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77 Cards in this Set

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What is the case that will go along with an EKG showing asystole?
Answer asystole for a patient who suddenly loses his pulse and blood pressure, but other causes of pulselessness have been excluded. It is not possible to distinguish between asystole, ventricular fibrillation, pulseless electrical activity from tamponade, or tension pneumothorax without and EKG.
What is the characteristic on the EKG that gives the diagnosis of Afib?
Afib is characterized by a normal QRS duration of <120 milliseconds and the presence of fibrillatory waves. Atrial fibrillatory waves eliminate any organized atrial activity such as a P-wave or even a flutter wave. The atrium is having a "seizure." The rhythm is irregularly irregular. There is no fixed pattern between the R-waves.
What is the case that will go along with Afib?
Answer Afib when the patient presents wiht palpitations and has an "irregularly irregular" heart rhythm. The history will often contain CHF, hypertension, or hyperthyroidism, although simple caffeine excess is also a possibility.
What is the characteristic on the EKG that gives a diagnosis of atrial flutter?
The QRS is of normal duration (<120msecs) and there is a "sawtooth" pattern to the atrial waves. The R-R intervals are regular. The flutter waves are identical to each other. This regularity as well as teh presence of atrial activity is what distinguishes this narrow-compex tachycardia from atrial fibrillation.
What is the case that will go along with atrial flutter?
The patient will have palpitations and may be lightheaded. The pulse will be regular. This distinguishes it from atrial fibrillation, which is irregular. The rate is often slower than that of SVT. You cannot distinguish atrial flutter form SVT without an EKG if they both have the same heart rate.
What does SVT look like on EKG?
The EKG shows supraventricular tachycardia (SVT). SVT is a regular tachycardia with narrow QRS complexes, and no apparent P-waves, fibrillatory waves, or flutter waves. A normal QRS duration is <120 milliseconds.
What case will go along with SVT?
Look for a paatient who presents with rapid palpitations and lightheadedness. Triggers include the intake of caffeine or other sympathetic system-stimulating drugs, ppsychological distress, and hyperthyroidism.
How do you treat SVT?
Treatment includes carotid massage, followed by intravenous adenosine. If adenosine does not work, calcium channel blockers (e.g., verapamil or diltiazem), digoxin, or beta blockers can be used.
How is Multifocal atrial tachycardia (MAT) characterized on EKG?
MAT is characterized by irregulrly irregular rhythm as demonstrated by variability in the P-P intervals and the R-R interals. There are multiple P-R intervals and at least three different P-wave morphologies. The atrial rate is over 100 per minute. When the rate is lower it is no longer "tachycardia" and is called "wandering atrial pacemaker."
What is the most common cause of MAT on EKG?
MAT is caused by right heart strain and the effect of chronic pulmonary disease on the right side of the heart such as in COPD.
How is Torsades de Pointes characterized on EKG?
The most distinctive feature of Torsade on EKG is the "undulating" amplitude that gives the imprssion of the EKG 'twisting' around a point. Torsade is a form of wide-complex tahycardia. The QRS width or duration is >120 msecs. Essentially, Torsade is ventricular tachycardia with an undulating amplitude.
What is the case that will go along with Torsades de Pointes?
Just like ventricular tachycardia, Torsade may present wiht anything form simple palpitations to syncope to sudden death. You cannot tell without the EKG. Look for hypomagnesemia in the question. Torsade can also be caused by the toxicity of medications such as TCAs, amiodarone, dofetilide, ibutilide, macrolides, and rarely, quinolone antibiotics.
What are the characteristics of Vfib on EKG?
EDG has no organized activity at all. There may be either low or high amplitude to the EKG tracing. If you see either an organized P-wave, QS, or regular rhythm, then it is NOT Vfib. On the other hand, there is electrical activity. It is not flat like it is in asystole.
What is the case that will go along with Vfib?
Patients wiht Vfib have no pulse and no respirations. They have no blood pressure and have suffered "cardiac arrest." You cannot distinguish between Vfib, asystole, pulseless electrical activity, adn certaain forms of pulseless ventricular tachycardia without an EKG.
What case will go along with Vtach?
Look for a patient presenting wiht syncope, lightheadedness, symptoms of congestive heart failure, or sudden death. The range is very broad and there may only be palpitations.
How do you treat Vtach?
Treatment for ventricular tachycardia depends on patient stability:

