EP Board Review Flashcards
How to differentiate JT vs AVNRT: PAC’s
PAC’s ø influence HH or VV :: junctional rhythm
Any influence (advance/delay/terminate) :: AVNRT
JT vs AVNRT: ∆HA
HA(RVP) - HA(SVT)
- (+) :: junctional
- (-) :: AVNRT
LQTS1:
- Clinical presentation
- Genes affected
- QT appearance
- Channel affected
- Treatment
- Swimming, stressed (emotional)
- KCNQ1, KCNE1
- Long, but normal T wave
- Decreased Iks
- Nadolol, beta blocker
LQTS2:
- Clinical presentation
- Genes affected
- QT appearance
- Channel affected
- Treatment
- Post Partum (2 of you now); loud noise (2nes, tunes)
- HERG, KCNH2
- Bifid, notched (2 bumps)
- Decreased Ikr
- Nadolol? BB
LQTS3:
* Clinical presentation
* Genes affected
* QT appearance
* Treatment
- Sleep
- SCN5A, gain in fxn
- Long, isolectric segment
- Mexiletene, flecainide
Jervell & Lange-Nielsen:
* Labs
* Symptoms
* Onset
- Elevated gastrin
- Deafness
- Onset in childhood
LQT7:
* Syndrome eponym
* QT appearance
* Symptoms
* Gene
* Arrhythmia findings
* Treatment
- Anderson-Tawil
- Long QT +/- U wave
- Intermittent weakness, periodic paralysis, hypoK
- KCNJ2, loss of function
- Bidirectional VT
- Flecainide
Definition of chronotropic incompetence
< 75% age-related HR with exercise
Phase 4 Block explanation
Incoming impulse meets phase 4 depolarization
Paroxysmal AV block
Deceleration dependent; short-long
Bystander entrainment
* Manifest/Concealed fusion
* PPI-TCL in/out
- Concealed fusion
- PPI-TCL out
S-A - V-A interpretation
PPI-TCL > 115
SA-VA > 85
:: AVNRT
(V is surface QRS)
JET vs AVNRT Maneuvers:
* Late, His-refractory PAC
- Advance/Delay subsequent His & resets :: AVNRT
- No effect :: JET
JET vs AVNRT Maneuvers:
* Early PAC advances His with short AH
- Terminates SVT :: AVNRT
- Resets SVT :: JET
VT Score
* Criteria
* Interpretation
≥3 = VT
* Initial dominant R in V1
* Initial r ≥ 40 ms in V1, V2
* Initial R in aVR
* Lead II R wave peak time ≥ 50 ms
* Absent R in precordial leads
* AV dissociation/fusion/capture (2 pts!)
Good impedance drops:
* Atrium
* Ventricle
- Atrium: 5-8 Ω
- Ventricle: 10-12 … 15 Ω
Electrical remodeling in AF
- 70% decrease in I caL
- 70% decrease in Ito, Ina
How to ibutilide
Give 1 mg, wait 10 minutes
~ ø conversion, repeat 1 mg of 10 minutes
Sarcoid ICD indications (6)
- VT, EF ≤35%
- Indication for PPM
- Unexplained syncope, possible arrhythmogenic
- Inducible VT on EPS
- EF 36-49%, RVEF <40%, despite GDMT
- CMR with LGE
Myotonic dystrophy 1 & 2:
Indications for ICD
- Inducible VT on EPS
- ø inducible VT, but HV ≥ 70 ms
Does family hx of SCD predict Brugada syndrome adverse event?
