8/6- Case Discussion of Interesting ECGs Flashcards Preview

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Flashcards in 8/6- Case Discussion of Interesting ECGs Deck (19):
1

Recap: What are they key signs demarcating the key stages of the evolution of an MI?

- Acute MI:

- Evolving MI:

- Old MI:

- Acute MI: ST elevation ONLY

- Evolving MI: ST elevation AND T wave inversion or pathologic Q wave

- Old MI: pathologic Q waves ONLY

2

Recap: When does ST segment elevation occur in an MI and how long does it last?

ST segment is elevated immediately in an MI and normalizes in 2-14 days

3

Recap: When do pathologic Q waves and T wave inversions occur in an MI and how long do they last?

Pathologic Q waves and T wave inversions appear at 8-12 hours

- Pathologic Q waves stay indefinitely

- T wave inversions are highly variable

4

Case)

- 48 yo man

- Acute onset of pressure-like (oppressive) chest pain associated with diaphoresis and nausea

- Pain woke him up

- At this time, he's been having pain for 1 hr

- Hx: HTN, DM, family Hx of premature coronary artery disease

- Physical: Decreased S1, rales in both lungs, 3rd heart sound S3 (ventricular gallop) at the apex

- Normal vital signs

- EKG shown Which of the following bets describes the ECG in this pt?

A. ST elevations in septal and anterior chest leads

B. ST depressions in inferior limb leads

C. Both A and B

D. Neither A nor B

Q image thumb

EKG shown Which of the following bets describes the ECG in this pt? 

A. ST elevations in septal and anterior chest leads 

B. ST depressions in inferior limb leads 

C. Both A and B

D. Neither A nor B

A image thumb
5

Which of the following causes of ST segment elevation best explains Mr. Jones' clinical presentation?

(Recall: he had acute oppressive chest pain, diaphoresis, nausea, Hx of coronary artery disease, S3 sounds, and ST elevation (septal/anterior chest leads) and ST depression (inferior limb leads).

A. Acute MI

B. Prinzmetal's angina

C. Acute pericarditis

D. Early repolarization

Which of the following causes of ST segment elevation best explains Mr. Jones' clinical presentation?

A. Acute MI

B. Prinzmetal's angina 

C. Acute pericarditis

D. Early repolarization

Early repolarization is not something that happens acutely in someone with chest pain

6

Which of the following is the MOST life threatening cause of ST segment elevation?

A. Acute myocardial infarction

B. Prinzmetal's angina

C. Acute pericarditis

D. Early repolarization

Which of the following is the MOST life threatening cause of ST segment elevation? 

A. Acute myocardial infarction

B. Prinzmetal's angina

C. Acute pericarditis 

D. Early repolarization

7

If both chest pain and ECG changes resolve after SL NTG, what is the likely cause of chest pain?

A. Acute myocardial infarction

B. Prinzmetal's angina

C. Acute pericarditis

D. Early repolarization

?

8

Which of the following best differentiates acute pericarditis from acute myocardial infarction?

A. ST elevations occur in acute MI but not in acute pericarditis

B. ST elevations occur in both but are diffuse in acute pericarditis

C. PR segment depressions occur in acute pericarditis only

D. Both A and C

E. Both B and C

Which of the following best differentiates acute pericarditis from acute myocardial infarction?

A. ST elevations occur in acute MI but not in acute pericarditis

B. ST elevations occur in both but are diffuse in acute pericarditis

C. PR segment depressions occur in acute pericarditis only 

D. Both A and C

E. Both B and C

- PR segment depression may happen (often don't see it); and if so, it ONLY happens in acute pericarditis

9

Which of the following treatments for acute myocardial infarction may be harmful in acute pericarditis?

A. Aspirin

B. Beta-blocker

C. Angiotensin-converting enzyme inhibitor (ACEI)

D. Thrombolytic drug

E. Nitroglycerin

Which of the following treatments for acute myocardial infarction may be harmful in acute pericarditis? 

A. Aspirin 

B. Beta-blocker 

C. Angiotensin-converting enzyme inhibitor (ACEI) 

D. Thrombolytic drug

E. Nitroglycerin

Thrombolytic drugs are very potent; used in pts with MI if primary stenting is NOT available. It is an appropriate treatment, but not used 1st line. It increases the risk of bleeding (may cause bleeding into pericardium in pt with pericarditis)

10

This ECG was obtained in a 23 yo man with a 24 hr Hx of mild sharp chest pain increased by inspiration and cough. This pain is worse when he lies down and is relieved by sitting up. Which of the following is the best treatment in this pt?