1) Unstable patients: electrical cardioversion
2) Stable patients: amiodarone, lidocaine, procainamide
How is WPW characterized on EKG?
The EKG shows a short PR interval and slurring on the upstode of the QRS (delta wave),
What case in the question will go along with WPW?
The patient can have supraventricular tachycardia (SVT) alternating wiht ventricular tachycardia. There will be both preexcitation on teh EKG and paroxysmal tachycardia. The SVT may be described as "worsened after a calcium blocker or digoxin."
What is the pathology behind WPW?
An accessory pathway for cardiac conduction form the atria to the ventricles that bypasses the AV node and causes earlier activation (pre-excitation) of the ventricles.
What is Coronary Angiography or Cardiac Catheterization?
An angiography is the placemen to fa catheter from teh femoral or brachial artery into the coronary artery with the injection of iodinated contrast material.
When is Coronary Angiography or Cardiac Catheterization?
Angiography is the answer when:

1) The cardiac stress test is abnormal
2) Prior to coronary surgery or angioplasty
3) In an acute coronary syndrome such as unstable angina.
What does Coronary Angiography or Cardiac Catheterization show?
Angiography provides an exact measure of the degree of stenosis of the coronary artery adn teh number of vessels involved. The degree of stenosis must be >70% to be considered significant.
What is BNP?
Brain natriuretic peptide (BNP) is a hormone released from the heart and brain in response to stretch of the atria adn ventricles. BNP has diuretic, natriuretic, and hypotensive effects and inhibits the renin-angiotensin system in response to fluid overload states. BNP goes up with congestive heart failure and other causes of hypervolemia.

CHF
Pneumonia
COPD
Embolus
What is BNP the answer?
BNP is the answer when teh patient is short of breath and the history and physical are not sufficiently specific to make an accurate diagnosis. BNP is sensitive but not specific for CHF. It is CHF, pneumonia, COPD, or an embolus? Use BNP to help exclude CHF.
What is the most accurate test to confirm an elevated BNP?
An elevated BNP is confirmed with an echocardiogram.
What is CK-MB?
CK-MB si elevated in teh serum as a marker for myocardial injury. CK-MB is useful in detecting infarction and therefore the right answer in assessing any patient with chest pain especially with cardiac risk factors. CK-MB normally increases within 4 to 6 hours from the start fo the chest pain. It peaks at about 12-24 hours. CK-MB has a relatively short half-life when compared to the other specific myocardial marker troponin. CK-MB is particularly useful in detecting re-infarction.
When is CK-MB the right answer?
Answer CK-MB when there is a patient with chest pain that is possibly ischemic in nature. The EKG does not have to have ST segment elevation in order for the CK-MB to be abnormal. Answer CK-MB when chest pain recurs after an infarction with the last few days.
What is Dobutamine Stress?
Dobutamine stress testing is a form of exercise tolerance or "stress testing that does not use pnysical exercise. It is a noninvasive method of determining myocardial perfusion.
How is dobutamine stress test done?
Dobutamine is a direct-acting agonist at beta-1-adrenergic receptors, causing inotropic stress. Dobutamine is injected and the echo is observed for a decrease in wall motion. Ischemic myocardium does not move as well as normal myocardium.
When do you answer Dobutamine stress test?
Dobutamine is used in patients who cannot exercise. Look for a person who has a history of chest pain but in whom the story is equivocal and the EKG is nondiagnostic. The indications are the same as those for persantine stress testing. It also used for patients with reactive airways diseases who cannot undergo a persantine thallium test.
What is the most accurate diagnostic test?
The coronary angiogram is the most accurate test of myocardial perfusion.
What is an EP study?
An EP study is the indroduction of a catheter with an electrical sensing and stimulating electrode into the heart. This allows both the detection of abnormal cardiac rhythm disturbances as well as the stimulation of the heart to determine the site of origin of an abnormal rhythm.
When is an EP sgudy the answer?
EP studies are used for:

