Systemic, Congenital, Pericardial Flashcards
(36 cards)
1
Q
What is required for the diagnosis of acute pericarditis?
A
- ► 2 of the following:
- Chest pain
- sharp, pleuritic, improved by sitting up and leaning forward
- Pericardial friction rub
- EKG changes
- widespread ST-elevation or PR depression
- New or worsening pericardial effusion
- Chest pain
2
Q
What are the diagnostic criteria for recurrent pericarditis?
A
- All 3 criteria must be present:
- Documented first attack of acute pericarditis
- Symptom-free interval of ► 4-6 weeks
- Evidence of subsequent recurrence of pericarditis
- Labs (WBC, ESR, CRP)
- pericardial friction rub
- EKG changes
- Echo evidence of worsening pericardial effusion
3
Q
What are high risk features of pericarditis that warrant hospitalization?
A
- Fever ( F > 38 C)
- Anticoagulants
- Trauma
- Subacute onset
- Large pericardial effusion
- Immunosuppression
- Tamponade
- Myocarditis (concomitant)
4
Q
What is the treatment for acute pericarditis?
A
- NSAID x 2-4 week (taper)
- Colchicine x 3 months
- prevents recurrence
5
Q
When are glucocorticoids used in pericarditis?
A
- unable to take NSAID therapy
or
- special conditions
- autoimmune disease
- renal failure
- pregnancy
- concomitant anticoagulant therapy
6
Q
Describe the stepwise protocol for recurrent pericarditis
A
7
Q
What is required for diagnosis of metabolic syndrome?
A
► 3 of the following criteria
- abdominal obesity / waist circumference
- men ► 102 cm
- women ► 88 cm
- TG > 175
- HDL:
- men < 40
- women < 50
- BP ► 130 / 85
- Fasting plasma glucose ► 100
8
Q
A
9
Q
What are causes of RAD?
A
- Dextrocardia
- Ostium secundum ASD
- Lead reversal
- LPFB
- Lateral MI
- Vertically positioned heart
- COPD
- PE
10
Q
What are causes of prominent U waves?
A
- Most commonly found with:
- Hypokalemia
- Bradycardia
- Less common causes:
- Hypocalcemia
- Hypomagnesemia
- Hypothermia
- HCM
- Elevated intracranial pressure
- LVH
- Drugs
- Digoxin
- Class Ia (Quinidine, Procainamide)
- Class III (Amiodarone, Sotalol)
11
Q
Describe the findings:
A
RV VT with LBBB morphology / ARVD
12
Q
Describe the findings and diagnosis
A
ARVD
- Epsilon waves
- TWI in V1-V3
- Prolonged S-wave upstroke of 55 ms in V1-V3 (95% of patients)
- Localized QRS widening of 110 ms in V1-V3
- Paroxysmal episodes of VT with LBBB morphology
13
Q
What medications used in A-fib can cause increased serum Digoxin levels when used concomitantly?
A
- Verapamil
- Amiodarone
- Dronedarone
- Quinidine
- Rivaroxaban
- Apixaban
- Erythromycin, Clarithromycin
- Cyclosporine
- Ketoconazole
- Itraconazole
****P-glycoprotein inhibitors (in bold)
14
Q
Describe the findings and treatment:
- 30 year old, healthy, relatively asymptomatic patient
A
Idiopathic LV (fascicular) VT
- Re-entrant tachycardia involving most commonly the left posterior fascicle
- EKG
- mildly wide complex tachycardia
- RBBB-like morphology
- superior or left axis
- Treatment:
- Verapamil
- rhythm is highly sensitive to verapamil
- low-risk tachycardia –> catheter ablation of fascicle is usually curative
15
Q
Describe the differential/algorithm for narrow QRS tachycardia (QRS < 120 ms)
A
16
Q
What is the recommended medical therapy in a patient with:
- Brugada syndrome
- ICD and shocks
- Recurrent VT
A
Quinidine or Catheter Ablation
- Class Ia antiarrhythmic
- Ito and IKr blocker effects
- Class I recommendations
17
Q
Describe localization of AP using surface EKG
A
20
Q
What is the diagnosis and next best step?
- 30 year old male with syncope (x2 in the last year while exercising)
- No medical problems or medications
- FH: Uncle died at 34 in drowning accident
*
A
- Brugada syndrome
-
EKG with high precordial leads
- recording V1 and V2 in second and third intercostal space can assist in the diagnosis of borderline cases
22
Q
What are the indications for ICD placement in Brugada syndrome?
