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249 Cards in this Set
- Front
- Back
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What do we call 1st degree AV-block?
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(Prolongation of the PR interval above 200 ms.)
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Which ventricular conduction defect is characterized by extreme right frontal QRS-axis deviation?
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(Left posterior fascicular block.)
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At least how long is QRS complex in a complete left bundle branch block?
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(120 ms)
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Which QRS axis is described as an extreme right deviation?
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(A right deviation of more than +110°.)
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According to which point of the ST-segment is the extent of ST-depression quantified?
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(We quantify the deviation of the point 60 or 80 ms after the J-point from the isoelectric line.)
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What is the importance of repolarization abnormalities with a complete left bundle branch block?
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(The ST-T changes are consequences of the bundle branch block itself, thus we call them secondary repolarization abnormalities; the usual diagnostic evaluation of ST-segments and T-waves is not possible.)
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What is the "coronary T-wave" like?
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(Symmetrical, peaky, negative T-wave.)
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What are the characteristics of a pathological Q wave, which is the consequence of previous myocardial necrosis?
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(The pathological Q-wave has a duration of at least 40 ms and/or an amplitude at least 25% of the corresponding R-wave.)
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The position of which points qualify the ST-depression to be ascending, horizontal or descending?
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(One should compare the position of the first point of ST-segment (J-point) with the point 60 or 80 ms after the J (J+60 or J+80).)
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Please specify at least three stress testing methods applicable in the diagnosis of coronary artery disease.
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(Treadmill or bicycle-ergometry, pharmacological stress test using dobutamine, dipyridamole or adenosine.)
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What do we call "white-coat hypertension"?
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(If the office blood pressures exceed 140 mmHg systolic or 90 mmHg diastolic value but home measurements are in the normal range.)
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How can myocardial ischemia be detected with echocardiography, if the resting echocardiographic picture is normal?
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(Myocardial ischemia manifests itself during stress echocardiography as a stress-induced segmental wall motion disorder – hypo- or akinesis.)
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What is the velocity of systolic blood flow, under physiologic conditions, through the aortic valve?
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(ca. 0.9-1.7 m/s)
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What do we call the "left ventricular ejection fraction" and what is its normal range?
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(The ratio of the left ventricular stroke volume and end diastolic volume in percent. Normal between 55 and 75%.)
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What is the difference between a myocardial perfusion scintigraphy [SPECT] and a nuclear multiple gated angiocardiography [MUGA]?
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(The former detects perfusion of the myocardium itself, latter shows the blood inside the heart cavities, and depicts the shape and hemodynamic function of the heart cavities.)
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What do we call a viable myocardium?
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(A myocardium that seems to be dead on the basis of its actual mechanical and/or biochemical function, but recovers with time or after improvement of perfusion or oxygenation parameters. The myocardium may then regain its full biochemical, mechanical and electrophysiological functions.)
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What do we call „overdrive suppression”?
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(Overstimulation, stopping a tachycardia using higher-rate stimulation/pacing.)
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In which situations do cardiac patients require dual platelet inhibitor treatment?
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(Following coronary stent implantation or acute coronary syndrome.)
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What do the abbreviations "DES" and "BMS" mean?
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(Drug Eluting Stent, Bare Metal Stent.)
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What do we call a pulse-deficit?
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(The arithmetic difference between heart rate determined by auscultation and the simultaneously recorded radial pulse rate within one minute. Two persons are needed for the detection of a pulse-deficit. Typically seen with atrial fibrillation, less often in multifocal atrial tachycardia or frequently occurring premature ectopic beats. The shorter heart cycles provide only short ventricular filling time and the subsequent ventricular contractions result in hemodynamically impaired ejection with low amplitude pulse waves.)
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Is it possible to detect diagnostic signs of a previous myocardial infarction on the ECG in WPW-syndrome?
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(Usually not because the delta-wave typical in Wolf-Parkinson-White syndrome can mimic or mask pathological Q-waves, making the necrosis-diagnostics impossible.)
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What is the state of the art treatment of symptomatic WPW-syndrome?
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(Invasive electrophysiological -EP- testing and radiofrequency ablation of the Kent bundle.)
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. Which medications are contraindicated at atrial fibrillation with WPW-syndrome?
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(Digitalis and verapamil - they decrease the refractory period of the Kent-bundle, making a higher-rate AV-conduction possible and probable.)
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What are the two main causes of sudden cardiac death?
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(Ventricular rhythm disorder, acute heart failure.)
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In which program-mode do we use the defibrillator for ventricular fibrillation?
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(Asynchronous, which is the default mode.)
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What do we call a "torsades de pointes"?
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(Chaotic or multifocal ventricular tachycardia, the "turning of the points" means a polarity change during wide-QRS-tachycardia with increasing-decreasing QRS amplitudes and varying RR-intervals.)
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Does a ventricular tachycardia without AV-dissociation exist?
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(Yes, if retrograde conduction is present, and the QRS-complex is followed by negative P-waves.)
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What do we call a Lenegre syndrome?
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(A type of bifascicular block, the coexistence of a right bundle branch block and a left anterior fascicular block.)
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How can an atrial myxoma cause syncope?
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(It can temporarily occlude the valve if it enters the venous ostium/mitral valve, or via cerebral embolisation.)
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What do we call electromechanical dissociation?
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(If despite retained electrophysiological heart activity, there is no hemodynamically effective pump function, peripheral pulse and blood pressure.)
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Which class of antiarrhythmic drugs may improve patient survival?
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(ß-1-receptor selective beta blockers, and according to some studies, in some cases amiodarone.)
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What is the mechanism of chinidine syncope?
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(Torsades de pointes ventricular tachycardia.)
