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Cardiology Board Review > EP Board Review > Flashcards

EP Board Review Flashcards

1
Q

How to differentiate JT vs AVNRT: PAC’s

A

PAC’s ø influence HH or VV :: junctional rhythm
Any influence (advance/delay/terminate) :: AVNRT

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2
Q

JT vs AVNRT: ∆HA

A

HA(RVP) - HA(SVT)
- (+) :: junctional
- (-) :: AVNRT

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3
Q

LQTS1:
- Clinical presentation
- Genes affected
- QT appearance
- Channel affected
- Treatment

A
  • Swimming, stressed (emotional)
  • KCNQ1, KCNE1
  • Long, but normal T wave
  • Decreased Iks
  • Nadolol, beta blocker
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4
Q

LQTS2:
- Clinical presentation
- Genes affected
- QT appearance
- Channel affected
- Treatment

A
  • Post Partum (2 of you now); loud noise (2nes, tunes)
  • HERG, KCNH2
  • Bifid, notched (2 bumps)
  • Decreased Ikr
  • Nadolol? BB
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5
Q

LQTS3:
* Clinical presentation
* Genes affected
* QT appearance
* Treatment

A
  • Sleep
  • SCN5A, gain in fxn
  • Long, isolectric segment
  • Mexiletene, flecainide
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6
Q

Jervell & Lange-Nielsen:
* Labs
* Symptoms
* Onset

A
  • Elevated gastrin
  • Deafness
  • Onset in childhood
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7
Q

LQT7:
* Syndrome eponym
* QT appearance
* Symptoms
* Gene
* Arrhythmia findings
* Treatment

A
  • Anderson-Tawil
  • Long QT +/- U wave
  • Intermittent weakness, periodic paralysis, hypoK
  • KCNJ2, loss of function
  • Bidirectional VT
  • Flecainide
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8
Q

Definition of chronotropic incompetence

A

< 75% age-related HR with exercise

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9
Q

Phase 4 Block explanation

A

Incoming impulse meets phase 4 depolarization
Paroxysmal AV block
Deceleration dependent; short-long

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10
Q

Bystander entrainment
* Manifest/Concealed fusion
* PPI-TCL in/out

A
  • Concealed fusion
  • PPI-TCL out
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11
Q

S-A - V-A interpretation

A

PPI-TCL > 115
SA-VA > 85
:: AVNRT

(V is surface QRS)

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12
Q

JET vs AVNRT Maneuvers:
* Late, His-refractory PAC

A
  • Advance/Delay subsequent His & resets :: AVNRT
  • No effect :: JET
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13
Q

JET vs AVNRT Maneuvers:
* Early PAC advances His with short AH

A
  • Terminates SVT :: AVNRT
  • Resets SVT :: JET
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14
Q

VT Score
* Criteria
* Interpretation

A

≥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!)

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15
Q

Good impedance drops:
* Atrium
* Ventricle

A
  • Atrium: 5-8 Ω
  • Ventricle: 10-12 … 15 Ω
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16
Q

Electrical remodeling in AF

A
  • 70% decrease in I caL
  • 70% decrease in Ito, Ina
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17
Q

How to ibutilide

A

Give 1 mg, wait 10 minutes
~ ø conversion, repeat 1 mg of 10 minutes

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18
Q

Sarcoid ICD indications (6)

A
  • VT, EF ≤35%
  • Indication for PPM
  • Unexplained syncope, possible arrhythmogenic
  • Inducible VT on EPS
  • EF 36-49%, RVEF <40%, despite GDMT
  • CMR with LGE
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19
Q

Myotonic dystrophy 1 & 2:
Indications for ICD

A
  • Inducible VT on EPS
  • ø inducible VT, but HV ≥ 70 ms
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20
Q

Does family hx of SCD predict Brugada syndrome adverse event?

