Cardiology

Question 1

Features suggesting instability in cases of dysrrhythmia:

Answer 1

ALOC<div>SOB/respiratory distress</div><div>Syncope</div><div>Chest pain (ACS)</div><div>Hypotension</div>

Question 2

<div>Anti Arrhythmic Medications Classification:</div>

Answer 2

“<div><b>Some Block Potassium Channels</b></div> <div>I: Sodium Channel blockers(membrane stab)</div> <div>II: BB (…lols)</div> <div>III: Potassium Channel blockers (Action potential widening)</div> <div>IV: Calcium Channel blockers</div> <div>_____________________________________</div> <div>IA: (Double Quarter Pounder)</div> <div> Disopyramide, Quinidine, <b>Procainamide</b></div> <div></div> <div></div> <div>IB: (Lettuce, Tomato, Mayo)</div> <div> <b>Lidocaine</b>, Tocainamide, Mexiletine</div> <div> Pure Na blockers, only effective inventricular arrhythmias</div> <div></div> <div>IC: (More, Fries, Please)</div> <div> Moricizine, <b>Flecainide</b>, Propafenone</div> <div> <i>Avoid in HF and IHD</i></div> <div></div> <div>III: (A Big Dog Is Scary)</div> <div> <b>Amioradrone</b>, Bretylium, Dofetilide, Ibutilide, <b>Sotalol</b></div> <div></div> <div>IV: (Very Nice Drugs)</div> <div> Verapamil, nifedipine, diltiazem</div>”

Question 3

Other Na channels blocker drugs

Answer 3

TCA<div>Citalopram<br></br><div>Carbamazepine</div><div>Neuroleptics</div><div>Antihistamines</div><div>Cocaine</div><div>Shellfish toxins</div><div><br></br></div></div>

Question 4

Sick sinus syndrome

Answer 4

Sinus brady<div>Sinus arrest</div><div>SA exit block</div><div>Tachy-brady syndrome</div>

Question 5

SSS is suspected in:

Answer 5

Elderly pt with syncope + ECG demonstrate sinus impulse abnormalities

Question 6

Long term Mx of SSS

Answer 6

Permanent pacemaker placement + Rx for A. fib

Question 7

<div>What are three ECG presentations of sick sinus syndrome?</div>

Answer 7

<div>Think about it in any elderly patient with syncope! </div>

<div>● Tachy-brady syndrome </div>

<div>● A. fib with episodes of incomplete sinus block </div>

<div>● Complete sinus block</div>

Question 8

SINUS ARREST WITH SA EXIT BLOCK

Answer 8

● Missing P waves on ECG <br></br>● Sinus block = no impulse conducted from the SA node <br></br>● Sinus arrest = no impulse generated <br></br>● Can be benign (vagal tone) or pathologic

Question 9

Sinus exit block

Answer 9

Complete absence of PQRST comples<div>Completely missed beat</div>

Question 10

ECG features of rt vent STEMI

Answer 10

STE in V1<div>STE III > II</div><div>STE V1>V2</div><div>STE V1 + ST dep V2 (highly specific)</div><div>STE rt sided leads (V3R-V6R)</div>

Question 11

What is the worst type of STEMI

Answer 11

Anterior due to large surface area involved

Question 12

Features of a significant (pathologic) Q-wave

Answer 12

> = 4 ms (0.04 mm)<div>1/3 ht of R wave</div>

Question 13

Factors favors BER on ECG

Answer 13

Features of STE:<div> Concave upwards</div><div> Precordial leads only</div><div> Elevated J-point</div><div>Non-specific for coronary anatomy</div><div>NO receprocal STD</div><div>No dynamic changes with time</div><div>No Q-wave</div>

Question 14

Features predict MI in ECG

Answer 14

STE features:<div> Horizontal</div><div> Convex upwards</div><div>Specific for coronary anatomy</div><div>Presence of receprocal STD</div><div>Dynamic changes with time</div><div>Early features: Hyperacute T-Wave</div><div>Late features: Q-Wave</div>

Question 15

What STEMI causes heart block

Answer 15

Anterior (Mobitz 2 propagating to 3rd degree)<div>Inferior (3rd degree)</div>

Question 16

Anterior STEMI may cause:

Answer 16

Tachydysrrhythmia<div>2nd or 3rd degree heart block</div><div>LV aneurysm</div>

Question 17

Drugs cause long QT

Answer 17

Macrolides (Azithromycin)<div>Fluroquinolones (cipro, levo, moxi)</div><div>Phenothiazines (prochlorperazine, chlorpromazine)</div><div>5HT3 antagonists (ondanosteron)</div>

Question 18

Rx of unstable TDP

Answer 18

Immediate unsynchronized defibrillation<div>Mg sulfate iv</div>

Question 19

Ind of PCI in MI

Answer 19

CHF with hypotension<div>Symp > 12 hrs</div><div>High risk of bleeding</div><div>Recent brain bleed</div><div>Triple vessel dis (? do CABG)</div><div>If can be reached within 90 min</div>

Question 20

Other causes of STE (STEMI mimics)

Answer 20

“LV aneurysm<div>Pericarditis<br></br>Myocarditis</div><div>BER</div><div>Prinzmetal’s angina</div><div>LVH<br></br>WPW<br></br>HOCM</div><div><br></br></div><div>HyperK</div><div>LBBB</div><div>Hypothermia (Osbourne wave)</div><div>Brugada syndrome</div><div>Vent paced rhythm</div><div>Raised IC pressure</div><div>Takotsubo CMP</div>”

Question 21

What are the components of prehospital management of AMI

Answer 21

Activation of the EMS system <br></br>BLS care (for cardiac arrests) <br></br>ACLS care: <br></br> ○ 12 lead ECG - to rule in/out STEMI <br></br> ○ Administration of chewable ASA 160-325 mg PO <br></br> ○ Administration of SL nitroglycerin <br></br> ○ Possibly administration of oxygen if Sp02 <94%

Question 22

Risk factors for atypical presentation of ACS:

Answer 22

● Women <br></br>● Elderly (Especially > 85 years) <br></br> ○ Dyspnea, fatigue, confusion, syncope <br></br>● Diabetics <br></br>● Non-Caucasian <br></br>● No prior hx of MI <br></br>● Dementia

Question 23

Describe the ECG characteristics of Left Main Occlusion

Answer 23

Widespread horizontal ST depression, most prominent in leads I, II and V4-6 <br></br>ST elevation in aVR ≥ 1mm <br></br>ST elevation in aVR ≥ V1

Question 24

ECG Features of Pericarditis

Answer 24

Diffuse STE (except aVR=STD)<div>PR seg depression (I, II, aVF, V6) = insensitive</div><div>PR seg elevation in aVR</div>

Question 25

LBBB

Answer 25

QRS duration of > 120 ms
Dominant S wave in V1
Broad monophasic R wave in lateral leads (I, aVL, V5-V6)
Absence of 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)

Question 26

RBBB

Answer 26

Broad QRS > 120 ms
RSR’ pattern in V1-3 (‘M-shaped’ QRS complex)
Wide, slurred S wave in the lateral leads (I, aVL, V5-6)

Question 27

STEMI equivalants

Answer 27

Wellens type A & B

Shark T

De Winter ST-T

Sgarbossa 

Isolated post STEMI 

LVH

Hyperacute T-wave

Question 28

DDX of high Tropinin 

Answer 28

● Acute coronary ischemia
     ○ ACS
     ○ Cocaine
     ○ Variant angina
     ○ Coronary embolism/vasculitis
● Comorbidities causing myocardial injury
     ○ Renal failure, sepsis, ARDS, stroke, SAH
● Systemic shock states
     ○ Distributive shock states (sepsis, CO poisoning, burns)
     ○ Cardiogenic shock states (myocarditis / myocardial contusion / cardiomyopathy)

Question 29

Advantages of ACEI in ACS

Answer 29

Reduce CV mortality

Reduces recurrence of MI

Reduces CHF

Question 30

Indications of rescue PCI

Answer 30

1. Persistent chest pain
2. Persistent ST elevation
3. Cardiogenic shock
4. Post-reperfusion ischemia
5. Ventricular dysrhythmias

Question 31

When to get a 15 lead ECG?

