General Cardio

Question 1

Indications for Transvenous pacing?

Answer 1

Symptomatic arrhythmia with cardiovascular compromise + pharmacotherapy has failed + transcutaneous pacing has failed or contraindicated

Question 2

Contraindications to transvenous pacing?

Answer 2

All relative
- Appropriate site CVC contraindications present
- Prosthetic tricuspid valve
- Severe hypothermia causing arrhythmia (unlikely to succeed, likely to cause VF)

Question 3

Arrhythmias requiring pacing?

Answer 3

All are + cardiovascular compromise
- Sick sinus syndrome
- Sinus arrest
- Symptomatic sinus bradycardia
- AF with slow vent response
- 3rd degree heart block
- 2nd degree block Mobitz II

Question 4

What are the best sites for transvenous pacing in order?

Answer 4

1- R) IJ
2- L) subclavian
3- LIJ + R) subclavian
4- any other site

Question 5

What are reasonable initial settings for transvenous pacing?

Answer 5

Rate 70-80
Current 15-20mA
Sensitivity 1-2V

Question 6

What are reasonable initial settings for transcutaneous pacing?

Answer 6

Rate 70-80 or 20 above intrinsic
Current 70mA
Once capture turn current down to 5-10 above threshold
If no capture at current up to 130 then resite electrodes

Question 7

How should defibrillation be performed in conscious VT?

Answer 7

If QRS and T waves are distinguishable then an attempt at synchronisation should be done

Synchronised shock biphasic 100-200J
Unsynchronised shock biphasic 200j
Unsynchronised monophasic 360j

Question 8

What are some of the causes of cardiac sounding syncope in a patient who is now stable?

Answer 8

Severe aortic stenosis
ARVD
WPW +/- AF
Brugada syndrome
Long Qt with TdP
High grade heart block (although usually still asymptomatic)
Short Qt syndrome
HOCM
VT (ie ischaemic cardiomyopathy)

Question 9

What are some relatively benign causes of syncope that can be managed as an outpatient?

Answer 9

Cough syncope
Micturition syncope
Vasovagal syncope
Orthostatic hypotension (autonomic dysfunction, drugs, dehydration)

Question 10

What are the routine medical treatments for a STEMI?

Answer 10

• Aspirin 300mg
• Nitrates (S/L, patch, infusion) as long as BP can take it
• Clopidogrel/Ticagrelor/Prasugrel
• Analgesia (Morphine, fent etc)
• Aim sats >94% (02 only if needed)
• Heparin infusion/bolus prior to PCI

Question 11

When should fibrinolysis be done over PCI?

Answer 11

• > 120 mins from first contact to availability of PCI (aim <90mins from ED arrival to cath lab)
• Ischaemic symptoms present for less than 12hrs
• No contraindications to fibrinolysis

Question 12

What are the potential causes for an acute bradycardia?

Answer 12

Acute ischaemia
Chronic cardiomyopathy
Drug overdose
Hypothermia
Hypoxia
Hypothyroidism
Electrolyte disturbance (Hyper K)
Raised ICP
Inflammatory/infiltrative (Sarcoid, SLE, TB, amyloid)
Typhoid fever (relative bradycardia)
Vagal stimuli
Normal variant

Question 13

In those without access to immediate PCI, what are the indications for thrombolysis?

Answer 13

• ECG meets STEMI criteria for >20mins
• Chest pain >20mins within the last 12hrs (may have resolved)
• No contraindication to thrombolysis

Question 14

What are the high and low risk features for someone with chest pain having ACS?

Answer 14

Question 15

What are some of the causes of a troponin rise other than ACS?

Answer 15

Question 16

What are the principle causes of a dilated cardiomyopathy?

Answer 16

Question 17

What are the main drugs causing dilated cardiomyopathy?

Answer 17

Clozapine
Phenothiazines
Chloroquine
Antiretroviral
- Zidovudine, Zalcitabine
Chemotherapeutics
- Cyclophosphamide, Anthracyclines, Trastuzumab

Question 18

What are statistics of syncope ED presentations?

