Cardiology Boards

which 2 narrow tachycardias are LONG RP

sinus tachycardia
atrial tachycardia

which 2 narrow tachycardias are SHORT RP

AVNRT - pseudo R’ in V1 or psuedo S in inferior leads
AVRT

where anatomically does lead V1 sit

over the right atrial appendage — common to see “flutter” waves there during atrial fibrillation

management of MAT

treat underlying cause (lung disease)

calcium channel blockers

UNLIKELY to work if you cardiovert it

what is CHADS-VASC system and scoring

CHF/Cardiac Dysfunction

HTN

Age 65-74

Diabetes

Stroke (2 points)

Vascular Disease - prior MI, PAD, aortic plaque

Age > 75

Sex (female)

what CHADS-VASC score is a class I indication for anticoagulation? what is the associated stroke risk?

score of 2 or more in men, 3 or more in women (stroke risk > 2% per year)

what CHADS-VASC score is a class IIa indication for anticoagulation? what is the associated stroke risk?

score of 1 in men, 2 in women

what counts as “valvular” AFib?

moderate-severe mitral stenosis or severe MS

mechanical valve in ANY position

these patients get WARFARIN always

these patients ALWAYS get AC regardless of CV score

when do you dose reduce apixaban

2.5 BID if they have 2/3 of
age >= 80

weight <= 60 kg

creatinine >=1.5 mg/dl

what is the mechanism of dabigatran

direct thrombin inhibitor

which 2 agents can be used for pill in pocket cardioversion? what class antiarrythmic is it

class 1c (sodium channel blocker)

flecainide and propafenone

watch out for hypotension, bradycardia, 1:1 flutter, and VT

if patient has a normal heart, which antiarrythmics for AF can you use first line before amiodarone?

class 3 and class 1c

(dofetilide, dronedarone, flecainide, proprafenone)

sotalol is a second line agent

if patient has heart failure with reduced EF, which antiarrythmics for AF can you use first line?

dofetilide, amiodarone.

dronedarone can be used but not if they have had symptomatic class III/IV heart failure or recent decompsensation in last 30 days

RIGHT bundle, LEFT axis - young patient with WCT.

what do you use to treat

fascicular tachcyardia. use verapamil

AFib with pre-excitation - what to use to treat?

procainamide

true or false

adenosine only. terminates SVTs

false can also terminate RVOT VTs

what does ARVC look like on ECG

LBBB morphology with TWIs in V1-V3 and epislon wave

SCN5A (sodium channel) loss of function mutation is what disease

Brugada syndrome

if a patient has a brugada pattern, what other finding increases the probability that they have a true genetic mutation (and which gene)

prolonged PR interval w/ brugada syndrome —> 40% chance of SCN5A mutation

how do you treat brugada syndrome? (NOT BRUGADA PATTERN)
medical and procedural

quinidine
ICD
epicardial RVOT ablation — ONLY if symptomatic w/ recurrent shocks

what are triggers for brugada syndrome

alcohol, drugs

fever

what is bidirecitonal VT mean?

either dig toxicity or CPVT (catecholaminergic polymorphic VT)

who gets ICDs in CPVT?

almost nobody - definitely not as monotherapy

mutations in RyR2 - what do they do?

leaky calcium channels —> delayed after depolarizations —> CPVT

medications for CPVT

nadolol + flecanaide
consider sympathectomy

which LQT mutation is worse?

LQT2 is more dangerous than LQT1

if you call someone long QT syndrome, you MUST order genetic test - why?

affects prognosis/therapeutics

loss of function KCN channels (potassium)

whicih is more worrying - a QTc of 480 at a HR of 120 or at a HR of 40?

HR of 40

what counts as a long QT length?

males - 450

females 460

don’t forget to subtract out the wide QRS over 120

loss of function mutation in potassium channels cause what

long qt sydnrome
(LQT1/2)

LQT3. is caused by SCN5A mutation that causes leaky channels (same gene, different problem than Brugada)

How can you tell LQT1 from LQT2 clincally and on EKG.

LQT1 - more adrenaline based events. EKG with slow rising T wave.

