Mehl. arrhytmias: Afib, flut., VT, SVT

Question 1

M. Afib. pattern?

Answer 1

“irregularly irregular” rhythm with absent p-waves.

Question 2

M. Afib.
AF is hugely important because it can cause turbulence/stasis within the left atrium that leads to a LA mural thrombus formation. This thrombus can launch off (i.e., become an embolus) and go to brain (stroke, TIA, retinal artery occlusion), SMA/IMA (acute mesenteric ischemia), and legs (acute limb ischemia).

Answer 2

.

Question 3

M. Afib. AF HY in older patients, especially over what age?

Answer 3

75

Question 4

M. Afib.

Vignette will usually be an older patient with a stroke, TIA, or retinal artery occlusion, who has normal blood pressure (this implies carotid stenosis is not the etiology for the embolus).

Answer 4

.

Question 5

M. Afib. AF usually is paroxysmal, which means it comes and goes. The vignette might say the patient is 75 + had a TIA + BP normal + ECG shows sinus rhythm with no abnormalities -> next best step is??

Answer 5

Holter monitor (24-hour ambulatory ECG monitor) to pick up the paroxysmal AF (e.g., when the patient goes home and has dinner).

Question 6

M. Afib. After AF is diagnosed with regular ECG OR Holter –> next step in 2CK?

Answer 6

echocardiography as the next best step to visualize the LA mural thrombus.

Question 7

M. Afib. Dx arba paprastoj ECG, arba holteriu!!!

Answer 7

.

Question 8

M. Afib.Patient who has severe abdominal pain in setting of AF or hyperthyroidism (which can cause AF), diagnosis is ???? best next step??

Answer 8

acute mesenteric ischemia; next best step is mesenteric angiography; Tx is laparotomy if unstable (answer on NBME).

Question 9

M. Afib. Patient who has severe abdominal pain in setting of AF or hyperthyroidism (which can cause AF). If patient unstable, what Tx?

Answer 9

Tx is laparotomy if unstable (answer on NBME).

Question 10

M. Afib. Severe pain in a leg + absent pulses in patient with irregularly irregular rhythm, Dx?

Answer 10

acute limb ischemia;

Question 11

M. Afib. Severe pain in a leg + absent pulses in patient with irregularly irregular rhythm, Tx?

Answer 11

USMLE wants “embolectomy” as answer.

Question 12

M. Afib. Severe pain in a leg + absent pulses in patient with irregularly irregular rhythm. Buvo nbme 10 ar 11 panasi situacija su ranka, kad dingo pulsas. Buvo teisingas ats cardioecho (kad surasti embola) vs angiography (wrong)

Answer 12

.

Question 13

M. Afib. Any structural abnormality of the heart, either due to LV hypertrophy, ischemia, growth hormone/anabolic steroid use, prior MI, etc., can lead to AF.

Answer 13

.

Question 14

M. Afib. You need to know AF patient will get either??2 possible drugs

Answer 14

aspirin or warfarin.

Question 15

M. Afib. You need to know AF patient will get drugs (aspirin or warfarin). how to know which drug?

Answer 15

This is determined by the CHADS2 score. There are variations of the score, but the simple CHADS2 suffices for USMLE: CHF, HTN, Age 75+, Diabetes, Stroke/TIA/emboli.

Each component is 1 point, but stroke/TIA/emboli is 2 points. If a patient has 0 or 1 points, give aspirin; if 2+ points, give warfarin.

nu siaip yra chads-vas, bet jis paminejo tik chads

Question 16

M. Afib.

“Emboli” refers to Hx of AF leading to stroke, TIA, acute, mesenteric ischemia, or acute limb ischemia – i.e., any Hx of embolic event.

2CK IM form gives short vignette of 67F with chronic AF + Hx of acute limb ischemia + no other info relating to CHADS, and answer is warfarin to prevent recurrence; aspirin is wrong.

Question 17

M. Afib. CHADS-VAS - kazkodel mehl rase tik apie chads, bet kad pagal situacijas su chads-vas geriau suskaiciuoti ir nuspresti gydyma.

