischemia, Myocarditis, arrhythmia, stroke, dissection
See- widened QRS, QT prolongation
What does amphetamine toxicity cause?
Peripheral and central smypathomimetic effects
HTN
Tachy
How is cocaine arrhythmia treated?
Sodium bicarbonate
How is the horizontal axis determines?
R wave progression
Towards hypertrophy
Away from infarcts
V1-neg, V6-pos
What are four causes of poor R wave progression?
Prior anterior infarct
L/RVH
Dilated cardiomyopathy
LBBB
Where do you look on an ECG for suspected right atrial enlargement?
Tall peaked P wave over 2.5mm
Most evident in II, III, aVF
Biphasic P wave in V1
Where do you look on an ECG for suspected left atrial enlargement?
Notched P wave in III
Biphasic P wave in V1
What are the criteria for RVH?
R wave reversal
V1, V2 strain pattern
RAD
What are the criteria for LVH?
Deepest S in V1 or V2 + tallest R in V5 or V6= 35mm
R wave in aVL >11mm
Where are strain patterns sen during hypertrophy?
I, aVL, V5, V6
Classically w/ ST depression
Define Early Repolarization
Greater than or equal to 0.1mV J-point elevation in 2 or more adjacent leads with slurred/notched morphology
What type of PT usually presents w/ early repolarization?
ASx young and athletic PT
Define Athletic Heart
Extenxive PT leading to structural and physiologic adaptations that can appear as abnormal EKGs
Hypervagotonia
Early repolarization
Inc chamber size
What are the benign findings usually seen with Athletic Heart?
Sinus arrhythmia Bradycardia Wandering atrial/junctional rhythm 1* AV block Mobitz 1 Wenkebach 2* block Isolated LVH voltage criteria Early repolarization pattern Mild RAD in young/thin PTs
ECGs are not recommended/seen as controversial for what PTs?
When are ECGs used for pre-op?
ASx
Athletes
Prior to low risk procedures in ASx PTs
High risk procedures/suspected medical problems
Most HCM PTs are ASx but they can present with what issues?
Typically in young athletes Dyspnea on exertion Chest pain Syncope Sudden death
How is HCM detected and how is the Dx confirmed?
Harsh creshendo-decrescendo systolic murmur that inc w/ valsalva and dec w/ squatting
Echo confirms
How does HCM present on ECG?
Significan Qs almost everywhere
LVH
How is HCM managed?
Echo Holter or Event monitor Refrain from vigorous activity Rx= Verapamil or BBs Consider implanting pacemaker
Characteristics of Long QT syndrome
Ventricular arrhythmia from dysfunctional ion channel
QT interval is longer than 1/2 of cardiac cycle
What meds can cause Long QT Syndrome
Levaquine Amiodarone Zoran Azithromycin Fluconazole Anti- histamine, psychotic, depreeseant ABX
How is Long QT Syndrome treated?
BB and ICD
How is Short QT Syndrome Dx?
QTc under 360
SIDS, Sudden arrest, Syncope, A-Fib, Polymorphic VT or VF
Acquired Short QT Syndrome can be caused by what 4 outlying issues?
How are these PTs treated?
Hyper K
Hyper Ca
Digitalis
Acidosis
Implant ICD
Define Brugada Syndrome
Genetic Dz characterized by abnormal ECG
Dx depends on:
EKG criteria
Clinical- syncope, agonal respirations, dizzy, palpitations
FamHx of sudden death under 45y/o
Death from Ventricular arhhythmias
What does Brugada Syndrome look like on ECG?
How are these PTs treated?
Sail sign in V1-V3
Tx w/ ICD and Genetic Studies
Define Arrhythmogenic RVCardiomyopathy
Genetic cardiomyopathy causing fibrous RV
seen as ventricular arrhythmia w/ LBBB
How does Arrhythmogenic RVC look on ECG?
Prolonged S wave
Inverted T waves V1-V3
Epsilon wave- R ventricle post excitation and is most characteristic finding
What is the best first tool for distinguishing VT and SVT?
12 lead ECG
What can be done to treat/manage VT vs SVT with Aberrancy?
What needs to be avoided?
Vagal maneuver or Adenosine can help Dx or terminate SVT
CCBs are avoided, may negatively impact structural heart Dz or WPW
What are the typical characteristics of Wide Complex Tachycardia typical w/ SVT?
Young w/ no CAD
QRS
What are the typical characteristics of Wide Complex Tachycardia typical w/ V-Tach?
Older w/ CAD QRS >.14 Capture/Fusion beats P wave dissociation Pos/Neg concordance Extreme RAD Cannon A waves on JVP
Define Fusion Beat
Combo of beats that fuse together as result of two impulses activating the same area
Define Takotsubo Cardiomyopathy
Broke Heart Syndrome
Transient apical L ventricular dysfunction that mimics MI
90% in women
How does Takotsubo Cardiomyopathy present?
Chest pain
ST elevation
Inc troponins
Normal vessels on coronary arteriography
How is Takotsubo Cardiomyopathy treated?
Removing stressor rapidly improves Sxs
What are the common causes of hyperkalemia?
CKDz Uncontrolled diabetes Dehydration Excess K in diet ACEIs ARBs NSAIDs K sparing diuretics Bactrim
What is the function of K in the heart?
Repolarization of the ventricular myocyte action potential
Inc K= inc conductance
Inc K causes what changes seen on ECGs?
Shortened repolarization ST depression Peaked T wave QT shortening QRS widening Wide to flat to no P wave
High levels of K lead to what abnormal HR?
V-Fib
How is hyperkalemia managed?
IV Calcium gluconate
Redistribute K w/ IV Dextrose, insulin and Beta agonists
Lower K w/ diuretic, dialysis and gastro binder
What are the common causes of Hypokalemia?
Diuretic Diarrhea- lax overuse/vomit Eating d/o Hyperaldosteronism CKDz Low Mg Sweat
How does Hypokalemia look on an ECG?
Flat/inverted T wave
U waves
Arrhythmia
Torsades, Polymorphic VT and VT
How is Hypokalemia treated/managed?
IV K
Oral K
Nutrition consult
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