1) Definitive diagnosis of abnormal cardiac rhythms, particularly the etiology of unexplained syncope;
2) Mapping of the cardiac conduction system;
3) Ablation of aberrant conduction tract abnormalities such as SVT or WPW syndrome
4) Placement of automatic implanted cardioverter / defibrillators;
5) searching for the site fo origin of sustained ventricular tachycardia.
What is ergonovine test?
Ergonovine testing involves the injection of ergonovine to provoke coronary vasospasm. This is the diagnostic maneuver to detect Prinzmetal's angina, which is coronary vasospasm.
When is ergonovine testing the answer?
Answer ergonovine testing is the most accurate test when they give you a younger patient (<45) complaining of atypical anginal-type chest pain who has clean coronaries on cardiac catheterization. The pain will not bear a fixed relation ship to exercise.
What is the treatment for Prinzmetal's angina?
Prinzmetal's variant angina is treated with calcium channel blockers and nitrates.
What is Holter Monitoring or 24-Hour Continuous Ambulatory Cardiac Monitoring?
Holter monitoring is a way of recording an EKG for 24 hours of continuous reading from a single lead.
How does a holter monitor work?
The patient wears leads on his chest and carries teh recording device around his neck like a portable tape or CD player while he is at home. The strip can then be analyzed at high speed by the physician to detect brief rhythm disturbances that may not have been detected on the original EKG.
What is the most accurate test for heart palpitations or syncope?
Abnormalities on teh Holter can be further analyzed by electrophysiological studies in a laboratory and by echocardiogram.
When do you answer Holter monitor?
Answer Holter monitor when the patient has palpitations or syncope and the EKG does not detect an abnormality
For which condition is MUGA scans the most accurate test?
MUGA is the single most accurate method of assessing ejection fraction. MUGA also assesses left ventricular wall motion and cardiac muscle damage.
How is MUGA scans performed?
MUGA is performed by injecting red blood cells, radiolabled with technetium 99, into the patient's bloodstream and recording the emissions with a gamma camera.
When do you answer MUGA scan?
MUGA is very useful in assessing and following cardiac function in patients during the delivery of potentially cardiotoxic chemotherapy such as adriamycin. The accuracy and reproducibility of hte study make it suitable to detect sebtle, early changes in cardiac function that might easiy be missed by other techniques, such as the echocardiogram.
What is Persantine Thallium?
Persantine thallium is a form of exercise tolerance or "stress" testing. it is a noninvasive method of determining myocardial perfusion that uses a medication to substitute for physical exercise.
How is persantine thallium done?
Persantine (also called dipyridamole) is a phosphodiesterase inhibitor that dilates coronary arteries and increases oxygen flow to the myocardium. Thallium is a radioisotope that should be picked up by normal myocytes. Persantine gives increased thallium uptake in teh normal areas of the heart and less in the diseased parts of the heart.
When do you answer persantine thallium?
Answer persantine thallium when patients cannot exercise sufficietly to do a standard exercise tolerance test. The patient has a history of chest pain but you are not certain if it is ischemic in nature. It can also be used for preoperative screening.
When is Persantine thallium the wrong answer?
Persantine cannot be used for patients with asthma, COPD, or emphysema because it provokes bronchospasm. Stess testing in general should not be done wiht an acute infarction or unstable angina.
What is the alternative choice to persantine thallium?
Use a dobutamine echocardiographic stress test when you cannot use persantine.
What is the most accurate diagnostic test for myocardial perfusion?
The single most accurate test of myocardial perfusion is the coronary artery angiogram.
What is sestamibi testing?
A sestamibi test is a type of nuclear stress test, also named Tc99m.
How is sestamibi testing done?
Tc99m-labled compounds require intact perfusion, and a viable myocardial cell. Essentially, a myocardial perfusion agent is indicated for detecting coronary artery disease. Diseased or infarcted myocardium picks up less of the nuclear isotope. Ischemic myocardium re-perfuses at rest. The defect is "reversible." Infarcted myocardium does not change with rest.
When do you answer sestamibi testing?
The bottom-line answer for Sestamibi is that it is a nuclear stress test that you use with obese patients and female patients with large breasts.
What is stress testing?
Stress testing is the attempt to detect myocardial ischemia in patients without the need for coronary angiography. it is used when the diagnosis of ischemia is not clear in a person who has chest pain.
How is stress testing done?
The patient exercises to >80% of maximum heart rate based on a maximum rate of 220-age. The EKG is observed for signs of ischemia, such as ST segment depression. Hypotension, light-headedness, and chest pain are taken as positive tests as well.
When is stress testing the answer?
Answer stress test when:

