deck 3 Flashcards
(25 cards)
what are the 3 types of atrial fibrillation (based on duration of arrhythmia)
- paroxysmal Afib (lasts < 7 days)
- persistent Afib (lasts > 7 days)
- permanent (refractory to cardioversion)
which anti-arrhythmic should be given with an AVN blocker when initiating therapy for AFib?
flecainide & propafenone (both IC agents)
major contra-indications to usage of dronedarone?
- class IV NYHA heart failure
- class II-III NYHA heart failure with recent decompensation requiring hospitalization
first-line therapy for pt with typical Aflutter?
catheter ablation of the cavotricuspid isthmus`
What is the RV response to mildly increased preload (2)? Severely increased preload? (4)
- mildly increased preload: increased RV size & NORMAL wall motion
- severely increased preload: increased RV size, tricuspid regurg, wall motion abnormalities, septal shifting
what is the RV response to acutely increased afterload?
acutely increased afterload causes free wall hypokineses/akinesis
visual estimation technique for evaluating for RV volume overload?
in A4C, RV size should appear no more than 2/3 that of LV size (In end diastole)
what is the dimensionless index and how can it be used to diagnose severe AS?
dimensionless index = Vlvot/Va, where Vlot = peak velocity @ lvot & Va = peak velocity @ aortic valve Vlvot/Va < 0.25 implies severe AS
Pt is transferred to your hospital after found in VF arrest at home s/p defibrillation. After hypothermia protocol she now has regained full neurologic function & full recovery is expected. What intervention can you recommend to improve mortality & which landmark trial can you cite as evidence?
placement of ICD will improve mortality above was shown in AVID trial (secondary prevention of cardiac death w/ ICD implantation)
For the following patient a/w acute MI, name which factors make him likely to have a favorable outcome when treat with lytic therapy: 55M no prior medical history who has a blood pressure of 125/68, HR 80, Killip class I.
- Young age
- normal heart rate
- well-controlled BP
- No DM (least predictive of all factors)
- above findings are from GUSTO trial
Which medication can you give to reduce the incidence of intracranial hemorrhage in a pt receiving lytics for acute MI?
give beta-blockers
You are consenting a pt for fibrinolytic therapy for acute STEMI. He does not want PCI. What should you quote as the approximate risk of stroke?
1% risk of stroke (based on most contemporary trials)
An ED physician from outside hospital wants to transfer a pt who presented w/ acute STEMI 30 minutes ago. He tells you that lytic therapy was given already. Which agent was likely given?
- probably reteplase, which can be given as a bolus rather than an infusion
- *note that reteplase has same mortality/stroke incidence as alteplase (which must be given as an infusion)
65M is a/w acute MI, 3 hours after revascularization he has VF arrest & is successfully resuscitated. What should you tell the family regarding prognosis?
prognosis is poor despite successful resuscitation VF arrest within the first 48 hours doubles mortality
68F with h/o secondum ASD presents for elective RHC. The following saturations are obtained: aortic 98%, PA 88%, RV 87%, RA 83%, SVC 63%, IVC 69%. What is the Qp/Qs?
- Qp/Qs = [SaO2 - MVO2]/[PVO2 - PAO2] = [98 - 64.5]/ [98 - 88] = 33.5/10 = 3.3 *note: MVO2 = [3*SVCO2 + 1*IVCO2]/4 = 64.5%
- This is consistent with a large left-to-right shunt
How to quantitate degree of left to right shunting?
- calculate Qp/Qs Qp/Qs
- 1-1.5: small shunt
- Qp/Qs 1.5-2: moderate shunt
- Qp/Qs >2: large shunt
2 absolute contra-indications to V-gram?
- LVEDP > 25
- critical left main stenosis
What is Sellar’s criteria & how is it typically used?
- Sellar’s criteria is used to grade regurgitant murmurs (on scale of 1-4):
- mild (1): PARTIAL filling of PC [eg LV fills partially during aortogram]
- mod (2): COMPLETE filling of PC (LESS dense than DC) [eg LA fills completely during LVgram, less dense than LV]
- severe (3): EQUAL OPACIFICATION of PC in 4-5 beats
- very severe (4): EQUAL OPACIFICATION of PC in
45M with bicuspid AV p/w increasing DOE. o/e (+) 3/6 late-peaking SEM @ RUSB. TTE shows AVA of 1.5 by continuity. EF is preserved. What to do next?
- perform cardiac cath with simultaneous arotic & LV pressures (indicated because clinical assessment points to symptomatic severe AS which is not shown by TTE)4
- GLs: obtain simultaneous aortic/LV pressures from cath lab when non-invasive assessment is discordant w/ clinical exam or inconclusive (class I)
typical clinical scenario for free wall rupture of myocardium post MI? (3)
- p/w pleuritic CP, syncope -> death
- o/e tamponade signs (Beck’s triad) vs. PEA arrest
- echo: large, layered echogenic pericardial effusion, MV/TV inflow variation
most common site of free wall rupture?
distal anterior/lateral LV (terminal distribution of LAD)
84F presents with dizziness 1 week after experiencing a few days’ worth of CP. o/e she is hypotensive (80s/40s), tachycardic, (+) JVD. Echo shows akinetic lateral wall with layering thrombus in pericardial space. What to do next?
refer for surgical eval surgery is the only option for hemodynamically-unstable LV pseudo aneurysm
What are the 4 main categories of AFib patients to consider when looking for a method for maintenance of sinus rhythm?
- No heart disease: 1C agent/sotalol -> amio/dofetilide vs. catheter ablation
- hypertensive heart disease (substantial LVH): amiodarone -> catheter ablation
- CAD: dofetilide/sotalol -> amio vs. catheter ablation
- heart failure: amio/dofetilide -> catheter ablation
What percentage of LV has to be infarcted to cause cardiogenic shock?
40%
