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EP Flashcards

1
Q

Triple therapy

A

Decrease INR to 2-2.5

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2
Q

Ebsteins

A

a/w bypass tract WPW -> AVRT

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3
Q

Pre-excitation

A

short PR, slurred upstroke before QRS

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4
Q

Orthodromic AVRT

A

R-P interval >70ms (long RP tachycardia)
Narrow complex
Antegrade through AVNode
Retrograde thru accessory pathway

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5
Q

Antidromic AVRT

A

Antegrade conduction down accessory pathway (pre-excited tach)
Retrograde up AV Node
Wide QRS, RBBB since venticle activated from lateral side first instead of septal (normal AVN)

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6
Q

Pre-excited AF

A

complex irregular rhythm
high risk of RR int <250ms
Tx: ibutilide/procainamide/DCCV
NO AVN agents - 1:1 conduction and death (no verapamil, BB, adenosine)

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7
Q

PPM indications

A 
Sx brady
acquired AVB with Sx brady
Escape rate <40bpm
Pauses >3s in SR
Pauses >5s in AF
s/p AVN ablation
alternating BBB
SND in EPS
Chronotropic incompet
Mobitz II or CHB (3rd deg)
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8
Q

LQTS

A 
Syncopal event with long QT on ECG
Genetic testing needed
refrain from competitive sports
put on BB tx
Screen family members
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9
Q

ICD LQTS

A

1) cardiac arrest

2) VT/Syncope while on BB

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10
Q

LQTS 1

A 
BB tx if symptomatic
30-35%
KCNQ1 - loss of fxn (K)
broad based regular t wave
Swimming/excercise
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11
Q

LQTS 2

A 
BB tx if symptomatic
25-30%
KCNQ2 - loss of fxn (K)
low voltage notched t wave
Alarm clock
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12
Q

LQTS3

A

5-10%
SCN5A - gain of fxn (Na+ (opp of brugada)
long ST segment with normal twave (narrow)
Sleep

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13
Q

Risk

A

Highest - QTc>500, LQT1,2, male LQT3

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14
Q

CRT-D

A

RBBB QRS>150ms

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15
Q

Afib unknown duration

A

don’t use amio as has cardioversion capability

CCB (vereapamil, diltiazem - neg ionotropes) ok if no CHF/LV dysfxn/AV blcok

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16
Q

AV Block during MI

A

AWMI - CHB - incidence lower than in IWMI, myocardial injury greater and block is below node

IWMI - incidence higher of CHB, higher or in AVN, less myocardial injury

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17
Q

Pre-excited AF

A

IV ibutilide
Procainamide
DCCV
NO AVNodal agents or BB or adenosine -> 1:1 AF ->VT/VF

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18
Q

Sx WPW

A

Class I - catheter ablation

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19
Q

BIVI Pacing

A

beneficial if 100% paced
If only paced 25% of time - needs AV node ablation to prevent rapid afib rate control (not candidate for rhtym control 2/2 BP or HF).

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20
Q

SVT

A

adenosine
metoprolol

if broncospasm can use VERAPAMIL
DCCV

Procainamide only for pre-excited afib
DO NOT USE BB/AVN agents - can cause 1:1 conduction down pathway and ->VT/VF

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21
Q

VT

A 
wide QRS
atypical RBBB R>r'
QRS>140
S>R V6
Precordial concordance of QRS
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22
Q

Torasades de point

A

Magnesium tx…

23
Q

Hypersensitive carotid sinus syndrome

A

10 seconds carotid massage
asystole>3 sec or BP drop >50mm Hg
cardioinhibition -vagal nerve stim
vasodpression -sympathetic nerve withdrawwal
Tx: Dual chamber PPM (cardioinhib component)
Vasodepressor component - augment salt/water, removal of diuretics or vasodepressor meds, use of fludrocortisone or midodrine

24
Q

Vasovagal syncope

A

Upright posture >30s
deaphoriss, warmth, nausea, palor
hypotension/brady
hot environments/dehydration

Dx - tilt table h&p

Tx: water/sodium, postural maneuvers
BB, midodrine, flucortisone
PPM if syncopal episodes with asystole