Answer 31

(1) ST segment changes (depression or elevation) in leads V1 to V3, either in an isolated lead or in more than one; 
(2) Equivocal ST segment elevation in the inferior (II, III, aVF) or lateral (I, aVL) limb leads or both; 
(3) All inferior STEMI; and
(4) Hypotension in the setting of ACS

Question 32

List 10 possible causes for ST segment elevation

Answer 32

E = EBR (early benign repolarization)

L = LBBB

E = Electrolytes (Hyper K+)

V = Ventricular hypertrophy

A = Aneurysm

T = Treatment

I = Ischemia

O = Osborne

N = Normal variant/neurological

Question 33

List five possible findings of aortic dissection on chest x-ray

Answer 33

Widened mediastinum

Depression of L mainstem bronchus

NG tube displacement

L pleural effusion/apical cap

Calcium sign – displaced intimal calcification

AP window opacification

Double density or localized bulge along aorta

Disparity in calibre between ascending and descending aorta

Question 34

List three possible presenting symptoms of aortic dissection

Answer 34

Chest pain

Stroke

Heart failure

Syncope

Buttock and leg pain

Back and flank pain

Abdominal pain

Question 35

QRS too wide

Answer 35

BBB

Ventricular complexes

Paced rhythm

LVH

Electrolytes imbalance (hyperK, HypoCa)

Delta wave (WWW)

Question 36

LBBB causes

Answer 36

Conduction system dis

MI

CMP

LVH

Myocarditis

Question 37

List 6 historical predictors of acute HF and 6 clinical features of acute HF 

Answer 37

● Hx

○ Past history of HF

○ PND

○ SOBOE

○ Orthopnea

○ Nocturia

○ Hx of any type of heart disease

 

● Px

○ Hypertension

○ Diaphoretic

○ Pulmonary crackles

○ Pulmonary wheezes (cardiac asthma - due to peribronchial edema) - which may respond to bronchodilator therapy!!

○ JVD

○ Edema

○ S3 

Question 38

List 5 CXR and 5 ECG findings of HF 

Answer 38

❏ Pleural effusions

❏ Cardiomegaly (enlargement of the cardiac silhouette)

❏ Kerley B lines (horizontal lines in the periphery of the lower posterior lung fields)

❏ Upper lobe pulmonary venous congestion (bat wing appearance)

❏ Interstitial oedema. 

Question 39

ECG Findings in acute CHF

Answer 39

LVH

LAE

RAE

RV Strain: ST depression and T wave inversion in the leads corresponding to the right ventricle, i.e The right precordial leads:  V1-3, often extending out to V4. The inferior leads:  II, III, aVF, often most pronounced in lead III as this is the most rightward-facing lead

Fascicular blocks and bundle branch blocks

Question 40

Goals of Rx of CHF

Answer 40

Reduce cardiac workload by decreaseing preload and afterload

Control excessive salt and water retention

Improve contractility

Question 41

How to improve contractility

Answer 41

Stop bad drugs

Optimize Ca ions

Oxygen

Decrease excessive catecholamines/acidosis

Question 42

Rx of CHF + Adequate perfusion

Answer 42

POND

Positioning

O2

NIPPV

Nitrates

Diuretics

Question 43

Rx of CHF with inadequate perfusion

Answer 43

POND

(Avoid nitrates)

Vasopressors/Inotrops

Question 44

List 10 treatment options for chronic HF

Answer 44

1. Cardiovascular exercise and strength training / conditioning program
2. Obesity reduction
3. Healthy diet
4. Beta-blockers
5. ACE Inhibitors
6. ARBs
7. Diuretics
8. Spironolactone
9. Digoxin
10. Cardiac resynchro therapy (biventricular pacemaker)

These medications have been shown to reduce five-year mortality 

Question 45

Classical ECG of cardiac temponade

Answer 45

Low voltage QRS

Electrical alternans

Tacycardia

Question 46

What does the first letter of the pacemaker code indicate?

Answer 46

The first letter indicates the chamber that is paced (A – atrium, V – ventricle, D – dual, 0 – none).

Question 47

"Question: What infectious etiology is associated with complete heart block?"

Answer 47

Lyme disease.

Question 48

What is the definition of a fusion beat?

Answer 48

A supraventricular and a ventricular impulse coincide to produce a hybrid complex called a fusion beat. Indicates 2 foci of pacemaker cells firing spontaneously.

Question 49

Supraventricular tachycardia that does not convert with adenosine can often be confused with what rhythm?

Answer 49

Atrial flutter with a 2:1 block.

Question 50

Features of unstable cardiac patient

Answer 50

Altered mental status

Chest pain

SOB

Diaphoresis

Dizziness

Syncope

Question 51

In what scenario is it impossible to distinguish a Mobitz type I from type II AV block?

Answer 51

If the conduction ratio is 2:1.

Question 52

Congenital causes of cardiac syncope

Answer 52

• Short PR, 
• long QT syndrome, 
• hypertrophic cardiomyopathy, 
• arrhythmogenic right ventricular dysplasia 
• Brugada syndrome

Question 53

Name three ECG clues that are highly specific for VT?

Answer 53

Very wide QRS (>160)

Fusion beats

Capture beats

Question 54

Which of the following AV nodal blocks is most commonly associated with an acute inferior wall myocardial infarction?

Answer 54

Mobitz type 1

Question 55

What are the Conduction Abnormalities of Inferior MI

Answer 55

Sinus brady

First degree AV Block

Mobitz 1(Wenckebach)

Third degree AV Block

Question 56

What are the Conduction abn in Anterior MI

Answer 56

First degree AVB

Mobitz 2 AVB

Third degree AVB

Question 57

Anatomically, where is the block located in Mobitz II?

Answer 57

The block is below the level of the AV node, generally in the His-Purkinje system.

Question 58

Causes of MAT

Answer 58

COPD

CHF

Hypoxia

Pulm htn

Question 59

What is the most common dysrhythmia associated with Wolff-Parkinson-White syndrome?

Answer 59

Narrow complex atrioventricular reentry tachycardia (can be treated as PSVT)

Question 60

Risk factors for DVT in ambulatory pt

Answer 60

""

Question 61

DVT must be treated in:

Answer 61

Unprovoked DVT

Hx of DVT or PE

Clot close to proximal veins

Extensive thrombosis in multiple veins

Active cancer

Question 62

What is phlegmasia cerulea dolens?

