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Royal College: Emergency Medicine > Cardiac System > Flashcards

Cardiac System Flashcards

This deck covers Chapters 68-74 in Rosens, compromising all of cardiology.

1
Q

What is AVRT orthodromic vs antidromic and why do we care?

A

AVRT with Orthodromic Conduction

Anterograde conduction occurs via the AV node with retrograde conduction occurring via the accessory pathway.

Treatment of Orthodromic AVRT

  • Like SVT

AVRT with Antidromic Conduction

Anterograde conduction occurs via the accessory pathway with retrograde conduction via the AV node.

Treatment of Antidromic AVRT

  • Unstable
    • Procainamide
    • DC Cardioversion
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2
Q

Describe the “runaway PM syndrome”.

A

Runaway Pacemaker Syndrome

  • Low battery causes spikes in HR which can cause VF
  • May cause failure to capture due to low voltage spikes
  • Rare in current age PPMs

​Treatment

  • Magnet
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3
Q

List 6 vascular phenomena seen in IE

A
  1. Arterial emboli
  2. Splinter hemorrhages
  3. Septic pulmonary infarcts
  4. Mycotic aneurysm
  5. Conjunctival hemorrhage
  6. Janeway lesions
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4
Q

What is this?

A

Pacemaker-mediated tachycardia (PMT)

  • Retrograde p waves sensed w/ ventricular pacing
  • Ventricular pacing causes retrograde p waves
  • Causes endless loop and rate-related ischemia
  • New PPM have programming to terminate PMT

​Treatment

  • Slow AV conduction
    • Adenosine
    • Magnet
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5
Q

List 8 causes of PVCs/VT

A
  1. Acute MI
  2. Previous MI
  3. Cardiomyopathy
  4. Myocardial contusion
  5. Hypokalemia
  6. Hypomagnesemia
  7. Hypoxemia
  8. Hypercapnia
  9. Acidosis
  10. Alkalosis
  11. Methylxanthine toxicity (caffeine)
  12. Valvular heart disease
  13. Catecholamine excess
  14. TCAs
  15. Idiopathic
  16. Digitalis toxicity
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6
Q

List clinical features that would help you distinguish SVT with aberrancy and VT

A

VT: >50 years, hx of MI, ASD, CHF, VT in the past

SVT: <35, healthy

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7
Q

List 8 early complications of MI

A
  1. Death
  2. CHF
  3. Dysrhythmias
  4. Cardiogenic shock
  5. LV free wall rupture
  6. Ruptured interventricular septum
  7. Papillary muscle rupture
  8. Pericarditis
  9. Hyperglycemia
  10. Stroke
  11. LV Aneurysm
  12. Post-PCI pseudoaneurysm
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8
Q

List 10 infectious causes of myocarditis

A
  • Viral
    1. Hep A/B/C
    2. Herpes 3,4,5,6,7
    3. Influenza A/B
    4. Enteroviruses
    5. Adenovirus
    6. HIV
  • Bacterial:
    1. S. pneumoniae
    2. M. pneumoniae
    3. C. pneumoniae
    4. TB
    5. Lyme
    6. Diptheria
  • Others:
    1. Chagas’ – protozoa
    2. Trichinosis – helminth
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9
Q

List the common presentations of ICD malfunction.

A

Increase or changes to shock frequency

  • Shocking SVT
  • Shocking non-cardiac signals
  • Oversensing T waves
  • Increased VF/VT (electrolytes, ischemia)

Syncope or dizzy

  • VT w/ low shock strength
  • SVT w/ hypotension
  • Inadequate backup rate

Cardiac Arrest

  • ICD malfunction
  • VF failing to respond to ICD parameters
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10
Q

What is this?

A

Paroxysmal SVT

  • Produce retrograde atrial depolarization and a P’ wave
  • But these P’ waves are usually buried in the QRS
  • Most common = AVNRT (AV node is used for anterograde conduction)

Treatment

  • Vagal maneuvers
  • Adenosine 6 mg (can repeat 12 mg x 2)
  • CCB (Diltiazem 0.25 mg/kg or 20 mg IV)
  • UNSTABLE: Electrical 50J
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11
Q

What is the CCS classification of stable angina?

A

Class I

  • No angina with ordinary activity

Class II

  • Slightly limited activity
    • Climbing stairs, emotional stress, walking

Class III

  • Severely limited activity
    • Walking 1-2 blocks, climbing 1 flight of stairs

Class IV

  • Can’t do any activity without pain
  • Pain at rest
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12
Q

According to new guidelines, what are our targets for PCI, thrombolytics, transfer, etc.?

A
  • Door to ECG goal: ≤10 min
  • Door to lytics: ≤30 min
  • Door to balloon goal: ≤90 min
  • FMC to balloon goal (transferred): ≤120 min
  • Lytics if unable to get PCI within 120 min

Transfer all patients in cardiogenic shock

Primary PCI for patients >12h out with ongoing ischemia

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13
Q

What are 4 Class I indications for an ICD?

A
  1. Cardiac arrest from VF/VT
  2. Sustained VT
  3. Syncope with inducible VF/VT
  4. Nonsustained VT with CAD, MI, EF <35%
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14
Q

What is the management of Acute Rheumatic Fever?