Answer 17

CHA2DS2-VASc

Congestive Heart
Failure/LV dysfunction
Hypertension
Age >= 75 y.o (2points)
Diabetes Mellitus
Stroke/TIA/TE (2 points)

Vascular disease
Age 65-74
Sex category (female
gender)

Question 18

Afib. CHA2DS2-VASc

Congestive Heart
Failure/LV dysfunction
Hypertension
Age >= 75 y.o (2points)
Diabetes Mellitus
Stroke/TIA/TE (2 points)

Vascular disease
Age 65-74
Sex category (female
gender)

Jeigu <65 - 0 points

Answer 18

Male 0/female 1 = no drug
Male 1/female 2 = anticoagulation needed

female visada tures uz lyti bent 1 taska.

Where the CHADS2 score is 1 (moderate risk) then either aspirin or anti-coagulants can be offered

Patients with 2 or more points should receive full anticoagulation with warfarin, dabigatran, rivaroxaban or apixaban.

Question 19

M. Afib.

Question 20

M. Afib.
Some students will ask about NOACs, e.g., apixaban, etc., for non-valvular AF àI’ve never seen NBME care about this stuff. They seem to be pretty old- school and just have warfarin as the answer, probably because there isn’t debate around whether it can be used; use of NOACs is less textbook.

Answer 20

.

Question 21

M. Afib. AF patient should also be on rate control before rhythm control.

Answer 21

.

Question 22

AF patient should also be on rate control before rhythm control.

Answer 22

The USMLE actually doesn’t give a fuck about this component of management, although in theory metoprolol or verapamil is standard. You could be aware for Step 3 that flecainide is first-line for rhythm control if patients fail rate-control and have a structurally normal heart and no coronary artery disease.

Question 23

M. Afib. NBME for 2CK AF who has hemodynamic instability (i.e., low BP). , Mx?

Answer 23

NBME for 2CK has “electrical cardioversion”

Question 24

M. Afib. What you need to know is: sometimes AF can trigger “rapid ventricular response,” where HR goes >150 and low BP can occur.

Answer 24

.

Question 25

M. Atrial flutter. Low yield.

Answer 25

nebuvo pas mehlman nieko. bet tooth-wave ecg. Mx kaip afib.

Question 26

M. Ventricular tachycardia (VT). HIGH YIELD!!!. Causes wide-complex QRS complexes (>120 ms; normal is 80-120 ms).

Answer 26

.

Question 27

M. Ventricular tachycardia (VT). Exceedingly HY for 2CK that you know VT is wide-complex, whereas SVT is narrow-complex.

Answer 27

.

Question 28

M. Ventricular tachycardia (VT). complexes look wide like mountains. Tx? stable

Answer 28

VT is treated with anti-arrhythmics – i.e., amiodarone.

Question 29

M. Ventricular tachycardia (VT). Tx? UNstable

Answer 29

If patient has coma or hemodynamic instability (low BP), the NBME answer is direct current countershock or cardioversion (same thing).

Question 30

M. Ventricular tachycardia (VT). Premature ventricular complex (PVC) is asked on 2CK. Wide complex (meaning ventricular in origin) that occurs earlier (hence premature). What they do on the NBME is show you this strip and ask where this abnormality originates from, then the answer is just “ventricle.” Tx?

Answer 30

Don’t treat PVCs on USMLE.

Question 31

M. Supraventricular tachycardia (SVT). Causes narrow / needle-shaped complexes. Make sure you’re able to contrast this with VT above, which is wide-complex.

Answer 31

Notice the complexes are narrow / look like needles. This means the tachy originates above the ventricles (hence SVT).

Question 32

M. Supraventricular tachycardia (SVT). Treatment of SVT exceedingly HY on 2CK. First step is????

Answer 32

is carotid massage (aka vagal maneuvers).

Question 33

M. Supraventricular tachycardia (SVT) Treatment of SVT exceedingly HY on 2CK. First step is (IN PEDS WHAT CAN WE DO)????

Answer 33

In pediatrics, they can do icepack to the face.

Question 34

M. Supraventricular tachycardia (SVT) If carotic massage/ice pack doesnt work, next step in Tx?

Answer 34

If the above doesn’t work, the next step is give adenosine (not amiodarone).

Question 35

M. Supraventricular tachycardia (SVT) Same as with VT, if the patient has coma or low BP,Tx?

Answer 35

Shocking the patient is the first step. In other words, for both SVT and VT, you must shock first in the setting of coma or hemodynamic instability. It’s for stable SVT and VT that the treatments differ on USMLE.