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רהב לב > leads > Flashcards

leads Flashcards

1
Q

anteroseptal

A

v1

v2

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2
Q

anterior

A

v1
v2
v3
v4

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3
Q

extensive anterior

A

v1, v2, v3, v4, v5, v6
Limb Lead I
avL

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4
Q

anterolateral

A

V3, V4, V5, V6
Limb Lead I
avL

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5
Q

inferior

A

Limb Lead II
Limb Lead III
aVF

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6
Q

Posterior

A

V1, V2
expect opposite, so ST depression and R wave tall
opposite of what is seen in anteroseptal wall

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7
Q

high lateral

A

Limb Lead I
aVL
NO PRECORDIALS

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8
Q

abnormally wide beats

A

pacemaker beats

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9
Q

PR

A

0.12-0.2

3-5 small boxes

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10
Q

QRS

A

0.04-0.1

1-2.5 small boxes

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11
Q

DUBINS

A

300-150-100-75-60-50-42 (?)

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12
Q

6 seconds method

A

QRS in six second strip X 10

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13
Q

1500 method

A

small boxes between 2 R waves divided by 1500 (1500 small boxes in a minute)

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14
Q

Atrial Foci

A

60-80

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15
Q

Junctional Foci

A

40-60

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16
Q

Ventricular Foci

A

20-40

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17
Q

SA

A

60-100

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18
Q

Exercise Rx

Frequency

A

3-5 sessions a week

if <3METS do multiple sessions throughout the day

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19
Q

Exercise Rx

Duration

A

30 minutes

broken into 6 minute intervals to watch HR stabilization and recovery

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20
Q

Exercise Rx

MODE

A

Treadmill, Leg Ergometer

POWER = kg x meter/revolution x rev/minute

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21
Q

Exercise Rx

Intesnity

A

BORG: (can start at 13/20)
12-16/20
if they say it is 11/20 it needs to be increased

START: 40-60% and work up (if fit 70-80%)

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22
Q

EQUATIONS FOR VO2 and HR

A

%VO2
Target VO2 = [[(I%)(VO2 max - VO2 rest)]+ VO2 Rest}

%HR
Target HR: [(I%)(HRmax-HRrest)+HRrest]

220-age = max HR: not a good estimate in ill populations

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23
Q

Exercise Rx

Progerssion

A

Start: light muscle endurance, 40-60% moderate aerobic

every 6th session can progress 5%
every 8th session can increase 5min
(6-12 weeks to increase 2 MET)

LOOK FOR:
adaptation to training: BORG 12/20, HR stabilize early

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24
Q 
Conversions
WATT = kgm/minute
KG = lbs
INCH = feet
METER = cm
MPH = m/minute
A 
1 WATT = 6kgm/minute
1 KG = 2.2 lbs
1 INCH = 12 feet
1 METER = 100cm
1 MPH =26.8 m/minute
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25
Q

3 Conditioning Stages

A

Initial: 4 weeks

  • –light endurance exercise, moderate aerobic 40-60%
  • –can do 15-20 minutes

Improvement: 4-5 months long
—-gradually increase exercise stimulus to increase fitness based on rate of adaptation

Maintenance: after 5-6 months
—-aim to meet 1,000kcal/week: moderate level of exercise

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26
Q

MET Risk Stratification

A

Low risk at or above 7mets

Moderate Risk below 5 METS

Highest Risk = above 3 METS

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27
Q

Ejection Fraction Risk Stratification

A

Lowest: at or above 50%

Moderate: 40-49%

Highest: Below 35% or below 40%

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28
Q

Risk Factors For Cardiac

A

Not Modifiable:
Age above 65 yrs
Gender of male
Family history 1 degree of male before 55yrs or female before 65 years

Modifiable:
Dyslipidemias
Tobacco
HTN
DM
Sedentary
Stress
Obesity
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29
Q