A

Treat streptococcus

  • Penicillin V 500 mg PO TID x10 days

Treat arthritis

  • ASA (or another anti-inflammatory)
  • Until symptoms resolve and CRP/ESR normalize

Treat carditis

  • Corticosteroids (conflicting evidence)
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15
Q

List 8 common precipitating causes of acute HF

A
  1. Non-compliance
  2. Fluids
  3. Sodium intake
  4. HTN
  5. MI
  6. Dysrhythmia
  7. Infection
  8. Myocarditis
  9. Valvular disorder
  10. PE
  11. Pregnancy
  12. Trauma
  13. Exercise
  14. Thyroid
  15. Hypoxia
  16. Anemia
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16
Q

What is the Jones Criteria for the diagnosis of ARF?

A

Positive DX of Rheumatic Fever if:

  • Strep + 2 Major or
  • Strep + 1 Major + 2 Minor

Proof strep infection

  • Culture
  • ASOT positive

Major (JONES)

  • Joint pain
  • cOrditis (carditis)
  • Nodules
  • Erythema marginatum
  • Sydenham chorea

Minor (PEACH F)

  • PR prolongation
  • ESR elevated
  • Arthralgias
  • CRP elevated
  • History of preceding GAS infection
  • Fever
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17
Q

List 5 causes of completely irregular (chaotic) rhythms

A
  1. Atrial fibrillation
  2. Multifocal atrial tachycardia
  3. AT/AF with varying conduction
  4. Extrasystoles
  5. Wandering pacemaker
  6. Parasystole
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18
Q

What’s the best mode for surgery?

A

VOO

  • Asynchronous pacing
  • Ventricle paced at a pre-programmed rate
  • Sensing not interfered with by cautery
  • Monitor for R on T with cautery –> torsades de pointes
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19
Q

Describe the 4 stages of pericarditis

A
  1. Diffuse STE and PR depression (hours/days)
  2. Flat T wave, ST/PR normalizes (days/weeks)
  3. TWI (2 weeks)
  4. Normalization (months)
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20
Q

What are the 5 types of MI?

A
  • Type 1: Plaque rupture
  • Type 2: Supply-Demand
  • Type 3: Sudden death
  • Type 4: PCI-related
  • Type 5: CABG-related
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21
Q

List 10 causes of pericarditis

A
  1. MI
  2. Viral/Bacterial/Fungal/Lyme
  3. Surgical
  4. Idiopathic
  5. Uremic
  6. Traumatic
  7. Rheumatoid arthritis
  8. SLE
  9. Amyloid
  10. Scleroderma
  11. Radiation
  12. Tumours
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22
Q

List 6 treatments to manage an electrical storm?

A

Rule out reversible causes (electrolyte AbN, myocardial ischemia, TCAs, hyperthyroidism)

  1. Amiodarone
  2. B-blockers
  3. Sedation
  4. Overdrive pacing
  5. Emergent catheter ablation
  6. Hemodynamic support with IABP, LVAD
  7. Transplantation
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23
Q

List 10 secondary causes of HTN

A
  1. Cushing’s syndrome
  2. Conn’s syndrome
  3. OCP use
  4. Pheochromocytoma
  5. Hyperthyroidism
  6. OSA
  7. Chronic pyelonephritis
  8. PCKD
  9. Renal artery stenosis
  10. Sympathetic drugs
  11. Licorice Root
  12. Chronic EtOH abuse
  13. Atherosclerosis
  14. Aortic coarctation
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24
Q

Describe the 2 Types of Wellen’s Patterns:

A

Type A

  • Biphasic, initial positivity
  • 25% of cases

Type B

  • Deeply, symmetrically inverted
  • 75% of cases

The T waves evolve over time from Type A to Type B

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25
Q

What is this?

A

Antidromic AVRT

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26
Q

Define Unstable Angina

A
  1. New onset angina
    * Class II angina onset within last 2 months
  2. Rest angina
    * Rest pain > 20 min within 1 week of ED presentation
  3. Progressive angina
    * Less precipitation, more often, longer duration
  4. Resistant angina
    * Previously effective anginal meds don’t work
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27
Q

What is the normal myocardium resting membrane potential (RMP)? How is the RMP maintained?

A

Normal RMP: -90 mV

Na+/K+- ATPase

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28
Q

What’s the diagnosis and management of 3rd Degree AVB

A

Pacemakers above His bundle:

  • Narrow complexes at HR 45 – 60
  • Will respond to atropine

Pacemakers below His bundle:

  • Wide complexes at HR 30 – 45
  • Will NOT respond to atropine

Treatment

  • Transcutaneous or transvenous pacing (if unstable)
  • Epinephrine 2 – 10 mcg/min
  • Dopamine 2 – 10 mcg/kg/min
  • AVOID Type I antidysrhythmics (stop escape rhythm)
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29
Q

When should you CONSIDER antibiotic prophylaxis for IE in the ED? What do you give for prophylaxis?

A

Step 1: High-risk condition for endocarditis?

