Cardiology Flashcards
(218 cards)
1
Q
Define orthostatic hypotension
A
A drop in the systolic BP of > 20mmhg when standing up
2
Q
Your feel a pulse that seem to be vibrating. What term do you use to describe it?
A
A thrill
3
Q
What are 3 things in your differential if you have a paradoxical pulse?
A
Cardiac Tamonponade, pericarditis and obstructive lung disease.
4
Q
On palpation, what size is normal for the aorta?
A
<3cm
5
Q
A fixed or consistent split S2 sound should make you think of what diagnosis?
A
ASD - atrial septal defect
6
Q
A pathologic S3 is most commonly associated with what diagnosis>?
A
CHF
7
Q
A mid systolic click is hear on ausculation of the heart - you immediately think of what diagnosis?
A
MVP - Mitral valve prolapse
8
Q
An opening snap on asucultation of the heart should make you think of what diagnosis?
A
Mitral stenosis
9
Q
A continuous murmur most likely involves what area of the heart?
A
most likely it is a septal defect
10
Q
you hear a continuous machine like murmur. What are you thinking?
A
PDA - patent ductus arteriosis
11
Q
List 3 medications which may be used for a pharmacological stress test.
A
Adenosine, dobutamine, dipyraidamole and persantine.
12
Q
What is the gold standard for diagnosing coronary arterial disease?
A
Cardiac catheterization
13
Q
What is the most common cause of secondary hypertension?
A
chronic kidney disease
14
Q
What are the treatment parameters for HTN according to JNC 8?
A
< 60 yo, no comorbidities - < 140/90
> 60 yo <150/90
15
Q
No matter what medications you use, you are having trouble keeping a patient’s blood pressure under control. You also note hyper pigmented skin and truncal obesity. What is the most likely diagnosis?
A
Cushings disease
16
Q
List 3 sings or symptoms which will likely be included in a description of a patient with a pheochromocytoma?
A
Thin, diaphoretic, tachycardia, agitated and hypertensive.
17
Q
You have a patient with a diagnosis of a pheochromocytoma. While waiting for surgery should you use an alpha-blocker or beta-blocker?
A
ALPHA!!! never use a pure beta blocker.
18
Q
A young boy comes into the office. He has an elevated blood pressure in the arms, but no palpable femoral pulses. What is the most likely diagnosis?
A
coarctation of the aorta
19
Q
According to the CDC, what is the range for a normal BMI?
A
18.5-24.9
20
Q
What is the first line medical treatment for stage 1 hen according to JNC 8?
A
Thiazide diuretic, ACEI, CCB, ARB
21
Q
What is the JNC 8 hen goal for a patient with diabetes?
A
<140/90 no matter the race or sex. Initiate ACEI/ARB
22
Q
If the patient is < 60 and African American - what medication is preferable to start?
A
CCB or thiazide diuretic.
23
Q
Following a myocardial infarction, what medication should you be using to treat HTN?
A
beta blocker.
24
Q
Paroxysmal nocturnal dyspnea should make you think of what diagnosis?
A
CHF
25
What is the most common cause of CHF?
Coronary artery diasease
26
What. ejection fraction is typical for a patient with CHF?
35-40%
27
What is the most likely diagnosis for a young man who experiences sudden death while playing sports?
hypertrophic cardiomyopathy
28
Bat wing vessels or KErley B lines on a CXR should make you think of what diagnosis?
CHF
29
A beta natruirectic peptide below what level rules out CHF?
<100
30
What is the therapeutic range for INR after a mechanical valve replacement?
2.5-3.5
31
What is the first line IV inotropic agent when dealing with cariogenic shock?
dopamine
32
What diagnosis is most likely in an IV drug user with new heart murmur and fever?
Endocarditis
33
List 2 diagnosis which require antibiotic prophylaxis for " dirty procedures"?
Prosthetic valve, valve repair with any prosthetic material, prior endocarditis diagnosis, congenital cyanotic heart defect. NOT MVP
34
Does a patient with a mitral valve prolapse require prophylactic antibiotics for dental work?
No - recent changes move. MVP from high risk to moderate risk
35
What are 3 major criteria for endocarditis?
2 positive blood cultures,
a positive Transesophageal echo,
new murmur
36
Which are painful and found on the fingers and toes - Osler nodes or Janeway lesions?
