PP EM Cardiology Flashcards
(141 cards)
1
Q
How is a 12 lead EKG organized? What are the corresponding major vessels?
Anterior?
A
Anterior
Leads= v3, v4
Vessel= Diagonal branch of the left anterior descending artery
2
Q
How is a 12 lead EKG organized? What are the corresponding major vessels?
Septal?
A
Septal
Leads= v1, v2
Vessel= Septal branch of the left anterior Descending Artery
3
Q
How is a 12 lead EKG organized? What are the corresponding major vessels?
Lateral?
A
Lateral
Leads= Lead I, AVL, V5, V6
Vessel= Left Circumflex
4
Q
How is a 12 lead EKG organized? What are the corresponding major vessels?
Inferior?
A
Inferior
Leads= Lead II, III, AVF
Vessel= Right Coronary Artery
5
Q
What is the progression of EKG Changes seen in hyperkalemia?
A
Normal K 3.5 - 5.0
K+ 5.5-6.5
Peaked T waves (V1, V2, AVR)
Short QT
K+ 6.5-8.0
Wide QRS, Long PR, Flat P waves
K+ >8.0
Loss of P waves, Wide QRS,
Interventricular/bundle branch blocks, Sine wave
6
Q
How is low voltage defined on an EKG?
A
Adding the QRS measurement of Leads I, II, & III.
Less than 15mm total.
or
Adding the QRS measurements of leads V1, V2, V3.
Less than 30mm Total
7
Q
What causes low voltage on an EKG?
A
Decreased ability of EKG leads to detect the signal.
Pericardial effusion
Pleural Effusion
COPD
Obesity
8
Q
Which Electrolyte derangements are associated with a prolonged QTc?
A
Hypokalemia
Hypomagnesemia
Hypocalcemia
9
Q
How is ST Elevation Myocardial infarction (STEMI) Diagnosed?
A
ST Elevation of >1mm in two contiguous leads ina ll leads except V2 & V3.
For Leads V2 and V3:
Women = ST Elevation >1.5mm
Men >40 = ST elevation >2mm
Men <40 = ST elevation >2.5mm
10
Q
What are some STEMI equivalents?
A
deWinters T Waves
Wellens syndrome
Hyperacute T waves in 2 or more contiguous leads
Sqarbossa criteria present for LBBB
Posterior MI
Isolated T Wave Inversion in AVL
ST elevation in AVR with diffuse ST depression in 6 or more leads
11
Q
What are seven conditions that may cause ST elevation on an EKG?
A
STEMI
Pericarditis
Prinzmetal Angina
Hyperkalemia
Early repolarization
LV aneurysm
Hypothermia
12
Q
What Mnemonic is used to show what leads show reciprocal changes in MI?
A
PAILS
AILSP
Posterior MI Results in ST depression in Anterior Leads
Anterior MI Results in ST depression in Inferior Leads
Inferior MI Results in ST depression in Lateral Leads
Lateral MI Results in ST depression in Septal Leads
Septal MI Results in ST depression in Posterior Leads
13
Q
What Is the reciprocal change for a
Posterior MI
A
Anterior Depression
Posterior MI Results in ST depression in Anterior Leads
PAILS
AILSP
14
Q
What Is the reciprocal change for an
Anterior MI
A
Inferior Depression
Anterior MI Results in ST depression in Inferior Leads
PAILS
AILSP
15
Q
What Is the reciprocal change for an
Interior MI
A
Lateral depression
Inferior MI Results in ST depression in Lateral Leads
PAILS
AILSP
16
Q
What Is the reciprocal change for a
Lateral MI
A
Septal Depression
Lateral MI Results in ST depression in Septal Leads
PAILS
AILSP
17
Q
What Is the reciprocal change for a
Septal MI
A
Posterior Depression
Septal MI Results in ST depression in Posterior Leads
PAILS
AILSP
18
Q
What is the morphology of Wellen’s Syndrome on an ECG?