  • Previous IE
  • Prosthetic valve
  • Unrepaired cyanotic heart lesion
  • Repair that is young (<6 months)
  • Transplanted heart with a valve

Step 2: High-risk procedure?

  • Gingival manipulation
  • I&D of skin
  • Incision of the respiratory tract

Step 3: Prophylaxis?

  • Amoxicillin 2g PO
  • Clindamycin 600 mg PO
  • Ceftriaxone 1g IV
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30
Q

What organisms make up the HACEK group?

A

Fastidious gram neg. bacilli that are difficult to isolate

  • Haemophilus species
  • Aggregatibacter (prev. Actinobacillus)
  • Cardiobacterium hominis
  • Eikenella corrodens
  • Kingella kingae
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31
Q

What is the new 2018 definition of MI?

A

Elevated troponin plus one of:

  • Symptoms of ischemia
  • New ECG changes
  • Pathologic Q waves
  • Imaging evidence of myocardial injury
  • Coronary thrombus by angiography
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32
Q

List 8 causes of PM malfunction in 4 categories

A

Failure to Capture

  • Leads disconnect or break
  • Exit block
  • Battery dies

Failure to sense

  • Leads move
  • Leads fracture
  • Poor contact

Oversensing

  • Oversensing extracardiac signals (shivering)
  • T wave sensing

Inapproprate Rate

  • Low battery
  • Pacer mediated tachycardia
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33
Q

What is the LOWN classification of PVC and which are concerning for developing a malignant arrhythmia?

A
  • 0: none
  • 1: <30/hr
  • 2: >30/hr
    1. Multifocal
  • 4a. Two consecutive
  • 4b. Three consecutive
    1. R on T

Class 3-5 are concerning for arrhythmia

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34
Q

Provide 5 DDX for ST depression

A
  1. MI
  2. Reciprocal changes
  3. PE
  4. Demand ischemia
  5. Digoxin effect
  6. Hyper/hypokalemia
  7. ICH
  8. Myocarditis
  9. Rate-related depression
  10. Pneumothorax
  11. Repolarization abnormality
  12. LVH with strain
  13. BBB
  14. Paced rhythm
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35
Q

What is this ECG?

A

Multifocal Atrial Tachycardia

  • At least THREE distinctly different P waves with varying P’-R, R-R and P’-P intervals
  • Irregular rhythm

Causes of MAT (same as for PAT)

  • PACs (MCC)
  • PVC (rare)
  • Electrolyte or acid-base disturbance
  • Drug toxicity
  • Fever
  • Pulmonary disease & hypoxemia

Treatment Options for MAT (or PAT, NPAT)

  • Treat underlying cause
  • BB or CCB
  • MgSO4 2–4 g IV
  • Overdrive pacing
  • Synchronized cardioversion (50 – 100J)
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36
Q

Define the Vancouver Chest Pain rule? Any good?

A
  1. Is there an abnormal ECG, positive troponin at 2 hrs, or prior ACS or nitrate use?
    * If Yes to any = No early discharge
  2. Does palpation reproduce the pain?
    * Yes = early discharge and don’t move to step 3
  3. Age ≥50, or does the pain radiate to neck, jaw, or left arm?
    * If Yes to any = No early discharge
    * If No to all = Early discharge with FU for stress testing

The rule was validated in 2014 on 1635 patients. Sensitivity is 99.1%, Specificity is 16.1%.

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37
Q

Explain pause- vs. tachycardia-dependent torsades de pointes

A

Acquired QT prolongation (pause-dependent)

  • Majority of adult cases are acquired
  • Precipitated by a SLOW HR
  • Treatment
    • Increase HR
    • Overdrive pacing or drugs for HR 100-120
    • IV MgSO4

Congenital QT prolongation (tachycardia-dependent)

  • Eg. Romano-Ward, Jervell and Lange–Nielsen, Timothy
  • Precipitated by catecholamine excess
  • Typical story: patient presents with syncope after exertion
  • Treatment
    • Slow HR
    • Can use BBs
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38
Q

What is the mechanism of action of nitroglycerin?

A
  • Gets converted in body to NO
  • NO activates guanylate cyclase
  • Leads to accumulation of cGMP:
    • Sequesters Ca2+ in SR
    • Results in relaxation of vascular smooth muscle
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39
Q

List 8 ABSOLUTE contraindications to fibrinolytics in ACS

A

Absolute CI

  1. Any prior ICH
  2. Known structural cerebral vascular lesion (eg, AVM)
  3. Known malignant intracranial neoplasm (primary or mets)
  4. Ischemic stroke within 3 mo EXCEPT acute within 4.5 h
  5. Suspected aortic dissection
  6. Active bleeding or bleeding diathesis (excluding menses)
  7. Significant closed-head or facial trauma within 3 mo
  8. Intracranial or intraspinal surgery within 2 mo
  9. Severe uncontrolled hypertension (unresponsive to tx)
  10. For streptokinase, prior treatment within last 6 mo
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40
Q

What are the 2014 STEMI criteria (ECS/ACCF/AHA)?

A

New ST segment elevation in 2+ contiguous leads >1mm in all leads other than V2-V3.