Answer 62

Painful blue leg syndrome caused by extensive iliofemoral occlusion from a venous clot causes vascular congestion and venous ischemia.

Question 63

Gold standard imaging for DVT

Answer 63

Venography

Question 64

What type of cardiac surgery is often complicated by complete heart block?

Answer 64

AVR

Question 65

Why should electrical cardioversion be performed using the synchronized setting in AVNRT?

Answer 65

Unsynchronized cardioversion (defibrillation) risks an R on T phenomenon where the electricity is delivered during cardiac repolarization, leading to torsades de pointes or ventricular fibrillation.

Question 66

Which medications should be avoided in patients with Wolff-Parkinson-White syndrome who develop a wide complex tachydysrhythmia requiring treatment?

Answer 66

Adenosine, 

amiodarone, 

beta-blockers, and 

calcium channel blockers.

Question 67

What are the six causes of high-output heart failure?

Answer 67

Hyperthyroidism, 

wet beriberi, 

arteriovenous fistula, 

Paget disease, 

severe anemia, and 

pregnancy

Question 68

ECG features of raised ICP

Answer 68

Widespread giant T-wave inversion
QT prolongation
Bradycardia

Others:
STE/depression
U wave

Question 69

Vasospastic Angina (Prinzmetal Angina)

Answer 69

• Patient with a history of HTN, smoking, DM, obesity, or cocaine use 
• Complaining of squeezing, pressure-like chest discomfort at rest 
• ECG will show transient ST-segment elevations and cardiac enzymes will be normal 
• Diagnosis is made by cardiac stress test 
• Most commonly caused by coronary artery spasm 
• Treatment is calcium channel blockers and nitrates
• BB are contraindicated due to unopposed alpha stimulation

Question 70

What is the most common physical finding in patients with infective endocarditis?

Answer 70

Heart Murmur

Question 71

Which gram-negative organisms which are difficult to culture can cause endocarditis?

Answer 71

HACEK group (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella).

Question 72

Causes of Acute Pericarditis:

Answer 72

• Infectious – mainly viral (e.g. coxsackie virus).
• Immunological – SLE, rheumatic fever
• Uremia
• Post-myocardial infarction / Dressler’s syndrome
• Trauma
• Following cardiac surgery (post pericardiotomy syndrome)
• Paraneoplastic syndromes
• Drug-induced (e.g. isoniazid, cyclosporin)
• Post-radiotherapy

Question 73

What are the most common complications of AAA repair?

Answer 73

Graft infection, 

aortoenteric fistula

anastomotic aneurysm.

Question 74

Causes of acute cor pulmonale

Answer 74

PE

ARDS

Both resulted in RV dilation rather than RV hypertrophy (which occurs in chronic cor pulmonale)

Question 75

Causes of chronic cor pulmonale

Answer 75

COPD

PE

Pulm fibrosis

OSA

M. gravis

Poliomyelitis

Sarcoidosis

Question 76

Dx of infective endocarditis by Duke Criteria

Answer 76

Either of

2 majors

1 major and 3 minors

5 minors

Question 77

Modified Duke Criteria for IE

Answer 77

"BE FEVIR

Majors:

Blood culture positive

Endocardial involvement (echo +ve for IE like new vegitation/abscess OR new valve regurgitation)

Minors:

Fever > 38

Immunological phen (GN, Osler nodes, Roth spots)

Vascular phen (major arterial emboli, septic pulm infarction, Janeway lesions)

Echo minor criteria eliminated

Risk factors (IVDU, prosthetic valve, long tubes)

"

Question 78

What is the most common X-ray finding in acute aortic dissection?

Answer 78

Mediastinal widening 

Question 79

Takotsubo

Answer 79

• Patient will be a woman
• With a history of a recent increase in stress
• Complaining of chest pain and other symptoms of STEMI
• Echo will show apical ballooning
• Diagnosis is made by:
  • 1) ST-segment elevation
  • 2) transient regional wall motion abnormalities of apex and mid ventricle
  • 3) the absence of coronary artery disease
  • 4) the absence of other causes of left ventricular dysfunction such as pheochromocytoma or myocarditis
• Treatment is supportive care

Question 80

What is the most common complication of mitral stenosis?

Answer 80

Atrial fibrillation.

Question 81

What is the most common congenital cause of tricuspid regurgitation?

Answer 81

Ebstein’s anomaly.

Question 82

Why does COPD cause right ventricular failure?

Answer 82

Via hypoxic vasoconstriction causing increased right ventricular afterload.

Question 83

What primary disease process is associated with sterile vegetation endocarditis on both sides of the involved valve?

Answer 83

SLE

Question 84

What physical exam findings are specific to high output heart failure?

Answer 84

Bounding pulse with a quick upstroke and a wide pulse pressure.

Question 85

Drugs showed mortality benefit after STEMI

Answer 85

ASA

ACEI

BB

Question 86

What clinical findings represent right ventricular infarction in the setting of an inferior MI?

Answer 86

Jugular venous distension

hypotension

Question 87

Viruses responsible for myocarditis

Answer 87

Entero

Parvovirus B19

Herpes virus 6

Question 88

What is the most common cause of myocarditis worldwide?

Answer 88

Chagas disease caused by the protozoan Trypanosoma cruzi.

Question 89

ECG findings of RVH

Answer 89

Tall R wave and small S wave in V1

Question 90

ECG findings in Emphysema

Answer 90

Tall P wave in (II, III, aVF)

Rt axis deviation

PR and ST depression in (II, III, aVF)

Decrease R-wave progression in chest leads

Low QRS voltage

Question 91

"

Coronary artery bypass graft: indications

"

Answer 91

"

DUST:^[1]p. 31

Depressed ventricular function

Unstable angina

Stenosis of the left main stem

Triple vessel disease

"

Question 92

Exercise ramp ECG: contraindications

Answer 92

"

RAMP:^[1]p. 31

Recent MI

Aortic stenosis

MI in the last 7 days

Pulmonary hypertension

"

Question 93

Heart blocks

Answer 93

"

If the R is far from P, then you have a First Degree.

Longer, longer, longer, drop! Then you have a Wenkebach.

if some P's don't get through, then you have Mobitz II.

If P's and Q's don't agree, then you have a Third Degree

"

Question 94

ST elevation causes in ECG

Answer 94

"

ELEVATION:^[1]p. 34

Electrolytes

LBBB

Early repolarization

Ventricular hypertrophy

Aneurysm

Treatment (e.g. pericardiocentesis)

Injury (AMI, contusion)

Osborne waves (hypothermia)

Non-occlusive vasospasm

"

Question 95

What is the most common cause of heart failure with reduced ejection fraction?

Answer 95

Ischemic cardiomyopathy.

Question 96

How does mitral stenosis result in hoarseness?

Answer 96

Left atrial enlargement can cause compression of the recurrent laryngeal nerve resulting in hoarseness.

Question 97

Which of the following is the most predictive risk factor for cardiac ischemia?

Answer 97

Past medical history of coronary artery disease

Question 98

Above what blood pressure is antihypertensive therapy required prior to giving thrombolytics in acute ischemic stroke?

Answer 98

> 185/110 mm Hg.

