General Flashcards by Kasia Lenz

Outline the san francisco syncope rule

Low risk if
No ecg changes
No SOB
No hypotension (SBP

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Define ACS

Manifestation of coronary artery disease which is seen as a spectrum from stable angina to unstable angina to non-STEMI and STEMI

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Unstable Angina

Angina characterized by any of the following:
· New onset angina: class II angina onset within last 2 months
· Rest pain: > 20 min within one week of ED presentation
Progressive angina: less precipitation, more often, longer duration

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Define STEMI

STE at J point in at least 2 contiguous leads ≥ 2mm men or ≥1.5mm women in V2-3 and ≥ 1mm in other leads. OR new LBBB
ST depression >-2mm V1-4 with STE in AVR=LM or pLAD

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List 7 early complications of AMI

ACUTE COMPLICATIONS

Pump failure
- Bradydysrhythmias
- Tachydysrhythmias
- Cardiogenic shock

Mechanical:
- LV free rupture
- Septal rupture
- Acute MV prolapse
- Tamponade
- Papillary muscle rupture

Iatrogenic events: 
- Bleeding
- Pseudoaneurysm


SUBACUTE COMPLICATIONS
- Pericarditis
- Dressler’s
- Stent thrombosis
- Stent restenosis
- Stroke

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List 5 causes of prominent T waves:

AMI
Hyperkalemia
BER
LVH
LBBB
Pre-excitation syndromes
Pericarditis

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Differentiate STE of AMI vs BER

BER characteristics:

STE
Concave ST segments
J point notching
Symmetric, concordant large amplitude T waves
Diffuse STE
Temporal stability over time

BER different from STEMI:
- J point elevation

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Provide an organized Differential Diagnosis of ST Segment Elevation on the ECG

· Normal
		o Normal variant
		o Benign early repolarization
	· Extra cardiac disease
		o ICH
		o Hyperkalemia
		o Hypercalcemia
		o Hypothermia – Osborne wave
		o Pulmonary embolus
		o Iatrogenic
			§ Post-cardioversion
	· Heart outside à in:
		o Pericardium: Percarditis
		o Vessels
			§ STEMI - Thrombus/embolus
			§ Prinzmetal’s angina – vasospasm
			§ Aortic dissection into coronary ostia
		o Muscle
			§ LV aneurysm
			§ LV hypertrophy
			§ Myocarditis
			§ Takosubo
		o Conduction system
			§ LBBB
			§ Paced rhythm
			§ Brugada

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Provide a differential for TWI:

N variant
- ACS
- LVH
- BBB
- Paced rhythm
- Myocarditis
- Pericarditis
- PE
- Pneumothorax
- WPW
- CVA
- Hypokalemia
- GI disorders
- Hyperventilation

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Describe the coronary blood flow in relation to regional infarcts in AMI

Anterior: LAD, D1 if lateral extension
Lateral: LAD (anterolateral), RCA (inferolateral), Left Cx (posterolateral)

Inferior: 90% RCA, 10% LCx

Posterior: RCA, LCx

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What morphology of anterior ST depression should make you think of posterior STEMI?

A. Tall, wide R
B. Horizontal ST depression
C. Tall, upright T wave
D. R:S > 1
STE on posterior leads

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List 5 things that cause a tall prominent R wave in V1 (R:S >1):

WPW
- Posterior MI
- RBBB
- Incomplete RBBB
- Ventricular ectopy
- RVH
- Acute RV dilation (RV strain)
- HCM
- Progressive muscular dystrophy
- Dextrocardia
- Misplaced precordial leads
- Rare: normal variance

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What is suggestive of an RV infarction?

STE III > II
- STE V1 with inferior STEMI
- V4r STE on 15 lead ECG
- Clinical: nitrite induced hypotension

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How is left main disease seen on ECG?

STE >0.5mm aVR
- SN 78%; SP 83%
- DDx = multivessel disease

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How is Left ventricular aneurysm differentiated from acute STEMI?

Most commonly found anteriorly with ST elevation in V1 to V6 and I, aVL, may have Q waves present
Classically starts 2 weeks post MI

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What are the Sgarbossa Criteria for AMI and how many points are needed

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Need score of 3

STE GT 1mm concordant with QRS (5pts)

ST depression GT 1mm in V1, V2 or V3 (3pts)

STE GT 5mm and discordant with QRS (2pts)

What are the fratures of LAFB

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LAD

qR in I and rS in III

What are the features of LPFB

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RADrS in I and qR in III

What are contraindications to UFH / LMWH?

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HIT
- Aortic dissection possible
- Prior hemorrhagic CVA
- Major surgery or trauma

At what time from Sx onset is the benefit lost from lytics?

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GT 12 hrs (LATE trial)
- LT 6 hrs best outcomes
- Exception is stuttering chest pain over 12-24hrs

What are the absolute and relative contraindications to lytics (AHA / ACC 2013)?