  • For V2-V3:
    • ≥1.5mm in Women
    • ≥2mm in Men >40years
    • ≥2.5mm in Men <40 years
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41
Q

Describe the ECG characteristics of an RBBB. List 5 causes of RBBB.

A
  • QRS > 120 msec
  • RSR’ pattern in V1-3 (‘M-shaped’ QRS complex)
  • OR broad monophasic R wave or qR complex
  • Wide, slurred S wave in the lateral leads (I, aVL, V5-6)

Causes

  1. RVH (cor pulmonale)
  2. PE
  3. Ischemic heart disease
  4. Myocarditis
  5. Rheumatic heart disease
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42
Q

Which organs are typically affected and which conditions can arise during a hypertensive emergency?

A
  • Brain
  • Heart
  • Kidney
  • Aorta
  • Eyes
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43
Q

What other scoring methods are used to risk stratify potential ACS patients?

A

PURSUIT: Does not include troponin assays as part of score and the majority of the score is dependent on patient age.

TIMI: Simple to use, but has a poor predictive power (i.e. c-statistic 0.65)

GRACE: Very complex to use and a large portion of the score is dependent on the patient age. Also, patients not divided into different risk groups

FRISC: Like TIMI, is simple to use but has a poor predictive power (i.e. c-statistic 0.70)

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44
Q

According to the 2018 CCS Guidelines for Atrial Fibrillation, list 3 populations that could be safely cardioverted in the ED

A
  1. Unstable Afib
  2. NVAF <12 hours and no recent TIA/CVA
  3. NVAF <48 hours and CHADS2 <2
  4. On anticoagulation for >3 weeks
45
Q

What is the NYHA classification for chronic HF?

A

Class I

  • Asymptomatic at normal exercise

Class II

  • Symptomatic at normal exercise

Class III

  • Symptomatic with less than ordinary exercise

Class IV

  • Symptomatic at rest
46
Q

In WPW with AFib and RVR, what drugs should you avoid?

A

ABCDs

  • Adenosine
  • BBs
  • CCBs
  • Digoxin
47
Q

Name 4 auscultation findings of HOCM

A
  1. S4 gallop
  2. Harsh crescendo-decrescendo systolic murmur (LUSB)
  3. Murmur is louder with Valsalva (decreased preload)
  4. Murmur is quieter with squatting (increased preload)
48
Q

Outline the HEART score for risk stratifying possible ACS patients in the ED

A

HEART

  • History: Not / Mod / Suspicious
  • ECG: Normal / Non-specific / ST-D
  • Age: <45 / 45-64 / >65
  • RF: 0 / 1-2 / 3+
  • Troponin: Normal / 1-3x normal / >3x normal

Interpret

  • 0-3 Low risk (outpatient)
  • 4-6 Moderate risk
  • 7+ Admit
49
Q

Describe the Vaughn Williams classification for antiarrhythmics

A

Class I

  • A: Na (int): Procainamide, Quinidine (QT-prolonging)
  • B: Na (fast): Lidocaine, phenytoin
  • C: Na (slow): Flecainide (QT-prolonging) propafenone

Class II

  • Beta-blockers

Class III

  • K+ Channel: amiodarone/sotalol (QT-prolonging)

Class IV

  • Ca2+: Verapamil/Diltiazem
50
Q

Provide 12 DDX for STE

A
  1. Ischemia
  2. AMI
  3. Hyperkalemia
  4. BER
  5. LVH
  6. LBBB
  7. Pericarditis
  8. Normal variant
  9. Brugada
  10. Post-electrical cardioversion
  11. Brain bleed
  12. LV aneurysm
  13. Ventricular paced rhythm
  14. Pulmonary embolism
51
Q

What is this ECG?

A

2:1 Atrial Tachycardia

  • Regular narrow complex tachycardia
  • Ventricular rate > 100
  • From a non-sinus focus above AV node
  • Each QRS preceded by P’ wave that is morphologically different from sinus P wave
  • If P’ wave is inverted, a low atrial source is likely
52
Q

What is this?

A

AV dissociation

Ventricular Tachycardia

53
Q

BP targets for:

  • Ischemic Stroke: Given tPA
  • Ischemic Stroke: No tPA
  • Post/During tPA
  • ICH
  • SAH
A
  • Ischemic Stroke: Given tPA: <185/110
  • Ischemic Stroke: No tPA: <220/120
  • Post/During tPA: <180/105
  • ICH: ~140 (MAP <130)
    • Interact-2/ATACH : No difference if lowered
  • SAH: <140
54
Q

List indications for biventricular pacing (i.e. indications for CRT)

A

All of the above:

  1. NYHA III/IV HF despite optimal Rx therapy
  2. EF <35%
  3. Sinus with QRS >120ms
  4. LBBB

Biventricular pacing “resynchronizes” the ventricles by simultaneously pacing the left and right ventricles, eliminating the delay in LV free wall contraction and improving systolic function

55
Q

What are the Brugada Criteria for VT? (4)

A

Step 1

RS complex in precordial leads?