25
Prevent inappopriate ICD shocks
MADIT RIT Program higher VT/VF rate cutoffs more detection only zones AF isn't fixed with anti-tach pacing ``` Primary prevention montior zone 160 to first tx zone one or more tx zone detection 6-10 seconds lowest tx zone 185-200 ATP attempt >1 unless pacing needed set VVI 40 ``` Secondary prevention set lowest VT zone 10-20bpm below lowest clinically relevant VT rate
26
Idiopathic left ventricular VT
left posterior fasicle - RBBB morph with superior axis + LAD (neg forces in inferior leads) sensitive to VERAPAMIL
27
Typical Aflutter
Typical - isthmus dependent TV annulus (counter clock) - narrow isthums between IVC & TV essential - ECG pattern - flutter waves upright in V1, negative in II, III, aVF (sawtooth) - counterclock wavefront Less common - clockwise isthmus dependent AFL - sawtooth pattern is superior in inferior leads
28
Non-isthmus dependent aflutter
- seen after cardiac surgery or AF ablation (IE PVI ablation line gaps, linear roof line, mitral isthmus line) or congenital heart disease - gaps in lines create substrate for left atypical AFL - absense of sawtooth pattern - ablation of cavotricuspid isthmus will not termminate non-isthmus dependent AFL
29
Indications for EP study
Post infarct patient with syncope | EF<40 AND NSVT - EPS to determine inducible VT (MUSTT, MADIT)
30
Atrial Tach (AT)
Long RP tachycardia - pwave morph/PR interval distinct from SR - gradual rate increase and decrease DOES NOT terminate with AVB (not dep on AVN) can have Crista terminalis, CS, bahcman's bundle, MV annulus, PV Dx: IV adenosine can show P-waves but will not terminate Tx: BB/CCB, Class I agents or ablation
31
Sinus node dysfunction
Sinus node recovery tiem (SNRT) >525ms abnormal
32
Pacing indications
Sinus node dz I - Sx sinus brady or pauses -Sx chronotropic incompet -sx sinus brady due to required drug therapy IIa HR<40 Sx c/w brady but clear assoc between brady and sx unclear -unexplaned syncope and abn SN fxn on EPS asystole >3 sec in Sr, >5 sec pause in afib alternative R/LBBB syncope due to spontaneous carotid sinus hypersen with asystole >3 sec
33
Patient activated event monitor
record ecg immediate prior to and during event
34
Tilt table
orthostasis or postural orthostatic tachy
35
Syncope causes
1) Arrythmias - syncope at onset before barorectors can restore BP 2) Structure obstructions - ie PE, HOCM, AS, Ao Diss 3) Hypotensive failure - dehydration, hypotensive Rx, autonomic neuropathy, initial orthostatic hypotension 4) Reflex mediated - vasovagal, carotid sinus syncope, IWMI hypotnesion/brady (Bezold=Jarisch response)
36
BiviICD
LVEF<35% LBBB QRS > 150ms NYHA II-IV(ambulatory)
37
Mobtiz I vs II
Carotid sinus massage worsens AV conduction so Mobitz I (AV dz) will worsen conduction V-rate improves His Purk conduction in mobitz II Excercise improves AVN conduction - will worsen His purkinje conduction so Mobitz II will worsen V-rate
38
CHB vs AV dissociation
CHB - AV node doesn't conduct anything to ventricles - atrial rate faster than ventricular or jnc escape rhtym AV dissociation - ventricular rate similar to or slightly faster than a-rate - occasional atrial signals will come through AV node and see as "capture beats" or fuse with ventricular beats "fusion beats" -> suggestive of VT (must be >100bpm?)
39
Afib stroke risk
CHADS2 CHF, HTN, Age>75, DM, Stroke/TIA(2) CHA2DS2-VASc CHF, HTN, Age>65(1)>75(2), DM, Stroke/TIA(2), vascular dz (PAD, MI, CAD)
40
Cryo vs RF ablation
RF More durable ablation More risk of PPM/CHB
41
AVNRT
short RP tachycardia negative p-wave at terminanl of QRS Atach and aflutter not likely terminated with adenosine (will cease AV conduction temporarily and see p-waves only but will start again)
42
PVC localization
1) Morphology - RBBB - comes from left, LBBB - comes from right 2) Axis -
43
RVOT VT
LBBB inferior axis (large postive deflections in inferior leads) late precordial R wave transition
44
LCC VT
RBBB inferior axis early R wave transition
45
Brugada pattern SCN5A LOSS OF FXN Na+
Sodium channel blockers 1c (flecanide, proprafenone) can unmask brugada in pt with otherwise normal ecg Can cause polymorphic VT/VF push up V1/V2 leads to 2nd / 3rd ICS ICD if h/o SCD 2nd prev ICD if spontaneous type I brugada (off drugs) and h/o syncope Pt without spontaneous ECG type 1 brugada (drug needed to see) and no symptoms do not need ICD Avoid fever triggers If shocks with ICD - QUINIDINE
46
Torsades
can be caused by QT prolongation on CLass III agents (sotolol, dofetilide)
47
Neurogenic syncope
Droxidopa, midodrine, fludrocortisone
48
Intracardiac electrocardiogram
``` Surface ECG High RA His CS RV ``` AVNRT - see first atrial reading in His with short V->A time - rules out any tachycardia using an accessory pathway since V-A time would have to be longer typical AVNRT - see pseduo r' (short RP interval) - very short VA interval Left atrial tachycardia - earliest atrial activation would have to be coronary sinus electrode
49
Reduce ICD shocks
patients with structural heart dz & reduced EF Sotolol and amiodararone reduce ICD shocks & mortality DO NOT USE Ic (flecanide, proprafeone) - inc'd risk of VT
50
Pre-excited AF
risk of SCD procainamide or ibutilide (IV) or DCCV if unstable DO NOT IMPLANT ICD needs catheter ablation DO NOT USE AVN (BB, CCB, adenosine) agents -> deg to VF...
51
Catheter ablation risks
Typical AVNRT - 1% risk CHB AVRT (bypass tract) - left heart - 1% risk of CVA/TIA Atach - high crista terminalis - 1% phrenic nerve injury Afib/Atach mapped to PV - 1% PV stenosis
52
CPVT
Bidirectional VT DAD diastolic Ca overload (like dig toxicity) 1. SCD-> ICD 2. Syncope or Asx - BB (nadolol, propranolol) +- flecandie (ryanadine receptor stabilizer) Breakthrough left denervation
53
EAD
from Class III antiarrythmics prolong QT - work better in slower HR (rev use dep) inc likelihood that ectopy will bring AP back to depolarization and set up torsades Treatment - pacing/isoproteronol
54
DAD
diastolic calcium O/L Dig toxicity CPVT Tx with BB, CCB or flecanide for CPVT Need to slow HR (use dependence) DO NOT OVERDRIVE PACE

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