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Which antiarrhythmic drugs lengthen QT? Name at least two.
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(Chinidine, sotalol, amiodarone)
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Which antiarrhythmic drugs should be avoided during and after myocardial infarction?
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(Vaughan-Williams I/C class.)
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Name at least three side effects of amiodarone
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(Severe, even lethal, pulmonary fibrosis; thyroid disorders – more ofter hyper- than hypothyroidism; liver function disorders; cornea deposits; discoloration of the skin and photosensitivity.)
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Name two antiarrhythmic drugs from Vaughan-Williams class IV.
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(Verapamil, diltiazem.)
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What pharmacodynamic interactions may present when using beta blockers and bradycardizing calcium channel blockers together? Name at least two effects.
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(Sinus bradycardia, AV-block, heart failure due to the cumulation of negative inotropic effect.)
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What does the letter „I” mean in the pacemaker type code?
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("Inhibited": if physiological activation can be sensed the pacemaker won’t trigger, in other words works „on demand”.)
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What does the letter „R” mean as the 4th letter in the pacemaker type code?
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("Rate-responsive": it raises the heart rate according to the level of physical activity.)
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What happens if the set base frequency of the pacemaker is lower than the heart rate?.
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(Pacemaker will not work because of the "demand" or "inhibited" function.)
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List at least four major risk factors of ischemic heart disease.
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(Age, male gender, type II diabetes mellitus, smoking, hypertension, hypercholesterolemia.)
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What are the body mass index criteria for overweight and obesity?
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(obesity: BMI is over 30 kg/m2, overweightness: BMI is between 25 and 30 kg/m2.)
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Name at least three presentations of ischemic heart disease other than stable and unstable pectoral angina and acute coronary syndrome.
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(Sudden cardiac death, silent angina, myocardial hibernation and stunning, acute left ventricular failure, chronic congestive heart failure, arrhythmias with palpitation and/or syncope.)
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What is the difference between myocardial hibernation and stunning?
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(A hibernating myocardium has reversibly damaged metabolism and function as a result of chronic myocardial ischemia. Myocardial stunning is a prolonged and spontaneously reversible metabolic and functional disorder caused by temporary ischemia.)
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Name at least two factors that may provoke chest pain in case of stable angina pectoris
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(Physical exercise in case of effort angina, emotional stress in case of emotionally provoked angina, a meal in case of postprandial angina, cold or weather changes.)
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Name at least three forms of unstable angina
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(New onset angina, angina at rest, crescendo angina, vasospastic/Prinzmetal angina.)
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What is the clinical presentation of Prinzmetal angina?
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(Severe angina presenting at rest or possibly after emotional stress, with significant and usually convex ST elevations on ECG.)
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What is the difference in the pathological background of stable angina and acute coronary syndrome?
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(The former is caused by a stable plaque formed as a part of chronic atherosclerosis, the latter is provoked by thrombotic event connected to the rupture of an unstable plaque.)
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Is there a preexisting hemodynamically significant coronary artery stenosis in all cases of acute coronary syndrome?
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(No. One type of acute coronary syndrome is caused by the rupture of an atherosclerotic plaque and thrombotic occlusion of the vessel. In this case the previous coronary stenosis is often not significant.)
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How can we distinguish stable and unstable angina pectoris?
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(According to the case history.)
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How to distinguish a musculoskeletal derived left sided chest pain from angina pectoris? Name at least three differences.
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(The former is rather stabbing not pressure; can be provoked by compression and changing body position; may be worsened by deep inhalation; is not relieved by nitrates, but by painkillers; its radiation is not typical; often can be shown with one finger.)
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How to distinguish a pulmonary embolism derived left sided chest pain from angina pectoris? Name at least three differences.
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(The former is a suddenly onset, rather stabbing not pressure; can hardly be provoked by compression and changing body position, but strongly worsens by deep inhalation; is not relieved by nitrates; often radiates to the back; patient tends to lie on their left side to minimize pleural movement.)
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What is the significant mark of exercise provoked myocardial ischemia during treadmill ergometry.
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(At least 0.1 mV horizontal or descending ST depression compared to the baseline ECG before stress test.)
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What is the target heart rate during ergometry?
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(In patients without drug influence 220 minus age gives the „calculated maximal heart rate”, 85% of which should be reached during stress test to consider negative test result evaluable.)
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What does “symptom limited” mean for ergometry?
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(There are no artificial criteria to stop the test; it should be stopped due to exhaustion, lack of cooperation, presence of complaints or safety considerations.)
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What is the sign of myocardial ischemia during stress echocardiography?
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(Appearance of regional/segmental wall motion disorder (hypo-, akinesia). Impairment of regional diastolic function would be a more sensitive parameter, but it is more difficult to measure.)
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How do aspirin and clopidogrel act?
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(COX inhibitor, ADP receptor blocker, antiplatelet agents.)
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How do nitrates act? Name at least two effects.
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(Reduce preload due to venodilation, mild coronary artery dilation, antianginal effect.)
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What is the most characteristic ECG sign of an acute coronary syndrome due to the total proximal occlusion of LAD - ramus interventricularis anterior – 2 hours after the occlusion?
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(Convex/dome-shaped ST elevation in V1-6 and possibly in I, aVL; possible complete left bundle branch block.)
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What does crescendo angina mean?
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(It is a presentation of acute coronary syndrome, where the intensity or duration of effort angina pectoris increases during succeeding episodes.)
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What is the best option to reopen the occluded coronary artery in acute coronary syndrome?
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(PCI)
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In which types of acute coronary syndrome is statin therapy indicated?
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(All of them.)
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What is the main goal of therapy in acute coronary syndrome with ST segment elevation?