How to determine risk from cardiac risk stratification

A

LOW: 0-1 risk factors

MODERATE: 2 or more risk factors

HIGH: known systemic disease or symptoms

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30
Q

Dyslipidemias

A

total cholesterol 35 or 40mg/dl

want diet:
15-25% fat
<100mg

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31
Q

Tobacco

A

smoker if smoked in past six months

if quit over 6 months ago no longer a smoker

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32
Q

HTN

A

BP 140/90

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33
Q

DM

A

fasting blood glucose 125
want fasting glucose 110, Hb A1C 5-7
want glucose below 120 and HbA1C below 6.5

34
Q

Sedentary

A

best is >1,500kcal/week

worst is <700kcal/week

35
Q

Stress

A

stress

36
Q

Obesity

equation
kg vs lb

A

BMI above 30

BMI equation:
mass in kg/(height in meters)^2

lb–>kg:
2.2lb in 1 kg

37
Q

Nonmodifiable risk factors

A

Age above 65 yrs
Gender of male
Family history 1 degree of male before 55yrs or female before 65 years

38
Q

PR width

A

0.12-0.2

3-5 small boxes

39
Q

QRS width

A

0.04-0.1
1-2.5 small boxes

normal: above AV node
wide: originating at or below the AV node (20-40bpm)

+v5,v6
-v1,v2

40
Q

ST depression or elevation

A

elevation: injury, non Q wave MI
depression: suspect ischemia (need to see other leads), ie q wave MI

41
Q

T inverted

A

PVC

42
Q

v1

A

4th intercostal space, R sternal border

anteroseptal, anterior, excessive anterior
posterior

43
Q

v2

A

4th intercostal space, L sternal border

anteroseptal, anterior, excessive anterior
posterior

44
Q

v3

A

midway between v2 and v4

anterior, excessive anterior
anterolateral

45
Q

v4

A

5th intercostal space mid clavicular line

anterior, excessive anterior
anterolateral

46
Q

v5

A

5th intercostal space, anterior axillary line

excessive anterior,
anterolateral

47
Q

v6

A

5th intercostal space, midaxillary line

excessive anterior,
anterolateral

48
Q

tachycardia

A

above 100bpm

49
Q

bradycardia

A

below 60bpm

50
Q

normal hr

A

60-100 bpm

51
Q

atrial flutter

A

3P:1QRS
PR hard to distinguish
QRS normal
T wave: none

SAW TOOTH

significance: DECREASED CO because decreased preload from the atria: blood not moving well and clot can form (anticoagulant needed)
AV node blocking atrial impulses and only every few can be conducted to the ventricles
atria firing 250-350bpm but ventricles 60-150bpm

52
Q

atrial fibrillation

A

reduced pumping efficiency of the heart–ventricles are not filled well, thrombi can form and cause stroke/pulmonary embolus/peripheral (give anticoagulant or diuretic)

atrial firing 300-400 bpm and multi focal irritated in the atria is quivering and not effective, cant determine ventricle rate

P: no
PR: no
QRS: normal when they happen
T: YES

rhythm: irregular

53
Q

junctional rhythm

A

AV node is pacing the heart at 40-60bpm
passive flow through atria causes risk of clot

P: NONE
QRS: normal
T: INVERTED

54
Q

Supraventricular tachycardia

A

decreased CO because atria are not filling an emptying efficiently –shorter cycle

high HR above 150bpm
less coronary filling
GIVE B BLOCKER or Calcium channel blocker

P: hard to see
QRS: normal!

55
Q

PVC

A

ventricle foci irritable generating impulse
decreased CO
can lead to ventricular tachycardia and ventricular fibrillation
–risk of clotting in bigeminy

P: NONE

QRS: WIDE (above 0.04-0.1 or above 1.5-2 small boxes)

T WAVE: INVERTED

56
Q

Bigeminy PVC

A

every other beat PVC
50% PVCs
BF delay through ventricle and clot can form in the ventricle
stop exercise and call doctor

NO P
WIDE QRS
INVERTED T

57
Q

Multifocal PVC

A

more than 2 irritable foci being pacemaker because irritable (ischemia)

NO P
WIDE QRS
INVERTED T

58
Q

R on T

A

dangerous because ventricles are stimulate during refractory period (T WAVE: ventricular repolarization)

this can lead to ventricular fibrillation

such as a PVC on the T wave

DO NOT EXERCISE
CAN CAUSE CARDIAC ARREST!!!