A
Type A (25% of cases) - Biphasic T wave in leads V2, V3
Type B (75% of cases) - Deep, symmetric T wave inversions in leads V2, V3
19
Q
What are the clinical implications of Wellen’s Syndrome?
A
Highly specific for critical stenosis of the LAD
These patients should not undergo stress testing and should instead go for PCI
They do not typically respond to medical management, hence the need for PCI.
20
Q
When is Sgarbossa’s criteria applied?
A
Paced ECG and patients with left bundle branch block.
21
Q
What is Sgarbossa Criteria?
A
STEMI equivalent if any of the following are present:
Concordant ST segment elevation in any lead
Concordant ST segment depression in V1-V3
Discordant ST segment elevation >5mm
22
Q
What classic ECG pattern can be seen in a patient with cardiac tamponade?
A
Electrical alternans
23
Q
What ECG Changes can be seen in the setting of an aortic dissection?
Why?
A
ST elevation in inferior leads due to dissection into the right coronary artery.
Signs similar to pericarditis or electrical alternans due to pericardial effusion.
24
Q
What ECG finding can be seen in the setting of hypothermia?
A
Osborn Waves
25
What are the ECG findings in a person with Wolf Parkinson White Syndrome?
Delta Waves (slurring upstroke of the QRS)
Short PR Interval
26
What are the ECG findings in a patient with benign early repolarizations?
Diffuse concave ST elevations, mostly in the precordial leads
Notching or slurring of the J point
ST elevation in less than 25% of the T wave amplitude in V6
ST elevation usually <2mm in the precordial leads and <0.5mm in the limb leads
No reciprocal changes
No dynamic changes
27
What are the common risk factors for ACS?
```
Diabetes
HTN
HLD
Family history
Male Gender
Obesity
Prior history
Sedentary Lifestyle
Family History of MI
```
28
Which patient population often present with nonclassical symptoms of an MI?
Women
Elderly
Diabetics
29
What are the atypical symptoms of an acute MI?
Sharp, Burning, discomfort or pain free, no radiation, exertional fatigue / SOB, Lightheadedness
30
What are the typical symptoms of an acute MI?
Substernal chest pressure that radiates to the left arm or jaw and worsens with exertion
31
What are the typical symptoms
and
Atypical symptoms
of an acute MI?
Typical:
Substernal chest pressure that radiates to the left arm or jaw and worsens with exertion
Atypical:
Sharp, Burning, discomfort or pain free, no radiation, exertional fatigue / SOB, Lightheadedness
32
What is the first sign of an acute MI on ECG?
Hyperacute, wide, tall, T waves
33
What is the first sign of an acute MI on ECG?
| What is the subsequent progression of changes on ECG in an acute MI?
First Sign: Hyperacute, wide, tall, T waves
```
Subsequent Changes:
Hyperacute T waves,
ST elevation,
Q Waves with T wave inversion
ST elevations improve
T waves Normalize, Q waves persist
```
34
What is the HEART score?
A risk stratification tool for ACS in patients who are presenting with chest pain.
```
It is composed of:
History
ECG
Age
Risk factors
Troponin value
```
35
What cutoff for the HEART score is safe to discharge?
Typically a heart score <4 may go home if they have close outpatient cardiology follow up.
Scores of >4 or with poor outpatient follow up should be considered for admission and further testing.
36
What dosing of aspirin should be administered in a patient with evolving ACS?
At least 161mg,
| typically 324mg
37
Why is aspirin chewed and not swallowed?
Chewing increases surface area for rapid absorption and facilitates faster platelet inhibition
38
What 2 medications are shown to improve outcomes in patients with acute MI?
Aspirin
Beta Blockers
(within first 24 hours)
39
What is the most common type of MI?