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(Recanalisation of the occluded vessel as soon as possible.)
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What does “rescue PCI” mean and when is it applied?
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(It is a coronary intervention performed after unsuccessful thrombolysis.)
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What medications should be administered to a patient following PCI. Name four medications
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(Combined antiplatelet therapy, statin, beta blocker, ACE inhibitor.)
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Which antiarrhythmic agents are used most often to treat myocardial infarction associated arrhythmias? Name at least two of them
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(Cardioselective beta blockers, amiodarone, maybe lidocaine.)
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How to identify residual myocardial ischemia?
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(Ergometry, exercise myocardial perfusion SPECT, stress echocardiography.)
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Which medications should be given for secondary prevention of myocardial infarction?
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(Antiplatelet agents, statin, beta blocker, ACE inhibitor.)
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In what dose should aspirin be administered?
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(100-325 mg)
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What should be used if aspirin is contraindicated?
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(Clopidogrel, 1x75 mg)
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Name at least three statins.
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(Lovastatin, simvastatin, fluvastatin, atorvastatin, rosuvastatin, (cerivastatin).)
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. Name at least four beta blockers.
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(Metoprolol, atenolol, bisoprolol, nebivolol, carvedilol, propranolol, esmolol, pindolol, bopindolol.)
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Name at least four ACE inhibitors
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(Captopril, enalapril, perindopril, ramipril, fosinopril, quinapril.)
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What signs and symptoms may indicate Cushing’s disease?
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(Diabetes mellitus, calf cramps, documented hypokalaemia, central obesity, buffalo hump, livid striae.)
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What does emergency hypertension mean?
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(High blood pressure (over 220/120 mmHg) that poses a risk for cerebral bleeding or acute heart failure.)
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What is the difference between emergency hypertension and hypertensive crisis?
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(In the latter case, signs of target organ damage are present; most commonly headache and neurological disorders.)
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Which group(s) of medication(s) should be the first choice to treat essential hypertension?
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(According to present guidelines it can be any of ACE inhibitors, ARBs, beta-blockers, Ca channel blockers, diuretics and alpha-blockers. Reaching target blood pressure is the most important.)
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What are the unfavorable and beneficial side effects of alpha-blockers?
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(Reflex tachycardia, orthostatic hypotension; helps urination in males with prostate hyperplasia.)
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Why is captopril not recommended as a regular drug for the treatment of chronic hypertension?
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(It has a short duration of action that may lead to unfavorable sympathetic stimulation, blood pressure fluctuation and insufficient blood pressure control. Needs to be taken three times a day which may lead to poor compliance.)
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What is the most common side effect of ACE inhibitors?
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(Dry cough)
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Which Ca-channel blockers may be used for antiarrhythmic purposes?
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(Bradycardizing phenylalkylamines and benzothiazepines, verapamil and diltiazem group.)
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Name at least two dihydropyridine Ca-channel blockers.
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(Nifedipine, amlodipine, lercanidipine.)
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What is the most common cause of diastolic heart failure?
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(Hypertension.)
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Which type of heart failure (diastolic or systolic) is regularly associated with dilated, hypertrophic and restrictive cardiomyopathies, respectively
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(DCM: systolic, HOCM: diastolic, RCM: diastolic.)
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In which position should the jugular vein be examined?
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(Seated, half seated or standing position; in the supine position the jugular vein may be distended even in healthy individuals.)
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What can be heard above the lungs in left-sided heart failure, during auscultation?
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(Fine, medium or coarse crackles, usually on both sides, more intensively in the lower fields.)
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What is the sputum like in pulmonary edema?
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(Pink, frothy sputum.)
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How common is diastolic heart failure?
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(30-50% of all heart failures.)
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Name at least two causes of jugular venous distension.
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(Right-sided heart failure, failure of right atrial filling e.g. pericardial tamponade or constrictive pericarditis, vena cava superior syndrome, conditions with elevated chest pressure.)
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What does NYHA-III functional group mean?
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(According to the New York Heart Association heart failure classification, for patients with NYHA-III less than ordinary activity causes complaints such as fatigue, palpitation, or dyspnea.)
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Can a patient with heart failure have no complaints at the time of examination?
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(Yes. Patients with NYHA-I-III stage heart failure are without complaints during rest. Patients treated effectively may also be without complaints or symptoms.)
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Which medications should be administered to heart failure patients unless contraindicated?
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(Beta blockers, ACE inhibitors.)
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In which type of the three basic cardiomyopathies is the end-diastolic diameter of the left ventricle the largest?
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(Dilated cardiomyopathy - DCM.)
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Name at least three etiologies of dilated cardiomyopathy
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(DCM-like secondary conditions: e.g. ischemic DCM, advanced hypertonic cardiopathy, end stage aortic stenosis, advanced aortic insufficiency, end stage mitral insufficiency. Main causes of true DCM: toxic agents e.g. alcohol, drugs – cytostatics; autoimmune disease-related; post-infectious; irradiation associated; genetic etc.)
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Which is the most important noninvasive instrumental examination in the diagnostic of dilated cardiomyopathy?
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(Echocardiography.)
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What is the purpose of coronary angiography and coronary CT in the diagnosis of dilated cardiomyopathy?
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(To distinguish it from ischemic heart disease, which can be improved by revascularisation and its progression can be delayed with medical therapy.)
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What is the probable diagnosis, if the dilated cardiomyopathy-like echocardiogram is resolved in two weeks?
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(Myocarditis.)
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Name at least three features of the echocardiogram in dilated cardiomyopathy.
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(Enlarged chambers, sloppy moving left ventricle, diffuse left ventricular hypokinesis, low ejection fraction, thin ventricular walls – or at least not severe hypertrophy, mitral and tricuspidal insufficiency.)