  • If none = VT
  • If any = move to step 2

Step 2

Measure RS interval:

  • If > 100 ms -> VT is diagnosed.
  • If < 100 ms -> move on to step 3

Step 3

Look for AV dissociation

  • If AV dissociation –> VT
  • If no AV dissociation –> go to step 4

Step 4

If positive R wave in V1, VT if:

  • Smooth monophasic R wave
  • Taller left rabbit ear (Marriott’s sign)
  • A qR complex (small Q wave, tall R wave) in V1

In V6, VT if:

  • QS complex — a negative complex with no R wave
  • R/S ratio < 1 — small R wave, deep S wave
56
Q

List 9 ECG differences between VT and SVT

A
  1. Absence of typical RBBB or LBBB morphology
  2. Extreme axis deviation (“northwest axis”)
  3. Very broad complexes (>160ms)
  4. AV dissociation (P and QRS complexes at different rates)
  5. Capture beats
  6. Fusion beats
  7. Precordial concordance
  8. Brugada’s sign - The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms
  9. Josephson’s sign - Notching near the nadir of the S-wave
  10. RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller
57
Q

List the Sgarbossa criteria

A

Sgarbossa Criteria for AMI in patient with old LBBB

  • Concordant STE >1mm OR 25.6 (5 pts)
  • Concordant STD >1mm in V1, V2 or V3. OR 6.0 (3 pts)
  • Discordant STE >5mm OR 4.3 (2 pts)

Modified rule got rid of last criteria (5mm disc) and replaced with:

  • Discordant STE ≥ 25% of the depth of the preceding S-wave.
58
Q

List 3 immunologic phenomena seen in IE

A
  1. Osler’s nodes (are painful Osler -ouch!)
  2. Rheumatoid factor
  3. Roth’s spots (retinal hemorrhage)
59
Q

What is the best pacemaker mode for floating a pacer?

A

VVI

  • Ventricular pacing and sensing
  • Pacemaker will pace at pre-programmed rate unless sensed beat
  • If sensed then pacing inhibited
  • Asynchronous pacing
60
Q

List 8 adverse effects of digitalis

A
  1. GI
  2. Fatigue
  3. Drowsy
  4. Visual
  5. Colour Disturbance
  6. Headache
  7. Depression
  8. Heart block
  9. Ectopy
  10. Ventricular tachycardia
  11. Psychosis
61
Q

List 8 causes of atrial fibrillation

A
  1. HTN
  2. CHF
  3. Valvular Disease including RF or MR
  4. Pericarditis
  5. Fever
  6. Viral illness
  7. Hyperthyroid
  8. PE
  9. Cardiac surgery
  10. Alcohol
  11. Idiopathic
  12. Electrolyte abnormalities
  13. Pneumonia
  14. Sepsis
62
Q

What is “Pacemaker Syndrome”?

A

Clinical consequences of AV dyssynchrony with PPM

Iatrogenic disease - often underdiagnosed.

Symptoms due to:

  • Decreased cardiac output
  • Cannon A waves (atria contract against closed AV valve)
  • Loss of atrial contribution to ventricular filling (Atrial kick)
  • Vasodilation (due to ANP production)
  • VA conduction – retrograde - dyssynchrony
63
Q

What are the Duke Criteria for diagnosing IE?

Definite:

  • 2 Major
  • 1 Major and 3 Minor
  • 5 minor

Possible

  • 1 Major and 1 minor
  • 3 minor
A

BE FEVIER

Major (2):

  • Blood C+S positive x2
    • 1+ BCx Coxiella Burnetti
  • Echo evidence

MINOR (6):

  • Fever
  • Echo findings (not in major) - removed in Modified Duke
  • Vascular phenomena
  • Immunologic phenomena
  • Evidence: single positive C+S
  • Risk factors: IVDU, a predisposing heart condition
64
Q

What is this?

A

Brugada sign (Red)
Josephson’s Sign (Blue)

65
Q

List 8 adverse effects of amiodarone

A
  1. Bradycardia
  2. Hypotension
  3. QT prolongation
  4. GI
  5. Photosensitivity
  6. Hyperthyroid
  7. Pulmonary fibrosis
  8. Decreased contractility
66
Q

Outline your 1st and 2nd line antihypertensive agents for the following conditions:

  1. ACS
  2. CHF
  3. AoD
  4. CVA
  5. ICH
  6. Hypertensive encephalopathy
  7. AKI
  8. Preeclampsia/Eclampsia
  9. Sympathetic Crisis
A
  1. ACS - Nitro
  2. CHF - Nitro
  3. AoD - Esomolol + Nitroprusside/Labetalol
  4. CVA - Labetalol
  5. ICH - Labetalol
  6. Hypertensive encephalopathy - Labetalol
  7. AKI - Nicardipine
  8. Preeclampsia/Eclampsia - Labetalol/Hydralazine
  9. Sympathetic Crisis - Benzos
67
Q

Explain the 5 letter PPM Code

A

Pilsener, Stout, IPA

  • Pacing (A, V, Dual)
  • Sensing (A, V, Dual)
  • Inhibitor Functioning (Trigger, Inhibit, Dual)
  • Programmability (Rate adaptive, Simple)
  • Anti-tachycardia (Pacing, Shock, Dual)
68
Q

