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midterm 2 Flashcards

1
Q

what are we looking for with atrial hypertrophy

what would we see normally

A

look at V1
and II

normally you have a little cute P wave in II and a biphasic in V1

With RAH you have a peaked P in II and a peaked by in V1

with LAH you have a notched P wave in II and a negative biphasic wave in V1

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2
Q

what causes RAH (4)

A

pulmonary HTN
COPD
Tricuspid stenosis
congenital

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3
Q

what causes LAH

A

mitral stenosis

combined with LVH

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4
Q

Causes of LVH

A

aortic stenosis
mitral incompetence
HCM
HTN

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5
Q

criteria for LAH

A

Less than 1 box

notched P in I and II

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6
Q

criteria for RAH

A

greater than 1 small bok in V1 and

>2.5mm P in II

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7
Q

other than lead II where else would you expect to see a peaked p in a pt suspected of RAH

A

II AVF (all inferior)

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8
Q

lateral precordial and coronal leads

A

I

V5 and V6

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9
Q

RVH

A

V1–>V4

very large R wave
RAD in the is usually seen

usually you have a very small R with negative S in these leads

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10
Q

when attempting resuscitation of cardiac arrest what is not shockable

A

PEA asystole

only vtach and vfibb are shockable

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11
Q

how do you distinguish wandering pacemaker from MAT

A

MAT is wandering pacemaker over 100

remember we are seeing a P prime wave in all of these because it is not sinus paced

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12
Q

why do we see MAT

A

COPD or digitalis toxicity

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13
Q

no single impulse is depolarizing the atrium in this tachy that is seen with occasional impulse escape causing ventricle depolarization

A

A fibb

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14
Q

what is the increase in stroke associated with a fibb

A

fivefold

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15
Q

what is the increase in dementia associated with a fibb

A

twofold

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16
Q

what is the increase in heart failure associated with a fibb

A

threefold

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17
Q

what is the increase in deatg associated with a fibb for men/women

A

men 50%

women 100%

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18
Q

risk of developing a fibb in adults 40 and older

A

1/4 lifetime risk

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19
Q

supraventricular tachy associated with depolarization of 300-600 bpm

A

a fibb

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20
Q

why does a fibb occur

A

foci and frequency of ectopy increase with remodeling as fo electrical reentry

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21
Q

RF for Afibb

A 
obesity
 OSA
hyperthyroidism
diabetes
cardiomyopathy
heart failure
 LAE
excessive alcohol
and 
genetic predisposition

10!

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22
Q

sxs of a fibb (5)

A 
palpitations
dyspnea
fatigue
exercise intolerance
lightheadedness
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23
Q