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What is the treatment of dilated cardiomyopathy?
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(There is no specific treatment. Prohibition of alcohol and elimination of other possible etiological factors. Treatment of heart failure. Consider anticoagulation. In end stage, consider heart transplantation.)
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What acute complications may be caused by myocarditis?
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(Arrhythmias, heart failure.)
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Name at least three features that distinguish pericardial friction rub sound from other heart murmurs
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(Louder, continues over the borders of heart cycles, three-parted locomotive murmur, may change with body position, can be heard more intensively in a seated and forward leaning patient.)
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What does heart tamponade mean?
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(A condition, when fluid accumulated in the pericardium impedes the hemodynamic function of the heart, especially the filling of the atria.)
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Name four possible causes of pericardial tamponade.
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(Rupture of ventricle wall, aortic dissection, irradiation pericarditis, autoimmune disease, infection, endocrinological disease, uremia, tumor, hypoalbuminemia, trauma.)
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What is the therapy of pericardial tamponade?
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(Pericardial puncture, pericardiocentesis, pericardial fenestration.)
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What is called a „buttonhole stenosis” in the case of mitral vitium?
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(Very severe mitral stenosis, usually a result of rheumatic endocarditis. Sometimes it causes no murmurs, thus it may be hardly recognized during physical examination.)
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Why is rheumatic endocarditis becoming rarer, and why is it present especially among the elderly?
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(Due to use of antibiotics, especially penicillin derivates.)
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On which structures does infective endocarditis usually develop?
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(On endocardium or implants, where high-velocity turbulent flow is present: thus usually on previously damaged valves, near ventricular septal defect, in hypertrophic cardiomyopathy in the narrowing of the left ventricular outflow tract etc.)
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What is Schottmüller’s triad?
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(Original determination: murmur in infective endocarditis, splenomegaly, microscopic hematuria. Present determination: murmur/endocarditis, septic splenic infarctions, glomerulonephritis/renal infarctions.)
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Which organs are affected by septic embolisation in infective endocarditis?
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(In left-sided infective endocarditis the organs of the systemic circulation – most visibly brain, kidney, spleen, skin. In right-sided infective endocarditis the lungs are affected.)
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Name at least four features of antibiotic therapy in infective endocarditis.
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(empiric therapy should be started immediately, then changed to target therapy as soon as possible; wide spectrum; high dose; intravenous; long term – 4 to 6 weeks.)
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Name at least four characteristic features of mitral insufficiency murmur.
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(Blowing, high-pitched, even intensity, holosystolic murmur at Erb’s point and/or at apex radiating toward the axilla, does not change remarkably with body position.)
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. Name at least four symptoms of severe aortic stenosis
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(Angina pectoris, dyspnea, acute left ventricle failure, syncope, palpitation.)
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What is the blood pressure of a patient with significant aortic valve regurgitation like?
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(High or normal systolic, remarkably low diastolic value.)
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What is Corrigan’s pulse like?
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(Celer et altus, water-hammer. Present in case of at least III grade aortic regurgitation.)
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Name at least four features of aortic insufficiency murmur.
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(Diastolic, low-pitched, blowing, usually silent, maximal point is above the aortic valve, above the sternum or the epigastrium. In case of more severe regurgitation, more decrescendo-like.)
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What does III/A recommendation for the use of an antiarrhythmic agent mean in the guideline?
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(Surely contraindicated.)
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What does a recommendation with “level of evidence C” mean?
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(There is no randomized, well-controlled trial for it, it is based on consensus of experts’ opinion and/or small studies, retrospective studies, registries.)
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According to the CAST multicentric, controlled, international pharmacological study, which antiarrhythmic agents should be avoided in patients with a prior myocardial infarction?
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(Vaughan-Williams I/C group agents.)
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How long is the normal PR interval, QRS duration and corrected QT interval [QTc]?
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(120-200 ms, max. 100 ms, max. 450-470 ms.)
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What are the ECG features of Mobitz II 2nd degree AV block?
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(P waves not followed by QRS can be found. PQ interval for conducted beats is constant.)
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What is the upper limit of normal average blood pressure during ambulatory blood pressure monitoring [ABPM]?
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(125/80 mmHg)
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Name at least four indications to stop ergometry
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(Fatigue, lack of further compliance, presentation of ST segment elevation reaching 0.2 mV, presentation ST segment depression reaching 0.4 mV, AV block higher than I degree, ventricular tachycardia, blood pressure dropping below baseline blood pressure, blood pressure exceeding 220 mmHg systolic or 120 mmHg diastolic pressure during exercise, increasing chest pain, markedly increasing dyspnea.)
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Name at least two pharmacological stress testing methods.
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(Dobutamine, dipyridamole, adenosine stress testing.)
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How large is the left ventricular basal end diastolic diameter normally?
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(Max. 53-55 mm)
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Approximately how high is the specificity and sensitivity of stress myocardial perfusion SPECT to detect myocardial ischemia?
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(90-90%)
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Which isotopes are used for myocardial perfusion scintigraphy?
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(Tc-99m labeled MIBI and Tl-201.)
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Which types of stress testing can be combined with myocardial perfusion scintigraphy to detect myocardial ischemia?
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(Dipyridamole, dobutamine, adenosine stress testing, ergometry.)
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How to evaluate the viability of left ventricular "stunned" myocardium with thallium scintigraphy?
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(Perfusion defect at rest is completely or partially resolved after Tl-201 re-injection.)
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What is the sign of myocardial ischemia on stress myocardial perfusion scintigraphy?
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(Perfusion defects are more emphasized during stress than during resting.)