Question 99

What diagnostic test can help identify right coronary artery vs. left circumflex artery involvement in an acute inferior wall myocardial infarction?

Answer 99

Right-sided electrocardiogram with a focus on V4R. An upright T wave in lead V4R indicates involvement of the distal right coronary artery, and ST segment elevation indicates a proximal right coronary artery lesion.

Question 100

What are signs of right ventricular hypertrophy on ECG?

Answer 100

Right axis deviation, 

dominant R wave in V1, 

dominant S wave in V5 or V6, 

QRS < 120 ms.

Question 101

Pulsus paradoxus

Answer 101

Cardiac temponade

Constrictive pericarditis

PE

COPD

Asthma

Question 102

What musculoskeletal findings can be associated with mitral valve prolapse?

Answer 102

Scoliosis and pectus excavatum.

Question 103

What three classes of medications are used for most patients with STEMI and NSTEMI?

Answer 103

Antiplatelet agents, antithrombins, and nitrates.

Question 104

What dysrhythmia is most commonly associated with tricuspid regurgitation?

Answer 104

Atrial fibrillation (80% of patients with tricuspid regurgitation).

Question 105

What other anomalies are ass w coarctation of aorta? 

Answer 105

IC aneurysm

Turner syndrome

Question 106

What are the five cyanotic congenital heart defects?

Answer 106

Transposition of the great arteries,

tetralogy of Fallot,

tricuspid atresia,

truncus arteriosus, and

total anomalous pulmonary venous return.

Question 107

What is the mechanism by which warfarin can cause a hypercoagulable state early in treatment?

Answer 107

Rapid depletion of protein C and protein S

Question 108

Although rare, what is the most common bacterial cause of myocarditis?

Answer 108

Acute rheumatic fever caused by group A β-hemolytic streptococci.

Question 109

Which of the following disorders is the most common delayed valvular complication of streptococcal pharyngitis?

Answer 109

Mitral stenosis

Question 110

What is the most common nontraumatic cause of cardiac tamponade?

Answer 110

Metastatic malignancy.

Question 111

Risk factors for AAA

Answer 111

smoking history, 

male sex, 

history of peripheral vascular disease, 

Caucasian race,

family history of AAA

Question 112

What are the most common pacemaker settings used?

Answer 112

VVI (ventricular paced, ventricular sensed, inhibited sensing output pulse response).

DDD (dual chamber pace/sense/inh response)

Question 113

What are the two most common post-acute myocardial infarction dysrythmias?

Answer 113

Premature ventricular contractions and sinus bradycardia

Question 114

What is the genetic association with hypertrophic cardiomyopathy?

Answer 114

It is an autosomal dominant disease.

Question 115

In an anterior wall STEMI, what decreases the rate of aneurysm development?

Answer 115

Time to revascularization

Question 116

What is the most common cause of aortic stenosis in people < 65 years old?

Answer 116

Congenital bicuspid valve.

Question 117

What is the treatment for patients with arrhythmogenic right ventricular cardiomyopathy?

Answer 117

Antiarrhythmic medication and an implantable cardiac defibrillator.

Question 118

"Name 7 features on history that would be worrisome for a life-threatening cause of his syncope"

Answer 118

-Exertional
-No prodrome
-Palpitations
-Chest pain
-Occurs after loud noise/fright
-Prolonged LOC
-Sudden onset of HA prior to syncope
-Post-ictal/incontinence/seizure-like activities
-Recurrent episodes
-Head trauma
-PMHx – DM (hypoglycemia), marfan’s, medications, etc
-FHx of SCD/CM/arrhythmia

Question 119

"What was the likely cause of syncope in HOCM?"

Answer 119

Dynamic LVOT obstruction decreases cardiac output and results in syncope, ventricular dysrhythmias, complete heart block

Question 120

"Name one treatment option of HOCM?"

Answer 120

beta blockers, 

myomectomy, 

pacemaker (for right ventricular pacing), 

ICD

Question 121

"Name 4 initial interventions you should order now in ACS"

Answer 121

"-IV access
-02 via NRB
-Cardiac monitor
-Move to high acuity bed
-Administer ASA 160-320mg to chew
-Analgesia"

Question 122

"List six further investigations you would order in ACS"

Answer 122

"-CBC: WBC, Hgb
-Troponin, CK
-Glucose
-INR
-PTT
-Creatinine
-Lipase
-BNP
-D. dimer
-Portable CXR"

Question 123

"What are the ECG criteria for thrombolysis in AMI?"

Answer 123

"-ST elevation greater than 1mm in 2 contiguous leads (>2mm in anterior leads)
-New or presumed new LBBB (would probably still get you the mark on the exam)
-LBBB with sgarbossa's criteria (more up to date and likely acceptable on exam now)

--all with a history of 30 mins of chest pain consistent with ischemia

"

Question 124

"What are five absolute contraindications to thrombolytic therapy in AMI? (5 Marks)"

Answer 124

"-Any prior ICH
-Known structural cerebral lesion (AVM)
-Known malignant intracranial neoplasm
-Ischemic stroke >3 hours or < 3 months
-Spinal/intracranial surgery in past 2 months
-Severe uncontrolled hypertension
-Suspected aortic dissection
-Active bleeding or bleeding diathesis (excluding menses)
-Significant closed head trauma or facial trauma within 3 months"

Question 125

"Name 4 findings on physical examination that would support Dx of aortic dissection:"

Answer 125

"-Neurologic deficits
-Variation in arm BPs (>20mmHg)
-Variation in radial pulses
-HTN
-New aortic regurgitation murmur (decrescendo diastolic murmur)
-Signs of pericardial effusion/tamponade (muffled heart sounds, pulsus paradoxus, JVD, hypotension)
-Shock"

Question 126

What are the criteria for thrombolyzing a STEMI?

Answer 126

• Ischemic chest discomfort at least 20 minutes in duration but <12 hours since symptom onset AND
• New ST elevation ≥ 1mm at the J-point in two contiguous leads (except V2-V3)
     • Men >40: ST elevation > 2mm in V2-V3
     • Men < 40: ST elevation > 2.5 mm in V2-V3
     • Women ST elevation > 1.5mm in V2-V3

. New LBBB or New Sgarbossa criteria for old LBBB

Question 127

Absolute CI of thrombolytic Rx in STEMI

Answer 127

CNS:

     Any prior ICH

     Prior ischemic stroke <= 3 months (exception ischemic stroke within 3 hours)

     Known malignant intracranial neoplasm (primary or metastatic)

     Known cerebral vascular lesion (AVM)

     IC or intraspinal surgery <= 2 months

     Significant closed head injury or facial injury <= 3 months

CVS:

     Suspected aortic dissection 

     Active bleeding or bleeding diathesis (excluding menses)

     Severe uncontrolled high BP at time of administration

For streptokinase, prior treatment within the previous 6 months

Question 128

Relative CI of thrombolytic Rx in STEMI

Answer 128

CNS:

     Ischemic stroke > 3 months

     Dementia

CVS:

     SBP>180 or DBP > 110

     Traumatic or prolonged CPR (>10 minutes)

     Infective endocarditis

     Recent (2-4 wks) internal bleeding

     Current use of oral anticoagulant therapy

Procedures:

     Major surgery <= 3 wks

     Puncture of noncompressible blood vessel <= 2 wks

Women:

     Pregnancy

     OCP

GIT:

     Hx of PUD

     Advanced liver disease

      

Question 129

Whar are the causes of STE?

