Week 4

Question 1

You are reading the EKG of a patient who complains of dizziness and poor exercise tolerance. On it, you see lengthening of the PR interval with each successive beat until eventually there is a P wave but no QRS. This pattern repeats itself over the EKG. Which of the following is most consistent with this finding?

1. First degree AV block
2. Second degree AV block, Mobitz type I (Wenckebach)
3. Second degree AV block, Mobitz type II
4. Third degree AV block

Answer 1

Answer: B. Second degree AV block, Mobitz type I

The presence of dropped QRS beats excludes A. The lengthening of PR intervals excludes C. And the relationship between the P wave and QRS wave exclude D. If you see a prolonged PR interval (> 5 small boxes) but no dropped beats, then you have A. First Degree AV block. If you saw a consistent PR interval (instead of one that lengthens with successive beats) and intermittently a P wave without a QRS complex following, you’d have C. Second degree AV block, Mobitz type II. If you saw P waves and QRS complexes that seemed completely independent of one another with a widened QRS, then you have D. Third degree AV block.

Lecture: 135a Bradycardia

Learning Objective: 4. Describe ECG diagnosis of bradycardia (MKS 1b,1d)

Question 2

You have a patient who presents with shortness of breath, heart palpitations, and chest pain. On EKG you see a regular heart beat of 200 bpm with P waves in a saw-toothed pattern. What abnormality explains this patient’s findings?

1. Atrial Fibrillation
2. Atrial Flutter
3. Ventricular Tachycardia
4. Ventricular Fibrillation

Answer 2

Answer: B. Atrial Flutter

Atrial Flutter is characterized by regular beats with saw-toothed P wave. A. Atrial Fibrillation is characterized by irregularly irregular beats with no organized P waves. C. Ventricular tachycardia can be monomorphic with a single consistent QRS morphology or polymorphic with a changing QRS morphology (ie Torsades de Pointes). D. Ventricular Fibrillation has no discrete QRS complexes and can cause sudden death.

Lecture: 136a Tachyarrhythmias

Learning Objective: Describe the mechanisms and basic clinical features and management of paroxysmal supraventricular tachycardia, atrial fibrillation and flutter. (MKS 1b, 1e)

Question 3

List the top 3 risk factors or peripheral vascular disease.

Answer 3

Answer: 1. Smoking 2. Diabetes 3. Hypertension

Lecture: 137A Peripheral Vascular Disease

Learning Objective: 1. Explain the natural history and pathophysiology of peripheral arterial disease (MKS1b,1c)

Question 4

You’re in your ECMH clinic and you see a patient for a physical. He has no complaints but has a history of hypertension. Which stage would you classify for this patient for heart failure?

1. Stage A
2. Stage B
3. Stage C
4. Stage D
5. No staging applicable as he doesn’t have symptoms

Answer 4

Answer: A. Stage A

Stage A is no symptoms but with risk factors (hypertension in this case). Stage B is no symptoms but structural heart disease or functional cardiac abnormalities like LV hypertrophy, myocardial infarction etc. Stage C is symptomatic heart failure with structural disease. Stage D is symptoms at rest that are refractory to medical therapy with advanced structural disease.

Lecture: 138A Heart Failure Pathophysiology

Learning Objective: 1. Define the staging system for heart failure (MKS 1b)

Question 5

Which of the following is true about Rhythm Control Antiarrhythmics?

1. Classes I and III are used for Rhythm Control, which act on the SA node.
2. Classes I and III are used for Rhythm Control, which acts at the AV node to get regular ventricular control regardless of atrial rate.
3. Classes II and IV are used for Rhythm Control, which act on the SA node.
4. Classes II and IV are used for Rhythm Control, which act at the AV node.

Answer 5

Answer: A. Classes I and III are used for Rhythm Control, which act on the SA node.

Classes II and IV are used for Rate Control, which act at the AV node.

HINT: The SketchyPharm videos are very useful for the antiarrhythmic drugs.

Lecture: 139a Pharmacology of Antiarrythmic Drugs

Learning Objective: 3. Recapitulate the Vaughan-Williams Classification Scheme of Antiarrhythmic Drugs

Question 6

Match the features associated with Mitral Stenosis vs Aortic Stenosis.

• Increased risk of stroke
• Increased afterload
• Left atrial dilation
• Diastolic rumble with opening snap
• Midsystolic outflow murmur
• Rheumatic Fever

Answer 6

Answer: Mitral Stenosis: Increased risk of stroke (due to A Fib due to left atrial dilation), Left atrial dilation, Diastolic Rumble with opening snap, Rheumatic fever (is primary cause)

Aortic Stenosis: Increased afterload, Midsystolic outflow murmur

Lecture: 141a Valvular Disease: Obstructive

Learning Objective: 1. Explain normal hemodynamics and the abnormal hemodynamics that are created by mitral stenosis and aortic stenosis, which translate into the physical findings and abnormalities in chest X-ray and echocardiography. (MKS1b,1d)

Question 7

Match the features associated with Aortic Regurgitation vs Mitral Regurgitation

• Increased preload and afterload
• Widened pulse pressure
• Increased preload
• Marfan’s
• Mitral valve prolapse
• Holosystolic murmur
• Diastolic blowing decrescendo murmur

Answer 7

Answer: Aortic Regurgitation: Increased preload AND afterload, widened pulse pressure, Marfan’s, Diastolic blowing decrescendo murmur

Mitral Regurgitation: increased preload, Mitral valve prolapse, holosystolic murmur

Lecture: 142a Valvular Heart Disease: Regurgitant

Learning Objective: 1. Explain the abnormal hemodynamics created by regurgitation of the aortic and mitral valves, which translate into the physical findings and abnormalities in chest X-ray and echocardiography. (MKS1b,d)

Question 8

Fill in the appropriate pressures as a catheter would move through the heart.

Right atrium

Right Ventricle

Pulmonary Artery

Wedge

Left Atrium

Left Ventricle

Aorta

Answer 8

Answer:

Right atrium: 6 mmHg

Right Ventricle: 24/6 mmHg

Pulmonary Artery: 24/12 mmHg

Wedge: 6-12 mmHg

Left Atrium 6-12 mmHg

Left Ventricle: 120/6-12 mmHg

Aorta: 120/60 mmHg

Lecture: 143a Clinical Hemodynamics and Ventricular Function

Learning Objective: 2. List normal systolic and diastolic hemodynamic parameters in the following cardiovascular structures: right atrium, right ventricle, pulmonary artery, left atrium, left ventricle, and aorta (MKS 1b, 1d).

Question 9

What 3 classes of medications are the first you would prescribe a patient who has just been diagnosed with heart failure?

Answer 9

Answer: ACE-inhibitor, diuretic, and beta-blocker

Lecture: 144a Heart Failure Treatment

Learning Objective: List which heart failure therapies improve symptoms and which therapies improve outcomes (MKS 1b, 1c, 1e)