Cardiology

Question 2

NYHA Classification of Heart Failure

Answer 2

• Class I: no symptoms
• Class II: symptoms with mod activity, slight limits
• Class III: symptoms with minimal activity, mod limits
• Class IV: symptoms at rest, severe limits

Question 3

Management if statin induced myalgias

Answer 3

• CK
  
  • normal: hold, resume when asymptomatic, repeat CK in 6-12 weeks after restarting
  • • >10x ULN: stop, Cr, urine myoglobin, consider rehydration, trend to normal
• Consider changing to different stating/lowering dose depending on severity

Question 4

Wells PE Score

Answer 4

SSx DVT: 3 points

PE is most likely diagnosis: 3 points

Tachycardia > 100 BPM: 1.5 points

Immobilization > 3d/Surgery within 4 wks: 1.5 points

Hx of VTE: 1.5 points

Malignancy (within 6 mo.): 1 point

Hemoptysis: 1 point

6 points = 60%

4: Imaging

Question 5

HOCM (ECG)

Answer 5

LVH

Dagger Q’s in Inferolateral leads

Tall R waves V1-V2

Question 6

ARVD

Answer 6

Epsilon Waves, V1-V3

TWI’s, V1-V3

Slight prolongation QRS

LBBB type VT/PVC’s

Question 7

ECG signs of tamponade

Answer 7

Low Voltage: I+II+III

V1 + V2 + V3

Tachycardia

Electrical Alternans

Question 8

ECG Signs of LMCA Stenosis

Answer 8

STE aVR + V1/V2

STE aVR > 1.5 mm = 75% mortality

Question 9

ECG signs Posterior MI

Answer 9

R waves V1-V2

STD V1-V3 with upright T waves

Question 10

Brugada Syndrome (ECG)

Answer 10

Incomplete RBBB with STE in V1-V3

Type 1: Convex STE

Type 2: Saddleback STE

Question 11

ECG Signs RV infarct

Answer 11

STD in V2 whith normal ST or STE in V1

STE III>II

Question 12

Amal Mattu’s ECG Approach to Pericarditis

Answer 12

1. Is there any STD?
2. Is there any convex/horizontal STE?
   3) Is STE III>II?

if YES, then AMI, if NO then

look for PR depression +-friction rub

look for checkmark sign (STEMI)

look for Spodick’s sign (downsloping TP, pericarditis)

Question 13

Left Atrial Enlargement

Answer 13

1. Large bifid P-wave lead II (p mitrale): >40 ms between peaks, >110 ms total duration
2. V1: biphasic p-wave, terminal portion > 1mm deep and >40 ms duration

Question 14

Right Atrial Enlargement

Answer 14

II, III, aVF: p-wave > 2.5 mm (p pulmonale)

V1-V2: p-wave > 1.5 mm (p pulmonale)

Usually peaked p-wave

Question 15

STEMI criteria

Answer 15

1) Use J-point, two contiguous leads
2) Men 3) Men >= 40: 2 mm in V2-V3 and 1 mm in all other leads
4) Women: 1.5 mm in V2-V3 and 1 mm in all other leads

V7-V9 use 0.5 mm cutoff except for men

Question 16

Wellen’s Syndrome

Answer 16

Biphasic or deeply inverted T-Waves in precordial +-lateral leads

Often in the absence/after resolution of symptoms

Sign of proximal LAD disease

Question 17

NSTEMI ACS Algorithm

Answer 17

Question 19

AHA FMC-to-balloon time for patients presenting to primary PCI centre

Answer 19

90 minutes

Question 20

AHA Door-in-to-door out time for STEMI at non-PCI hospital

Answer 20

30 minutes

Question 21

AHA TTT times for STEMI at non-PCI hospital

Answer 21

To primary PCI FMC-balloon = 120 minutes

If anticipated >120 minutes then lytic within 30 min

then

Transfer to PCI if failed reperfusion

or within 3-24h if successful

Question 22

RVH Criteria

Answer 22

RAD (90-180) + R>Q in V1 or S>R in V6

Question 23

LVH Criteria

Answer 23

Precordial:

S in V1 or V2 + R in V5 or V6 >35 mm

R in V5 >26 mm

R in V6 > 18 mm

R in V6 > R in V5

Limb:

R aVL > 13 mm

R aVF > 21 mm

R I > 14 mm

R I + S III > 25 mm

Question 24

LAFB

Answer 24

Can be normal

LAD

+

No QRS prolongation

+

qR I, aVL

rS II, III, aVF

Question 25

LPFB

Answer 25

Always abnormal

RAD

+

rS I, aVL

qR II, III, aVF

Question 26

Bifascicular Block

Answer 26

RBBB

+

LAFB/LPFB

Question 27

Trifascicular Block

Answer 27

RBBB

+

LAFB/LPFB

+

AV Block

or LBBB + 1st deg AVB

Question 28

Causes of prolonged QTc

Answer 28

hypo-K

hypo-Ca

hypo-Mg

hypothermia

Na Ch Blockers (TCA, Quinidine, antidepressants)

MI

IICP

Congenital

Question 29

ECG signs of TCA overdose

Answer 29

Tachycardia

RAD

R wave aVR >= 3 mm

IVCD

Question 30

RBBB + LAFB + CP

Answer 30

• call cath lab
• high chance LAD occlusion (Smith ECG blog)

Question 31

When to worry about STEMI in RBBB

Answer 31

• V1, V2 should have some STD
  
  • isoelectric or STE is always abnormal
• There shouldn’t be STD/STE anywhere else
• RBBB + LAFB (Dr. Smith’s ECG blog) = cath

Question 32

Approach to Narrow Complex, Regular Tachycardia

Answer 32

• Sinus tach
  
  • max is 220-age
• SVT
• Aflutter with 2:1 conduction
  
  • 150 +- 20 BPM
  • flip ECG upside down, check for sawtooth pattern (P-waves often inverted so hard to see on upright ECG)
  • Bix rule
    
    • if T wave is halfway between QRS complexes, look for a buried P wave in it, and the other buried P in the QRS complex

Question 33

Bidirectional Vtach

Answer 33

QRS Axis changes 180 deg with each alternating beat

Sign of severe digoxin toxicity

Also sometimes in familial CPVT

Question 34

Sustained vs. Non-sustained Vtach

Answer 34

• sustained
  
  • HR >120/130
  • lasts >30s or HD unstable
  • shock or amio/procainamide
• non-sustained
  
  • HR >120/130
  • <30 s and stable
  • don’t use antiarrhythmics
  • Mg if low
  • search for reversible causes
  • beta blockers OK

Question 35

STEMI Activation Criteria

Answer 35

• STEMI
• ischemic pain + ECG changes despite aggressive medical therapy (cath or transfer, no lytics)
• ischemic CP + new acute heart failure
• AMI + vtach (sustained or unsustained)
• AMI + HD instability
• Wellen’s Syndrome
• Diffuse ST depression + elevation in aVR
• deWinter T waves
• ROSC after Vfib/pulseless Vtach arrest
• ROSC after some PEA arrests

Question 36

Approach to Vtach

Answer 36

see Evernote