Inferior wall MI
40
What is "broken heart Syndrome"
STEMI appearance on ECG with possible elevation in troponin but with a clean cath
Echo will show regional wall motion abnormalities
Also know as Takosubo cardiomyopathy, thought to be induced from extreme catecholamine release related to severe emotional stress
41
Does resolution of chest pain after nitro prove ACS?
Does reproducible Chest pain?
Does negative troponin and a normal ECG?
No
| Unstable angina is part of the spectrum of ACS
42
HFrEF Treatment (Sarah)
```
BB
Entresto
Spironalacto
SGLT2
Statin (likely)
```
Ivabradine for tachycardia
Loop for fluid/edema
43
HFpEF Treatment (Sarah)
Spiro
Loop
SGLT2
Treat symptoms/ conditions ie HTN, DM, AFIB
44
Post Stent Treatment (Sarah)
Aspirin (DAPT)
Plavix
BB
Statin (Atorvastatin)
Nitro
<40EF Entresto (can use ACE/ARB)
45
Asymptomatic <40 EF (Sarah)
Use ACE/ARB over Entresto
46
AFIB (symptomatic) (Sarah)
Dilt drip over night
if don't convert
TE Cardiovert
47
AFIB with high chads vasc (Sarah)
DOAC
Metoprolol or Dilt (first line metoprolol)
No CCB if bad EF
48
ATTR Amyloidosis Treatment (Sarah)
Tafamidis
49
What biomarkers are elevated in the presence of an MI?
Myoglobin (First)
CK-MB
Troponin I
Troponin T
50
What biomarker elevates in the presence of an MI First?
Myoglobin
51
What is stable vs unstable angina?
Stable angina =
Predictable cardiac chest pain that occurs with exertion and resolves with rest
Unstable angina =
Cardiac chest pain in the absence of elevated cardiac markers or ST elevation on ECG
52
Stable angina
Stable angina =
| Predictable cardiac chest pain that occurs with exertion and resolves with rest
53
Unstable angina
Unstable angina =
| Cardiac chest pain in the absence of elevated cardiac markers or ST elevation on ECG
54
What is an NSTEMI?
Non ST elevation myocardial infarction
Cardiac chest pain with elevation of troponin in the absence of ST elevation of ECG
55
What is the normal pulse pressure at rest?
30-40mmhg
56
What are some etiologies of a narrow pulse pressure?
```
Significant blood loss
Aortic stenosis
Tachycardia
Pericardial effusion
Constrictive pericarditis
```
57
What are some etiologies of a wide pulse pressure?
```
Systolic HTN
Aortic regurgitation
Severe anemia
Thyrotoxicosis
Pregnancy
AV fistula
Thiamine deficiency
Congenital anomalies (PDA, COA)
```
58
What happens to a pacemakers function when a magnet is placed on it?
Turns off the sensing capability and resets pacemaker to a fixed rate.
59
What happens to the defibrillator function when a magnet is placed on an AICD?
Turns defibrillator function off
60
What are some indications for pacemaker insertion?
```
CHF with EF <25%
Symptomatic sinus bradycardia
Mobitz Type II (second degree AV block)
Third degree AV Block
Sick sinus syndrome
Frequent episodes of V-Tac
```
61
What are pacemaker codes?
There are 5 of them but the first 3 are the most important in the ED.
Informs which chambers are paced
Which chambers are sensed
and the response of the sensing
62
What are some complications most commonly seen during the first 6 weeks of pacemaker placement?
```
Hemopneumothorax
Bleeding
Venous in the SVC/Subclavian veins
Air embolism
Post-operative infection
Lead displacement
```
63
What is failure to capture?
The pacemaker sends a signal
| but the myocardium does not depolarize
64
What is failure to pace?
Pacemaker does not send the signal to the myocardium
65
What is failure to sense?
Pacemaker does not recognize the the myocardium has depolarized
66
What does it mean to interrogate a pacemaker?
A special device is placed over the pacemaker and electronically connects to the pacemaker
The machine prints out when the pacemaker fired and why.