Osler nodes
37
List the 4 minor criteria for diagnosing endocarditis
fever
embolic event (janeway lesions or petechiae or splinter hemorrhages)
immunological event (Osler nodes, glomerulonephritis)
1 positive blood culture
38
What are the 5 components of the tetralogy of Fallot>
```
VSD
RVH
Right ventricular outflow obstruction (pull valve stenosis)
Overiding aorta,
right sided aortic notch
```
39
What is the gold standard for diagnosing myocarditis?
Myocardial biopsy
40
Where of most aortic dissections occur?
the ascending or descending thoracic arch
41
A patient complains of severe pleuritic chest pain that is relieved with sitting and leaning forward. What is the most likely diagnosis>
Pericarditis
42
What is the first line medical treatment for pericarditis?
ASA and NSAIDs
43
What it set name of the syndrome that involves pericarditis several days - 2 weeks after AMI?
Dressler's syndrome
44
A patient presents to the ED with chest pain. An EKG shows diffuse ST elevations in almost half the leads - what is the diagnosis?
Pericarditis
45
Define paradoxical pulse
There is a large difference in pulse pressure between inhalation and exhalation
46
Define pulses alternans
EKG waveform changes from beat to beat.
47
What is the definitive treatment for cardiac tamponade?
Pericardiocentesis - 2nd ICS MCL
48
On physical exam, you hear a harsh systolic murmur along the Right sternal border. What is the most likely diagnosis?
Aortic stenosis
49
A wide pulse pressure with a blowing diastolic decrescendo murmur at the right 2nd ICS should make you think of what diagnosis>
Aortic regurg
50
What is the best location to hear problems with the aortic valve?
2nd right ICS
51
Where is disease of the pulmonary valve heard best>
2nd LEFT ICS
52
What 2 antibiotics are used for empiric treatment of endocarditis?
Vancomycin and ceftriaxone are first line
53
What 2 valvular issues do patient with MArfan's syndrome often have?
Aortic regard and MVP
54
What are 2 main causes of aortic stenosis
Congential bicuspid valve
| calcification of the valve secondary to CAD
55
And elderly patient presents with dyspnea, angina, and syncope. The EKG is normal. What is the most likely diagnosis?
Aortic stenosis
56
On auscultation, you hear a harsh, blowing, pansystolic murmur at the apex. What is the most likely diagnosis?
Mitral regurg
57
You suspect mitral regard. What is the most accurate way to prove your diagnosis?
Transesophageal echo
58
A patient with a mitral valve prolapse will often have what physical characteristics?
its often a thin female
59
What is the best patient position to hear aortic regard and aortic stenosis?
Sitting up and leaning foraward
60
What is Tietze syndrome?
Costochondritis
61
Are most pulmonary valve problems congenital or acquired?
95% are congenital
62
What is the therapeutic range for INR following an organic valve replacement?
2-3
63
A 60 yo male presents to the ED with severe dizziness and back pain. His blood pressure is dropping, and you end feel and abdominal pulsatile mass on PE. What is the most likely diagnosis?
Ruptured AAA
64
In a patient with aortic stenosis, the PMI will be medially displaced, normal, or laterally displaced?
laterally displaced due to LVH
65
A patient complains of severe crushing chest pain. EKG shows ST segment elevations. All labs including troponin and CK-MB are negative. What is the most likely diagnosis?
Prinzmetal's angina
66
A question about Prinmetal's angina will often contain what key thing in the patient's history?
cocaine use.
67
Name 2 things that would constistute a positive stress test.
A drop in blood pressure
a new arrhythmia
an increase in angina symptoms
ST depressions
68
Are ulcers from venous insufficiency painful or painless
Painless
69
A patient has just received a cardiac stent. How long will he be on ASA and Clopidogrel?
1 year
70
Where is the disease of the mitral valve best heard?
at the apex
71
What is the initial treatment for myocardial infarction?
MONA - morpine, oxygen, NTG, asa
72
Clot busting drugs should be used within 3 hours of which 2 cardiac events?
STEMI and new left bundle branch blocks
73
List 3 catastrophic complications of a myocardial infarction
Papillary muscle rupture
myocardial wall rupture
left ventricular aneurysm
74
A EKG sows a regular heart rate of 200bpms. QRS is narrow. What is the most likely diagnosis
Supraventricular tachycardia
75
Acute endocarditis is most commonly caused by what organism?