Answer 129

Cardiac:

     Dysrrhythmia:

          LBBB

          WPW

          Brugada

          BER

          Vent paced rhythm

          Post DC

     Vascular:

          ACS

          Coronary a. vassospasm

          Aortic dissection

     Myocardium:

          Myocarditis

          HOCM

          LVH

          LV aneurysm

     Pericardium:

          Pericarditis

SAH and Raised ICP

HyperK

Hypothermia

Question 130

What are the complications post AMI?

Answer 130

• Brady/tachyarrhythmias
• Cardiogenic shock
• Angina
• Reinfarction/Infarct Extension
• CHF
• Ventricular Septal Rupture
• Papillary Muscle Rupture (Mitral regurge days 3-5)
• Left Ventricular Free Wall Rupture
• Pericarditis (infarct pericarditis, dresslers – delayed 2-10weeks)
• Left Ventricular Aneurysm (late)
• LV thrombus (embolic stroke) (late)

Question 131

Medications that causes syncope:

Answer 131

1. Cardiac medications: CCB, BB, diuretics, digitalis
2. QT prolongers leads to TDP
3. Recreational drugs
4. antidepressants

Question 132

What are 5 ECG findings to look for in the syncopal patient? 

Answer 132

1. Dysrhythmias

2. Pre-excitation

3. Shortened PR

4. Prolonged QTc

5. ST Elevation (regional and diffuse)

6. Brugada pattern (RBBB in association with ST elevation in V1-V3)

7. Right ventricular strain pattern

8. Electrical alternans 

Question 133

List 6 important questions to ask on history of aortic dissection

Answer 133

Characteristic of pain
Onset of pain 
Pattern of pain
History of same
Drug/medications
Associated symptoms – vomit, diaphoresis, syncope, palpitations
Past medical history



Initial investigations: ECG, trop, CXR, bedside echo

Question 134

Name 6 possible findings of aortic dissection on CXR

Answer 134

• Wide mediastinum ≧ 6- 8 cm
• Abnormal aortic contour
• Left pleural effusion
• Displacement of NG/trachea to right
• Displacement of intimal calcification (double calcium sign)
• Cardiomegaly
• Upwards displacement of right mainstem
• Depression of left mainstem bronchi
• Apical cap

Question 135

Name 5 risk factors for aortic dissection

Answer 135

• HTN
• History of cardiac surgery
• Bicuspid aortic valve
• Cocaine use
• Connective tissue disorders (e.g. Marfans)
• Family history
• Pregnancy (T3/peripartum/postpartum)
• Trauma

Question 136

Name five complications of aortic dissection

Answer 136

• Dissection can propagate:
• Cardiac tamponade
• Aortic insufficiency
• RCA (inferior STEMI)
• CHF
• Hemorrhage shock
• Focal neuro deficits (cerebral ischemia/stroke)
• Spinal cord infarcts
• Pleural hemorrhage
• Mesenteric ischemia
• Aortoenteric fistula
• Renal failure
• Lower limb ischemia, pulse deficits
• HEENT: mass effect- stridor, SOB, horner syndrome, hoarseness, SVC
syndrome

Question 137

5 tests you would order or perform in patients with suspected pericarditis and why?

Answer 137

• TTE (or bedside cardiac ultrasound)- pericardial effusion
• ECG  
• CXR (pleural effusions, cardiac silhouette, CHF)
• Bloodwork
     • ESR/CRP – inflammatory markers
     • CBC
     • Trop – concurrent myocardial involvement
     • Urea/Cr
• Physical exam – pericardial friction rub

Question 138

Name 5 poor prognostic indicators of pericarditis

Answer 138

Major:
• Fever > 38 C
• Subacute onset
• Large pericardial effusion
• Cardiac tamponade
• Lack of response to aspirin or NSAIDs after >1 week of therapy

Minor
• Myopericarditis
• Immunosuppression
• Trauma
• Oral Anticoagulant therapy

Question 139

HEART Score

Answer 139

""

Question 140

DDX of acute respiratory distress

Answer 140

-Pulmonary embolism
-AECOPD/asthma
-Acute decompensated congestive heart failure
-Anaphylaxis
-Foreign body aspiration
-Valve pathology (e.g. acute aortic regurge)
-Pneumothorax

Question 141

"What are the precipitants of Acute decompensated heart failure?"

Answer 141

"""HEART FAILED""

H – Hypertension, 

      Heart anatomy (valvular, myocarditis, effusion, cardiomyopathy)
E – endocrinopathies
A – anemia
R – rheumatic disorders
T – toxins (cocaine, ETOH, chemo)
F – failure to take medications
A - arrhythmia
I – infection, infarction, ischemia
L – lung pathology (COPD, PE, pneumonia)
E – electrolyte abnormality
D – diet, diaper (pregnancy)

"

Question 142

"Name four lifestyle modifications you can recommend to this patient to prevent them from returning AECHF"

Answer 142

"-Limit alcohol consumption
-Low salt diet
-Limit fluid intake
-Weight reduction
-Quit smoking
-Compliance with medications
-Exercise (supervised) – cardiac rehab"

Question 143

"Name three contraindications to using nitroglycerin."

Answer 143

-Recent use of PDE5 inhibitors (e.g. Viagra)
-Hypotension
-Severe aortic stenosis
-Inferior myocardial infarction with RV involvement

Question 144

Drugs to avoid use in severe aortic stenosis

Answer 144

-Nitrates
-Calcium channel blockers
-Hydralazine

Question 145

"Name three causes of regular wide complex tachycardia"

Answer 145

-Ventricular tachycardia
-Polymorphic VT (torsades)
-SVT with aberrancy 
-A. flutter with aberrancy

Question 146

"Name three causes of irregular narrow complex tachycardia"

Answer 146

-Atrial fibrillation
-MAT (multifocal atrial tachycardia)
-Atrial flutter with variable conduction

Question 147

"Name precipitants for irregular narrow complex tachycardia"

Answer 147

"""PIRATES""

P - PE, pulmonary disease, post op
I - Ischemic heart disease, idiopathic, infectious
R – Rheumatic valvular disease/ any valvular disease
A – Anemia, alcohol, age
T – Thyroid, toxins
E – Elevated blood pressure, electrolytes
S – Sleep apnea, sepsis

"

Question 148

"Name two drug classes that can be used in the management of AF"

Answer 148

-Rate control:       Beta-Blockers, Calcium Channel-blockers, cardiac glycosides (digoxin)
-Rhythm control: Class Ia (procainamide) - sodium channel blocker
                             Class III (amiodarone) – potassium channel blocker

Question 149

CI of DOAC

Answer 149

-Mechanical heart valve
-Severe renal failure
-Pregnancy
-Severe liver disease

Question 150

"Define hypertensive emergency versus hypertensive urgency"

Answer 150

-Emergency – Elevated BP associated with target organ dysfunction

-Urgency – Clinical presentation associated with severe elevations in BP (generally >180/110) without, but at risk for progressive target organ dysfunction

Question 151

"Name 5 clinical syndromes/conditions that would define a patient’s hypertension as a hypertensive emergency"

Answer 151

-Aortic Dissection
-Acute Pulmonary Edema/ Heart Failure
-ACS
-ARF
-Severe pre-eclampsia
-Hypertensive encephalopathy
-SAH
-ICH/SAH
-Ischemic stroke
-Sympathetic Crisis
-MAHA

Question 152

"Name 5 investigations that should be ordered in all patients where hypertensive emergency is a consideration"

Answer 152

"-CBC
-Electrolytes
-Creatinine
-Urea
-Glucose
-Troponin
-Urinalysis
-ECG
-CXR
(Note: CT head is not accepted as not ALL patients require this, ONLY if they have symptoms of HTN encephalopathy)"

Question 153

Meds for Hypertensive emergency Rx:

Answer 153

CCB:     Nicardipine

BB:        Labetolol

              Esmolol

Nitrates: Nitroprusside

Question 154

"What is your goal of treatment of HTN emergency?"