59
Q

Torsades Point

A

abnormal Mg or potassium

looks like twisted ribbon

ventricular tachycardia (we shock heart)
LETHAL because not effective CO
60
Q

Ventricular Fibrillation

A

we shock heart

almost no blood flow, near death, need to shock heart

it looks chaotic, starting near the ventricles, no normal EKG waves at all

EMERGENCY

61
Q

1 degree Heart Block

A

delay at the AV node–not blocked

P: present in good ratio
PR: prolonged
QRS: NORMAL

can still exercise

62
Q

2nd degree Heart Block Type 1

A

Winkiback
do not exercise

long PR that gets longer
QRS is lost sometimes

can progress to complete heart block

63
Q

2nd Degree Heart Block Type 2

A

Mobitz 2

ischemia of the AV node
block is at the bundle of his

fixed PR
no QRS (ie 2P waves: 1QRS)

can progress to complete heart block

64
Q

3rd Degree Heart Block

A

complete heart block –no impulse through AV node at all, and depend on the venticels (can result in: decreased CO, hypotension, angina, CHF, cardiac arrest)

atria and ventricles function normally but independently
See P in the T wave

no communication between the P and the QRS (wide QRS)

NEED MEDICAL ATTENTION

65
Q

Left BBB

A

delay in the left ventricle depolarization
R–>L

force travels through septum right to left

see a NEGATIVE deflection at v1 and a POSITIVE deflection at V6

66
Q

Right BBB

A

rabbit ears
R–>R’

delay in right ventricle depolarization

force travels L–>R

left depolarization is delayed

67
Q

Non specific intraventricular delay

A

QRS above 120mseconds without morphology of RBB or LBBB

68
Q

P -how to know if it starts in the SA node

A

upright on limb lead II

also I, aVL, V3, V4, V5, V6

69
Q

QRS: wide

A

wide: originating below AV node

R wave height increases from V1-V6 (transition at V4)

70
Q

ST acute/recent/distant

MI

A

Q WAVE MI:

acute–elevated ST segment with peak in T wave is active MI (ST can elevate in pericarditis also)

recent: T inverted (wide QRS indicated it happened)
distant:

NON Q WAVE MI:
QRS not wide
ST segment changes

71
Q

T wave in MI

A

initiallly peak
invert in a few hrs
resume to normal 2 weeks to a year

72
Q

when should we shock the heart

A

VTACH

VFIB

73
Q

sustained tachycardia

A

3 or more PVC in a row

100-250bpm

74
Q

failure to capture

A

pacemaker implant sends signal that doeesnt cause electrical mechanical action of heart

75
Q

failure to sense

A

pacemaker implant sends signal at inappropriate time

76
Q

what to do in ST depression

A

give O2, fio2 facemask

sit and take BP

77
Q

what to do if 3 PVC in a row

A

nonsustained ventricular tachycarida

STOP exercise
give O2
give nitroglycerin in sitting since it is a vasodilator that will lower BP and SUPINE WILL CAUSE PRELOAD TO INCREASE (risk of pulmonary edema) risk of bradycahrdia

or call 911

78
Q

how does changing position change preload

A

if systemic venous return is suddenly increased (e.g., changing from upright to supine position), right ventricular preload increases leading to an increase in stroke volume and pulmonary blood flow. Increased pulmonary venous return to the left atrium leads to increased filling (preload) of the left ventricle, which in turn increases left ventricular stroke volume by the Frank-Starling mechanism. In this way, an increase in venous return can lead to a matched increase in cardiac output.

79
Q

qualify heart transplant

A

n most medical centers, a Vo2max score of 14 (in ml/kg/minute) or less qualifies you for heart transplant.