No
Bugs that make you extract CIED (4)
S. aureus
CoNS (S. epi)
Proprionibacterium
Candida
Bacteria remove or observe CIED (3)
a-hemolytic strep
ß-hemolytic strep
Enterococcus
Bacteria observe CIED (~2)
Gram negative
Pneumococci
Pregnancy & AAD’s
Most AAD’s are Class C … except:
* B: (3)
* D: (2)
- B: Sotalol, acebutolol, pindolol
- Amiodarone, atenolol
Pregnancy SVT
Beta blockers associated with pregnancy problem
IUGR
HV pattern to exclude antidromic AVRT
HV (as opposed to VH, retrograde)
Normal HV interval
Pregnancy & AAD
Most AAD’s are C, except:
* B: (3)
* D: (2)
- B: sotalol, acebutolo/pindolol
- D: amiodarone, atenolol
Pregnancy & SVT
Acute tx for SVT in pregnancy
Adenosine or DCCV
Pregnancy & SVT
Ongoing/Chronic therapy for SVT in pregnancy
IIa: Digoxin
sotalol
flecainide, propafenone
Lopressor, propranolol
Verapamil
first line
Which drugs require dose adjustment when giving dronedarone
decrease digoxin dose
ø effect on warfarin
can* increase* pradaxa and eliquis levels
Which drugs require dose adjustment when giving amiodarone
You should decrease doses of digoxin and warfarin
His signal noted after surface QRS
* DDx: (2)
Antidromic reentrant tachycardia
Pre-excitation
SA - VA
Indication
Interpretation
AVNRT vs AVRT
PPI-TCL > 115, SA-VA > 85 :: AVNRT
PPI-TCL < 115, SA-VA < 85 :: AVRT
Signs of epicardial VT (6)
Pseudo ∆ > 34 ms
Intrinsicoid deflection V2 > 85 ms
Shortest precordial RS ≥ 121 ms
QRS > 200 ms
MDI: >0.54
Q wave in lead I
II and III findings in parahisian or moderator band PVC
II (+)
III (-)
II and III findings in anterolateral papillary muscle PVC
II (-)
III (+)
(-) in V1, abrupt (+) in V2
PVC location?
Septal, basal
Notched Q in V1
PVC location?
LVOT, L/R commissure
Dronedarone interacts with which statins?
simvastatin, atorvastatin, lovastatin
Which statin is okay with amiodarone and dronedarone
Crestor
PRKAG2
* Dz states (4)
* Genetic impact
* Inheritance
* Gain/Loss of function
- HCM, WPW, AF, conduction abnormalities
- Missense mutation G2 subunit of AMP-activated protein kinase
- Autosomal dominant
- Gain of fxn
Features that favor sarcoid > ARVC
(5)
- Older age
- AV block
- Septal scar
- Apical VT
- LV dysfunction
Digoxin mechanism
inhibits Na/K ATPase pump
Mexilitene mechanism
Inhibits late inward Na current
Shortens repolarization
Quinidine mechanism
inhibits Ito
Useful in Brugada and VA’s
Dofetilide contrainidication QTc cutoffs:
* normal QRS
* BBB
- Normal: 440 ms
- BBB: ≥ 500
Dofetilide loading dose at CrCl’s
- 20: 125 mcg
- 40: 250 mcg
- 60: 500 mcg
20/40/60 :: 125/250/500
CRT-P/Physiologic vs RV apical PPM
When to do apical pacing vs phsysiologic
EF > 50% :: RV apical
EF 36-50% & expected V pacing > 40% :: CRT/PhysPM
Explain repetitive non-reentrant VA synchrony (RNVAS)
PVC with retrograde A
A falls within PVARP and ignored
A lead paces during atrial refractory period :: ø capture
A paced, not captured; sequential V pace
Appears as A noncapture and V pacing
How to fix repetitive non-reentrant VA synchrony (RNRVAS)
Shorten PVARP (risk PMT)
Shorten AV delay
Redce LRL or sensor driven rate
Noise on widely spaced bipoles likely secondary to …
Muscle stimulation: diaphragm, pectoral
If noise on wide spaced bipole AND tip-ring, likely cause
insulation breach
Inappropriate sinus tachycardia definition
- Mean HR over 24˚ > 90 BPM
- Resting daytime HR > 100 BPM
POTS definition
- HR ≥ 120 BPM during tilt
- HR increase ≥ 30 BPM w/in 20 seconds of HUT
- ø Orthostatic HoTN