Answer 154

Reduce BP by 20 % acutely

Resolution of symptoms

Question 155

"Name three genetic conditions that may result in a younger patient having an implantable cardioverter-defibrillator (ICD) placed?"

Answer 155

-Brugada syndrome
-Long QTc syndrome
-Hypertrophic cardiomyopathy
-Familial dilated cardiomyopathy
-Arrhythmogenic right ventricular dysplasia (ARVD)

Question 156

"

While in the emergency department his ICD fires twice. You review the rhythm strip leading to the firing of the ICD (see below). What is your next step in management? (1 point)

"

Answer 156

"-Apply magnet (1 point)
-Consult cardiology for device interrogation (0.5 points)"

Question 157

"

Now assume this rhythm strip below was seen and that the ICD fired three more times. What are two medications that can be used in the management of this patient? (2 points)

"

Answer 157

"-Amiodarone
-Procainamide
-Lidocaine
-Metoprolol, propranolol, esmolol (beta-blockers)

Clinical Pearl: remember to reverse any precipitants (ischemia, heart failure, electrolyte abnormality, hyperthyroidism), despite none having been specifically mentioned in this case"

Question 158

"

A 72 year old male presents with shortness of breath. You order a chest X-ray to assess for pneumonia.

Q1. Interpret the CXR below (1 point)The patient is stable. Given your findings, what is your next step in management. (1 point)

"

Answer 158

-Lead dislodgement. (Cannot see ICD atrial electrode, coiling around ICD), no pneumonia.
-Discuss with cardiology for replacement

Question 159

"Aside from medications or overdoses name five causes of bradycardia"

Answer 159

-Ischemia
-Hyperkalemia
-Hypothermia
-Hypothyroidism
-Structural heart disease
-Infiltrative (amyloid, hemochromatosis, sarcoid),
-Autoimmune
-Lyme disease/infectious/myocarditis

Question 160

"Name four classes of drugs that may of caused symptomatic bradycardia or complete heart block"

Answer 160

-Beta- Blockers
-Calcium-channel blockers
-Digoxin (digitalis glycosides)
-Organophosphates (any cholinergic medication e.g. physostigmine)
-Alpha-agonist (clonidine)
-Class III anti-arrhythmics (e.g. amiodarone)
-Class I anti-arrhythmics (e.g. procainamide)

Also:

Opiates

Chloralhydrate

ETOH

Benzos

Question 161

High risk conditions for aortic dissection

Answer 161

Marfan synd

FHx of aortic disease

Known aortic valve dis

Recent aortic manipulation

Known thoracic aortic aneurysm

Question 162

O/E suggestiv of aortic aneurysm

Answer 162

Evidence of perfusion deficit: 

     pulse deficit, 

     SBP differential, 

     focal neuro deficit

New aortic insufficiency mumur

Hypotension/shock
Marfanoid Features

Question 163

What antiarhythmic agent is used for TDP

Answer 163

Lidocain

Question 164

Predisposing factors for Brugada syndrome

Answer 164

• Fever
• Ischemia
• Drugs
• HypoK
• Hypothermia

Question 165

Predisposing factors for Brugada syndrome

Answer 165

• Fever
• Ischemia
• Drugs
• HypoK
• Hypothermia

Question 166

Factors predispose to Brugada

Answer 166

• Fever
• Ischemia
• Drugs
• HypoK
• Hypothermia

Question 167

Drugs to avoid in WPW

Answer 167

BB

CCB

Adenosine

Question 168

DDx of Cardiac Syncope

Answer 168

WPW

Brugada

Long/short QT syndrome

HOCM

PE

ARVD

Trifasicular block

Tachy/brady dysrhythmia (syndrome)

Question 169

What are the general etiology of arrhythmia

Answer 169

Re-entry pathway

Afterdepolarization

Automaticity

Question 170

Name findings to help differentiate VT versus SVT with aberrancy

Answer 170

Clinically:
• Clinical: age > 35, cardiac history/risk factors, family history SCD
• No response to vagal maneuvers
• No prior ECG with BBB or WPW with similar morphology
• Cannon A waves 

 

ECG Findings:
• Absence of typical RBBB or LBBB pattern
• Extreme axis deviation (northwest axis - QRS is positive in aVR and negative in I + aVF)

• QRS duration (very broad > 160msec)
• AV dissociation (P and QRS at different rates)
• Positive or Negative Concordance – V1-V6 all same direction
• Fusion beats
• Capture beats
• Brugada Sign
• Josephen Sign
• RSR’ complexes with taller Left rabbit ear

Question 171

Name six causes of atrial fibrillation

Answer 171

• P-pulmonary embolism, pulm disease, post-op
• I-Ischemic heart disease, idiopathic, infectious
• R- rheumatic valvular disease/valvular heart disease
• A- anemia, alcohol, age
• T – thyroid, toxins
• E – elevated BP, electrolytes
• S- Sleep apnea, sepsis, surgery

Question 172

Name 4 investigations you work consider/order in new onset atrial
fibrillation.

Answer 172

• CBC
• Electrolytes
• TSH
• Cr
• Coag profile
• Echo as outpatient

Question 173

How would you decide between rate control versus rhythm control?

Answer 173

""

Question 174

Special circumstances to consider Early Rhythm Control of A.Fib

Answer 174

Highly symptomatic

Multiple recurrences

Extreme QOL impairment

Arrhythmia-induced CMP

Question 175

How do you decide who gets anticoagulated?

Answer 175

CHADS2 Score:

Congestive heart failure

Hypertension (>140/90)

Age >= 65

DM

Hxof stroke or TIA

Question 176

What are the four risk factors for bleeding in patients on anti-
coagulation?

Answer 176

HAS BLED

Hypertension (>160)

Abnormal liver or kidney function

Stroke Hx

Bleeding (Hx or predisposition)

Labile INR

Elderly (>65)

Drugs/Alcoho; (antoplatelets, NSAIDS)

Question 177

Name five causes of bradyarrhythmias

Answer 177

• Medications (BB, CCB, dig)
• Ischemia
• Hyperkalemia
• Lyme disease/myocarditis
• Structural heart disease
• Hypothermia
• Hypothyroidism (cushing)
• Autoimmune (lupus)
• Infiltrative (amyloid, hemochromatosis, sarcoid)

Question 178

What are five management steps you can consider in symptomatic
bradyarrhythmias?