It will detect if overdrive pacing has occurred in an AICD
It will tell you if any shocks were delivered
It can also tell you about what rhythms the patient has been in and when
67
What is the treatment of a patient who gets on shock form their AICD?
HPI to assess for repetitive arm movement that might have falsely triggered AICD
Interrogate the AICD to determine why it went off
Observe in the ED and then close outpatient follow up with EP
68
What is the treatment for a patient who gets repeated shocks from an AICD?
Typically these patients are admitted
(Same as single shock)
HPI to assess for repetitive arm movement that might have falsely triggered AICD
Interrogate the AICD to determine why it went off
Observe in the ED and then close outpatient follow up with EP
69
What is the definition of an electrical storm?
3 or more appropriate shocks in a 24 hour period
70
What is Twiddlers syndrome?
Dislodgment of pacemaker wires and malfunction of the pacemaker from external manipulation by the patient
71
When analyzing tachycardiac rhythms, what are common ways to categorize them?
Wide vs Narrow
Stable vs unstable
72
A narrow complex tachycardia indicates that the rhythm is originating in which part of the heart?
Supraventricular (above the ventricle)
73
In which cases will supraventricular tachycardia (SVT) appear to be a wide complex rhythm?
SVT with underlying bundle branch block or WPW
74
What etiologies of a wide QRS need to be considered?(Tachy or not)
Hyperkalemia
Acidosis
NA+ channel blockers
75
How is Torsades de Pointes Treated?
IV Mag
If refractory to Mag:
Overdrive pacing
Consider Isoproterenol
Cardioversion used in the unstable patient
Defibrillation used in the pulseless patient
76
What treatment should be attempted first in a stable patient with SVT?
Vagal maneuvers
REVERT Procedure (modified valsalva)
77
What medication (including dosage) is used in a stable patient with SVT?
Adenosine 6mg
2nd dose is 12mg
Push it fast then follow with a fast flush push
78
How is SVT in the unstable patient treated?
Synchronized cardioversion
79
What is happening when the synchronization function is turned on?
T Waves are detected to prevent delivering a shock during repolarization
80
Why is hitting the synchronized function so important when cardioverting?
Prevents R on T phenomenon which leads to ventricular fibrillation
81
If unable to determine if the rhythm is V tach or SVT with Wide QRS, how should it be approached?
Treat as V Tach
82
What is atrial fibrillation?
Irregular and uncoordinated atrial electrical activity
No discernable P waves
Can be narrow or wide complex
83
What term is used to describe an atrial fibrillation rhythm?
Irregularly irregular
84
What is atrial fibrillation with rapid ventricular Response?
A FIB with RVR
Tachycardic atrial fibrillation where the ventricle is hypersensitive to the irregular atrial electrical activity, resulting in rates >120bpm
85
Treatment of A FIB with RVR should be focused on what two priorites?
Identifying underlying causes of A FIB with RVR to focus treatment
Restoring a normal rate or rhythm (depends on time of onset)
86
A patient with previously undiagnosed atrial fibrillation should be evaluated for what potential endocrine etiology?
Hyperthyroidism
87
If a patient with atrial fibrillation, with or without RVR, is unstable due to the rhythm, what is the preferred treatment?
Synchronized cardioversion
88
Why is rhythm control (synchronized cardioversion or medication) not always used to treat A FIB?
After 48hrs of continuous A FIB, an atrial thrombus can develop
May result instroke if rhythmically converted
89
What two classes of medications are used for rhythm control in A FIB?
What determines which medication is used for rate control?
Medications: CCB, BB
Choice depends on:
Provider preference
Patients current medications...
(If already on one, try more of it)
Beta Blockers preferred in CHF Patients
90
What scores are used to help determine the need for anticoagulation in a patient with atrial fibrillation?
CHA2DS2-VASc
| HAS-BLED
91
What is the preferred oral anticoagulant per the American College of Cardiology?
