Cardiology 2.0 Mksap 16 (Part 2)

Front 1

Class IC antiarrhythmics are contraindicated in

Back 1

after MI (increases risk of polymorphic VT)

Front 2

Class III agents (not amio) initiated, what to watch out for?

Back 2

start in–patient over 3 days to monitor for torsades, if QTc >500 or increases by >15% or 60msec, decrease or discontinue dose

Front 3

S/E of amiodarone

Back 3

thyroid dysfunction, liver toxicity, pulmonary fibrosis, and skin hypersensitivity

Front 4

advantages of the newest antiarrhythmic agent dronedarone

Back 4

reduce hospitalization or death in Afib atrial or flutter, and less side effects cf amio

Front 5

S/E of dronedarone

Back 5

increased crea but does not change GFR; do not use in NYHA II or III with recent decompensation or Class IV; should not be used as rate control agent in those with permanent AFib

Front 6

MOA of adenosine

Back 6

blocks the A1 receptors in the AV node and can terminate reentrant SVTs

Front 7

what is paroxysmal, persistent and permanent Afib

Back 7

terminates on its own – paroxysmal; >7days – persistent; continuous and cardioversion has failed or no longer attempted – permanent

Front 8

atrial fibrillation occurs in the absence of structural heart disease in a patient younger than 60 years

Back 8

lone Afib

Front 9

Afib >48 hours, two strategies before cardioversion

Back 9

warfarin x 3 weeks then cardiovert or full anticoagulation then TEE, if NEG, then cardiovert

Front 10

post cardioversion of Afib, next step?

Back 10

4 weeks of warfarin with goal INR 2–3 because atrium is stunned

Front 11

when should cardioversion be done emergently in Afib?

Back 11

hypotension, angina or heart failure

Front 12

goal INR in patients with rheumatic mitral stenosis and atrial fibrillation

Back 12

2–3

Front 13

If a mechanical heart valve is present in a patient with atrial fibrillation, the level of anticoagulation is based on the type of valve, with a minimum INR of

Back 13

2.5

Front 14

Prasugrel in Afib?

Back 14

There is currently no role for prasugrel for stroke prophylaxis in atrial fibrillation

Front 15

RE–LY trial

Back 15

dabigatran was shown to be superior to warfarin in preventing ischemic and hemorrhagic stroke, with a reduced risk of life–threatening bleeding but a higher risk of gastrointestinal bleeding

Front 16

Rivaroxaban for Afib?

Back 16

approved for prevention of stroke and systemic embolism in atrial fibrillation. It is noninferior to warfarin for stroke prevention with no difference in major bleeding, but demonstrates a reduction in intracranial hemorrhage

Front 17

when should oral anticoagulation be interrupted in patients with Afib needing invasive procedures

Back 17

If the patient has a low short–term risk (CHADS2 score of 0–2) and the duration of interruption is less than 1 week, then bridging is not needed. If the patient has a higher short–term risk (CHADS2 score of 5–6, recent stroke, mechanical or rheumatic mitral valve) or if the interruption is more than 1 week, then use of a bridging agent should be considered more strongly

Front 18

resting heart rate goal for Afib

Back 18

<110 /min

Front 19

“pill–in–the–pocket” approach for patients with symptomatic paroxysmal Afib

Back 19

short–acting B–blocker or calcium blocker 30 minutes before flecainide or propafenone

Front 20

anticoagulation after afib ablation

Back 20

continue warfarin x 2–3 months, thereafter guided by CHADS2 score

Front 21

Nonpharmacologic strategies for Afib

Back 21

Afib ablation, AV node ablation, maze surgery

Front 22

involves several incisions or ablations in the right and left atria to interrupt potential reentrant pathways required for atrial fibrillation maintenance

Back 22

Maze surgery

Front 23

causes of bradycardia

Back 23

dysfunction of sinus node, AV node, or His–Purkinje system; + reversible causes KIDLAT! (hyperK, drugs, Lyme, Thyroid disease)

Front 24

underlying cause of pathologic sinus bradycardia in most patients

Back 24

fibrotic replacement of the sinus node associated with aging (other causes – infarction, surgery damage, infiltrative processes, inc vagal tone, meds, genetic diseases)

Front 25

pathology in second degree AV blocks

Back 25

Mobitz type 1 is disease within AV node, type 2 more worrisome suggesting His Purkinje disease; HR of progressing to CHB

Front 26

two or more nonconducted P waves occur for each QRS complex

Back 26

Advanced second–degree heart block, or high–grade heart block

Front 27

pathology in CHB

Back 27

conduction block in His bundle or below

Front 28

treatment for symptomatic sinus bradycardia or heart block without reversible causes

Back 28

permanent pacemaker

Front 29

common causes of sinus tachycardia

Back 29

pain, fever, anxiety, anemia; in younger, SVTs, in older, AFib, aflutter, Vtach; any age – PACs and PVCs

Front 30

Class II and Class IV antiarrhythmics are contraindicated in

Back 30

decompensated systolic HF or WPW syndrome

Front 31

Class IC antiarrhythmics are contraindicated in

Back 31

after MI (increases risk of polymorphic VT)

Front 32

Class III agents (not amio)initiated, waht to watch out for?