A

No

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21
Q

Bugs that make you extract CIED (4)

A

S. aureus
CoNS (S. epi)
Proprionibacterium
Candida

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22
Q

Bacteria remove or observe CIED (3)

A

a-hemolytic strep
ß-hemolytic strep
Enterococcus

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23
Q

Bacteria observe CIED (~2)

A

Gram negative
Pneumococci

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24
Q

Pregnancy & AAD’s

Most AAD’s are Class C … except:
* B: (3)
* D: (2)

A
  • B: Sotalol, acebutolol, pindolol
  • Amiodarone, atenolol
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25
Q

Pregnancy SVT

Beta blockers associated with pregnancy problem

A

IUGR

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26
Q

HV pattern to exclude antidromic AVRT

A

HV (as opposed to VH, retrograde)
Normal HV interval

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27
Q

Pregnancy & AAD

Most AAD’s are C, except:
* B: (3)
* D: (2)

A
  • B: sotalol, acebutolo/pindolol
  • D: amiodarone, atenolol
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28
Q

Pregnancy & SVT

Acute tx for SVT in pregnancy

A

Adenosine or DCCV

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29
Q

Pregnancy & SVT

Ongoing/Chronic therapy for SVT in pregnancy

A

IIa: Digoxin
sotalol
flecainide, propafenone
Lopressor, propranolol
Verapamil

first line

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30
Q

Which drugs require dose adjustment when giving dronedarone

A

decrease digoxin dose
ø effect on warfarin
can* increase* pradaxa and eliquis levels

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31
Q

Which drugs require dose adjustment when giving amiodarone

A

You should decrease doses of digoxin and warfarin

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32
Q

His signal noted after surface QRS
* DDx: (2)

A

Antidromic reentrant tachycardia
Pre-excitation

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33
Q

SA - VA
Indication
Interpretation

A

AVNRT vs AVRT
PPI-TCL > 115, SA-VA > 85 :: AVNRT
PPI-TCL < 115, SA-VA < 85 :: AVRT

34
Q

Signs of epicardial VT (6)

A

Pseudo ∆ > 34 ms
Intrinsicoid deflection V2 > 85 ms
Shortest precordial RS ≥ 121 ms
QRS > 200 ms
MDI: >0.54
Q wave in lead I

35
Q

II and III findings in parahisian or moderator band PVC

A

II (+)
III (-)

36
Q

II and III findings in anterolateral papillary muscle PVC

A

II (-)
III (+)

37
Q

(-) in V1, abrupt (+) in V2
PVC location?

A

Septal, basal

38
Q

Notched Q in V1
PVC location?

A

LVOT, L/R commissure

39
Q

Dronedarone interacts with which statins?

A

simvastatin, atorvastatin, lovastatin

40
Q

Which statin is okay with amiodarone and dronedarone

A

Crestor

41
Q

PRKAG2
* Dz states (4)
* Genetic impact
* Inheritance
* Gain/Loss of function

A
  • HCM, WPW, AF, conduction abnormalities
  • Missense mutation G2 subunit of AMP-activated protein kinase
  • Autosomal dominant
  • Gain of fxn
42
Q

Features that favor sarcoid > ARVC
(5)

A
  • Older age
  • AV block
  • Septal scar
  • Apical VT
  • LV dysfunction
43
Q

Digoxin mechanism

A

inhibits Na/K ATPase pump

44
Q

Mexilitene mechanism

A

Inhibits late inward Na current
Shortens repolarization

45
Q

Quinidine mechanism

A

inhibits Ito
Useful in Brugada and VA’s

46
Q

Dofetilide contrainidication QTc cutoffs:
* normal QRS
* BBB

A
  • Normal: 440 ms
  • BBB: ≥ 500
47
Q

Dofetilide loading dose at CrCl’s

A
  • 20: 125 mcg
  • 40: 250 mcg
  • 60: 500 mcg

20/40/60 :: 125/250/500

48
Q

CRT-P/Physiologic vs RV apical PPM

When to do apical pacing vs phsysiologic

A

EF > 50% :: RV apical
EF 36-50% & expected V pacing > 40% :: CRT/PhysPM

49
Q

Explain repetitive non-reentrant VA synchrony (RNVAS)

A

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

50
Q

How to fix repetitive non-reentrant VA synchrony (RNRVAS)

A

Shorten PVARP (risk PMT)
Shorten AV delay
Redce LRL or sensor driven rate

51
Q

Noise on widely spaced bipoles likely secondary to …

A

Muscle stimulation: diaphragm, pectoral

52
Q

If noise on wide spaced bipole AND tip-ring, likely cause

A

insulation breach

53
Q

Inappropriate sinus tachycardia definition

A
  • Mean HR over 24˚ > 90 BPM
  • Resting daytime HR > 100 BPM
54
Q

POTS definition

A
  • HR ≥ 120 BPM during tilt
  • HR increase ≥ 30 BPM w/in 20 seconds of HUT
  • ø Orthostatic HoTN
55
Q

Low signal/recording in a lead can be a sign of…

A

Lead insulation failure
Auto-gain will decrease sensitivity that physiologic signals are no longer seen