DOAC's
Direct Oral Anticoagulants
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
92
If the patient has mechanical valves, what anticoagulant is used?
Warfarin
Goal INR of 2.5-3.5
93
What is the path of the cardiac conduction system?
```
SA Node
AV Node
Bundle of His
Bundle Branches
Purkinje Fibers
```
94
What causes a bradycardic rhythm?
Impaired conduction at the SA or AV node
Can be intrinsic or extrinsic
Impaired conduction through the His-Purkinje system
95
What are soe extrinsic causes of bradycardia?
```
MI
Hypothermia
Electrolyte imbalance (ie Hyperkalemia or hypoglycemia)
Infection (ie sepsis)
Intracranial hemorrhage
```
Medications
BB, CCB, Digoxin, Clonidine, Opiates, ethanol, anticholinesterase meds (ie aricept)
96
What initial determination needs to be made in a patient presenting with a heart rate of 38 bpm?
Hemodynamically stable?
Check mental status
BP (ie hypotension)
97
Why can bradycardia lead to hemodynamic instability?
Bradycardia can lead to reduced cardiac output
```
Cardiac output (CO) =
Heart Rate (HR) x Stroke Volume (SV)
```
CO = HR x SV
98
What medication can be used to increase the heart rate in bradycardia?
Atropine
99
If atropine does not increase the HR, what other medication could be considered in bradycardia?
Epinephrine
100
What is a common electrolyte abnormality that causes bradycardia and often makes the rhythm difficult to treat until the imbalance is addressed?
Hyperkalemia
Often presenting as a bradycardic high degree block
101
What is the treatment alternative to atropine for a patient that is hemodynamically unstable patient?
Cardiac Pacing
102
What are the typical presenting symptoms of a patient experiencing heart failure?
Dyspnea
Edema (pulmonary or peripheral)
Fatigue
103
Which race has the highest incidence of heart failure?
African American
104
What is one method to characterize heart failure that is determined with an echocardiogram?
Ejection Fraction (EF)
Impaired ejection fraction <40% = HFrEF
Preserved ejection fraction >50% = HFpEF
105
What symptoms result from left sided heart failure?
Pulmonary edema
Hepatomegaly
Vascular congestion
106
What is the most common cause of right sided heart failure?
Left sided heart failure
107
What is acute heart failure?
| What causes acute heart failure?
An acute event that causes inadequate cardiac output
```
Causes:
Acute myocardial infarction
Valvular rupture
Infection
Dysrhythmia
```
108
How does acute heart failure typically present?
Flash pulmonary edema
| Hypotension (cardiogenic shock)
109
What triggers a patient with chronic heart failure to have an acute exacerbation?
Triggers:
Non compliance (meds and diet)
Infection, anemia, cardiac ischemia
```
Presentation
Worsening dyspnea (often exertional)
Lower extremity edema
Orthopnea
fatigue
Weight gain
```
110
What physical exam findings are often present in a patient with heart failure exacerbation?
```
Tachycardia
Increased work of breathing
Presence of rales, rhonchi
diminished lung sounds
JVD
Hepatojugular reflex (due to hepatic congestion)
```
111
What is cardiogenic shock?
End organ damage caused by inadequate perfusion secondary to decreased cardiac function
112
Are patients with cardiogenic shock fluid overloaded?
Possibly, but they may also be intravascularly depleted with interstitial edema
113
When performing a lung Ultra Sound on a patient with concerns for heart failure, what finding indicates pulmonary edema?
B lines
114
What are some x ray findings in someone who has decompensated congestive heart failure?
```
Cardiomegaly
Pulmonary congestion
Pleural Effusion
Kerley B Lines
Alveolar edema (Bat wing Opacities)
```
115
What are initial treatment measures for decompensated congestive heart failure?