80
Q

exercise leads

A 
limb lead I
limb lead II
v4
v5 and
v6
81
Q

Endpoint exercise test

A
  1. Measurement Techniques and Sequences a. ECG –taken throughout exercise test, 12 lead (
    ACSM Guidelines for Exercise Testing
    Inbox

Dani Rosh
to me
2 days agoDetails
ACSM Guidelines for Exercise Testing

Contraindications to Exercise Testing

                    Absolute

Acute MI (within 2 days)

                    Acute pulmonary embolus

Unstable angina

Orthostatic BP drop of >20mm Hg with symptoms

Critical AS

Acute Systemic Fever (above 102)

Uncontrolled ventricular arrythmias

Uncompensated CHF

Active pericarditis or myocarditis

Inability to obtain consent

Resting ST segment displacement (>2mm Hg)

Other metabolic conditions (renal failure, thyrotoxicosis) that could affect exercise

performance or be aggravated by exercise

Physical disability that would preclude safe and adequate test performance

Relative

Resting SBP >200mm Hg or resting DBP >110mm Hg

Uncontrolled diabetes (resting blood glucose >300)

Uncontrolled atrial arrythmias

High degree atrioventricular block

Hypertrophic cardiomyopathy

Uncontrolled sinus tachycardia (>120bpm)

                    Mental impairment leading to inability to cooperate

                    Electrolyte imbalances

contraindications may be superseded if benefits outweigh risks of exercise*

Standard criteria for termination of exercise testing

                    - signs/sx of significant distress(cyanosis/pallor)
                    - significant angina (grade 3-4)
                    - dyspnea
                    - fatigue
                    - severe musculoskeletal pain (including claudication)
                    - more than moderate discomfort from any other cause
                    - sustained ventricular tachycardia
                    - increasing multifocal PVCs, coupled PVCs, or Ventricular Tachycardia
                    - rapid atrial arrythmias - a fall in systolic BP > 10mm hg (persistently below baseline), despite an increase in workload, when accompanied by any other evidence of ischemia
                    - extreme hypertensive BP response ( SBP >240mm hg)
                    - Central nervous system symptoms (ataxic gait, dizziness, near syncope)
                    - Patient’s request to stop
                    - ST elevation (>1.0mm) in leads without significan ! waves (other than V1 or aVR) - ST or QRS changes such as excessive ST displacement (horizontal or downsloping of >2mm) or marked axis shift - Development of bundle branch block that cannot be distinguished from ventricular tachycardia - Technical difficulties monitoring the ECG or systolic BP

        Submaximal Exercise testing Endpoints
  • any of the above criteria for standard exercise test
  • Exercise HR in excess of peak HR observed in previous GXT. If previous test was

A hospital predischarge test the HR should not exceed 130 bpm

  • Exercise workload in excess of peak workload observed on previous GXT. If previous test was a hospital predischarge test, the exercise workload should not exceed 7 METs
  • RPE > 15 (Borg 6-20 grade scale

Exercise Testing

                    Maximal vs Submaximal

                    Minimum requirements for measure assessed during exercise testing

                                Pretest Measures

Minimum of 5 minutes of rest prior to taking initial measures

                                            Information consent

                                            Demonstration of Equipment

Definition of maximal effort or desired endpoints

                                            Explanation of rating scales

                                            12 Lead EKG in supine and in position of exercise

                                            Blood pressure in supine and in position of exercise

                                            Assessment of medications, when last taken, and current symptom list

                                Exercise Measures

                                            12 lead EKG during last minute of each stage of exercise

                                            Blood pressure and RPE during last minute of each stage

                                            Other rating scales as appropriate

                                Post test Measures

Minimum of 6 minutes in sitting or supine position, or until near baseline measures are reached. A period of active cool down may be included in the 6 minute recovery period; for functional (non diagnostic) exercise tests a 1-3minute cool down is recommended, depending on the level of exertion (additional time for heavier exertion) to minimize postexercise effects of venous pooling in the lower extremities.

12 lead EKG every minute

Blood pressure immediately after exercise, then every 1-2 minutes until normotensive or near-baseline measures are reached

Symptomatic ratings each minute as long as they persist after exercise. Patients should be observed until all symptoms have subsided and the EKG is within acceptable limits, as determined by the supervising clinician.