Describe the ECG characteristics of an LBBB. List 5 causes of LBBB

A
  • QRS > 120 msec
  • Dominant S wave in V1
  • Broad monophasic R wave in lat leads (I, aVL, V5-V6)
  • No Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
  • Prolonged R wave peak time > 60ms in left precordial leads (V5-6)
  • Appropriate discordance
  • LAD

Causes

  1. Anterior MI
  2. Aortic stenosis
  3. HTN
  4. Dilated cardiomyopathy
  5. Hyperkalemia
69
Q

Describe the ECG changes in the following types of MI (Leads/Vessel/Reciprocal changes):

  • Anterior
  • Lateral
  • Inferior
  • RV MI
  • Posterior
A

Anterior MI

  • V1-V4
  • LAD
  • Inferior

Lateral MI

  • I, aVL, V5, V6
  • LCx
  • Inferior

Inferior MI

  • II, III, aVF
  • RCA
  • Lateral

RV MI

  • V4R
  • RCA
  • Lateral

Posterior MI

  • V7, V8 and V9
  • PDA (branch off of RCA or LCx)
  • V1-V2
70
Q

Draw the phases of the myocardial action potential, including ion flow at each stage

A
71
Q

List 3 causes of acute mitral regurgitation, describe the pathophysiology, and management

A

Cause

  • MI
  • Trauma
  • IE

Pathophysiology

  • Associated with low LA compliance
  • Sharply elevated LA pressure –> acute CHF

Clinical Features

  • Fulminant pulmonary edema
  • Harsh midsystolic murmur radiating to the BASE

Management

  • Aggressive afterload reduction (vasodilators)
  • Inotropes
  • Intubate, if required
  • Emergency Echo + Cardiac cath
  • IABP as a bridge to surgery
72
Q

Provide 12 DDX for T wave inversion

A
  1. Brugada
  2. CVA
  3. Hypokalemia
  4. GI disorders
  5. Normal variant
  6. Persistent juvenile T wave inversion
  7. Hyperventilation
  8. Post-MI changes
  9. ACS
  10. LVH
  11. BBB
  12. Paced rhythm
  13. Myocarditis
  14. Pericarditis
  15. PE
  16. Pneumothorax
  17. WPW
  18. Wellen’s Syndrome
73
Q

List 5 contraindications to labetalol use

A
  1. CHF (use nitro)
  2. Heart block
  3. Asthma
  4. Cocaine toxicity
    * Increases risk of seizures and death
    * Unopposed alpha
  5. Pheochromocytoma
    * May lead to paradoxical hypertension
    * Unopposed alpha
74
Q

How do you distinguish PACs with abnormal conduction from PVCs?

A

PAC

  • No pause
  • p waves
  • Looks like RBBB
  • Normal axis,
  • QRS not wide

PVC

  • Pause
  • Wide
  • Abnormal axis
  • No p waves
  • LBBB or similar looking
75
Q

Tachy Brady Syndrome. List 5 risk factors and treatment

A
  • Runs of tachycardia interspersed with long sinus pauses
  • Extremely low sinus rate
  • Sinus beats followed by paroxysms of junctional tachycardia

Risk Factors

  • Fibrosis (elderly)
  • Ischemia
  • Inflammatory diseases
  • Cardiomyopathy
  • Connective tissue diseases
  • Drugs (BB, CCBs, Digitalis, Quinidine)

Treatment:

  • Rate stimulation (Atropine or Pacing)
  • Rate control (BB, CCB, or Digoxin)
  • Cardiology referral for PPM + meds for Afib
76
Q

What is this?

A

Junctional Afib (Digoxin)

77
Q

What’s the formula for?

  • Cardiac Output
  • Blood pressure
  • MAP
A
  • CO = SV x HR
  • BP = CO x SVR
  • MAP = 2/3(DBP) + 1/3(SBP)
78
Q

What are the 3 key ECG features for WPW syndrome?

A
  1. Short PR (<120 msec)
  2. QRS > 100 msec
  3. Slurred upstroke of QRS complex (delta wave)
79
Q

Describe the mechanism of Enhanced Automaticity

A

Spontaneous phase 4 depolarization in non-pacemaker cells (abnormal automaticity)

  • Example: VT within 1st 24 hours after MI

An increase in the slope of depolarization in cells that normally undergo phase 4 depolarization (enhanced automaticity)

  • Example: catecholamine excess stimulating a non-SA-nodal pacemaker source to become the dominant pacemaker e.g. idioventricular rhythm after MI
80
Q

List 8 types of cardiomyopathies

A
  1. Arrhythmogenic right ventricular
  2. Dilated
  3. Hypertrophic
  4. Ion-channel disorder
  5. Inflammatory
  6. Mitochondrial
  7. Peripartum
  8. Restrictive
  9. Takotsubo
  10. Tachycardia-induced
81
Q

What’s an electrical storm? List 4 causes.

A

3+ episodes of sustained VT in 24h

Causes:

  • Drug toxicity
  • Electrolyte disturbances (hypoK and hypoMg)
  • CHF
  • Acute myocardial ischemia
  • QT prolongation
  • Thyrotoxicosis
82
Q

Provide 5 DDX for hyperacute T waves.