IV, O2, Monitor
Sublingual Nitroglycerin
NIPPV (non invasive positive pressure Ventilation)
Furosemide
116
If a decompensated heart failure patient is hypotensive, what type of shock are they in?
Cardiogenic shock (Pump Problem)
117
What is the approach to managing a patient in cardiogenic shock?
NIPPV (non invasive positive pressure Ventilation)
First,
Intubation as a last resort after resuscitation
Caution: can result in decreasing preload due to increased intrathoracic pressure
Gentle resuscitation of 250-500cc boluses
Early Vasopressors: Norepi or Epi
Inotrope: Dobutamine if additional support is needed after vasopressor
118
A patient is sent to the ED due to concerns for elevated BP discovered at an employee health screening. The patient is asymptomatic, how should they be worked up?
Consider ECG, If asymptomatic follow up with PCP, Patient does not need ED, Consider initialization of a low dose BP med to bridge until PCP follow up, (HCTZ or ACE)
119
What determines ED treatment for hypertension?
Profound elevation (>180 systolic and/or 120 diastolic) with signs of end organ damage.
120
What is the term used to describe the patient with hypertension and end organ damage?
Hypertensive emergency, ***(the term Hypertensive urgency is no longer used??)
121
Does the degree of BP elevation correlate to the severity of symptoms?
No the severity of symptoms does not correlate with level of BP
122
If a patient requires emergent treatment of their BP, what is the target reduction in the first hour?
25%
123
JNC 8 (joint national committee) defines normal blood pressure as what?
120/80
124
When can a patient with hypertensive emergency be transitioned from IV medication to Oral medication?
After 12-24 hours of successful BP control
125
What is endocarditis?
Infection with associated vegetations of cardiac valves, native or prosthetic, or indwelling cardiac devices
126
What is the common scoring tool that is used to help diagnose endocarditis?
Duke Criteria
127
What is the most common presenting symptom in patients with endocarditis?
Fever, Seen in 90% of acute cases
128
What imaging modality is best to determine the presence of a valvular vegetation?
Cardiac echo (TEE is more sensitive, TTE is more available)
129
What physical exam finding is observed in 85% of patients with endocarditis?
Cardiac murmur
130
What are some non cardiac exam findings that are concerning for endocarditis?
Janeway lesions (Painless Hands/feet), Osler nodes (Painful nodules on tips of fingers and toes), Roth's spots (Retinal hemorrhages with pale center)
131
What is a significant pulmonary complication seen in endocarditis?
Septic Pulmonary Emboli
132
What is the most common site for metastatic infection from endocarditis?
CNS (up to 20% of patients)
133
What organisms are commonly involved with endocarditis?
Staph > Strep, (Consider MRSA)
134
In patients with prosthetic valves undergoing an invasive procedure, what prophylaxis medication is indicated?
Amoxicillin (i.e. Cephalexin if PCN allergy)
135
What is pericarditis?
Inflammation of the pericardium (two layers of sac like tissue surrounding the heart), (there is normally a small amount of fluid naturally between the 2 layers to decrease friction)
136
How is acute pericarditis diagnosed?
Clinical diagnosis that includes at least 2 of the following criteria: Chest pain - typically pleuritic, worse when lying flat and improved when sitting upright. ECG abnormalities - (diffuse ST elevation, PR depression). Pericardial friction Rub, Pericardial effusion (acute or acute on chronic)
137
What alternative etiology must often be considered in a patient with suspected pericarditis?
STEMI
138
What ECG characteristics can help differentiate between STEMI and pericarditis?
Pericarditis will not have reciprocal changes and will have PR segement depression, STEMI should have reciprocal depression, will often be dynamic, and ST elevation in lead III > Lead II
139
Will a patient with pericarditis have an elevated troponin?
No, does not have any effect on myocardium
140
What is the treatment for pericarditis?
NSAIDS and Colchicine
141
How long should a patient be on NSAIDs to prevent recurrence of pericarditis?
At least 6 months