Staph aureas
76
List 3 congenital heart diseases
```
ASD
VSD
Coarctation of the aorta
tetralogy of ballot
PDA
```
77
What is the most common cause of an partial septal defect?
patent foramen ovale
78
Where on your patient should you listen for the murmur associated with a an atrial septal defect?
at the LEFT 2nd or 3rd interspace.
79
A CXR shows a "3" sign with notching of the ribs. Wha t it the most likely diagnosis?
coarctation of the aorta
80
What is the appropriate treatment for a patient with PDA
Indomethacin
81
A Black procedure is used to correct what congenital heart disease?
Tetrology of Fallot
82
You hear a loud hard pulmonic murmur along the left sternal border. What is most likely diagnosis?
VSD
83
Subacute endocarditis is most commonly caused by what organism>
Strep Viridans
84
What is the most common place for and aortic aneurysm?
In the abdomen and below the renal arteries
85
Who is more likely to have an aortic aneurysm - males of females?
males are 8 times more likely to have an aortic aneurysm
86
The accessory pathway known as the James bundle should make you think of what syndrome?
Low - Gaining-Levine syndrome
87
What imaging needs to be done before taking a patient to the OR with an aortic aneurysm?
CT (echoey be used as initial study, but CT is needed for surgery)
88
List 2 risk factors for an aortic dissection
HTN, MArfan's syndrome, bicuspid aortic valve, pregnancy
89
A patient presents to the ED with tearing chest pain radiating to his back. What is the most likely diagnosis>
aortic dissection
90
What will a CXR show for a patient with an aortic dissection?
widened mediastinum
91
What it the best test to diagnose an aortic dissection?
CT
92
List the 6 "P's" of an ischemic limb
Pain paraesthesia, pallor, pulselessness, poikilothermia, paralysis
93
you have a patient with pulses paradoxes. What 2 diagnosis should you be thinking of?
Pericarditis, pericardial effusion and obstructive lung disease
94
A patient complains of pain in his legs when he walks. it goes away after sitting. What term comes to mind with this symptom? what diagnosis goes along with it?
Intermittent claudication caused by peripheral arterial disease (PAD)
95
Giant cell arteritis is associated with what other disease?
polymylagia rheumatica
96
a sawtooth pattern on EKD=G should make you think of what diagnosis?
A flutter
97
What is the accessory pathway associated with Wolf-Parkinson-White
The bundle of KEnt
98
A biphasic P wave should make you think of what diagnosis?
Left partial enlargement
99
What is the gold standard for the diagnosis of giant cell arteritis
temporal artery biopsy
100
What is the treatment for giant cell artertitis
High dose prednisone
101
List the components of Virchow's triad
Stasis
vascular injury
hepercoagualbility
102
Calf pain should always make you think of what diagnosis?
DVT
103
Where is the disease of the tricuspid valve heard best:
along the left lower sternal border
104
What is the most common congenital heart disease?
VSD
105
Are ulcers from arterial insufficiency painful or pain less?
painless
106
give 2 contraindications for using ACEI
bilateral renal artery stenosis
history of angioedema
pregnancy
107
Both leads I and AVF have a positive QRS complexes; Does this represent normal, right or left axis deviation?
normal axis
108
What medication might you witch a patient to if they develop and intolerable cough?
ARBs
109
What class of cardiac medications should be avoided in patients with asthma?
Beta blockers
110
A boot shaped heart on CXR should make you think of what congenital heart defect?
Tetrology of Fallot
111
An RSR prime in leads V1 and V2 should make you think of what diagnosis>
RBBB
112
Which lab should be more tightly monitored in a patient taking and aldosterone antagonist?
Potassium - they may develop hyperkalemia
113
What is the best test for diagnosing CHF
echocardiogram
114
Which cardia medications is used to help with cardiac contractility after you have optimized most of the other cardiac medications?
digoxin
115
A blockage of which artery causes an anterior walll MI
Left anterior descending
116
What lab will result in increased the risk of digoxin toxicity?
hypokalemia or hypercalcemia
117
A patient presents to the ED in CUTE CHF - WHAT dRUG CLASS WILL LIKELY BE THE FIRST CHOICE FOR TREATMENT?