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What extent of coronary stenosis is considered anatomically significant?
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(At least 50% narrowing for the left main or at least 70% narrowing for the other coronary artery segments.)
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What does direct stenting mean?
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(Vessel is dilated in one step, with positioning and expansion of the stent, without previous balloon dilation.)
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Name at least three indications for an intracardiac electrophysiological examination
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(AVNRT, WPW syndrome, atrial flutter, ventricular tachycardia.)
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What coronary angiogram is expected in case of acute coronary syndrome with ST segment elevation
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(Complete, thrombotic occlusion of the coronary artery matching the leads with ST segment elevation.)
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Which anatomic structures form the reentry loop in case of orthodromic AV reciprocating tachycardia (AVRT) in WPW syndrome?
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(Atrium - AV node - His bundle - Tawara bundles – ventricular myocardium – Kent bundle – atrium.)
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What is the electrophysiological mechanism of chaotic ventricular tachycardia (torsade de pointes)?
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(Late after-depolarization.)
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What happens to sustained ventricular tachycardia after intravenous administration of adenosine?
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(Nothing)
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Which mechanisms cause the pro-arrhythmic effect of sotalol and chinidin?
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(Late after-depolarization, torsade de pointes.)
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How does carotid massage influence sinus tachycardia?
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(Slight decrease in heart rate.)
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Name at least 4 presentations of sick sinus syndrome.
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(Sinus bradycardia, sinus arrhythmia, wandering atrial pacemaker, ectopic atrial pacemaker, tachycardia-bradycardia syndrome, atrial fibrillation.)
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Name the 3 pulse qualities of atrial fibrillation with tachyarrhythmia absoluta.
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(Irregular, unequal, frequent.)
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Why should the defibrillator not be used in synchronized mode when treating ventricular fibrillation?
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(It would’t work, as it would wait for QRS like signs to synchronize to.)
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What is pulse and blood pressure like in case of ventricular fibrillation?
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(Pulse cannot be felt. Blood pressure is zero.)
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What is the danger of not using the synchronized mode of the defibrillator during the cardioversion of ventricular tachycardia?
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(DC shock accidentally delivered in a vulnerable phase may trigger ventricular fibrillation.
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In which types of ventricular conduction disorders does the QRS remain narrow?
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(Left anterior fascicular block, left posterior fascicular block.)
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What does trifascicular block mean? Name two examples.
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(Right bundle branch block + left anterior fascicular block + AV block, Right bundle branch block + left posterior fascicular block + AV block.)
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What does bifascicular block mean? Name at least three examples.
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(Right bundle branch block + left anterior fascicular block; Right bundle branch block + left posterior fascicular block; AV block + right bundle branch block; AV block + left anterior fascicular block; AV block + left posterior fascicular block; AV block + left bundle branch block.)
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Which type of collapse is typically provoked by shaving or turning the head sideways?
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(Carotid sinus hyperaesthesia.)
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What danger lies in the use of an automated external cardioverter-defibrillatior?
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(Nothing. Everyone should use it in emergency, laymen are also encouraged to use it, medical staff should be aware of the place and the operation of the devices.)
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Which anti-arrhythmic agents belong to class III according to the Vaughan-Williams classification?
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(Amiodarone, sotalol, dronedarone, bretylium.)
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Which anti-arrhythmic agents belong to class IV according to the Vaughan-Williams classification?
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(Verapamil, diltiazem.)
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Which anti-arrhythmic agents belong to class II according to the Vaughan-Williams classification?
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(Metoprolol, bisoprolol, nebivolol, atenolol.)
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What does letter “I” mean in the VVI pacemaker abbreviation?
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(“Inhibited” ; if own activity can be detected in the ventricle, pacemaker will not trigger, it will “inhibit” itself.)
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What does VAT pacemaker function mean?
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(Triggers in the ventricle, senses in the atrium, mode: trigger. Activity sensed in the atrium provokes a trigger to the ventricle after internal delay.)
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Which of the following medications may be discontinued after successful coronary artery bypass grafting in a patient free of complaints: nitrate, ACE inhibitor, beta blocker, cholesterol lowering drug, aspirin?
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(Nitrate)
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Which arteries are most commonly used for coronary artery bypass grafting? Name at least two.
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(Arteria thoracica interna sinistra or left internal mammary artery - LIMA, arteria thoracica interna dextra or right internal mammary artery - RIMA, right gastroepiploic artery, possibly radial artery.)
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What is the typical ECG sign of “acute coronary syndrome with ST segment elevation”?
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(At least 0.1 mV convex ST elevation in at least two leads representing the same region.)
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What pathological disorder causes acute coronary syndrome with ST segment elevation?
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(Complete thrombotic occlusion of a large, subepicardial coronary branch.)
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In which case of acute coronary syndrome without ST segment elevation may fibrinolysis be used?
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(None of them.)
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What are the contraindications of fibrinolysis in acute coronary syndrome with ST segment elevation? Name at least five
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(Damage or puncture of a non-comprimable artery, uncontrollable severe hypertension, cerebral bleeding in the case history, ischemic cerebral event in the past 6 months, active gastrointestinal bleeding, coagulopathies (e.g. hemophilia), significant operation in the past month, lack of informed consent.)
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What are the complications of acute myocardial infarction?
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(Ventricular tachycardia, ventricular fibrillation, AV block, heart failure, cardiogenic shock, rupture of the papillary muscle, rupture of the free wall and tamponade, rupture of the interventricular septum, left ventricular aneurism formation, left ventricular thrombus formation, cerebral thromboembolism.)
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What are the typical physical findings in right-sided heart failure? Name at least four
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(Pitting edema on the lower limbs and presacral region, hepatomegaly, jugular venous distension, ascites, pleural effusion.)