Low signal/recording in a lead can be a sign of…
Lead insulation failure
Auto-gain will decrease sensitivity that physiologic signals are no longer seen
Brugada Syndrome channels affected (2)
- Loss-of-function mutation of the sodium current
- Epicardial RV heterogeneity of transient outward potassium channels results in the shorter APD and prominent phase 1 notch, spike/dome
JET vs AVNRT
Early vs Late coupled PAC’s
JET: Late coupled PAC’s advance His with normal AH
AVNRT: Early PAC’s reset tachycardia, usually with long AH
Bundle Branch Reentry
* Typical
* Atypical
Typical:
* CCW
* LBBB
Atypical
* RBBB
* CW
Usually with BBB and long HV at baseline NSR
VT
Outer Loop
* Fusion
* PPI
* EGM-QRS
Manifest fusion
PPI > TCL
E-QRS Variable
VT
Inner Loop
* Fusion
* PPI
* EGM-QRS
- Fusion: Manifest
- PPI = TCL ± 30
- EGM-QRS: Variable
VT
Isthmus (Central)
* Fusion
* PPI
* EGM-QRS
- Fusion: Concealed
- PPI = TCL ± 30
- EGM-QRS: 30-70% TCL
VT
Distal isthmus (Exit)
* Fusion
* PPI
* EGM-QRS
- Fusion: Concealed
- PPI = TCL ± 30
- EGM-QRS: < 30% TCL
VT
Proximal Isthmus (Entrance)
* Fusion
* PPI
* EGM-QRS
- Fusion: Concealed
- PPI = TCL ± 30
- EGM-QRS: 70-100% TCL
VT
Adjacent Bystander
* Fusion
* PPI
* EGM-QRS
- Fusion: Concealed
- PPI > TCL
- EGM-QRS < s-QRS
Pacemapped Induction
* WTF is it
* Significance
VT
Slow pacing (~600 ms) induces VT
Pacing w/in reentrant circuit
Ablate here
Short QT Genes, Current affected
* SQT 1:
* SQT 2:
* SQT3:
- SQT1: HERG/KCNH2; Incr IKr
- SQT2: KCNQ1; Incr IKs
- SQT3: KCNJ2; Incr IK1
Mahaim Pathway refers to what exactly?
Atriofascicular
… w/ decremental properties?
Describe Crista Shunt
CTI flutter ablation appears incomplete
Conduction across crista when pacing from prox CS
Pace just medial to line and eval if truly breakthrough
Class I indications for EP study
- IHD + unexplained syncope
- NSVT w/ prior MI, EF ≤ 40%
- SHD w/ syncope presumed to be VA
First and second line management for Brugada VT/VF
- Quinidine
- Isoproterenol
Medical management of CPVT
- ßB … nadolol? (maximize)
- Flecainide (if ßB maximized)
PVC location/focus associated with idiopathic VF
RV moderator band
Inducible AVNRT despite a bunch of ablation: where else to ablate? (3)
CS
Left inferoseptum
Left inferolateral
Atriofascicular pathways:
* Antegrade/Retrograde ?
* Usual location of connection
* Decremental/non-decremental?
* Ablation target
- Anterograde only; therefore only antidromic AVRT
- Lateral RA to distal RBB
- Decremental
- AP potential along lateral tricuspid annulus
JT vs AVNRT
Effect of late PAC
Late PAC can enter slow pathway:
* Delays next His
* Pull in next His
* Terminate SVT
:: AVNRT
Antiarrhythmic for WPW SVT (2)
Flecainide
Propafenone
Antiarrhythmic for focal AT
Flecainide, propafenone
Paradoxically shorter AH during tachycardia than AH during NSR
* DDx? (2)
- ORT using nodoventricular AP
- Atypical AVNRT with bystander nodoventricular AP inserting into slow pathway
Reimplantation after CIED infection
* Bacteremia w/o vegetation
* Endocarditis native valve
* Endocarditis prosthetic valve
* Lead vegetation
- Bacteremia w/o vegetation: 2 weeks minimum, at least 3 days of negative cx’s
- Endocarditis native valve: 4 weeks
- Endocarditis prosthetic valve: 6 weeks
- Lead vegetation: 4 weeks for staph, 2 weeks for others
Radiation dose associated with CIED malfunction
> 5 Gy
Wide complex tachycardia that narrows as His becomes more apparent confirms which arrhythmia
VT