Loop diuretics
118
A patient has a GFR of 25 and HTN. Which class of diuretic should you use - loop of thiazide?.
Loop will work no matter how low the GFR is, a Thiazide will only work if GFR >30
119
Which EKG leads are used to diagnose an anterior wall MI?
V1, V2, and V3
120
Do loop diuretics cause hypekalemia or hypokalemia?
hypokalemia
121
Statins are the drug of choice to treat what type of dysplipidemia?
Elevated LDL
122
A patient recently started taking Lipitor. HE is now complaining of aches and pains. What lab test should be ordered?
Creatinine Kinase looking for rhabdomylolisis
123
How does Ezetimbe work?
Decreases the intestinal absorption of cholesterol
124
Which hyperlipidemia agent may cause flushing?
niacin
125
Name 3 classes which are used to reduce LDL
Statins, Ezetimibe, niacin, nicotinic acid
126
Name 2 fabric acid deriviatives
Fenofibrate and gemfibrozil
127
List 3 class 1a antiarrhythmics
disopyramide, quinidine, procainamide
128
you are counting boxes from the Peak of a QRS wave on an EKG in order to determine the heart rate. What would be the heart rate if the next QTS wave peak were 3 boxes away? what are the numbers associated with the first 5 boxes?>
```
3 boxes - 100beats/min
1 box = 300
2 = 150
3=100
4=75
5=60beats per miniute
```
129
A U wave on an EKG should make you think of what diagnosis?
Hypokalemia
130
What will the heart rate be if the AV node is pacing the heart?
40-60 beats / minute
131
Which cardia medication has gynecomastia in its side effect profile?
Spironolactone
132
Lead I has a QRS that is up and the AVF lead has a QRS complex that is down. Does this represent normal, left or right axis?
left axis deviation
133
An Osborn or J wave on EKG should make you think of what diagnosis?
hypothermia
134
What is the first line medication for a patient with symptomatic bradycardia?
atropine
135
On an EKG, there is an early but other wise normal
PQRS complex. After that beat there is a slight pause and then a normal rhythm continues what is the term for this one beat>
Premature atrial complex.
136
What is the management of a patient in supra ventricular tachycardia?
vagal maneuvers, carotid massage, adenosine
137
How do you treat PMR (polymylagia rheumatic)?
low dose prednisione
138
how do you treat temporal (giant cell) arteritis?
high dose prednisone
139
What is the definitive treatment for atrial flutter?
radio frequency ablation
140
The EKG shows irregularly irregular narrow QRS waves. What should you be thinking of?
Afib
141
An EKG shows a regular rate of 50 ppm. The QRS is narrow and there is no visible P wave. What is the most likely diagnosis?
junctional rhythm
142
Name a commons cause of junctional rhythm
Digoxin toxicity
143
An EKG shows two premature ventricular contractions. There two QRS waves look very different. What is the term for this?
Multifocal premature ventricular contractions.
144
What is the most common cause of suffer cardiac death?
V Fib
145
Pa patine tin the ED has no pulse. But on EKG there are wide irregular "complexes" which are at an irregular rate. They all appear very different from one another. What is the treatment for this patient?
He is in V Fib - defibrillate!!!
146
Tall Peaked T waves should make you think of what diagnosis?
Hyperkalemia
147
How do you define 1st degree Av block?
PR interval is longer than 0.2 seconds (1 block) on EKG
148
What is the other term for Mobitz type 1
Winkebach
149
What is the most important complication of giant cell arteritis
blindness
150
What 2 labs do you monitor on a patient on a ACEI?
creatinine and potassium
151
The heart rate is irregular, so you can't count boxes between QRS waves to determine heart rate. What is anothe meths you can use to determine rate on an EKG?
Count QRS waves in a 6 second strip and multiply by 10 to get beats per minute.
152
What is the treatment for a patient with Mobitz type 2 AV block?
Pacemaker
153
On an EKG - you see regular P waves and regular QRS waves but they do not seem to have any correlation to each other. What is this?
3rd degree AV heart block
154
Name 1 aldosterone antagonist.
Spironolactone, eplerenone
155
You see a short PR interval and a delta wave on EKG what is the most likely diagnosis?
Wolf Parkinson White
156
What 2 leads on and EKG do you use to determine the axis of the heart?
I and AVF
157
An RSR prime in lead V5 and V6 should make you think of what diagnosis?