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Name three of the main types of cardiomyopathies.
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(Dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy.)
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Which medications should be avoided in case of severe hypertrophic obstructive cardiomyopathy because of the risk of syncope?
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(Sublingual and intravenous nitrates, fast-acting antihypertensive drugs.)
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What is the echocardiographic difference between hypertrophic and restrictive cardiomyopathy?
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(Left ventricular hypertrophy is more pronounced in HCM.)
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What are the ECG signs of acute pericarditis?
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(Concave or convex ST elevations in multiple leads not representing a single coronary vessel, PR depression, non-specific repolarization abnormalities.)
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What are the typical symptoms of rheumatic fever?
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(High fever, temporary migrating polyarthritis (large joints), chorea minor - Sydenham, erythema marginatum, subcutaneous rheumatic nodules on the extensor side of the limbs.)
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Which microorganism typically causes fulminant infective endocarditis, with rapid valve destruction?
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(Staphylococcus aureus.)
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Which factors can predispose to the rarer right-sided infective endocarditis?
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(Immunodeficiency, HIV infection, intravenous cannula, intravascular implants, infection of pacemaker electrode, use of intravenous drugs.)
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What are the most important causes of mitral insufficiency? List at least three.
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(Structural damage of heart valves due to endocarditis or degenerative valvular disease, mitral prolapse, dilation of the mitral annulus eg. in DCM, rupture of the tendinous cord, rupture of the papillary muscle, fibrosis or ischemia.)
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What is the difference between the anticoagulation therapy of atrial fibrillation and atrial flutter
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(Nothing.)
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What is the therapeutic alternative of fibrinolytic therapy in STEMI?
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(Percutaneous coronary intervention.)
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What does heteroanamnesis mean?
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(Information gained by a physician by asking people who know the person (relatives, witnesses) and can give suitable information.)
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What is orthopnea?
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(It is caused by left ventricular heart failure; it means shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair.)
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What does nocturia mean? What can it refer to?
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(Excessive urination at night. It can be a consequence of right-sided heart failure, prostatic hypertrophy, urological infection, in the latter cases frequent urination of small amounts of urine is typical. It can be a consequence of diabetes mellitus or insipidus as well as diuretic treatment.)
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What is the difference between polyuria and pollakisuria?
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(Polyuria is a condition usually defined as excessive or abnormally large production of urine (at least 2.5-3 L over 24 hours in adults). Pollakisuria: abnormally frequent urination, without increase in daily volume of urinary output.)
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What is palpitation, which types of palpitation do you know? List at least two types.
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(Unpleasant sensations of irregular and/or forceful beating of the heart. - [1] heart skips a beat - premature beats, [2] regular big/forceful heart beats – hypertension, [3] irregular heart beat – atrial fibrillation, [4] regular fast heart beat - tachycardias.)
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What is CCS-I angina pectoris?
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(Ordinary physical activity does not cause angina, such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation.)
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Which complaints can be caused by an atrial fibrillation with 130/min ventricular heart rate?
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(Palpitation, shortness of breath, weakness, effort dyspnea or angina, exercise intolerance, dizziness.)
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What are the symptoms and physical signs of right-sided heart failure?
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(Symmetric peripheral edema, nocturia, right subcostal pain or discomfort, distended jugular veins, ascites.)
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How to calculate body mass index (BMI)?
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(Body mass index is defined as the individual's body mass divided by the square of his or her height (expressed in meters).)
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What is subfebrility?
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(Axillary body temperature: 37.1-37.5 °C)
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What is the proper technique to measure body temperature and what is its normal value?
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(Axillary: 37.0 C, oral or rectal measurement: 37.5 C.)
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What is the definition of oliguria and anuria?
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(Oliguria is defined as a urine output that is less than 500 ml/day, anuria: < 100 ml/day.)
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What does intermittent claudication mean? What can it refer to?
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(Intermittent claudication describes the pain that develops in the muscles of the legs when taking exercise, such as walking. Commonly, the calf muscles are the most affected, and patients describe a cramping discomfort, as characteristic of the pain. Initially, patients may be able to walk through the pain, but as the disease progresses further, this is not possible and the claudication pain causes limping and can only relieved by resting. Intermittent claudication refers to severe peripheral artery disease.)
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What does claudication index mean?
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(It means the claudication-free walking distance (expressed in meters), which is the distance that the patient can walk without pain in the limb(s).)
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What is the difference between transudate and exudate? Which probe is adequate to differentiate exudate from transudate?
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(Transudate has a low protein content in comparison to exudate. Rivalta test may be used to differentiate an exudate from a transudate.)
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Where is the left border of the relative heart dullness normally?
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(Left side, 5th intercostal space, 1 cm medially from the medioclavicular line.)
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Which type of heart dullness is percussed in daily clinical practice: relative or absolute dullness?
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(Relative.)
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In which line should we percuss the chest to estimate the upper border of the heart? What is the right position of the pleximeter finger?
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(In the left parasternal line; parallel to the expected border of the heart, i.e. horizontally, in the intercostal space.)
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What does radiation of heart murmurs mean?
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(Heart murmurs can be heard not only over the heart, but also over several extracardiac regions: carotid arteries, left axillary region, epigastric region.)
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What can be heard at the 2nd right intercostal space?
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(Sounds and murmurs of aortic valve.)
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Where is the Erb’s point?
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(Fourth intercostal space on the left sternal border.)
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What does it mean: increased intensity of A2? What can it be indicative of?
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(Increased intensity of second heart sound at the aortic auscultation position, so A2>P2; it can be caused by systemic hypertension or by coarctation of the aorta.)