A. Aspirin or a non-steroidal anti-inflammatory drug

B. Thrombolytic drug such as t-PA or r-PA

C. Beta-blocker such as metoprolol

D. ACEI such as lisinopril

E. Morphine 

Q image thumb

Which of the following is the best treatment in this pt?

A. Aspirin or a non-steroidal anti-inflammatory drug

B. Thrombolytic drug such as t-PA or r-PA 

C. Beta-blocker such as metoprolol 

D. ACEI such as lisinopril 

E. Morphine 

- His story (with the breathing and positional changes) make this sound more like issue with the pericardium.

- This pt probably has acute pericarditis

11

What does this ECG show? 

Q image thumb

Acute pericarditis

- Diffuse but subtle ST elevations

12

Case 2)

- 26 yo female - Presents with new onset of occasional palpitations in last 3 mo

- No apparent precipitating factors

- PE: normal

- ECG lead shown

Which of the following best describes the ECG in this pt

A. Wide QRS interval

B. Short PR interval

C. Delta wave

D. All of the above 

E. A and B 

Q image thumb

Which of the following best describes the ECG in this pt 

A. Wide QRS interval 

B. Short PR interval 

C. Delta wave 

D. All of the above 

E. A and B 

13

The ECG findings in this pt are indicative of what?

(Wide QRS interval, Short PR interval, Delta wave)

A. Delayed AV conduction

B. Ventricular depolarization via accessory pathway

C. Terminal heart disease

D. Severe hypertensive heart disease

The ECG findings in this pt are indicative of what?

(Wide QRS interval, Short PR interval, Delta wave) 

A. Delayed AV conduction

B. Ventricular depolarization via accessory pathway

C. Terminal heart disease 

D. Severe hypertensive heart disease

These three things are indicative of an accessory or bypass tract (classic triad of WPW)

- Short PR interval, because AV node is typically slowest part of conduction circuit; this tract bypasses it

14

What is this showing? 

Q image thumb

Triad features of Wolf-Parkinson-White

- Delta wave

- Short PR interval?

- Wide QRS interval

(No intrinsic delayed conduction in ventricles, just measuring delta wave with the rest of the QRS complex, making the whole thing wider)

 

A image thumb
15

What is this pointing to?

Q image thumb

Delta wave (WPW)

16

Presence of a delta wave on ECG (regardless of the cardiac rhythm) is indicative of which of the following?

A. Accessory pathway

B. Antegrade (from A to V) conduction down accessory pathway

C. Retrograde conduction (from V to A) up the accessory pathway

D. A and B

E. A and C

Presence of a delta wave on ECG (regardless of the cardiac rhythm) is indicative of which of the following? 

A. Accessory pathway 

B. Antegrade (from A to V) conduction down accessory pathway 

C. Retrograde conduction (from V to A) up the accessory pathway 

D. A and B

E. A and C

- Delta wave means conduction is using accessory pathway

- Pt may have tachycardia going down AV node and up accessory pathway (if conduction goes down AV node without accessory pathway, there's no delta wive and no widened QRS complex)

A image thumb
17

Which of the following may predispose WPW pts to potentially life-threatening arrhythmias?

A. Antegrade conduction down an accessory pathway at a very high rate (>250 bpm)

B. Antegrade conduction down the AV node at rates up to 180-200 bpm

C. Accessory pathway with a SHORT effective refractory period

D. Accessory pathway with a LONG effective refractory period

E. A and/or C

?

18

What can redispose to VERY FAST ventiruclar rates if the conduciton is downt he ACCESSORY Pathway?

- Short Refractory Period (under 200 ms).....

19

Two arrhythmias people with WPW are predisposed to? Details?

- AVRT (90-95%?): rather benign, up AV node, down accessory complex, no delta wave; give them a beta-blocker

- AVNRT: down the accessory pathway, wide QRS complex, up AV node. Only in those with SHORT refractory period will people be conducting at very fast rate; very rare, but life threatening

Refractory period is intrinsic part of the tissue; not something that can be altered by medicine