LBBB
158
Which finding requires immediate attention - LBBB or RBBB
new LBBB - is a STEMI equivalent.
| RBBB is usually not an issue
159
What medication class is used to lower triglycerides?
fibric acid derivatives (fenofibrate/gemfobrazil)
160
Tall Peaked P waves should make you think of what diagnosis?
Right atrial enlargement
161
List 2 causes of right atrial enlargement
Pulmonary HTN, severe lung disease, pulmonary valve stenosis
162
which EKG leads are used to diagnosis anterolateral MT
V5 and V6
163
which leads are used to diagnosis a lateral MI
2,3 AVF
164
A blockage of which artery can cause a lateral wall MI
Left circumflex
165
What is represented by ST segment depressions greater than 1mm on EKG?
Ischemia
166
Rheumatic fever commonly effects which valve?
mitral
167
What is the only cyanotic congenital heart disease on the NCCPA blueprint?
tetralogy of Fallot nonP wave.
168
In EKG there is an early wide QRS complex withAfter the treat there is a slight pause, then a normal rhythm continues. What is the term for this one bea
PVC (premature ventricular contraction)
169
What is the definitive treatment for a patient with recurrent ventricular tachycardia?
Implanted defibrillator
170
on an EKG you notice a patient has a gradual lengthening of the PR interval and then misses a QRS complex. the pattern repeats again. What type of AV block is this
Mobitz 1 or Wenkeback
171
List 3 side effects of digoxin
```
N/V,
Anorexia
confusion
arrthymias (sinus Brady/AV block)
fatigue
visual distrubances
```
172
What is the fist line treatment of torsades de pointes
Mg sulfate
173
What are symptoms of LEFT sided heart failure?
```
described as low output with increased venous pressure
SOB
DOB
Orthopnea
paroxysmal nocturnal dyspnea
```
174
What are symptoms of right sided heart failure
```
caused by left ventricular dysfunction
Edema
Hepatic conjestion
JVD
loss of appetites
nausea
```
175
Describe cardiac PRELOAD
how full the heart is before it squeezes
176
Describe cardiac AFTERLOAD
what is the ventricle pushing against?
177
Describe heart Contractility
the force the heart muscle can exert
178
how does heart rate effect the cardiac performance?
gages the demand - fast - slow
179
What are 4 factors that determine cardiac performance
Preload
Afterload
contractility
rate
180
What is "broken heart syndrome"
Acute CP and SOB similar to acute MI caused by LV apical ballooning following a high catecholamine stress
Normal arteries on a cardiac cath
"Taku-Tsubo" cardiomyopathy
181
how do beta blockers work
They interfere with cahanges caused by catecholamine release
decrease heart rate
decreased after load/BP
decrease cardiac output
182
how do diuretics such as LASIX work
Decrease peripheral vascular resistance
decrease plasma volume
decrease excess NA and fluid
decrease volume overload
183
Why do we do an echocardiogram evaluation
determines EF
evaluate LV function and wall motion
assess valve function
diagnosis cardiomyopathies
184
What Ejection fracture would you ex[pect in a normal patient?
one with CHF
50-70% is normal
35-40% can form CHF
<35% life threatening
185
How would you treat acute CHF
```
loop diuretic (LAsix)
SL/IV Nitroglycerin
O2/CPAP
ACEI
treat underlying cause
```
186
What are the classic signs of Infective Endocarditis
Petechiae of palate, conjucntiva, sublingual
Subungual splinter hemorrhages
Osler nodes (PAINFUL) finges / toes/feet
JAneway lesions (PAINLESS) palms and soles
Roth spots - exudative retinal hemorrhages
187
IS the pleural effusion in CHF transudative or exudative
Transudative Glucose >60, protein <3 LDH >200
188
What procedures require prophylaxis ( for those patient that need prophylaxis)?
Oral: extraction/root canal/ tonsils
GI: surgery/ERCP/colonoscopy with biopsy
GU: Prostate surgeyr/cystoscopy
189
Who needs antibiotic prophylaxis for procedures?
HIGH risk: prosthetic heart valve
Prior infective endocarditis
Cyanotic congenital heart disease
MODERATE : Rheumatic valvular heart disease with regard
HOCM
Mitral valve prophase with regurg
MVP NO LONGER REQUIRES PROPHYLAXIS
190
Dukes criteria for infective endocarditis
2 major. OR. 5 minor. OR1 major and 3 minor.