Answer 178

• Atropine
• Transcutaneous pacemaker
• Transvenous pacemaker
• Isoproterenol
• Pressors: epinephrine, dopamine
• If overdose – follow treatment for BB/CCB overdose
• Treat reversible conditions (e.g. hyperkalemia)

Question 179

When is atropine ineffective?

Answer 179

• Atropine is ineffective for blocks occurring below the AV node. E.g.
Second degree Mobitz II, Complete heart block with wide QRS
• Also, ineffective in cardiac transplant patients

Question 180

List three differences in clinical findings between embolic and
thrombotic peripheral artery disease/limb ischemia

Answer 180

""

Question 181

List three possible metabolic complications after revascularization

Answer 181

• Metabolic acidosis
• Hyperkalemia
• Myoglobinuria

Question 182

Clinical manifestations of end organ damage HTN emergency

Answer 182

""

Question 183

HTN + associated diseases Rx:

Answer 183

""

Question 184

Name 6 causes of secondary hypertension

Answer 184

• Cushings
• Pheochromocytomata
• Hyperthyroidism
• Obstructive sleep apnea
• Polycystic kidney disease
• Renal artery stenosis
• Nephritic/nephrotic syndrome
• Toxins – sympathomimetric use/ Chronic ETOH use
• Coarctation of the aorta

Question 185

Name four causes of non-cardiogenic pulmonary edema

Answer 185

• Pancreatitis
• Sepsis
• DIC
• ARDS
• Burns
• Drowning
• Fat embolism/amniotic fluid embolism
• Re-expansion
• High altitude pulmonary edema

 COVID

Question 186

Treatment of Acute Heart Failure

Answer 186

""

Question 187

Criteria for D/C from ED after Rx of CHF

Answer 187

""

Question 188

Types of Shock

Answer 188

""

Question 189

Cath Lab Activation:

Answer 189

"

• 1st Diagonal Branch of the Left Anterior Descending Artery Occlusion
  
  • STE in aVL and V2
  • Upright T-waves in aVL and V2
  • ST-Depression and inverted T waves in Inferior Leads (III and aVF)
• de Winter’s T Waves
• Left Main Coronary Artery Occlusion
  • STE in lead aVR AND/OR
  • Widespread ST-Depression
• Posterior STEMI

"

Question 190

ECG changes in electrolytes disturbances

Answer 190

"

"

Question 191

ECG suggestive of temponade

Answer 191

Low voltage QRS

Tachycardia

Electrical alternance

Question 192

Echo findings in Temponade

Answer 192

RV diastolic collapse

RA systolic collapse

IVC dilation 

Sonographic alternance

With evidence of fluid around the heart

Question 193

"

ECG Pearls for Syncope

"

Answer 193

• short PR: WPW
• long PR: AV conduction block
• narrow, deep QRS: HCM
• wide QRS + Epsilon waves: arrhythmogenic RV hypertrophy wide QRS: Vtach,WPW, BBB
• QT interval: long QT syndrome, (also short QT)
• Also, look for Brugada, ACS, myocarditis, and PE changes on ECG 
  

Question 194

Long QT Causes

Answer 194

Congenital Long QT

• inherited, often with deafness; syncope can be triggered by sudden loud noises or startling events, or spontaneously.

Acquired Causes: (& examples) 

• Antiarrhythmics (amiodarone, sotolol)
• Antibiotics (macrolides)
• Antidepressants (TCAs, citalopram)
• Antipsychotics (haldol, seroquel)
• Antihistamines (loratidine, benadryl)
• **Numerous other medications, as well as low K+, Ca+, and Mg+ (due to alcohol abuse, diuretics, malnutrition), myocarditis, hypothermia, methadone, and carbon monoxide, can lengthen the QT segment.**

Question 195

"What are the indications for admission in patients with Syncope?"

Answer 195

1. history of CHF,
2. history of ventricular arrhythmias,
3. associated symptoms of ACS,
4. exam evidence of significant CHF,
5. exam evidence of significant valvular disease,
6. abnormal ECG (ischemia, arrhythmia, BBB, prolonged QTc)

Question 196

Syncope Discharge Instructions

Answer 196

• For vasovagal: avoid known triggers, such as alcohol and warm environments, and maintain adequate hydration, food and sleep.
• To reduce injury: once syncope prodrome starts, lie down, and avoid driving or high risk activities.

Question 197

"Name 7 features on history that would be worrisome for a life-threatening cause of his syncope: "

Answer 197

-Exertional
-No prodrome
-Palpitations
-Chest pain
-Occurs after loud noise/fright
-Prolonged LOC
-Sudden onset of HA prior to syncope
-Post-ictal/incontinence/seizure-like activities
-Recurrent episodes
-Head trauma
-PMHx – DM (hypoglycemia), marfan’s, medications, etc
-FHx of SCD/CM/arrhythmia

Question 198

"Syncope
"

Answer 198

-WPW – short PR, delta/slurred upstroke
-Treatment is ablation

Question 199

"Syncope
"

Answer 199

-Brugada (cardiac sodium channel gene mutation). This is type I Brugada – coved ST elevation in V1-V3
-Causes VT/VF to induce syncope
-Treatment is an ICD

Question 200

"Syncope
"

Answer 200

-Long QT Syndrome (Na/K ion channel abnormality - congenital in this case, but could be due to meds/lytes etc)
-Causes torsades/VT/VF. Can be triggered by loud noise, strong emotion, exercise etc
-Tx – Beta blockers typically for asymptomatic patients, ICD after syncope, arrhythmia

Question 201

"Syncope
"

Answer 201

-Hypertrophic Cardiomyopathy. LVH, deep needle-like Q waves, anterior T-wave inversion
-Dynamic LVOT obstruction decreases cardiac output and results in syncope, ventricular dysrhythmias, complete heart block
-Tx – beta blockers, myomectomy, pacemaker (for right ventricular pacing), ICD

Question 202

Cardiac CP, what are the initial Rx?

Answer 202

High acuity bed
iv access
Monitor
O2 NRB
ASA 160-320 mg
Analgesia

Question 203

Absolute CI of Thrombolysis

Answer 203

-Any prior ICH
-Known structural cerebral lesion (AVM)
-Known malignant intracranial neoplasm
-Ischemic stroke >3 hours or < 3 months
-Spinal/intracranial surgery in past 2 months
-Severe uncontrolled hypertension
-Suspected aortic dissection
-Active bleeding or bleeding diathesis (excluding menses)
-Significant closed head trauma or facial trauma within 3 months

Question 204

"Name 4 findings on physical examination that would support Dx of Aortic dissection:"

Answer 204

-Neurologic deficits
-Variation in arm BPs (>20mmHg)
-Variation in radial pulses
-HTN
-New aortic regurgitation murmur (decrescendo diastolic murmur)
-Signs of pericardial effusion/tamponade (muffled heart sounds, pulsus paradoxus, JVD, hypotension)
-Shock

Question 205

Emergency BP reduction medicine in acute aortic dissection

Answer 205

Esmolol
Labetolol
Verapamil
Nicardipine
Nitroprusside

Question 206

"Name five precipitants that can lead to this acute decompensated HF"