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How can S1 be distinguished from S2?
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(The shorter period between heart sounds is the systole. Systole starts with S1, simultaneous cardiac auscultation and palpation of the radial/carotid pulse can help.)
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To where does the murmur of aortic stenosis radiate?
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(Towards the carotid arteries, if they are not obstructed.)
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What are the characteristics of the murmur in severe mitral insufficiency?
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(The first heart sound is followed by a high-pitched holosystolic murmur with punctum max. at the apex or at the Erb’s point, radiating to the left axillary region. The loudness of the murmur (usually 3/6-4/6) does not correlate well with the severity of regurgitation. Little change in its intensity with respiration or changing of body position.)
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What can be the problem, if you can hear systolic bruit over the right carotid artery but not over the left carotid artery? Name at least two causes of this phenomenon.
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(1. severe right carotid artery stenosis, left carotid artery is healthy. 2. radiation of the murmur of aortic stenosis into the right carotid, left carotid artery is obstructed, 3. right carotid artery is severely stenosed, left carotid artery is obstructed.)
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Can vitium be excluded, if there is no audible murmur?
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(No, because auscultation can be hindered by emphysema, obesity and in some cases, severe mitral stenosis is not accompanied by murmur.)
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What are the characteristics of murmur in acute pericarditis?
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(Pericardial rub; like scratching or the crunch of footsteps on cold snow; locomotive sound; it is neither systolic nor diastolic murmur, has three audible components; loud murmur; it is heard most frequently at end-expiration with the patient upright and leaning forward.)
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What type of murmur can be caused by severe aortic regurgitation?
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(Low-pitched diastolic murmur which is usually characterized as blowing, decrescendo, and heard best in the third left intercostal space. In severe regurgitation, it may be holodiastolic. It radiates widely along the left sternal border.)
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In which position is the artificial valve of the patient, if the S1 is the artificial valve sound?
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(Mitral position, rarely tricuspidal.)
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What is the difference between telesystolic and holosystolic murmur?
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(Telesystolic murmur can be heard at the end of ventricular systole, holosystolic is audible during the whole systole.)
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What is protosystolic murmur?
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(If the murmur can be heard early in the systole.)
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What is pectoral fremitus and bronchophony?
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(Both methods examine the vibrations of the chest caused by the vocalization of vowels or diphthongs (with low frequency). In the case of pectoral fremitus, the examiner feels for vibrations by placing hand over both left and right side of the patient's chest or back. During bronchophony we use a stethoscope for the same purpose. Decreased pectoral fremitus or bronchophony: pleural effusion, callus, obesity; increased PF/BP: pneumonia.)
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What can cause the following physical signs: dullness just above the right diaphragm, fine crackles, increased pectoral fremitus and bronchophony?
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(Pneumonia in the right lower lobe of the lung.)
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What is “wheeze” and what can cause it?
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(Wheeze is a continuous, coarse, whistling sound produced in the respiratory airways during breathing. For wheezes to occur, some part of the respiratory tree must be narrowed or obstructed, thus airflow velocity within the respiratory tree must be heightened. Wheezing is commonly experienced by persons with a lung disease; the most common cause of recurrent wheezing is asthma attacks.)
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What is tachypnea? When can tachypnea occur? What is the difference between tachypnea and dyspnea?
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(In adults at rest, any rate between 15-20 breaths per minute is normal and tachypnea means a ventilation rate greater than 20 breaths per minute. Dyspnea means difficulty in breathing or shortness of breath; tachypnea is a physical sign, dyspnea is a complaint of the patient).
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What is the percussion sound of the lung [1] in right-sided heart failure, [2] in left-sided heart failure and [3] in pneumothorax?
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([1] normal resonance or dullness due to hydrothorax, [2] normal resonance, [3] hyperresonant)
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Which illnesses may result in facial teleangiectasia?
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(Mitral stenosis or insufficiency, alcoholism, liver cirrhosis, autoimmune diseases - eg. SLE , hereditary teleangiectasia.)
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Where is cyanosis most visible?
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(Lips, palms or nails.)
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In which valvular heart disease can a blood pressure of 150/50 mmHg be characteristic?
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(Severe aortic regurgitation.)
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What is the pulse like in ventricular fibrillation? What is typical blood pressure in ventricular fibrillation?
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(Pulse is not palpable, blood pressure is unmeasurable - 0 Hgmm.)
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What are the characteristics of filiform pulse?
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(Frequent, parvus, mollis; it is specific for shock.)
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What may indicate, if blood pressure in the lower limb is lower than upper limb blood pressure?
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(Aortic coarctation, severe disease of aorta, Leriche syndrome, obliterative atherosclerosis of the lower limb.)
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What can you hear normally when auscultating the carotid artery?
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(Nothing/in several cases the heart sounds.)
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What can you hear normally, auscultating the femoral artery?
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(Nothing.)
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Where should peripheral edema be examined in bedridden or in ambulatory patients?
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(Presacral or pretibial, respectively.)
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What may cause non-pitting edema?
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(Myxedema - hypothyroidism.)
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Which features of the liver should be characterized during physical examination?.
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(Size: in the right hypochondrium, along the medioclavicular line during inspiration, comparing to the costal margin; edge: rounded or sharp; surface: smooth or nodular; consistency: soft or firm; tenderness.)
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What are the features of hepatomegaly caused by right-sided heart failure?
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(Consistency smooth or firm – it depends on the age of onset of heart failure, rounded, smooth, tender.)
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What are the physical signs of left-sided heart failure?
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(Auscultation of the lungs: fine, medium or coarse crackles during both inspiration and exhalation. Crackles can be heard bilaterally over the lower lobes of the lungs. In severe cases: orthopnea.)
