Systemic, Congenital, Pericardial Flashcards
What is required for the diagnosis of acute pericarditis?
- ► 2 of the following:
- Chest pain
- sharp, pleuritic, improved by sitting up and leaning forward
- Pericardial friction rub
- EKG changes
- widespread ST-elevation or PR depression
- New or worsening pericardial effusion
- Chest pain
What are the diagnostic criteria for recurrent pericarditis?
- All 3 criteria must be present:
- Documented first attack of acute pericarditis
- Symptom-free interval of ► 4-6 weeks
- Evidence of subsequent recurrence of pericarditis
- Labs (WBC, ESR, CRP)
- pericardial friction rub
- EKG changes
- Echo evidence of worsening pericardial effusion
What are high risk features of pericarditis that warrant hospitalization?
- Fever ( F > 38 C)
- Anticoagulants
- Trauma
- Subacute onset
- Large pericardial effusion
- Immunosuppression
- Tamponade
- Myocarditis (concomitant)
What is the treatment for acute pericarditis?
- NSAID x 2-4 week (taper)
- Colchicine x 3 months
- prevents recurrence
When are glucocorticoids used in pericarditis?
- unable to take NSAID therapy
or
- special conditions
- autoimmune disease
- renal failure
- pregnancy
- concomitant anticoagulant therapy
Describe the stepwise protocol for recurrent pericarditis
What is required for diagnosis of metabolic syndrome?
► 3 of the following criteria
- abdominal obesity / waist circumference
- men ► 102 cm
- women ► 88 cm
- TG > 175
- HDL:
- men < 40
- women < 50
- BP ► 130 / 85
- Fasting plasma glucose ► 100
What are causes of RAD?
- Dextrocardia
- Ostium secundum ASD
- Lead reversal
- LPFB
- Lateral MI
- Vertically positioned heart
- COPD
- PE
What are causes of prominent U waves?
- Most commonly found with:
- Hypokalemia
- Bradycardia
- Less common causes:
- Hypocalcemia
- Hypomagnesemia
- Hypothermia
- HCM
- Elevated intracranial pressure
- LVH
- Drugs
- Digoxin
- Class Ia (Quinidine, Procainamide)
- Class III (Amiodarone, Sotalol)
Describe the findings:
RV VT with LBBB morphology / ARVD
Describe the findings and diagnosis
ARVD
- Epsilon waves
- TWI in V1-V3
- Prolonged S-wave upstroke of 55 ms in V1-V3 (95% of patients)
- Localized QRS widening of 110 ms in V1-V3
- Paroxysmal episodes of VT with LBBB morphology
What medications used in A-fib can cause increased serum Digoxin levels when used concomitantly?
- Verapamil
- Amiodarone
- Dronedarone
- Quinidine
- Rivaroxaban
- Apixaban
- Erythromycin, Clarithromycin
- Cyclosporine
- Ketoconazole
- Itraconazole
****P-glycoprotein inhibitors (in bold)
Describe the findings and treatment:
- 30 year old, healthy, relatively asymptomatic patient
Idiopathic LV (fascicular) VT
- Re-entrant tachycardia involving most commonly the left posterior fascicle
- EKG
- mildly wide complex tachycardia
- RBBB-like morphology
- superior or left axis
- Treatment:
- Verapamil
- rhythm is highly sensitive to verapamil
- low-risk tachycardia –> catheter ablation of fascicle is usually curative
Describe the differential/algorithm for narrow QRS tachycardia (QRS < 120 ms)
What is the recommended medical therapy in a patient with:
- Brugada syndrome
- ICD and shocks
- Recurrent VT
Quinidine or Catheter Ablation
- Class Ia antiarrhythmic
- Ito and IKr blocker effects
- Class I recommendations
Describe localization of AP using surface EKG
What is the diagnosis and next best step?
- 30 year old male with syncope (x2 in the last year while exercising)
- No medical problems or medications
- FH: Uncle died at 34 in drowning accident
*
- Brugada syndrome
-
EKG with high precordial leads
- recording V1 and V2 in second and third intercostal space can assist in the diagnosis of borderline cases
What are the indications for ICD placement in Brugada syndrome?