Answer 206

HEART FAILED
H – Hypertension, heart anatomy (valvular, myocarditis, effusion, cardiomyopathy)
E – endocrinopathies
A – anemia
R – rheumatic disorders
T – toxins (cocaine, ETOH, chemo)
F – failure to take medications
A - arrhythmia
I – infection, infarction, ischemia
L – lung pathology (COPD, PE, pneumonia)
E – electrolyte abnormality
D – diet, diaper (pregnancy)

Question 207

"Name four findings on CXR that suggest Acute decompensated HF"

Answer 207

-Pleural effusions
-Kerley B lines
-Cardiomegaly
-Vascular cephalization
-Interstitial edema

Question 208

"Name four lifestyle modifications you can recommend to this patient to prevent them from returning with acute decompensated HF"

Answer 208

-Limit alcohol consumption
-Low salt diet
-Limit fluid intake
-Weight reduction
-Quit smoking
-Compliance with medications
-Exercise (supervised) – cardiac rehab

Question 209

"Name three contraindications to using nitroglycerin"

Answer 209

-Recent use of PDE5 inhibitors (e.g. Viagra)
-Hypotension
-Severe aortic stenosis
-Inferior myocardial infarction with RV involvement

Question 210

"Name three causes of regular wide complex tachycardia?"

Answer 210

-Ventricular tachycardia
-Polymorphic VT (torsades)
-SVT with aberrancy
-Aflutter with aberrancy

Question 211

"Name three causes of irregular narrow complex tachycardia?"

Answer 211

-Atrial fibrillation
-MAT (multifocal atrial tachycardia)
-Atrial flutter with variable conduction

Question 212

"
Name five precipitants that could cause the above ECG rhythm"

Answer 212

P - PE, pulmonary disease, post op
I - Ischemic heart disease, idiopathic, infectious
R – Rheumatic valvular disease/ any valvular disease
A – Anemia, alcohol, age
T – Thyroid, toxins
E – Elevated blood pressure, electrolytes
S – Sleep apnea, sepsis

Question 213

"What are two general management steps for this patient with acute AF?"

Answer 213

Rate or rhythm control
Decision/discussion on anticoagulation

Question 214

Criteria for anticoagulation in AF

Answer 214

CHADS2-65 or CHADS-VASC criteria
--Congestive heart failure
--Hypertension
--Age > 65, >75
--Diabetes
--Stroke/TIA/VTE
--Sex:Male
--Vascular disease

-Absence of high bleeding risk criteria (HAS BLED)

Question 215

"Define hypertensive emergency versus hypertensive urgency:"

Answer 215

-Emergency – Elevated BP associated with target organ dysfunction

-Urgency – Clinical presentation associated with severe elevations in BP (generally >180/110) without, but at risk for progressive target organ dysfunction

Question 216

"Name 5 clinical syndromes/conditions that would define a patient’s hypertension as a hypertensive emergency:"

Answer 216

"-Aortic Dissection
-Acute Pulmonary Edema/ Heart Failure
-ACS
-ARF
-Severe pre-eclampsia
-Hypertensive encephalopathy
-SAH
Ischemic stroke
"

Question 217

"Name 5 investigations that should be ordered in all patients where hypertensive emergency is a consideration?"

Answer 217

-CBC
-Electrolytes
-Creatinine
-Urea
-Glucose
-Troponin
-Urinalysis
-ECG
-CXR
(Note: CT head is not accepted as not ALL patients require this, ONLY if they have symptoms of HTN encephalopathy)

Question 218

"Name three reasons an ICD may fire incorrectly"

Answer 218

-Supraventricular tachyarrhythmias 
-Electromagnetic interference
-Hardware failure (lead placement/lead fracture)
-T wave or atrial oversensing (thinking this is actual a QRS complex)

Question 219

"Third degree AV block, Name four classes of drugs that may of caused "

Answer 219

-Beta- Blockers
-Calcium-channel blockers
-Digoxin (digitalis glycosides)
-Organophosphates (any cholinergic medication e.g. physostigmine)
-Alpha-agonist (clonidine)
-Class III anti-arrhythmics (e.g. amiodarone)
-Class I anti-arrhythmics (e.g. procainamide)

Question 220

Non-traumatic, non-cardiac causes of pericardial effusion:

Answer 220

Idiopathic
Infectious (viral, bacterial, fungal, parasitic, infective endocarditis)
Autoimmune (SLE, RA, Scleroderma, Sjogren’s, vasculitis, etc)
Dissecting aortic aneurysm
Malignant effusion (mets, primary or paraneoplastic)
Post-radiation
Metabolic (hypothyroidism, uremia)
Medication induced (rare: anticoagulants, thrombolytics, doxorubicin, etc)

Question 221

Mechanical causes for PEA

Answer 221

Thrombosis (PE, MI)
Tension pneumoTx
Temponade

Question 222

"NSTEMI, Name three indications for more urgent transfer to a tertiary center"

Answer 222

Refractory chest pain
Hemodynamic instability
Recurrent chest pain with dynamic ECG changes
Cardiac arrhythmias
Concurrent heart failure

Question 223

Indications for 15 leads ECG:

Answer 223

All inferior STEMI
Any STE or STD in V1-V3
Equivocal STE in inf or lat leads
Hypotension in the setting of ACS

Question 224

List the CHDs that require a patent ductus and why?

Answer 224

To preserve flow from aorta to pulmonic circulation

• Pulmonic atresia
• Tricuspid atresia
• Tetralogy of fallot
• Hypoplastic right heart syndrome

To preserve flow from pulmonic circulation to aorta

• Severe coarctation of the aorta
• Severe aortic stenosis
• Hypoplastic left heart syndrome

Question 225

What is the pharmacologic management to keep the ductus patent?

Answer 225

• Prostaglandin E1 0.1μg/kg/min

–Note side effect is apnea and decrease BP, therefore intubate and give boluses, dobutamine prn

Question 226

ECG patterns of PE

Answer 226

Tachycardia
Symmetrical T wave inversion in V1-V4
S1Q3T3
RBBB
RAD

Question 227

PERC Rule

Answer 227

"HAD CLOTS
If all no the pretest probability < 2 %=D/C home
"

Question 228

What is ECG findings are suggestive of ventricular tachycardia

Answer 228

Wide QRS
Rate > 100
Regular rhythm
Extreme RAD

Question 229

What are the causes of vent tachycardia

Answer 229

IHD
CMP
Mitral prolapse
Toxins (digoxin, procainamide, sympatho)

Question 230

Induced Hypothermia

Answer 230

• Inclusion Criteria:
• Post cardiac arrest
• ROSC <30 minutes
• Induction time < 6 hrs from ROSC
• Comatose
• MAP >65 mm Hg
• Best location for temperature probe: esophagus
• Target temperature: 32–36°C

Question 231

Narrow complex PEA is considered to be secondary to mechanical pathology including

Answer 231

·         cardiac tamponade,

·         tension pneumothorax,

·         pulmonary embolism, or

·         hypovolemia

Question 232

Wide complex PEA is considered to be the result of a metabolic abnormality: with a differential diagnosis of 

Answer 232

·         hyperkalemia,

·         severe acidosis,

·         myocardial infarction, and
sodium channel blocker overdose

Question 233

HAS-BLED

Answer 233

""