AF, IE, Brugada, PAD, VTE

Question 1

ECG findings in AF

Answer 1

Irregularly irregular rhythm

no discernable P-Waves

Question 2

CHADSVAS Scoring

Answer 2

CHF
Hypertension
Age >=75
DM
Stroke 
Vascular Disease
Age 65-75
Sex - Female

1 point each except for Stroke and Age >=75 given a score of 2

1pt - 1.3
2pt - 2.2
3pt - 3.2
4pt - 4.0
5pt - 6.7
6-9pt - >9

1pt - aspirin
>=2pt - anticoagulation

Question 3

AF Treatment: Pharmacologic Cardioversion

Answer 3

Amiodarone - if with structural heart dse

Flecainide, Ibutilide, Propafenone - if without structural heart disease

Question 4

AF Treatment: Rate Control

Answer 4

Beta Blockers, Verapamil, Diltiazem, Digoxin, Amiodarone

Question 5

AF Treatment: Electrical Cardioversion

Answer 5

For recent onset AF (<48h) with hemodynamic instability

Question 6

AF Treatment: Anticoagulation

Answer 6

Warfarin - Vit K Antagonism
Dabigatran - oral direct thrombin inh.
Rivaroxaban, Apixaban - oral direct factor Xa inh.

Question 7

Most Important Step in diagnosing IE

Answer 7

Serial Blood Cultures

Question 8

Risk Factors IE

Answer 8

Structural Heart Disease (RHD, VHD)
IV Drug Use
Prosthetic Heart Valves

Question 9

Duke’s Criteria

Answer 9

02/13/05
2 major or 1 major+3minors or 5 minors

MAJOR

• sustained bacteremia
• endocardial involvement documented by echocardiogram or established new valvular regurgitation

MINOR

• Predisposing condition (abnormal valve or abnormal risk of bacteremia)
• Fever
• Vascular Phenomena (septic arterial or pulmonary emboli, mycotic aneurysms, intracranial hemorrhage, janeway lesions)
• Immune Phenomena (GN, osler nodes, roth spots, Rheumatoid Factor)
• positive blood culture not meeting major criteria
• positive echocardiogram not meeting major criteria

Question 10

Etiology for

1. Acute IE
2. Subacute IE

Answer 10

Acute - s. aureus

Subacute - s. viridans

Question 11

Best Empiric Therapy for IE

Answer 11

Vancomycin + Gentamycin

- will cover most common organisms such as s. aureus, MRSA, s. viridans

Question 12

Most common cause of Sudden Cardiac Death

Answer 12

Brugada Syndrome

Ventricular Fibrillation that is ischemic in nature (secondary to ACS)

Take note of patient profile - young, male, Asian, with family history

Question 13

Brugada Syndrome pathophysiology

Answer 13

loss of function mutation in SCN5A gene causing decrease in sodium channel that affect the Phase 0 and Phase 1 of the cardiac action potential

Question 14

ECG findings in Brugada

Answer 14

pseudo RBBB and persistent ST segment elevation in V1-V2

Question 15

Brugada Pattern Types

Answer 15

Type 1: Coved
Type 2: Saddle-back
Type 3: Saddle-back (?)

Question 16

Diagnosis of Brugada

Answer 16

ECG - Type 1 Pattern in at least one right precordial lead plus one of the ff:

• documented vfib
• polymorphic VT
• family hx of sudden cardiac death age<45
• family hx of type 1 pattern on ECG
• inducivle vtach during EP study
• unexplained syncope
• nocturnal agonal respiration

Question 17

MEDICATIONS TO AVOID IN BRUGADA

Answer 17

Class I anti-arrhythmic drugs (ajmaline, flecainide, ranolazine)

Question 18

Management: Brugada

Answer 18

ICD implantation or Amiodarone 200mg once daily after initial loading dose of 400mg 2-3x daily for 1-2 weeks

Question 19

65/M, heavy smoker, with pain on both calves after walking a few blocks, and resolves with rest. Femoral and dorsalis pedis pulses are diminished bilaterally. Skin on legs are cool to touch and appears shiny with very little hair growth. DIAGNOSIS?

Answer 19

PAD

Question 20

Best initial test for PAD

Answer 20

Ankle Brachial Index
(Duplex Ultrasonography)
>1 normal
<0.9 PAD
<0.5 Severe Ischemia

Question 21

Most accurate test for PAD

Answer 21

Arteriography

Question 22

Leading cause of PAD

Answer 22

Atherosclerosis

Question 23

Primary site of involvement in PAD

Answer 23

90% Femoral and Popliteal Arteries

Question 24

Most common symptom of PAD

Answer 24

Intermittent Claudication

Question 25

6Ps of Acute Limb Ischemia (PAD)

Answer 25

``` Pain Pallor Paresthesia Paralysis Pulselessness Poikilothermia ```

Question 26

True of False. Calcium Channel Blockers can be used in management of PAD.

Answer 26

FALSE. WHY?

Question 27

Management: PAD

Answer 27

smoking cessation, BP control, exercise Cilostazol - first line Pentoxifylline - second line Antiplatelets - Aspirin ACEi, BB, Statins

Question 28

First Line Therapy for PAD

Answer 28

Cilostazol

Question 29

Virchow's Triad

Answer 29

Endothelial Injury Venous Stasis Hypercoagulable state

Question 30

Most common symptom of Pulmonary Embolism

Answer 30

Sudden onset unexplained breathlessness (dyspnea) in a patient with risk factors

Question 31

Rule Out test for DVT

Answer 31

D-Dimer - if normal, not DVT

Question 32

Most common symptom in DVT

Answer 32

Leg cramps or charley horse

Question 33

ECG findings in VTE

Answer 33

Sinus tachycardia S1Q3T3 T-wave inversion V1-V4

Question 34

Ultrasound finding in DVT

Answer 34

Loss of vein compressibility - primary criterion for DVT

Question 35

Diagnostic Test of Choice for DVT

Answer 35

Chest CT with Contrast

Question 36

Primary Therapy for DVT

Answer 36

Clot dissolution

Question 37

Secondary therapy for DVT

Answer 37

Anticoagulation IVC filter Compression stockings

Question 38

Only NOAC with a reversing agent

Answer 38

Dabigatran | reversing agent: Idarucimab

Question 39

Warfarin reversing agent

Answer 39

Prothrombin complex

Question 40

Protamine reverses effect of

Answer 40

Heparin, Enoxaparin, Dalteparin, Fondaparinux

Question 41

CPR rate

Answer 41

100-120 compressions per minute

Question 42

CPR depth

Answer 42

2-2.4 inches deep

Question 43

When to stop CPR

Answer 43

Patient is revived You are too tired to continue Help arrives

Question 44

Wide QRS

Answer 44

VTach, Vfib

Question 45

Narrow QRS

Answer 45

ST, AF, SVT, MAT

Question 46

Patient in pulseless VTach or VFib, what will you do?

Answer 46

SCREAM

Question 47

Patient in VT with pulse but unstable. What will you do?

Answer 47

Sedate then cardiovert starting 100j

Question 48

Patient in VT with pulse and stable. What will you do?

Answer 48

Manage medically. Give Amiodarone 150mg slow IV push...

Question 49

Patient in SVT, unstable. What will you do?

Answer 49

Sedate. Cardiovert starting 50j

Question 50

Patient in SVT, stable. What will you do?

Answer 50

Vagal maneuver Adenosine CCB (Verapamil)