1) The pain is atyupical and the story is equivocal
2) Post myocardial infaction to determine the need for angiography
3) Patients on medications to determine if the amounts of medications are sufficient to prevent ischemia.
What is the most accurate test to confirm an abnormal stress test?
Abnormal stress tests are confirmed wiht coronary angiography.
What is stress echocardiogram?
Stress echocardiogram is used to confirm the suspicion of coronary artery disease and estimate its severity.
How is stress echo done?
It uses both 2D echocardiogram and Doppler echocardiogram to detect ischemia. Myocardial injury gives a decrease in systolic contraction of the ischemic area, called a "regional wall motion abnormality." The patient is asked to exercise using a treadmill or bicycle. If she cannot exercise, Dobutamine can be used to increase myocardial demand.
What constitutes a positive stress echo?
A positive test consists of new regional wall motion abnormalities, a decline in ejection fraction, and an increase in end-systolic volume with stress on stress echo.
When do you answer stress echo?
Answer stress echo when the case is equivocal for ischemic heart disease and the EKG is so abnormal that you cannot read it for ischemia.
What is a thallium stress test?
Thallium scanning is the most acurate method of assessing myocardial perfusion without an angiography.
When is thallium stress testing the answer?
Thallium-labeled red cells are injected into the patient's blood stream. A thallium scan provides a view of the blood flow into the heart muscle. Stress thallium is an alternative to stress echo. The indications for stress thallium are:

1) When resting EKG changes make exercise EKG difficult to interpret, such as teh presence of an LBB, baseline S-T changes, left ventricular hypertrophy, pacemaker, or the effect of digoxin on the EKG
2) to localize the region of ischemia
3) to assess revacularization following bypass or angioplasty.
What is the most accurate test to confirm a positive thallium stress test?
The most accurate test of myocardial perfusion is a coronary angiogram.
What is tilt-table testing?
Tilt-table testing is used to evaluate unexplained syncope. It is the measurement of blood pressure and pulse at various angles while teh patient is tilted up and down while lying on a table.
How is tilt-table testing performed?
Blood pressure and pulse are measured before and after moving the patient into different positions. The development of syncope, dizziness, or abnormal drops in lood pressure constitute an abnormal test. isoproterenol and nitroglycerin can be used as provocative testing.
When is tilt-table testing the answer?
Answer tilt-table when there is unexplained syncope, particularly when there are signs of orthostasis such as an inappropriate bradycardia when standing up.
What is transesophageal Echocardiography (TEE)?
Transesophageal echocardiography (TEE) is an extremely sensitive method of assessing cardiac structure. TEE is particularly sensitive at assessing posterior structures of the heart such as diseases of the aorta; for example, dissection or aneurysm, atrial thrombi, patent foramen ovale, or vegetations on valves for the diagnosis of endocarditis. TEE is used when limitd transthoracic echocardiogram is inadequate.
How is TEE done?
TEE is performed by placing a sonographic transducer through teh mouth into the esophagus.
When do you answer TEE?
TEE is used to assess valvular heart disease as well as before the cardioversion of atrial fibrillation to exclude thrombi in the left atrium.
What is the most accurate diagnostic test to confirm an abnormal TEE?
The most accurate diagnostic test is a cardiac catheterization of the left heart.
What is Transthoracic or 2D Echocardiogram (TTE)?
TEE is used to detect chamber size and function, valve abnormalities, intracardiac masses, pericardial effusions, and aortic disease.
How is TTE done?
Images of the heart are obtained from a sonographic transducer placed over the anterior wall of the chest.
When do you answer TTE?
TTE is done to assess every patient with an auscultory abnormality for the severity of valve dysfunction. TTE has become the second most frequently done test to evaluate the heart after EKG. TTE is done to assess every patient with congestive failure (CHF) to obtain the ejection fraction. Therapy for CHF differs markedly based on whether there is systolic or diastolic dysfunction.
What is the most accurate diagnostic test to confirm an abnormal TTE?
Both the transesophageal echo and the coronary angiogram are more sensitive than the TTE.
What are troponin levels?
Troponin is an enzyme that is released only from injured myocardium. Troponin is extremely specific for the myocardium and is rarely derived from other sites in the body.
When are troponin levels answer?
Troponin levels are the answer in most acute coronary syndromes as teh most accurate means of assessing myocardial ischemia or infarction. Answer troponins in all patients in the emergency department with acute, severe pain. This is true even if the EKG is normal.
What is the most accurate test to confirm elevated Troponin levels?
Myocardial ischemia as found by elevated levels of troponins is confirmed with EKG.