A
  1. Ischemia
  2. AMI
  3. Hyperkalemia
  4. BER
  5. LVH
  6. LBBB
  7. Pericarditis
83
Q

Name 6 reasons why a patient with IE may require surgery

A
  1. CHF
  2. Fungal
  3. Annular abscess
  4. Heart block
  5. Recurrent emboli despite ABx
  6. Stroke
  7. Persistent bacteremia
  8. >1 cm vegetation with embolic disease
84
Q

List 3 causes of chronic mitral regurgitation, describe the pathophysiology, and management

A

Causes

  1. Dilated CM (enlargement of mitral annular ring)
  2. RHD
  3. MVP
  4. Connective tissue disorders (Ehlers-Danlos, Marfan)

Pathophysiology

  • Associated with high LA compliance
  • Near norm LA pressure with reduced forward output
  • Decompensate with volume

Clinical Features

  • Signs of chronic systolic HF
  • Holosystolic murmur at apex and radiates to AXILLA

Treatment

  • Standard CHF management
  • Consider valve replacement w EF <60%
85
Q

What is this?

A

Bidirectional VT (digoxin)

86
Q

List 8 acquired and 2 congenital causes of prolonged QT

A

Acquired

  1. Hypothyroidism
  2. Hypomagnesemia
  3. Hypokalemia
  4. Hypocalcemia
  5. Brain bleed
  6. MI
  7. PASTA CACA
    * Propranolol
    * Amiodarone
    * Sotalol
    * TCAs
    * Antimalarials
    * Cocaine
    * Antiemetics/Antibiotics
    * Carbamazepine
    * Antidysrhythmics

Congenital

  1. Jervell and Lange Nielsen
  2. Romano-Ward
  3. Timothy
  4. Mitral valve prolapse
  5. Sporadic
87
Q

Describe the 3 components of the re-entry mechanism:

A

For re-entry to occur, 3 conditions must be met:

  1. Two paths (or a circuit) must be available
  2. They must have unequal responsiveness
  3. One path must be slower
88
Q

What are the Class I indications for PPM in adults?

A
  • 3rd degree AVB or Advanced 2nd-degree AVB w/
    • Asystole >3s
    • Asystole >5s with afib
    • AV nodal ablation
    • Ventricular dysrhythmia
    • Symptomatic bradycardia
    • HR <40
    • Neuromuscular disease
  • 2nd-degree AVB with symptomatic bradycardia
  • 3rd-degree AVB w/ HR >40 and LV dysfunction
  • Bi/Trifasicular block w/ intermittent 3rd-degree AVB
  • Exercise-induced 2nd/3rd degree AVB
89
Q

List shocks that an ICD triggers for:

A

Appropriate Shocks

  • Ventricular fibrillation
  • Monomorphic VT
  • Polymorphic VT
90
Q

Explain the Frank-Starling mechanism. Provide 5 examples of factors that increase & decrease contractility

A

As preload (LV EDV) is increased, SV increases:

  • Increased force of contraction
  • Maximizes # of actin-myosin interactions
  • Eventually, sarcomere overstretched, leading to lower SV

Increase contractility:

  1. Sympathetic drive
  2. Inotropes
  3. Digitalis
  4. Catecholamines
  5. Increase HR (minimal)
  6. Post-extra-systolic potentiation

Decrease contractility:

  1. Parasympathetic drive
  2. Intrinsic depression
    * (MI, CHF, cardiomyopathy)
  3. Drugs & EtOH
    * (CCB, BB, barbiturates, procainamide)
  4. Hypoxia
  5. Hypercarbia
  6. Acidosis
91
Q

What is Poiseuille’s Law? What is Laplace’s Law?

A

Poiseuille’s

  • Flow is directly proportional to 4th power of the radius

Laplace

  • T = Pr
  • Tension is directly proportional to r (cavity size)
92
Q

What are 5 diseases associated with WPW?

A
  1. Idiopathic
  2. Tricuspid Atresia
  3. TGA
  4. Ebstein’s
  5. Endocardial Fibroelastosis
  6. Mitral Valve Prolapse
  7. HOCM
93
Q

What is the Ashman phenomenon?

A
  • Aberrant ventricular conduction of an atrial extrasystole after a long setup cycle (originates above AVN)
  • May occur in any irregular atrial arrhythmia
  • Classically seen in AF
  • In normal patients, the RBB is the last part of the infranodal system to repolarize completely
  • Thus, aberrantly conducted impulses in the Ashman phenomenon assume a RBBB appearance on ECG
94
Q

Describe the following murmurs:

  • Mitral Stenosis
  • Mitral Regurgitation
  • Mitral Valve Prolapse
  • Aortic Stenosis
  • Aortic Regurgitation
  • Tricuspid Regurgitation
  • Hypertrophic Cardiomyopathy
A
95
Q

What is this?