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How to examine if there is ascites in the abdomen?
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(Ballotation, flank dullness to percussion that shifts when patient is rotated (shifting dullness).)
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How can we distinguish between obesity, meteorism and ascites in case of abdominal enlargement?
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(Percussion of ascites: percussion note is tympanitic over the umbilicus and dull over the lateral abdomen and flank areas. Shifting dullness; Obesity: there is no clear border between umbilical and lateral abdominal percussion note; Meteorism: the percussion will elicit a tympanitic sound of a deeper pitch than normally over the whole abdomen. Fluid wave test (ballotation) is positive only in the case of ascites.)
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How can splenomegaly be diagnosed with physical examination?
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(With the palpation and percussion of the spleen.)
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What are the physiological borders of spleen?
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(On the left side between the 9th and 11th ribs, between anterior and mid axillary line.)
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What is the correct blood pressure measuring technique to determine the resting blood pressure?
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(With a Riva-Rocci sphygmomanometer (recently aneroid sphygmomanometer), the pressure cuff should be placed on the upper arm. In general, blood pressure should be measured while the patient is seated comfortably (for at least 3-5 minutes). The arm being used should be relaxed, uncovered, and supported at the level of the heart. Only the part of the arm where the blood pressure cuff is fastened needs to be at heart level. Korotkoff I. sound means systolic, Korotkoff V. sound means diastolic blood pressure.)
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Which sounds help us to measure the systolic and diastolic blood pressure?
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(Korotkoff I.: The pressure at which a sound is first heard is the systolic pressure, Korotkoff V. The pressure at which sounds disappear corresponds to the diastolic pressure.)
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What is the next step during physical examination, if pulses of a. dorsalis pedis and a. tibialis posterior are not palpable.
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(Palpation of popliteal and femoral pulsation, auscultation of femoral artery (systolic bruit?), auscultation of abdominal arteries.)
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What is the proper placement of green ECG leads?
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(Green limb lead, green chest lead=V3)? (Left foot, between V2 and V4.)
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What is the corrected QT interval? What is the upper limit of a normal QTc interval?
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(QT interval normalized to 60/min heart rate; QTc >450-470 ms is abnormal.
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What are the ECG signs of atrial fibrillation?
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(Irregular ventricular rhythm, absolute arrhythmia, absence of P waves.)
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What are the ECG signs of atrial flutter?
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(Regular, usually tachycardic ventricular rhythm, F waves.)
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What are the ECG signs of myocardial necrosis?
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(Pathological Q wave, or QS; R wave in leads V1-3; poor R wave progression in leads V1-6; R wave reduction.)
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Which ECG leads represent the inferior and posterior regions of the left ventricle, respectively?
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(Inferior: II-III-aVF; posterior: indirectly V1-3, directly V7-9 or D1-3.)
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What are the most common causes of wide QRS complex?
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(Intraventricular conduction disorders (LBBB, RBBB), ventricular pacemaker, hyperkalemia, ventricular pre-excitation (WPW), ventricular rhythm, left ventricular hypertrophy.)
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Which intraventricular conduction abnormalities do not cause QRS widening?
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(LAFB, LPFB.)
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How can complete right bundle branch block be diagnosed?
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(QRS > 120 ms, VAT is longer in V1 compared to V6.)
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How to distinguish complete right and left bundle branch block on the ECG?
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(RBBB: VAT is prolonged in V1, LBBB: VAT is prolonged in V6.)
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What are the ECG differences between Mobitz I and Mobitz II type AV-block?
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(Mobitz I: there is an increase in the PR intervals on consecutive beats followed by a blocked P wave (i.e., a 'dropped' QRS complex). Mobitz II heart block is characterized by intermittently nonconducted P waves not preceded by PR prolongation.)
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What are the causes of AV dissociation?
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(Third degree AV block, ventricular tachycardia, VVI pacemaker rhythm, rarely: heart transplantation.)
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What is the difference between bigeminal ventricular premature beats and ventricular couplet?
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(Bigeminy: following a premature ventricular complex there is a pause and then the normal beat returns, only to be followed by another PVC. Couplet: paired premature ventricular complexes.)
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Why is it important to analyze the QRS complex before the analysis of ST segment and T wave?
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(In case of widened QRS complexes, ST-T may not be evaluated.)
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What are the features of pathological Q waves? What can it refer to?
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(A pathological Q wave is a sign of previous myocardial infarction. Definition: >40 ms and >25% height of the representative R wave.)
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What is the J-point?
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(The point at which the QRS complex meets the ST segment.)
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What can cause a 0.25 mV descending ST depression in leads V5-6?
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(Left ventricular hypertrophy and strain, myocardial ischemia.)
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What is the proper treatment of ventricular fibrillation?
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(Immediate electrical defibrillation. Complex cardiopulmonary resuscitation if defibrillator is not immediately available. If no defibrillator is available, a precordial thump can be delivered at the onset of VF for a small chance to regain cardiac function.)
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What is the difference between defibrillation and electrical cardioversion?
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(Synchronized mode – unsynchronized mode, anesthesia is needed – anesthesia is not needed, the patient is conscious – unconscious/clinical death, careful preparation of the patient – immediate delivery of the shock.)
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What is the meaning of the defibrillator’s “synch mode”?
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(The electric shock is synchronized with the peak of the QRS complex (the highest point of the R-wave). Synchronization avoids the delivery of electric shock during cardiac repolarization (T-wave). If the shock occurs on the T-wave (during repolarization), there is a high likelihood that the shock can precipitate ventricular fibrillation.)
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What is the Sokolov index?
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(SV1+RV5 or SV2+RV6 > 3.5 mV.)
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