- Confirmed Brugada syndrome
and
- Cardiac arrest or Recent unexplained syncope
Describe localization of VT site of origin on EKG
QRS morphology = VT circuit exit site
- V1
- LBBB morphology
- RV or
- Septum
- RBBB morphology
- LV
- LBBB morphology
Precordial leads = sagittal plane origin
- V3, V4, V5
- R waves dominant
- Basal
- S waves dominant
- Apical
- R waves dominant
QRS axis = coronal plane origin
- Axis (inferior leads)
- Inferior axis (Positive inferior leads)
- Anterior or
- Lateral
- Superior axis (Negative inferior leads)
- Inferior
- Inferior axis (Positive inferior leads)
What are the recommendations for ICD placment:
- Hypertrophic Cardiomyopathy
- Class I
- SCD (resuscitated)
- Spontaneous VT with syncope
- Class IIa
- LV wall thickness ► 30 mm
- 1st degree relative with SCD caused by HCM
- Syncope (unexplained)
- Class IIb
- NSVT (on ambulatory monitoring) without other risk factors
What are the recommendations for ICD placment:
- ARVC
- Class I
- SCD (resuscitated)
- RVEF or LVEF « 35%
- Class IIa
- Syncope (presumed due to VA)
What are the recommendations for ICD placment:
- Cardiac Sarcoidosis
- Class I
- SCD (resuscitated)
- VT (sustained)
- LVEF « 35%
- Class IIa
- Syncope
- Myocardial scar by MRI or PET
- Positive EPS for inducible VT
- Indication for PPM
What are the recommendations for ICD placment:
- LQTS
Class I
- SCD (reuscitated)
- High risk patients in whom BB is ineffective or not tolerated
- < 40 years of age
- Females with LQTS 2
- LQTS 2 and 3
- onset of symptoms < 10 years of age
- prior cardiac arrest or recurrent syncope
- QTc > 500 ms
Class IIb
- Asymptomatic patients, QTc > 500 ms on BB
What are the recommendations for ICD placment:
- CPVT
Class I
- Recurrent VT or syncope while on maximal medical therapy (BB, Flecainide)
What are the recommendations for ICD placment:
- Brugada Syndrome
Class I
- Cardiac arrest or recent unexplained syncope
+
- spontaneous type 1 EKG pattern
Describe the prevalence of LQTS, mutations involved and channels involved in the mutations
90% of cases (1:300-7,000)
- LQT1 (KCNQ1)
- encoding for the potassium current IKs
- LQT2 (KCNH2)
- encoding for the repolarizaing potassium current IKr
- LQT3 (SCN5A)
- encoding for the alpha subunit of the sodim channel that conducts the depolarizing sodium current INa
What is a major distinguishing feature between Idiopathic LV and RV outflow tract VT?
Precordial transition point
- LVOT VT
- early precordial transition or
- broad initial R wave in V1, V2
- RVOT VT
- late precordial transition, typically leads V3-V4
**** LBBB morphology + Inferior axis in both
What are risk factors for arrhythmia in Brugada Syndrome?
-
Fever
- SCN5A channel is temperature sensitive
- Alcohol (heavy use)
- Cocaine
- Precipitating medications
- Fluoxetine
- Sodium channel blockers (INa)
- Propofol
- Lithium
- Antihistamines
- TCA’s
- Trifluoperazine
- Heavy metals
How can you differentiate AS and HOCM on intracardiac pressure tracings?
Post-PVC
-
Pulse Pressure
- HOCM –> decrease
- AS –> increase
-
Gradient
- Both –> INCREASE
Valsalva
-
Gradient
- HOCM –> increase
- AS –> decrease
-
Pulse Pressure
- Both –> DECREASE
What mechanical prosthetic valves require bridging anticoagulation?
- Bileaflet aortic valve with increased thromboembolic risk factors
- Caged ball or tilting disc prosthesis
- Mitral valve prosthesis
- Recent CVA/TIA
Describe the management of chronic, severe MR
- Primary, Severe MR
- Asymptomatic
Describe the algorithm in evaluating aortic prosthesis with PV > 3 m/s
Describe the frequency of monitoring in MS
- Progressive (stage B)
- MVA > 1.5 cm2 –> every 3-5 years
- Severe (stage C)
- MVA 1 - 1.5 cm2 –> every 1-2 years
- Very severe
- MVA < 1.0 cm2 –> every 1 year
What is the severity scale for aortic prosthetic valves?
- Peak velocity
- Normal < 3 m/s
- Possible stenosis 3-4 m/s
- Significant stenosis > 4 m/s
What is the severity scale for mitral prosthetic valves?
- PHT
- Normal < 130 ms
- Possible stenosis 130 - 200 ms
- Significant stenosis > 200 ms
