PANCE - Clinical Prep Pearls

_______ leads II, III, aVF

inferior

equation for cardiac output

CO = HR X SV note: normal physiologic variation....during inspiration, left sided stroke volume decreases

multifocal atrial tachycardia (MAT) is associated with severe ______

COPD

asystole rhythm (ventricular standstill) Tx

CPR epinephrine checks for shockable rhythm q 2 mins

eptifibatide (Integrilin) tirofiban (Aggrastat) abciximab (Reopro)

GP IIb/IIIa inhibitors

1st line drug for chronic management of stable angina

beta blockers note: reduces mortality

propranolol metoprolol esmolol

beta blockers class II anti-arrhythmic

along with coarctation of aorta, 70% also have ____

bicuspid aortic valves

what makes it unstable angina?

fixed stenosis negative cardiac enzymes NOT relieved by rest/NTG new onset angina note: > 90% occlusion can cause anginal Sx at rest aka pian at rest indicates 90% blockage!

ST depression horizontal- upslope- downslope-

horizontal-pathological upslope-may be benign downslope-pathological

electrolyte status with torsades

hypomagnesium hypokalemia

______ leads and _____ (vessel) II, III, aVF

inferior right coronary artery

PR interval is ____ in wolff-parkinson white

short

sinus arrest w/ alterations of paroxysms of atrial tachy and bradyarrhythmias, caused by sinoatrial node disease

sick sinus syndrome aka brady-tachy syndrome

pts w/ atrial fibrillation are on warfarin or aspirin for prophylaxis for ____ based on ____ score

stroke CHADS2 = CHF, HTN, age > 75 yo, DM, Stroke/TIA note: high risk (score > 2)-on warfarin (INR 2.0-3.0) moderate risk (score 1) -on warfarin or aspirin low risk (score 0)- none or aspirin

epinephrine norepinephrine

sympathetic system hormones increase heart rate

unstable VT with a pulse Tx

synchronized (direct current) cardioversion (DCC)

P waves not related to QRS

third degree AV block

troponin vs CK/CK-MB

troponin -most sensitive and specific for cardiac ischemia -appears 4-6 h -peaks 12-24 h -returns to baseline 7-10 d CK/CK-MB -appears 4-6 h -peaks 12-24 h -returns to baseline 3-4 d

wide, bizarre QRS occurring earlier than expected, usually the T wave is in the opposite direction of the R, associated with compensatory pause

premature ventricular complexes

electrical activity that is not coupled with mechanical contraction

pulseless electrical activity note: no mechanical contraction aka no pulse

definitive tx for paroxysmal supraventricular tachycardia (PSVT)

radiofrequency catheter ablation

atrial fibrillation Tx

rate vs rhythm control... rate -vagal -CCB -BB rhythm -DC cardioversion -DCC may also be done after 3-4 weeks of anticoagulation or TEE showing no atrial thrombi

most common cause of mitral stenosis

rheumatic heart disease note: R-sided heart failure, atrial fibrillation

coarctation of aorta CXR

rib notching note: "3 sign" on barium swallow angiogram gold standard Tx balloon angioplasty, PGE1

describe brugada syndrome

right bundle branch syndrome ST elevation V1, V2, V3 (often downsloping pattern) T wave inversion in V1, V2 +/- S wave in lateral leads most common in Asian males may cause syncope, ventricular fibrillation, sudden cardiac death prevented by implantable cardiodefribrillator

tetralogy of fallot ____ to ____ shunt

right to left (cyanotic) note: Sx "tet spells"

aspirin MOA

prevents platelet activation/aggregation (by inhibiting cyclooxygenase)

describe second degree AV block mobitz II

constant/prolonged PR interval

gold standard diagnostic test for definitive diagnosis of coronary artery disease/angina

coronary angiography aka "cath"

sokolow-lyon: S in V1 + R in V5 = 35 mm (men) S in V1 + R in V5 = 30 mm (women)

criteria for left ventricular hypertrophy

VT withOUT a pulse Tx

defibrillation/CPR (tx as ventricular fibrillation)

fondaparinux

factor Xa inhibitor

EKG prolonged PR-interval

first degree AV block PR interval > 0.20 sec

atrial flutter rate

250-350 bpm note: sawtooth pattern

_____-sided murmurs are best heard at end inspiration

Right

don't use nitrogen and morphine in ____-sided (inferior) myocardial infarction

Right-sided (because right-sided heart failure is preload dependent and nitrogen and morphine decrease preload via vasodilation)

Torsades de pointes Tx

IV magnesium

tetralogy of fallot CXR

boot-shaped heart

ST depression usually indicates

ischemia

percutaneous transluminal coronary angiography indications

1 or 2 vessels NOT involving main left coronary artery near/normal left ventricular function

tetralogy of fallot defects 1. 2. 3. 4.

1. VSD 2. R ventricular hypertrophy 3. overriding aorta 4. pulmonic stenosis (RV outflow obstruction)

3 ways renin increases BP

1. increases ACE > increase BP 2. increases ADH > increase H2O > increase BP 3. increases aldosterone > increase sodium > increase BP note: ACE = angiotension converting enzymes ADH = antidiuretic hormone

EKG way to calculate rate

300-150-100-75-60-50

junctional rhythm rate

40-60 bpm

normal sinus rate

60-100 bpm

describe wandering atrial pacemaker

> 3 P wave morphologies

describe ventricular tachycardia

> 3 consecutive PVCs at a rate of > 100 bpm

most common rhythm seen with digitalis toxcity

AV junctional dysrhythmia

aortic regurgitation + head bobbing

DeMussets

anti-arrhythmic classes I II III IV V

I- Na+ channel blockers (slow conduction velocity) Ia- procainamide, prolongs repolarization Ib- lidocaine, shortens repolarization II- beta blockers III- K+ channel blockers (K+ prevents efflux) IV- calcium channel blockers V- others, adenosine

_____-sided murmurs are best heard at end expiration

Left

aortic regurgitation + nailbed pulsations

Quincke pulses

area of infarct: posterior associated leads and artery involved?