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82
Q

Endpoint exercise test

A
  1. Measurement Techniques and Sequences a. ECG –taken throughout exercise test, 12 lead (
    ACSM Guidelines for Exercise Testing
    Inbox

Dani Rosh
to me
2 days agoDetails
ACSM Guidelines for Exercise Testing

Contraindications to Exercise Testing

                    Absolute

Acute MI (within 2 days)

                    Acute pulmonary embolus

Unstable angina

Orthostatic BP drop of >20mm Hg with symptoms

Critical AS

Acute Systemic Fever (above 102)

Uncontrolled ventricular arrythmias

Uncompensated CHF

Active pericarditis or myocarditis

Inability to obtain consent

Resting ST segment displacement (>2mm Hg)

Other metabolic conditions (renal failure, thyrotoxicosis) that could affect exercise

performance or be aggravated by exercise

Physical disability that would preclude safe and adequate test performance

Relative

Resting SBP >200mm Hg or resting DBP >110mm Hg

Uncontrolled diabetes (resting blood glucose >300)

Uncontrolled atrial arrythmias

High degree atrioventricular block

Hypertrophic cardiomyopathy

Uncontrolled sinus tachycardia (>120bpm)

                    Mental impairment leading to inability to cooperate

                    Electrolyte imbalances

contraindications may be superseded if benefits outweigh risks of exercise*

Standard criteria for termination of exercise testing

                    - signs/sx of significant distress(cyanosis/pallor)
                    - significant angina (grade 3-4)
                    - dyspnea
                    - fatigue
                    - severe musculoskeletal pain (including claudication)
                    - more than moderate discomfort from any other cause
                    - sustained ventricular tachycardia
                    - increasing multifocal PVCs, coupled PVCs, or Ventricular Tachycardia
                    - rapid atrial arrythmias - a fall in systolic BP > 10mm hg (persistently below baseline), despite an increase in workload, when accompanied by any other evidence of ischemia
                    - extreme hypertensive BP response ( SBP >240mm hg)
                    - Central nervous system symptoms (ataxic gait, dizziness, near syncope)
                    - Patient’s request to stop
                    - ST elevation (>1.0mm) in leads without significan ! waves (other than V1 or aVR) - ST or QRS changes such as excessive ST displacement (horizontal or downsloping of >2mm) or marked axis shift - Development of bundle branch block that cannot be distinguished from ventricular tachycardia - Technical difficulties monitoring the ECG or systolic BP

        Submaximal Exercise testing Endpoints
  • any of the above criteria for standard exercise test
  • Exercise HR in excess of peak HR observed in previous GXT. If previous test was

A hospital predischarge test the HR should not exceed 130 bpm

  • Exercise workload in excess of peak workload observed on previous GXT. If previous test was a hospital predischarge test, the exercise workload should not exceed 7 METs
  • RPE > 15 (Borg 6-20 grade scale

Exercise Testing

                    Maximal vs Submaximal

                    Minimum requirements for measure assessed during exercise testing

                                Pretest Measures

Minimum of 5 minutes of rest prior to taking initial measures

                                            Information consent

                                            Demonstration of Equipment

Definition of maximal effort or desired endpoints

                                            Explanation of rating scales

                                            12 Lead EKG in supine and in position of exercise

                                            Blood pressure in supine and in position of exercise

                                            Assessment of medications, when last taken, and current symptom list

                                Exercise Measures

                                            12 lead EKG during last minute of each stage of exercise

                                            Blood pressure and RPE during last minute of each stage

                                            Other rating scales as appropriate

                                Post test Measures

Minimum of 6 minutes in sitting or supine position, or until near baseline measures are reached. A period of active cool down may be included in the 6 minute recovery period; for functional (non diagnostic) exercise tests a 1-3minute cool down is recommended, depending on the level of exertion (additional time for heavier exertion) to minimize postexercise effects of venous pooling in the lower extremities.

12 lead EKG every minute

Blood pressure immediately after exercise, then every 1-2 minutes until normotensive or near-baseline measures are reached

Symptomatic ratings each minute as long as they persist after exercise. Patients should be observed until all symptoms have subsided and the EKG is within acceptable limits, as determined by the supervising clinician.

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