LQT2 - auditory triggered events, post-partum events, seizures. EKG with double hump T.

treatment for LQT1

beta blocks - nonselective (propranolol or nadolol)

do you give LQT patients an ICD

usually no unless cardiac arrest

which statin interacts with verapamil/diltiazem? what is max dose of that statin you can use if patient is on those meds?

simvastatin - max dose 10mg daily

if on amiodarone, amlodipine, ranolazine - max dose simvastatin is 20mg daily

if no PCI center on site, what is DtoB time goal?
what do you do if can’t meet it?

120 minutes

fibrinolytics + heparin + aspirin + clopidogrel (300)

half dose fibrinolytics if > 75, only 75 plavix if > 75

when would ibutilide 1mg IV be useful in a patient with wide complex tachycardia?

if you think its AF with WPW

(other option is procainamide)

what are the cutoffs for aortic valve calcium severe

>1300 Agatston units for women

or >2000 Agatston units for men

what is mechanism of class I antiarrythmics? what phase of action potential do they work on? what does this look like on the EKG?

block sodium channels.

work on phase zero to prevent influx of sodium into cells

widenes QRS and QT

what is mechanism of 1a antiarrythmics and which are they?

same as all class 1 - blocks sodium channels. but also works on the blocking of potassium channels as well.

quinidine and procainamide

which meds are 1b antiarrythmics?

lidocaine and mexilitine

they shorten the QT interval

which meds are 1c antiarrythmics?

flecanaide and propafenone

which meds are class 3 antiarrythmics? what do they do?

amiodarone, sotalol, dofetilide, ibutilide, dronedarone

they block the efflux of the outward potassium current

leads to prolonged QT

what is mechanism of torsades

early after depolarization - requires a long QT and is pause dependent

what is mechanism of ventricular arrythmia of digoxin toxicity

bidirectional VT - delayed late depolarization

what does use-dependent antiarrythmic medication mean? which category/meds does this apply to?

flecanide, propafenone (1c agents) — work better when heart rate is fast. that’s why you do piill-in-pocket.

what does reverse-use dependence mean? which meds are these

class III antiarrythmics. greatest effect is at slower rates. more effective for maintenance of SR rather than conversion. ie dofetelide, sotalol. (amiodarone is class III but does not have the reverse use depedence)

avoid in patients with excessive bradycardia or SND because it can cause EAD —> PMVT

class I agents

class III agents

what do they do in general? how can they be proarrythmic?

class I - slow conduction (Na influx block). can be proarrythmic by promoting re-entry

class III - prolong repolarization (k efflux block). can be proarrythmic by causing EAP/TdP

if you have coronary disease and AFIB, which class of meds do you avoid?

class Ic - flecanide, propafenone

what meds can you use in patients for afib who have CHF or CAD?

amiodarone OR dofetilide

if you have renal dysfunction, can you use sotalol?

no - cannot use any class III agents (sotalol, dofetilide)

can you use flecanaide w cirrhosis? w ckd?

no - mixed hepatic and renal clearance.

left vs right atrial abnormality on ECG

look at inferior leads. if it is WIDE (> 3 small boxes) it is left atrial. if it is TALL (>2.5 small boxes) then it is a right atrial abnormality.

Then look at V1. if the terminal neegative part is big, it’s left atrial. if initial positive part is big, its right atrial.

what electrolyrte abnormality mimics LQT3

hypocalcemia

what does dig toxicity cause in terms fo arrythmias

bidirectional VT, atrial tachycardia, junctional tachycardia

Notch 1 mutation is associated with?

bicuspid aortic valve and early aortic valve calcification.

T-box 5 (TBX5) mutation on the long arm of chromosome 12 is associated with which disease and which CV findings?

Holt-Oram syndrome. It plays a role in limb development (most frequently the thumb) and frequently is associated with ASD, VSD, conduction disease.

LMNA gene mutation is associated with?

autosomal dominant condition is one that almost always results first in conduction system disease, then in cardiomyopathy. The conduction disease manifests frequently as atrioventricular block (in this case complete heart block) and ventricular arrhythmias. Sudden death may be an initial presentation.

what’s a bad vO2 max?

< 14 ml/kg/min

loud click after S1 and a systolic murmur with palpitations should make you thinK?