MAJOR: 2 + BLC. TEE showing endocarditis new Murmur
MINOR:
fever/ vascular phenomenon 1+ BLC h/o IV drug use immunologic change
191
What is the gold standard test for myocarditis?
myocardial biopsy.
192
What is myocarditis?
```
sudden onset of heart failure
echo: dilated cardiomyopathy
EKD nonspecific
Edmea and S3 on PE
Sx SOB and pleuritic CP
```
193
What are the primary causes of Myocarditis
Coxsackie B virus (measles/flu/varicella)
| Kawasakis
194
Where would you hear an aortic murmur
2nd right ICS
195
where would you hear mitral murmur
APEX/ CML
196
where would you hear pulmonic murmur
2nd LEFT ICS
197
where would you hear tricuspid murmur
Left Lateral sternal border/ LLSB
198
Systolic murmurs
Aortic stenosis
| Mirtal regurg
199
Diastolic murmurs
Aortic regurg
| Mitral stenosis
200
Causes of Aortic stenosis
Congential bicuspid valve (presents 50-60yo)
| degenerative - calcification due to atherosclerosis
201
describe the murmur in aortic stenosis
systolic ejection, harsh and low, heart best right 2nd ICS and leaning forward and exhale
202
treatment of aortic stenosis
most common surgical valve replacement
Replace if CHF/ angina/syncope
Ross procedure (young patient ) mechanical/ TAVR (trans catheter aortic valve replacement)
bioprosthetic (porcine/bovine) good for elderly
203
murmur of aortic regurg
soft blowing diastolic murmur along LSB best with sitting forward and expire (also called Austin flint murmur)
204
S/Sx of aortic regurg
SOB
Widened pulse pressure
Waterhammer pulse (also called corrigans)
hyperactive enlarged LV
205
Who would get aortic regurg?
Rheumatic fever in elderly/foreigners
infective endocarditis/marfans syndrome(aortic root disease)
Inflammatory
206
Treatment of aortic regurg`
treat infective endocarditis - immediate surgery
Chronic: ACEI/ARB to decrease SOBand improve EF
valve replacement
207
causes of mitral stenosis
thickened leaflets (thick/stiff leaflet on echo)
fusion of the chord
Calcium deposits
(can see initial onset A Fib/ pregnancy)
208
describe the Murmur of mitral stenosis
mid-diastolic rumble heard best at apex with bell
| also can hear an opening snap with S2
209
Who gets mitral stenosis?
h/o rheumatic fever
| sx: orthopnea/PND.exertional dyspnea
210
treatment of mitral stenosis
- if asymptomatic - monitor, can be precipitated by pregnancy
treat underlying afib
Surgery: percutaneous balloon valuloplasty
211
What occurs with mitral regard?
increases preload and reduces after load, eventually enlarging LV which weakens it and the EF drops
212
Describe the murmur of mitral regurg
harsh blowing pan systolic murmur at apex that radiates to the axilla
213
Discuss MVP
thin young female with a floppy mitral valve - hear a Mid Systolic Click (MSC) heard best with standing or valsalvea
Confirmed by echo, treat with b-blocker
doesn't need prophylaxis
Usually asymptomatic
214
How is a HTN emergency classified and treated?
Diastolic pressure >130
requires substantial reduction in 1 hour to avoid morbidity and mortality
Could result in intracranial hemorrhage/pumonary edema/unstable angin/MI
215
Define malignant HTN
Sustaine BP >200/130 with present of encephalopathy/nephrolathy/pappiledema
216
Treatment for HTN emergency
LAbetolol IV (both alpha and beta blocker)
nicardipine IV
Esmolol IV
Goal to reduce BP 25% in 1-2 hours then decrease lower than 160/100 over next 2-6 hours
217
describe a paradoxical pulse
>10mmhg drop in systolic BP during inspiration
| Seen in COPD and cardiac tamponade
218
Describe the S1S2 heart sounds
S1 "lub" - clsoure of the mitral/tricuspid valves
S2 "dub" - closure of aortic/pulmonic valves.- can split with inspiration
S3 - early rapid LV filling - associated with CHF
S4 - rigorous atrial contraction with stiff LV - LVH/MI