MC physical exam finding for afibb

A

irregular and rapid pulse

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24
Q

other than irregular pulse what are some signs of a fibb

A

signs associated with heart failure
ischemic heart dz
and valvular heart dz

murmur, gallop, JVD, atrial bruits, crackles, hepatomegaly, peripheral edema,

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25
how do we evaluate cardiac function and structure in a pt with afibb
TTE | transthoracic echocardiogram
26
what should we do for a pt that has had a fibb
ecg tte blood work (metabolic and thyroid panels)
27
how can you dx transient a fibb
ambulatory rhythm monitoring and mobile telemetry | can use trans esophageal echocardiograph (before cardioversion as this could cause embolus)
28
categories of a fibb
paroxysmal persistent longstanding persistent permanent
29
what is paroxysmal A fibb
AF that terminated spontaneously or with intervention within 7 days and may reoccur with variable frequency
30
what is persistent A fibb
continuous AF (more than 7 days)
31
what is longstanding persistent a fibb
12 months
32
permanent a fibb
joint decision to stop trying | therapeutic attitude
33
two types of therapy for a fibb
rate control- sxs | rhythm control- for pts with sxs despite rate control
34
goal for rate control | and how do we achieve it
under 80 bpm BB non- dihydropyrodine CCB (not in pts with HF) digoxin adjunct to both of these
35
electrical cardioversion success for a fib
success 75-90% returns 40-60% of the times 60-80% of pts in 12 months
36
success of antiarrythmic drugs for pts with a fibb
50%
37
what is the most frequent site of AF electrical triggers and what kind of therapy targets them
MC cite is the pulmonary veins can be targeted with transvenous catheter ablation reoccurrence
38
primary goal of AF managment
stroke prevention
39
what is thought to be the reason for increased stroke risk
decreased blood flow velocity in the left atrial appendage this allows for thrombus formation
40
sxs of pericardial effusion
CP SOB DOE feels better when you lean forward
41
what is the most common EKG finding with pericardial effusion
low voltage QRS
42
electrical alternans points to
cardiac tamponade
43
what is electrical alternans
positively deflected QRS followed by low voltage amplitude | regularly irregular
44
low voltage is defined as a peak to peak QRS amplitude of
<5mm in the limb and or <10 mm in precordial
45
what causes low voltage EKG other than tompanade
``` obesity COPD severe hypothyroidism subcutaneous emphysema massive MI infiltrative/restrictive diseases such as amyloid cardiomyopathy ```
46
what is beck's triad
hypotension JVD muffled heart sounds for cardiac tamponade and pericardiocentiusis beck is eating a muffin with JVD and hypo
47
ecg triad for cardiac tamponade
sinus tachy low voltage electrical alternans
48
POCUS triad
point of care ultrasound pericardial fluid RV diastolic collapse dilated IVC
49
how to determine tahcy junctional rhythm
When assessing a rhythm strip for junctional tachycardia, look for a rate of 100 to 200 beats/min. The P wave is inverted in leads II, III, and aVF and can occur before, during (hidden P wave), or after the QRS complex.
50
paroxysmal tachy rate range
150-250
51
flutter rate range
25-350
52
a fibb range
350-450
53
3 pathophysiologies of a fibb
1. dilation in intra atrial pressure leads to activation of RAAS and atrial remodeling and fibrosis 2. disorganized electrical impulses develop usually originating from pulmonary veins 3. left atrial squeeze is diminished LA appendage is stunned
54
pathophysiology behind a fibb
larger number of ectopic sites can lead to fault atria and low CO or more commonly atria do not empty completely into ventricles because
55
sxs of A fibb
``` palpitations tachycardia DOE fatigue lightheadedness ``` but symptoms are absent in 1/3
56
RVR
the heart rate is on average 150
57
permanent af s also known as
longstanding persistent
58
RF for AF
``` OSA Obesity long standing HTN or CHF /heart dz valvular heart disease cardiac surgery hyperthryoidism genetic predisposition dehydrating factors: viral colonoscopy, cancer, alcohol ```
59
what type of valvular disease are we likely to see leading to A fibb
left sided (mitral regurgitation and mitral stenosis)
60
other than their pathophys origin how do AF stokes differ
more likely to reoccur and are often more fatal
61
where do AF stroke occur
thrombus formation in the left atrial appendage
62
what are the three treatment goals of Afibb
1. prevent embolic stroke through anticoagulation 2. prevent cardiac damage through heart rate control 3. back to normal when necessary
63
what is the stroke assessment?
CHADS2VASC score also want to assess LV function and LA size and function?
64
CHADVASC
``` CHF Hypertension Age over 75 Dm Stroke Vascular disease Age between 64-75 Sex: female ```
65
what medication should you be using based on a pts CHAD score
greater than 2 should be on . OACa if 1 should be on OAC or ASA
66
1 point stands for
clinically relevant non major
67
2 point chad score stands for
clinically relevant risk factor major
68
HASBLED stands for
``` Hypertension abnormal liver/renal stroke bleeding labile INR elderly >65 Drugs or alcohol ```
69
which HASBLED criteria are worth 2 points
abnormal liver or renal and drugs or alcohol because they are two categories
70
goal of anticoagulation therapy
to prevent embolic stoke by reducing thrombus burden in the heart LAA
71
what is the go to anticoagulant for pts with AF
warfarin titrated to an INR 2-3 | normal INR IS 1
72
what do we use HAS-BLED for
Estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care. with a score of 3+ the pt is at increase risk of bleeding need individualized approach
73
Types of NOACs
Xa inhibitors | IIa inhibitors
74
IIa inhibitors -name
dabigatran
75
Xa inhibitors names
rovaroxaban apixaban edoxaban
76
benefits of NOACs what are the CI
no blood testing no food interactions less drug interactions safer bleeding profile contraindicated in mechanical heart valves/ severe mitral stenosis/ESRD
77
how does Warfarin work
2,5,7,9 binds Ca and prevents the factors from forming a fibrin clot (from fibrinogen to fibrin)
78
which Xa inhibitor has low risk of bleeding and mortality benefit
eliquis (apixaban) need to dose twice
79
dabigatran pros and cons
direct thrombin IIa inhibitor superior for ischemic CVA prevention high risk for GI bleed and dyspepsia
80
meds for rate control in AF
``` BB bis met carve neb ``` Non dihydropyrodine CCB (verapamil and dilitizem) Digoxin for synergistic last resort pacemaker
81
when do we have to attempt rhythm conversion
in an unstable pt in emergent setting when comorbidities have destabilized a pt (HF CAD pt with unstable angina) thing of the algorithm unstable with a pulse
82
when should you consider rhythm control (5)
``` symtomatic AF despite rate control difficult rate control pts who have tachycardia mediated cardiomyopathy younger active pts small left atrial size ```
83
target HR in afibb
<110 is lenient <80 is strict need to titrate meds to lower rate based on symptoms with target being 70-90 is the range you want people to be in
84
three types of rhythm control
electrical w/ TEE- echocardiogram of heart with a probe placed in the esophagus Chemical cardioversion with amioderone any medication has a toxic potential though 3. transvenous catheter ablation- radio-frequency and cryotherapy on pulmonary veins (reoccurrence rate is 70-80%)
85
what are we looking at with TEE
Atrial appendage
86
what is the rules around stable rhythm conversion for a pt with a fibb as far as onset and treatment go THERE IS A QUESTION ABOUT THIS
with onset unknown pt must be anti-coagulated fro 4 weeks prior with onset known must occur within 48 hours and no TEE needed
87
how would amiodarone be used
for rhythm control | high success and safe for all types of pts but can only be used for a short time due to EF
88
how does a flutter treatment differ from AF
SVT re-entry tachy use anticoagulation and rate control rhythm control is considered early but doesn't respond well to meds atrial flutter ablation is typically much easier than AF (97%)
89
what is the AF alogrithm
anticoagulation bassed hon HASBLED and CHADSVASC rate control less than 110 to prevent heart damage consider rhythm conversion based on continued symptoms and co morbidities

EKG (7 decks)

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