A

Atrial Flutter

  • Regular atrial depolarization rate of 250 – 300 atrial complexes per minute
  • Rate of 300 bpm is classic
  • Abnormal atrial depolarizations in a “sawtooth” appearance (flutter waves)
  • Best seen in leads II, III, aVF, V1, V2

Treatment

  • STABLE
    • Control ventricular response rate:
      • CCB or BB
      • Digoxin (2nd line)
      • MgSO4 2-4 g IV (3rd line)
    • Cardioversion:
      • Procainamide or amiodarone
  • UNSTABLE
    • Synchronized CV (50 J)
96
Q

In general terms, what is the main treatment goal in a hypertensive emergency?

A
  • 10% reduction in MAP within 1 hour AND
  • <25% within 24 hours
  • Agent of choice:
    • Nitroprusside or Labetalol
97
Q

What 4 agents inhibit or reverse ventricular remodeling in HF (i.e. decrease mortality)?

A
  1. BBs
  2. ACEIs
  3. ARBs
  4. Aldosterone antagonists (e.g. spironolactone)
    * Bonus: ICD/CRT
98
Q

Outline the TIMI score for UA/NSTEMI

A

AMERICA

  • Age (greater than 65 years)
  • Markers (raised serum cardiac markers)
  • ECG (ST-segment depression at presentation)
  • Risk factors (at least three for coronary artery disease)
  • Ischaemia (at least two anginal events in last 24 hours)
  • Coronary stenosis (prior stenosis of 50% or more)
  • Aspirin (use in previous 7 days)

Score of 0/1 — 4.7 % Score of 2 — 8.3 % Score of 3 — 13.2 % Score of 4 — 19.9 % Score of 5 — 26.2 % Score of 6/7 — 40.9%

99
Q

Name 4 adverse effects of sodium nitroprusside

A
  1. Hypotension
  2. Coronary steal syndrome
    * Normal vessels dilate + divert flow from more diseased vessels (DON’T use in MI)
  3. CN toxicity (or thiocyanate)
  4. Methemoglobinemia
100
Q

List 8 RELATIVE contraindications to fibrinolytic therapy

A

Relative CI

  1. History of chronic, severe, poorly controlled HTN
  2. Significant HTN on presentation (SBP >180 or DBP >110)
  3. History of prior ischemic stroke >3 mo
  4. Dementia
  5. Known intracranial pathology not in absolute CI
  6. Traumatic or prolonged (>10 min) CPR
  7. Major surgery (<3 wk)
  8. Recent (within 2 to 4 wk) internal bleeding
  9. Noncompressible vascular punctures
  10. Pregnancy
  11. Active peptic ulcer
  12. Oral anticoagulant
101
Q

What is this?

A

Brugada

Inherited Na channelopathy

Type 1

  • Coved STE with a gradual descent to TWI

​Type 2

  • T wave is positive or biphasic
  • The terminal portion of ST is elevated (saddleback)

Type 3

  • T wave is positive
  • The terminal portion of ST elevated
102
Q

Explain the mechanism of Triggered Dysrhythmias

A

Triggered dysrhythmias are the result of after-depolarizations:

Delayed after-depolarizations

  • Enhanced by faster HR
  • Associated with intracellular Ca2+ overload
  • Example: digitalis toxicity

Early after-depolarizations

  • Enhanced by slower HRs
  • Classic example: torsades des pointes
103
Q

What is this?

A

Wellen’s

  • Pattern of deeply inverted or biphasic T waves in V2-3
    • Highly specific for critical stenosis of LAD
  • May be pain-free in ED and have normal/minimally elevated cardiac enzymes, but are at extremely high risk for extensive anterior wall MI within days-weeks
  • Cardio consult in ED

Diagnostic criteria:

  1. Deeply-inverted or biphasic T waves in V2-3
    * May extend to V1-6
  2. Isoelectric or min-elevated ST segment (< 1mm)
  3. No precordial Q waves
  4. Preserved precordial R wave progression
  5. Recent history of angina
  6. ECG pattern present in a pain-free state
  7. Normal or slightly elevated serum cardiac markers
104
Q

What are 3 common causes of dysrhythmia formation?

A
  1. Enhanced Automaticity
  2. Re-entry
  3. Triggered Mechanisms
105
Q

List 3 methods that can be used to differentiate VT from SVT with aberrancy

A

Wellen’s Criteria

  • Uses multiple unordered clinical data points to help estimate the likelihood of VT or SVT

Brugada Criteria

  • Uses 4 steps to identify VT (if absent, Dx = SVT)

Griffith Approach

  • Identifies classic BBB patterns to first identify SVT
  • Then seeks AV dissociation to find VT in the remainder
  • Brugada & Griffith approaches perform similarly
106
Q

What is the normal MAP for an LVAD patient? What is hypertension? What is hypotension?

A

Hypotension = <60 mmHg

Normal = 60-90 mmHg

Hypertension = >90 mmHg

107
Q

How do you take a blood pressure on a patient with an LVAD?

A

Arterial line

or

Manual - as sound returns by doppler/auscultation = MAP

108
Q

According to the 2018 CCS Guidelines for Atrial Fibrillation, list 4 populations that should be anticoagulated for 3 weeks before cardioverted

A
  1. Valvular Afib
  2. NVAF <12 hours and recent TIA/CVA
  3. NVAF 12-48 hours and CHADS2 >/= 2
  4. NVAF >48 hours

Royal College: Emergency Medicine (25 decks)

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