A
- Confirmed Brugada syndrome
and
- Cardiac arrest or Recent unexplained syncope
23
Q
Describe localization of VT site of origin on EKG
A
QRS morphology = VT circuit exit site
- V1
- LBBB morphology
- RV or
- Septum
- RBBB morphology
- LV
- LBBB morphology
Precordial leads = sagittal plane origin
- V3, V4, V5
- R waves dominant
- Basal
- S waves dominant
- Apical
- R waves dominant
QRS axis = coronal plane origin
- Axis (inferior leads)
- Inferior axis (Positive inferior leads)
- Anterior or
- Lateral
- Superior axis (Negative inferior leads)
- Inferior
- Inferior axis (Positive inferior leads)
24
Q
What are the recommendations for ICD placment:
- Hypertrophic Cardiomyopathy
A
- Class I
- SCD (resuscitated)
- Spontaneous VT with syncope
- Class IIa
- LV wall thickness ► 30 mm
- 1st degree relative with SCD caused by HCM
- Syncope (unexplained)
- Class IIb
- NSVT (on ambulatory monitoring) without other risk factors
25
Q
What are the recommendations for ICD placment:
- ARVC
A
- Class I
- SCD (resuscitated)
- RVEF or LVEF « 35%
- Class IIa
- Syncope (presumed due to VA)
26
Q
What are the recommendations for ICD placment:
- Cardiac Sarcoidosis
A
- Class I
- SCD (resuscitated)
- VT (sustained)
- LVEF « 35%
- Class IIa
- Syncope
- Myocardial scar by MRI or PET
- Positive EPS for inducible VT
- Indication for PPM
27
Q
What are the recommendations for ICD placment:
- LQTS
A
Class I
- SCD (reuscitated)
- High risk patients in whom BB is ineffective or not tolerated
- < 40 years of age
- Females with LQTS 2
- LQTS 2 and 3
- onset of symptoms < 10 years of age
- prior cardiac arrest or recurrent syncope
- QTc > 500 ms
Class IIb
- Asymptomatic patients, QTc > 500 ms on BB
28
What are the recommendations for ICD placment:
* CPVT
Class I
* Recurrent VT or syncope while on maximal medical therapy (BB, Flecainide)
29
What are the recommendations for ICD placment:
* Brugada Syndrome
Class I
* Cardiac arrest or recent unexplained syncope
+
* spontaneous type 1 EKG pattern
35
Describe the prevalence of LQTS, mutations involved and channels involved in the mutations
**90% of cases** (1:300-7,000)
* LQT1 (***KCNQ1***)
* encoding for the **potassium current IKs**
* LQT2 (***KCNH2***)
* encoding for the **repolarizaing potassium current IKr**
* LQT3 (***SCN5A***)
* encoding for the alpha subunit of the sodim channel that conducts the **depolarizing sodium current INa**
36
What is a major distinguishing feature between Idiopathic LV and RV outflow tract VT?
**Precordial transition point**
* LVOT VT
* early precordial transition or
* broad initial R wave in V1, V2
* RVOT VT
* late precordial transition, typically leads V3-V4
\*\*\*\* LBBB morphology + Inferior axis in both
38
What are risk factors for arrhythmia in Brugada Syndrome?
* **Fever**
* **SCN5A** channel is temperature sensitive
* Alcohol (heavy use)
* Cocaine
* Precipitating medications
* Fluoxetine
* Sodium channel blockers (INa)
* Propofol
* Lithium
* Antihistamines
* TCA's
* Trifluoperazine
* Heavy metals
39
How can you differentiate AS and HOCM on intracardiac pressure tracings?
**Post-PVC**
* **Pulse Pressure**
* HOCM --\> decrease
* AS --\> increase
* **Gradient**
* ****Both --\> INCREASE
**Valsalva**
* **Gradient**
* ****HOCM --\> increase
* AS --\> decrease
* **Pulse Pressure**
* Both --\> DECREASE
40
What mechanical prosthetic valves require bridging anticoagulation?
* Bileaflet aortic valve with increased thromboembolic risk factors
* Caged ball or tilting disc prosthesis
* Mitral valve prosthesis
* Recent CVA/TIA
41
Describe the management of chronic, severe MR
* Primary, Severe MR
* Asymptomatic
44
Describe the algorithm in evaluating aortic prosthesis with PV \> 3 m/s
45
Describe the frequency of monitoring in MS
* Progressive (stage B)
* MVA \> 1.5 cm2 --\> **every 3-5 years**
* Severe (stage C)
* MVA 1 - 1.5 cm2 --\> **every 1-2 years**
* Very severe
* MVA \< 1.0 cm2 --\> **every 1 year**
46
What is the severity scale for aortic prosthetic valves?
* Peak velocity
* Normal \< 3 m/s
* Possible stenosis 3-4 m/s
* Significant stenosis \> 4 m/s
47
What is the severity scale for mitral prosthetic valves?
* PHT
* Normal \< 130 ms
* Possible stenosis 130 - 200 ms
* Significant stenosis \> 200 ms