Ebstein anomoly with WPW syndrome (Twenty percent of patients with Ebstein anomaly exhibit variable degrees of pre-excitation as shown on ECG)

what duke treadmill score is good?

anything > 5 is low risk with survival > 97%

fixed split s2 is pathognomonic for

ASD

primum ASD - EKG findings

RBBB with LAFB

what are cutoffs above which you should not clsoe an ASD or VSD

if the PASP or PVR is > 2/3 the SBP or the SVR

holosystolic murmur with NO respirophasic variation and an ejection click

Ebsteins anomaly

only right sided lesion to DECREASE with inspriation

the click of pulmonic stenosis (gets softer)

mean gradient cutoff for severe PS

greater than 35

what’s cardiac findings associated with noonan syndrome

pulmonic stenosis and HCM, PAPVR

if you measure arm and leg at same time, it should be within … mmHg

20 mmHg. If arm is > 20 more than leg, suspicious for coarct.

DiGeorge syndrome - what mutation and what defects

22q11.2 microdeletion. conotruncal defects (Tetrology, Truncus, Arch) or VSD

whats a normal TPG (and calcuation)

mPAP - PCWP should be 7 or less

whats the point of a vasodilator test in PAH

if good response (mPAP drops by 10, drops below 40, and CO does not worsen) — can try CCBs. about 10% of PAH patients have a vasodilator response.

ambrisentan, bosentan, macitenantan — what category of meds?

endothelin ANTagonist

tretment for group 4 pHTN

pulmonary thrombendartectomy, BPA, and then residual disease - riociguat

what is sotatercept

binder of activin moleclule - activin signal inhibitor — 4th line category of meds for PAH

if you have a bioprosthetic mitral valve surgical replacement, and are asx, when do you get surveillance echos?

5 and 10 years and then annually for patients with a bioprosthetic MV, even in the absence of a change in clinical status

WCT with a left bundle appearance and inferior axis is suggestive of

RVOT VT

what is a normal HV interval on EGM

35-55

if it is long, patient should get a PPM

bifascicular block with syncope — do you put a PPM?

class 2a indication

how to make a delta wave dissappear on EKG?

Exercise may increase conduction through the AV node, thus decreasing the degree of pre-excitation and the delta wave will diminish.

what is happening in this pressure volume loop? blue is normal

patient with heart failure. the top line shifts down

what does this pressure volume loop repersent

increased afterload

what does this green pressure volume loop represent

HFpEF - shifting up the end-diastolic pressure–volume relationship and elevating end-diastolic pressure

how long after phosphodiesterase use can you give nitro?

avoid within 24 hours of sildenafil or vardenafil use or within 48 hours of tadalafil use

for what Wilkins score can you try a mitral valve balloon valvotomy?

score 8 or less

A Wilkins score > 8 is considered with low probability of valvotomy success.

for african americans with normal kidney funciton what is first line agent for HTN

CCB or thiazide (not ACE/ARB)

if someone has hyperaldo, what labs are you checking nad for what result is positve?

low renin < 1
high aldo > 20

ratio should be > 20-30 if they have primary hyperaldosteronism

If borderline 10-20 may need to do saline suppresison etc with endocrinology

if someone comes in with an acute aortic dissection, what should you do with their BP

get it to less than 120 within first hour

if someone comes in with eclampsia or a pheo, what do you to with their BP

get it down. to < 140 in the first hour

(for most other patients is 25% in first hour)

what is BP upper limit for using lytics for a stroke

< 185/110

treatment of hypertensive emergency with cocaine use

nitrates, CCB, benzos

BP cutoff in pregnancy

< 140/90

what is upper limit for aortic diameter in marfans in pregnancy

45 mm
or 40mm if high risk features (like family history)

whats a normal BNP in pregnancy

NORMAL. it should not elevate

if someone is on warfarin therapeutically at time of delivery, should you do vaginal or c-section?

c-section

is warfarin safe in pregnancy

yes. however in first trimester, there is risk of embryopathy (if does > 5mg). if dose is > 5mg daily, then can just put them on LMWH in first trimester then switch back to warfarin
it does cross placenta so baby is also anticoagulated

usually switch around time of delivery to heparin or LMWH. if using LMWH you HAVE to follow Xas not just weight based dosing

what are 2 meds you avoid in aortic dilation

fluoroquinolones
caution with CCBs - not strict contraindicated

inheritance of all genetic aortic pathology

Autosomal Dominant

marfan, LD, bicuspid aortas, ehlers

what is bifid uvula associated with

Loeyz Dietz

where in the aorta do you see aneurysms with loez dietz

can be anywhere in the aorta