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Absolute (8) 

Intracranial:
- Prior ICH
- Ischemic CVA >4.5hrs or 3m, dementia, other intracranial not covered by absolute C/Is
HTN
- Chronic, severe uncontrolled HTN
- SBP >180, DBP >110
Ý Bleeding Risk:
- Internal bleeding 10min
- Major surgery

What are the 3 main mechanisms for dysrhythmia formation?

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Enhanced automaticity:
a. Spontaneous depolarization of non-pacemaker cells, or lowered threshold for depolarization of pacemaker cells
b. Causes: ischemia, lyte abnormality, dig, post re-perfusion
Triggered activity: From after depolarizations
a. Torsades
b. Many ectopic atrial, junction, ventricular dysrhythmias
Re-entry
a. 2 pathways, one with longer refractory period
b. SVTs, some VTs

What are the classes of antidysrhythmic drugs

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Class I: Na channel blockers
Class II: BBs
Class III: Main effects on K+ channels Antifibrillatory agents (Sotalol, Amiodarone, Ibutalide)
Class IV: CCBs (Dihydro and Nondihydro)
Bastard Children (Dig, Mg, Adenosine)

How do class III antiarrhythmic agents work?

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Block K channels, variable effects on QTc
Amiodarone: Also class II, II, IV type activity
Sotalol: a BB with type III effects

List 8 causes of PVCs (Box 79-6)

``` - Metabolic disturbances o Hypokalemia o Hypomagnesemia o Hypoxia / hypercarbia o Acidosis / alkalosis - Cardiac: o Ischemia / infarct o Valvular HD o Myocardial contusion o Myocarditis / CM - Drugs / toxins: o Catecholamine excess o Dig toxicity o TCA o Methylxanthine o Class I antidysrhythmics ```

List 6 causes of irregularly irregular rhythms

``` a fib a flutter with variable block multifocal atraial tachycardia wandering pacemaker multiple extrasystoles parasystole ```

What are the 3 classic ECG findings of pre-excitation?

1. short PR 2. QRS GT 100ms 3. Delta wave 4. tall R wave in V1

which WPW has a WCT? | What treatments should you avaoid

antidromic Do not give adenosine (ie AVN blockade) as this may lead to unopposed conduction through accessory pathway leading to VF Treatment options are cardioversion or procainamide

What is the Ashman phenomenon?

- Abberant conduction of an early arriving atrial depolarization after a long RR - Long followed by short - His and / or RBB still refractory, result is RBBB pattern beat or run of beats

List 10 causes of afib

``` HTN cardiomyopathy ischemic heart dz valvular dz (mitral esp) CHF pericarditis Hyperthyroidism SSS Myocardial contusion Holiday heart syndrome cardiac surgery catecholamine excess PE Accessory pathway COPD Dgi toxicity hypoK ```

List 4 agents that can be used for pharmacologic cardioversion (Box 79-9):

``` procainamide amiodarone ibutilide propafenone flecanide ```

Outline your approach to the management of a refractory torsades:

1. 2 g IV MgSO4, repeat if needed 2. Cardioversion (Although often will not work) 3. Isoproterenol (B-agonist) 2-10 mcg/min, titrate to HR that breaks toursades 4. Overdrive pacing HR 100-120 5. Optimize K, Mg

List 5 class I indications for Permanent pacing in Adults

Symptomatic bradycardia from 2nd degree AV block Symptomatic Mobitz II or 3rd degree AV block bifasicular or trifasicular block Asymptomatic 3rd degree AV block with LVD or cardiomegaly 2nd or 3rd degree AV block during exercise in absence of ischemia

What is the 5 letter pacemaker code

Letter 1: chamber paced 2: chamber sensed 3. Sensing response 4. programmability 5. antitachycardia fxn

List 7 complications of implantation:

· Infection à pocket infection, IE · Hematoma · Ventricular wall perf / effusion · Hemo/ PTx · Thrombophlebitis à incidence 30-50%, only 0.5-3.5% develop Sx ?assocaition with PE · Twiddler’s syndrome · Pacemaker syndrome: o AV dyssynchrony; transmission and atrial depolarization from SA node results in atrial contraction against closed tricuspid and mitral. o Sx of CHF and orthostatic hypotension (if have poor CO requiring atrial kick) o Most common with VVI pacemaker à replace with DDD

What are 4 ways pacemakers can malfunction

failure to capture undersensing oversensing inappropriate rate

What are the 4 class I recommendations for ICD placement (Box 80-2)?

1. Cardiac arrest from VF or VT not caused by transient or reversible cause 2. Spontaneous sustained VT 3. Syncope NYD with clinically relevant, hemodynamically sustained VT or VF induced at EP study; when drug therapy not indicated, tolerated, or preferred 4. NS VT with CAD, prior AMI, LV dysfunction, inducible VF or VT at EP study not suppressed by class I antidysrhythmics

General Flashcards

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