Back 32

start in–patient over 3 days to monitor for torsades, if QTc >500 or increases by >15% or 60msec, decrease or discontinue dose

Front 33

usual rate of Aflutter

Back 33

250–350

Front 34

treatment of Aflutter

Back 34

same as afib

Front 35

usual site of flutter ablation

Back 35

isthmus between IVC and TV

Front 36

the most frequent paroxysmal SVTs

Back 36

AVNRT, AV reciprocating tachycardia (AVRT), atrial tachycardia

Front 37

short RP tachycardias

Back 37

AVNRT, AVRT, junctional tachycardia

Front 38

long RP tachycardias

Back 38

atrial tachycardia, sinus tachycardia, atypical AVNRT, and permanent form of junctional reciprocating tachycardia

Front 39

how does adenosine work in SVT?

Back 39

Blocks AV node conduction transiently,interrupts reentrant circuit, terminates AVNRT, AVRT. slows rate to demonstrate P waves in other SVTs (Afib, ST, atrial tach)

Front 40

most common paroxysmal SVT

Back 40

AVNRT

Front 41

treatment of AVNRT (7)

Back 41

vagal maneuvers, adenosine, β–blockers, nondihydropyridine calcium channel blockers, antiarrhythmic agents, or cardioversion; cath ablation also has high success rate

Front 42

a reentrant circuit that includes a bypass pathway and the AV node

Back 42

Atrioventricular Reciprocating Tachycardia

Front 43

WPW pattern vs syndrome

Back 43

preexcitation pattern on ECG = "WPW pattern"; pattern + symptoms (tachycardia) = "WPW syndrome"

Front 44

Risk factors for VF in patients with WPW syndrome (4)

Back 44

a history of AVRT, a rapidly conducting bypass pathway, multiple bypass pathways, Ebstein anomaly.

Front 45

first line therapy for patients with AVRT with symptoms and preexication, with history of rapid Afib

Back 45

catheter ablation

Front 46

preferred agents in AVRT

Back 46

procainamide and amiodarone (slows conduction down bypass pathway acutely) and not AV nodal blocking medications

Front 47

treatment of AVRT without preexcitation on EKG

Back 47

catheter ablation, β–blockers or antiarrhythmic agents

Front 48

treatment of PACs

Back 48

if symptomatic, B blockers or calcium blockers; usually needs only reassurance

Front 49

caused by an ectopic focus or area of micro–reentry that fires faster than the sinus rate

Back 49

atrial tachycardia

Front 50

treatment of atrial tach

Back 50

β–blockers, calcium channel blockers, digoxin, or antiarrhythmic agents; cath ablation also an option

Front 51

an irregular tachycardia that demonstrates three or more P waves of different morphologies and is usually associated with underlying pulmonary disease

Back 51

multifocal atrial tach

Front 52

treatment of MAT

Back 52

treat pulmonary disease, electrolyte repletion, and, occasionally, β–blockers or calcium channel blockers

Front 53

treatment of symptomatic PVCs

Back 53

B blocker or calcium blocker; antiarrhythmic agents rarely required; cath ablation if medical therapy failed

Front 54

define sustained VT

Back 54

lasts >30 secs or produces hemodynamic collapse

Front 55

*treatment of idiopathic VT

Back 55

mild – no treatment; frequent or severe Sx – calcium blockers or beta blockers, class I or III antiarrhythmic, cath ablation; ICD is not indicated

Front 56

the most common channelopathy

Back 56

Long QT syndrome

Front 57

mainstay of therapy in long QT syndrome

Back 57

b blockers

Front 58

drugs to avoid in long QT syndrome

Back 58

haldol, sotalol, erythromycin

Front 59

treatment for short QT syndrome

Back 59

quinidine to prolong QT interval; offer ICD

Front 60

what is Brugada syndrome

Back 60

a pattern of 2 mm or greater J–point elevation, coved ST–segment elevation, and T–wave inversions in leads V1 to V3 with an increased risk of syncope, VF, and sudden cardiac arrest

Front 61

VT during times of high adrenergic tone, carrying a high risk of SCD

Back 61

catecholaminergic polymorphic VT

Front 62

treatment of catecholaminergic polymorphic VT

Back 62

avoid exercise, beta blockers, ICD

Front 63

fibrofatty infiltration of the right ventricle resulting from dysfunction of the desmosome

Back 63

ARVC/D

Front 64

EKG findings in ARVC/D

Back 64

Tinv V1–V3, epsilon wave

Front 65

treatment of ARVC/D

Back 65

avoid exercise, ICD; no medical therapy to delay progression; B blockers, sotalol, amio and cath ablation can reduce ICD shocks

Front 66

treatment of symptomatic bradycardia (4)

Back 66

atropine, if ineffective, dopamine and epinephrine, until transcutaneous or transvenous pacing is initiated (ADEPt)

Front 67

NOTE: In infections of cardiac devices,

Back 67

it is important to not attempt aspiration of the device site because this can damage the leads.

Front 68

x most common cause of acute pericarditis

Back 68

viral infection

Front 69

How is diagnosis of pericarditis confirmed?

Back 69

2 of 3 classic findings: CP, pleuritic; friction rub; diffuse ST segment elevation; if (+) unexplained pericard effusion on echo, only 1 of 3 necessary

Front 70

unique feature of chest pain in acute pericarditis

Back 70

worsens in recumbent position

Front 71

pericardial friction rub is best auscultated at

Back 71

left lower sternal border during suspended respiration while leaning forward

Front 72

EKG in myopericarditis

Back 72

concave downward ST segment elevation like MI