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86 Cards in this Set
- Front
- Back
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Causes of LAD (5)
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LVH, LBBB, inferior MI, elevated diaphragm, WPW
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Criteria for left anterior hemiblock (4)
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LAD +
qR in I & rS in II III aVF + QRS <120 + no other causes of LAD |
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Causes of RAD (6)
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lateral MI, RVH, PE, COPD, septal defects, WPW
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criteria for left posterior hemiblock (4)
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RAD +
rS in I qR in III + QRS <120 msec + no other causes of RAD |
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Criteria for RBBB
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QRS>/=120msec
rSR' in V1 V2 wide S in I V5 V6 ST dep or TWI in R precordial |
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Criteria for LBBB
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QRS>/=120msec
broad slurred monophasic R I V6 no Q in I V5 V6 displaced ST & T opposite QRS PRWP/LAD/Qs in inf leads |
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Incomplete BBB
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QRS 100-119 msec
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Formula to correct QT
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Bazett formula QTc = QT/sq rt of RR
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Normal QTc
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</=440msec
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Causes of prolonged QT
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antiarrhythmics, psych drugs, antimicrobials, electrolytes, autonomic dysfunction, congenital
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class of antiarrhythmics that cause prolonged QT
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Class I & III
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Psych drugs that can cause prolonged QT
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phenothiazines haloperidol, atypicals, lithium
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which leads to look at for atrial enlargement
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II & V1
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Drugs other than antimicrobials / psych / antiarrhythmics that can cause prolonged QT
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antiemetics (droperidol, 5HT3 anag), alfuzosin, methadone
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Sokolow-Lyon criteria for LVH
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S V1 + R V5orV6 >/=35
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RVH criteria
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R>S in V1 or R in V1>/=7 S in V5 or V6 >/=7 RAD >/=_110
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criteria for biventricular hyeprtrophy
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LVH + RAD
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DDx of dominant R wave in V1 or V2
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RVH, true posterior MI, abnormal depolarization (RBBB) ... dextroversion, lead misplacement
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define pathologic Q waves
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>/=40 msec or >25% of R
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normal small septal q waves can be seen in
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I aVL V5 V6
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isolated Q waves in these leads can be normal
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III aVR V1
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define PRWP
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R in V3 </=3 mm
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possible causes of PRWP
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old anteroseptal MI, LVH RVH LBBB
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Name 6 differentials for ST elevations
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acute MI, coronary spasm, pericarditis/myocarditis, PE, repol abnormalities, normal early repol
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Where is normal early repol usually seen?
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leads V2-V5 in young adults
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describe ST elev in PE
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V1=V3, associated with TWI V1-V4, RAD RBBB
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describe ST elevation in pericarditis
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diffuse upward concavity, with PR dec
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Brugada syndrome
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rSR, downsloping ST elevation in V1-V2
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Causes of ST depression (4)
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ischemia or acute true posterior MI, digitalis effect, hypokalemia, repolarization abnormalities assoc with LBBB or LVH
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digitalis effect - describe
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downsloping ST + T wave abnormalities; does not correlate with digitalis levels
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typical angina
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substernal pressure -> neck jaw arm; <30 mins; dyspnea, diaph, n/v; inc with exertion, dec with NTG or rest
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typical MI description
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same as angina but greater intensity adn >/= 30 mins
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describe typical pericarditis
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sharp pain rad to traps; aggrav by respiration, relieved by sitting forward
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describe typical myocarditis
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sharp pain rad to traps; aggrav by respiration, relieved by sitting forward
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describe typical picture of Ao dissection
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sudden onset, tearing, knifelike pain, anterior or posterior mid-capsular
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describe typical costochondritis
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localized sharp or dull pain, tenderness to palpation
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types of exercise tolerance test or stress test
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exercise, pharmacologic, imaging
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when to hold or give antianginal meds in stress test
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hold if trying to Dx CAD; give if assessing if Pt ischemic on meds
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What information is derived from the exercise tolerance test? (6)
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HR, BP response, peak double product; max exercise capacity; occurence of symptoms, ECG changes, duke treadmill score, imaging (wall motion abnormalities)
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high risk exercise stress test results (ECG)
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ST dep >/=2 mm or >/=1mm in stage 1 or >/=5 leads or >/-5 min recover; ST elevation, VT
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high risk exercise stress test results (physiologic)
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dec BP, <4 METs, angina, Duke </=-11; EF <35
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how to determine myocardial viability? (4)
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MRI, PET, dobutamine stress echo, rest-redistribution thallium
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quantitative evaluation of extent of calcium and thus estimate plaque burden
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coronary calcium score
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precath checklist (6)
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document peripheral arterial exam (femoral, DP, PT pulses; femoral bruits); CBC, PT, Cr; IVF, blood bank sample; NPO>6h; ASA 325 +/- Plavix
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types of PCI
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balloon angioplasty, bare metal stents, drug-eluting stents
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When to pick PCI for coronary revascularization? (4)
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limited # of discrete lesions, normal EF, no DM, poor Sx candidate
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When to choose CABG for coronary revascularizatin? (4)
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extensive / diffuse disease; dec EF, DM or concomitant valvular heart disease
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meds after bare metal stents
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lifelong ASA + >/=4wks of Plavix
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meds after drug-eluting stents
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lifelong ASA + /=1y Plavix
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after PCI; this triad suggests a pseudoaneurysm
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pain, expansile mass, bruit
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When to consider an MI has occurred after PCI?
