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82 Cards in this Set

  • Front
  • Back
What are some risk factors for sudden death
late potentials
T-wave alternans
high grade ventricular ectopy
non-sustained, sustained or
inducible V-tach
What are the 3 causes(mechanisms) of Ventricular tachycardia
Which type of mechanism is acute?
Which type of mechanism is chronic
chronic- reentry
Where anatomically do automatic arrhythmias occur?
automatic- at the zone of infarction, d/t residual ischemia
Reentry- at the borders of the tachy zone, between the scar tissue and the healthy myocardium
Which mechanism is the most common?
Which is the least common?
What are some causes of automatic?
electrolyte abnormalities
acid-base imbalance
increased adrenergic tone
AMI within 48 hrs
What is the most common arrhythmia associated with automatic?
multi focal A tach, common with acute pulm disease
Name 4 common anti arrhythmics used to treat
amiodarone- class III
lidocaine- 1b
phenytoin- 1b
bretylium- anti arrhythmic
Which mechanism is inducible in the EP lab?
Which is not?
Reentry and triggered are inducible
Automatic is not inducible
Is a reentrant circuit permanent?
What about automatic?
Is underlying cardiac disease a mechanism for triggered or reentry?
Not required for triggered, but yes for reentry
What is sustained V tach?
greater than 30 seconds
or greater than 10 beats
Which mechanism is monomorphic typically seen in?
monomorphic is with reentry or triggered
polymorphic is with automatic or triggered
Can you ablate polymorphic V-tach?
What are the two distinct clinical syndromes of triggered vent activity?
pause dependent
catechol dependent
For pause dependent..
what phase of AP?
What electrolytes?
downslope phase 3
hypokalemia, hypomagnesmia
What high risk ECG element is associated with pause-dependent, thus making it pause dependent. What arrhythmia is it associated with?
long QT
What ECG finding is associated with EAD
U wave or distorted T wave
The longer the CL of the previous, the (more/less)exaggerated the TU aberration.
What are somethings that put patients at risk for pause dependent?
hypokalemia, hypomagnesmia
heart blocks
> in women
class 1a or III anti-arrhy.
anti microbials
anti histamine
GI prokinetic
anti-HIV (pentamidine)
Dig toxicity (chronic afib)
procainamide (proarrhythmic)
What phase is associated with catechol dependent
phase 4
Which is associated with congenital long QT?
catechol dependent
Which group do these belong in.. DADS, increased Calcium in cytosol, monomorphic.
catechol dependent
Calcium dependent ventricular activity occurs during an increase in (sympathetic/parasympathetic) tone
How do you treat catechol dependent activity?
Beta blockers
class I agents
Which type of V tach can be studied and ablated?
What type of pacing do you use to induce V tach?
programmed extra stimulus
What are most clinical V tach from?
reentrant around a scar
Why do we study Vtach
confirm inducibility and reentrant nature of rhythm
test efficacy of antiarrhythmics
map focus to direct ablation
test easibility of anti-tach devices
Describe the difference in conduction and refractory periods with the alpha and beta limbs of the reentrant circuit
alpha has slow conduction and fast refractory
beta has fast conduction and slow refractory
What catheters are used in Vt induction
RVA (or reposition to RVOT)
LVA (rarely used)
When inducing VT how many extra stimuli and how many CL's
up to 3 extra stimuli and 3 CL's
> than 3 PES is aggressive
What can you do if you complete protocol and don't induce VT
reposition to RVOT and repeat, give isuprel and repeat
Where in the heart is VT when pacing in the RVA
mid RV and LV apex
where in the heart is VT when pacing in the RVOT
LV base or RVOT
What cycle length should you never go below? and why
<200 msec, because at risk for nonclinical VT or VF (healthy myocardium will induce)
How can you tell if you are pacing in RVA or RVOT, what does lead II look like in both, what type of axis and BBB for both
RVA pacing- lead II neg, RBBB w/ left axis
RVOT pacing- lead II positive, LBBB w/ inferior axis
Why do we want to know the VERP? What is it?
to access refractoriness of ventricular tissue
it is the longest coupling interval that blocks the beat
What percent of the population does not have retrograde conduction?
what happens if they don't
30%, can't do study
How do you check for retrograde conduction?
pace in RVA until 1:1 conduction is lost, will have VH but no A
If you have no VA wencke at 250 msec, what does that mean?
Impulse probably getting to atria via another pathway, WPW, accessory
What is the significance of VERP?
ability to conduct and maintain arrhythmias
What do you need to do when you induce VT?
get 12 lead
record it
tell stimulator cycle length so they know how to pace terminate
What type of VT do you synchronize cardiovert, what type do you defibrillate?
synch- monomorphic > 200msec
defib-polymorphic or faster than 200msec
What is the criteria to determine VT vs. wide SVT
For VT..inducibility from ventricle not atria
QRS morphology atypical of BBB or pre-excitation
No response to adenosine
AV dissociation
How do you determine AV dissociation with VT?
Pace in atria, at faster rate than ventricle's VT, if it entrains the rhythm than it is originating from atria, if not then you have AV dissociation
What information do you want to know when you are documenting VT?
cycle length
hemodynamic effects
How can you tell if it is BBB or VT?
If it is reentrant BB VT... ..then you need a clear HIS, you would have H
another catheter to read RBB
add PES during VT to disturb and compare VH intervals with and without PES, one constant, one variable
may respond to adenosine b/c AV node is involved
What is BB VT associated with and what is it?
seen with LV dilation and partial or complete LBBB w/ long PRI in NSR
It is a macro reentrant circuit around 2 sides of intraventricular septum
How do you treat BB VT?
ablate RBBB
How can you terminate V tach
synch cardioversion or defibrillate, pre-med patient with versed or wait until unconscious
Pace terminate
How do you pace terminate
burst pacing 8-12 beats @ CL 10-20 msec faster than VT to entrain then stop
How many joules do you need for monophasic?
for biphasic?
mono-300-360 joules
bi-200 joules
What is the ultimate treatments for VT?
ablation of slow well tolerated V tachs
If you have an S1 and S2 what are you looking for?
If you are looking for ERP how do you know if it is AERP, AVNERP or VERP
if AERP or AVNERP than pacing in atria
if VERP than pacing in ventricle
If you see S2, S3, S4 then what are you looking for?
If in atria and if in ventricle?
if in atria then SVT
if in ventricle than VT or SVT
What type of pacing does SNRT use?
What do you have..S1, S2, S3, S4
only S1
what type of pacing does AV wenke and VA wenke use?
What do you have..S1, S2, S3, S4
only S1
what type of pacing is extrastimulus for?
What do you have S1, S2, S3, S4
only S1 and S2
For syncope what is the least responsible?
the most?
What does cardiac disease and V tach get you?
sudden death
What is EAD associated with?
Is automatic inducible?
Is reentrant inducible?
25-55 ms
55-125 ms
<30 msec
35-55 msec
80-110 msec
</= 450 msec for men
</= 470 msec for women
QTc formula
QT/ sq rt of mean RR(sec)
<1500 msec
<525 msec
50-125 msec
180-330 msec
230-450 msec
330-550 msec
170-290 msec
AV wenke
</= 450 msec
VA wenke
380-400 msec
CSNRT formula