56
Q

Brugada Syndrome channels affected (2)

A
  • 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
57
Q

JET vs AVNRT

Early vs Late coupled PAC’s

A

JET: Late coupled PAC’s advance His with normal AH
AVNRT: Early PAC’s reset tachycardia, usually with long AH

58
Q

Bundle Branch Reentry
* Typical
* Atypical

A

Typical:
* CCW
* LBBB

Atypical
* RBBB
* CW

Usually with BBB and long HV at baseline NSR

59
Q

VT

Outer Loop
* Fusion
* PPI
* EGM-QRS

A

Manifest fusion
PPI > TCL
E-QRS Variable

60
Q

VT

Inner Loop
* Fusion
* PPI
* EGM-QRS

A
  • Fusion: Manifest
  • PPI = TCL ± 30
  • EGM-QRS: Variable
61
Q

VT

Isthmus (Central)
* Fusion
* PPI
* EGM-QRS

A
  • Fusion: Concealed
  • PPI = TCL ± 30
  • EGM-QRS: 30-70% TCL
62
Q

VT

Distal isthmus (Exit)
* Fusion
* PPI
* EGM-QRS

A
  • Fusion: Concealed
  • PPI = TCL ± 30
  • EGM-QRS: < 30% TCL
63
Q

VT

Proximal Isthmus (Entrance)
* Fusion
* PPI
* EGM-QRS

A
  • Fusion: Concealed
  • PPI = TCL ± 30
  • EGM-QRS: 70-100% TCL
64
Q

VT

Adjacent Bystander
* Fusion
* PPI
* EGM-QRS

A
  • Fusion: Concealed
  • PPI > TCL
  • EGM-QRS < s-QRS
65
Q

Pacemapped Induction
* WTF is it
* Significance

A

VT
Slow pacing (~600 ms) induces VT
Pacing w/in reentrant circuit
Ablate here

66
Q

Short QT Genes, Current affected
* SQT 1:
* SQT 2:
* SQT3:

A
  • SQT1: HERG/KCNH2; Incr IKr
  • SQT2: KCNQ1; Incr IKs
  • SQT3: KCNJ2; Incr IK1
67
Q

Mahaim Pathway refers to what exactly?

A

Atriofascicular
… w/ decremental properties?

68
Q

Describe Crista Shunt

A

CTI flutter ablation appears incomplete
Conduction across crista when pacing from prox CS
Pace just medial to line and eval if truly breakthrough

69
Q

Class I indications for EP study

A
  • IHD + unexplained syncope
  • NSVT w/ prior MI, EF ≤ 40%
  • SHD w/ syncope presumed to be VA
70
Q

First and second line management for Brugada VT/VF

A
  1. Quinidine
  2. Isoproterenol
71
Q

Medical management of CPVT

A
  1. ßB … nadolol? (maximize)
  2. Flecainide (if ßB maximized)
72
Q

PVC location/focus associated with idiopathic VF

A

RV moderator band

73
Q

Inducible AVNRT despite a bunch of ablation: where else to ablate? (3)

A

CS
Left inferoseptum
Left inferolateral

74
Q

Atriofascicular pathways:
* Antegrade/Retrograde ?
* Usual location of connection
* Decremental/non-decremental?
* Ablation target

A
  • Anterograde only; therefore only antidromic AVRT
  • Lateral RA to distal RBB
  • Decremental
  • AP potential along lateral tricuspid annulus
75
Q

JT vs AVNRT

Effect of late PAC

A

Late PAC can enter slow pathway:
* Delays next His
* Pull in next His
* Terminate SVT
:: AVNRT

76
Q

Antiarrhythmic for WPW SVT (2)

A

Flecainide
Propafenone

77
Q

Antiarrhythmic for focal AT

A

Flecainide, propafenone

78
Q

Paradoxically shorter AH during tachycardia than AH during NSR
* DDx? (2)

A
  • ORT using nodoventricular AP
  • Atypical AVNRT with bystander nodoventricular AP inserting into slow pathway
79
Q

Reimplantation after CIED infection
* Bacteremia w/o vegetation
* Endocarditis native valve
* Endocarditis prosthetic valve
* Lead vegetation

A
  • 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
80
Q

Radiation dose associated with CIED malfunction

A

> 5 Gy

81
Q

Wide complex tachycardia that narrows as His becomes more apparent confirms which arrhythmia

A

VT

Cardiology Board Review (2 decks)

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