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CKMB >3x ULN
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In which types of patients do cholesterol emboli syndrome typically occur?
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middle-aged & elderly with Ao atheroma
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Cholesterol emboli syndromes (4)
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renal failure; mesenteric ischemia; intact distal pulses but livedo pattern and toe necrosis, Hollenhorst plaques in retinal arteries
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what to check in renal failure due to cholesterol emboli syndrome?
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Eos in urine
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Occlusion is subtotal
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UA / NSTEMI
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(+) troponin / CKMB
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NSTEMI & STEMI
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nonatherosclerotic CAD (3)
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spasm (Prinzmetal's / cocaine); vasculitis; Ao dissection w retrograde extension
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vasculitic causes of CAD (6)
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Kawasaki's Takayasu'a PAN, Churg-Strauss, SLE, RA
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associated symptoms of ACS (5)
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dyspnea, diaphoresis, N/V, palpitations, lightheadedness
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4 diagnostic tests for ACS
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ECG, cardiac biomarkers, echo, myocardial perfusion
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Posterior MI - location of ST changes
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St depression in V1 V2
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artery involved in septal MI
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prox LAD
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artery involved in anterior MI
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LAD
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artery involved in apical MI
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distal LAD, LCx or RCA
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artery involved in lateral MI
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LCx
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artery involved in inferior MI
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RCA
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artery involved in RV MI
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prox RCA
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artery involved in posterior MI
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RCA or LCx
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location of ST changes in RV MI
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ST elevation in V1 V2 & V4R (most sensitive)
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Troponins - rise and fall
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detectable 4-6h after injury, peaks in 24h; remains elevated x 7-10d in STEMI
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anti-ischemic treatment
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nitrates, B blockers, calcium channel blockers, morphine, oxygen
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how to give beta blockers in NSTE ACS
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metop 5 mg IV q4m x 3 then 25 mg PO q6h; titrate to HR 55-60
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contraindications for beta blockers
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HR<55; 2/3 deg AVB; SBP <100; mod/sev CHF; severe bronchospasm
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how to give aspirin in NSTE ACS
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162-325mg chewed then 75-162 mg PO qd
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MOA of clopidogrel
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ADP receptor blocker
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when can you give plavix in the ER?
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in addition to ASA if conservative strategy or PCI is planned; if CABG - will need to wait >5d after plavix discontinued
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GP 2b3a inhibitors
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abciximab; eptifibatide; tirofiban
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anticoagulant therapy in NSTE ACS
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UFH, lovenox, bivalirudin, fondaparinux
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MOA of bivalirudin
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direct thrombin inhibitor
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MOA of fondaparinux
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Xa inhibitor
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when to consider using bivalirudin?
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instead of heparin for patients with HIT
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describe the conservative approach in coronary angiography in NSTE ACS
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medical treatment with pre-d/c stress test; angio only if recurrent ischemia or strongly + ETT
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describe early invasive approach in coro angio in NSTE ACS
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routine angio within 24-48h
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when is early invasive approach (routine angio within 24-48h) indicated?
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high risk paitent; recurrnet ischemi, (+) Tx, ST changes, TRS>/=3, CHF, dec EF, recent PCI<6mos; sustained VT, prior CABG, hemodynamic instability
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treatment of Prinzmetal's angina
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high-dose CCB, nitrates, d/c smoking
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treatment to avoid in cocaine-induced vasospasm
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avoid BB (unopposed alpha stim can worsen spasm)
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