Answer 18

• 1-1.5% of all ED presentations
• Approx 20% of people will have an episode in their lifetime
• 35% of patients presenting to ED with syncope go on to be admitted
• Men have higher risk of arrhythmias

Question 19

What are the typical clinical and historical features of burgada syndrome?

Answer 19

• Autosomal dominant
• 2 year death rate after 1st ED presentation if not treated is 30%
• SE asian descent is risk factor
• Na+ channel defect
• Average age at presentation 30yo
• Causes 60% idiopathic VF
• Avoid Na+ channel blockers including class 1a and 1c

Question 20

What are the clinical features of silent AMI’s?

Answer 20

• Twice the mortality of those presenting with chest pain
• Higher risk in females, diabetics, CCF previous stroke and the elderly
• 1% per annum for people aged 45-65

Question 21

What is the Framingham Criteria for CCF?

Answer 21

At least 2 major or 1major and 2 minor critiera

Major
- PND/Orthopnoea
- Raised JVP
- APO
- Cardiomegaly on CXR
- S3 gallop

Minor
- Ankle oedema
- Nocturnal cough
- tachycardia >120
- SOB on exertion
- pleural effusions

Question 22

What are the indications for overdrive pacing?

Answer 22

Any regular tachycardia with a re-entrant circuit, as it short circuits the re-entrant circuit
- Ie SVT, VT, A flutter
- Also to prevent TdP in patients with prolonged QTc and relative bradycardia

Does not work on VF/AF

Question 23

How is overdrive pacing performed to terminate regular tachyarrythmias ?

Answer 23

Accelerate to about 10-15% greater rate than the intrinsic rate for 8-10secs then cease
Requires transvenous (temporary or permanent) pacing, transcutaneous cannot fire fast enough

Question 24

What are the factors favouring a rhythm controlled approach to AF?

Answer 24

• Haemodynamically unstable
• Young
• First presentation
• Onset <24hrs
• No structural/valvular HD
• No/corrected precipitant cause
• Normal/corrected electrolytes
• Normal TFT’s
• Intolerable symptoms

Question 25

What are the factors favouring rate control in AF?

Answer 25

- Age >80 yrs - Low HASBLED score - Failure of rhythm control - Minimal to no symptoms - Haemodynamically stable - Patient preference - Structural/valvular heart disease - Long term AF - Underlying precipitant has not/can not be fixed - intolerable side effects from pharmacological rhythm control

Question 26

What are the goals of management in AF?

Answer 26

- Reverse haemodynamic instability - Prevent thromboembolism - Alleviation of symptoms - Reduce CVS disease and mortality - Prevent adverse cardiac remodelling

Question 27

What is the ADAPT protocol for chest pain rule out?

Answer 27

TIMI score + 2 -ve troponins + no ischaemic changes on ECG = discharge

Question 28

What is the TIMI score for chest pain?

Answer 28

Used for risk stratification in chest pain, but originally derived from unstable angina/NSTEMI patients 30 day mortality - Age >65 - 3 or more CAD risk factors - Known CAD 50% or more - Aspirin use in last 7 days - Symptoms typical of severe angina >2 episodes in 24hrs - ECG ST changes >0.5mm - Positive cardiac marker

Question 29

What is the HEART score for chest pain?

Answer 29

Used in adult chest pain patients being considered for ACS workup - Divides into risk categories based on likelihood of major adverse cardiac events (MACE) H- History (slightly, moderate, very suspicious) 0-2 points E- ECG (normal, non-specific, sepcific ST changes) 0-2 A- <45, 45-65, >65, 0-2 points R- Risk factors (0, 1-2, 3 or more) 0-2 T- Troponin (normal, 1-3x limit, >3x limit) 0-2 points Low score - 0-3 points, <0.3% risk MACE Moderate score - 4-6 points, 12-16% MACE - High 7 or more, 50-65% MACE