ST depressions in V1, V2 right coronary artery, circumflex

ST elevation CONCAVE precordial leads PR depression seen in the same leads with the ST elevations no reciprocal changes

acute pericarditis

drugs used in pharmacologic stress testing

adenosine or dipyridamole dobutamine (2nd line)

describe second degree AV block mobitz I

aka wenckebach increased lengthnening of PR interval with dropped QRS

______ leads V1-V4

anterior

______ leads and _____ (vessel) V1-V4

anterior left anterior descending artery

stable sustained VT Tx

anti-arrhythmics (Amiodarone*, lidocaine, procainamide)

commonality? aspirin unfractionated heparin enoxaparin (Lovenox) clopidogrel (Plavix) GP IIb/IIIa inhibitors Fondaparinux

anti-thrombotic tx in UN/NSTEMI

diastolic decrescendo blowing @ LUSB

aortic regurgitation note: wide pulse pressure increases with handgrip decreases with amyl nitrate +/- austin flint murmur = mid-late diastolic rumble at apex

water hammer pulse associated w/ ____

aortic regurgitation note: aka collapsing pulse, cannonball pulse or pulsus celer, is used to describe a pulse with a rapid upstroke and descent, characteristically described in aortic regurgitation.

systolic "ejection" crescendo-decrescendo at RUSB radiates to carotids

aortic stenosis

chronic stable angina Tx

aspirin beta blocker statin PRN sublingual NTG

most common cause of MI

atherosclerosis

irregularly irregular rhythm

atrial fibrillation note: rate 350-600 bpm

systolic ejection crescendo-decrescendo flow murmur at PULMONIC AREA

atrial septal defect note: ostium secundum most common left to right shunt (noncyanotic)

____ play a major role in preventing/terminating ischemia induce by coronary vasospasm (Prinzmetal's angina)

calcium channel blockers

verapamil diltiazem

calcium channel blockers non-dihydropyridines class IV anti-arrhythmic

what makes it chronic stable angina?

caused by fixed stenosis (coronary plaque) relieved by rest/NTG

____ is useful in initial tx of acute coronary syndrome in pts with aspirin allergy

clopidogrel (Plavix)

systolic murmur that radiates to the back/scapula/chest increase BP upper > lower extermities delayed/weak femoral pulses

coarctation of aorta

most common causes of coronary artery vasospasm

cocaine prinzmetal's variant angina

accessory pathway in wolff-parkinson white

kent bundle

______ leads I, AVL, V5, V6

lateral

______ leads and _____ (vessel) I, AVL, V5, V6

lateral circumflex artery

EKG which lead to look at for atrial enlargement

lead II left atrial enlargement- "m-shaped" P wave right atrial enlargement- tall P

area of infarct: lateral wall associated leads and artery involved?

leads I, avL, V5, V6 cirumflex

area of infarct: inferior associated leads and artery involved?

leads II, III, avF right coronary artery

EKG which leads to look at for bundle branch blocks

leads V1* and V6 left bundle branch block- downward deflection; deep S in V1...when you turn left, you pull the steering wheel down right bundle branch block- upward deflection; RsR' in V1... when you turn right, you pull the steering wheel/turn signal up

area of infarct: anterior wall associated leads and artery involved?

leads V1-V4 left anterior descending (LAD)

coronary artery bypass graft (CABG) indications

left main coronary artery disease symptomatic 3 vessel disease left ventricular ejection fraction < 40%

enoxaparin (Lovenox)

low molecular weight heparin binds to antithrombin III to inhibit factor Xa

why avoid A-V nodal blocking agents in wolff-parkinson white?

may cause preferential conduction through accessory pathway

diastolic rumble at apex (low) in LLD may be preceded by OPENING SNAP

mitral Stenosis

blowing holosystolic murmur @ apex radiates to axilla

mitral regurgitation note: increases with handgrip decreases with amyl nitrate

midsystolic ejection click at apex

mitral valve prolapse note: reassurance and good prognosis in asymptomatic pts or with mild sx

acetylcholine (secreted by vagus n)

parasympathetic system hormone slows heart rate note: vagal maneuvers do the same; hold breath, bear down, carotid massage

continuous machinery murmur loudest at pulmonic area

patent ductus arteriosus note: left to right shunt (noncyanotic), continued PGE2 production promotes patency, IV indomethacin if preterm to close PDA

sick sinus syndrome Tx

permanent pacemaker

third degree AV block Tx

permanent pacemaker

what makes it NSTEMI?

positive cardiac enzymes no ST elevations on EKG

what makes a positive stress test?

positive if... ST depressions exercise-induced hypertension/hypotension arrhythmias Sx abnormalities in heart rate

atropine

tx bradycardia

amiodarone

tx supraventricular arrhythmias (class III) blocks SA/AV node

adenosine

tx tachycardia causes transient heart block in AV node class V

wolff-parkinson white Tx

vagal maneuvers antiarrhythmics (ex: procainamide, amiodarone) radiofrequency ablation *definitive tx

nitroglycerin contraindications

viagra (sildenafil) R ventricular MI

delta wave (slurred QRS upstroke)

wolff-parkinson white