CPR2 - Clinical

In the rhythm recognition process, what does the evaluation of 'QRS Width' determine?

Whether the QRS complex is Narrow or Wide.

The 'Regularity' step of rhythm recognition involves measuring which specific intervals?

The R-R intervals.

What relationship is analyzed in the final step of the 4-step rhythm recognition process?

The relationship of the P waves to the QRS complexes.

Term: Sinus Tachycardia

Definition: A heart rate of 100-160 bpm with the same morphology as Normal Sinus Rhythm.

What are common clinical causes of Sinus Tachycardia?

Fever, pain, anxiety, hypovolemia, and hyperthyroidism.

Which irregular rhythm is characterized by inconsistent R-R intervals and often stems from multiple electrical impulses?

Atrial Fibrillation.

Concept: Wandering Atrial Pacemaker (WAP)

A supraventricular rhythm with shifting pacemaker sites causing ≥ 3 different P-wave morphologies.

How is Multifocal Atrial Tachycardia (MAT) distinguished from Wandering Atrial Pacemaker (WAP)?

MAT has a rate ≥ 100 bpm, whereas WAP is usually slower.

What is the physiological role of an 'Escape Rhythm'?

It is a protective rhythm that emerges when the SA node fails to function as the primary pacemaker.

From what anatomical site does a Junctional Rhythm typically originate?

The AV node.

How do P waves typically appear in a Junctional Rhythm?

They are absent, inverted, or retrograde.

Which escape site produces the slowest rate and characteristically wide QRS complexes?

The Ventricular Myocardium.

Term: Premature Atrial Contractions (PACs)

Definition: Additional heartbeats originating from the atria that occur earlier than expected.

Term: Premature Ventricular Contractions (PVCs)

Definition: Additional heartbeats originating from the ventricles that interrupt the normal rhythm.

Tachy-Arrhythmias are broadly defined by a heart rate exceeding how many beats per minute?

100 bpm.

Which atrial arrhythmia is classically associated with a "sawtooth" P-wave morphology?

Atrial Flutter.

Name the type of SVT that involves a reentry circuit involving the AV node or an accessory pathway like WPW.

Reentrant Atrial Tachycardia.

How is Ventricular Tachycardia (VT) identified on an ECG strip?

As a fast, wide-complex ventricular rhythm.

Concept: Torsade de Pointes

A peculiar form of rapid ventricular tachycardia where the QRS outline looks like a "twisted ribbon."

What is the cardiac output status during Ventricular Fibrillation (VF)?

There is no effective cardiac output due to disorganized electrical activity.

Into which lethal rhythm does True Ventricular Flutter almost invariably deteriorate?

Ventricular Fibrillation.

In distinguishing SVT from VT, which rhythm is "very common" in patients with prior coronary disease or infarction?

Ventricular Tachycardia.

A QRS duration greater than .14 seconds is a diagnostic clue favoring which rhythm?

Ventricular Tachycardia.

Is AV dissociation showing captures or fusions a clue for Wide QRS Complex SVT or Ventricular Tachycardia?

Ventricular Tachycardia.

In the context of Wide QRS rhythms, what does 'Extreme Right Axis Deviation' typically suggest?

Ventricular Tachycardia.

Which rhythm is characterized by a rate of 40-100 bpm and wide QRS complexes, often seen post-MI?

Accelerated Idioventricular Rhythm (AIVR).

What is the key rule for determining if any regular rhythm is truly regular?

Measure the R-R intervals to ensure they are consistent.

In the context of sinus node failure, what is the definition of Sinus Arrest?

The total failure of the SA node to generate an impulse, causing the sinus node to stop firing for one or more cycles.

What is the key ECG feature that distinguishes Sinus Arrest from SA exit block regarding the duration of the pause?

The duration of the pause is not a multiple of the basic P-P interval.

Sick Sinus Syndrome often presents with a combination of sinus bradycardia and which other rhythmic abnormality?

Tachycardia-bradycardia syndrome.

Clinically significant pauses in SA node firing that may cause Stokes-Adams attacks (syncope) typically exceed how many seconds?

3 seconds.

How is First Degree AV Block defined on an ECG?

A constant PR interval greater than 200 ms (>5 small squares) where every P wave is followed by a QRS complex.

What is the characteristic PR interval pattern seen in Second Degree AV Block, Mobitz Type I (Wenckebach)?

Progressive lengthening of the PR interval with each beat until one P wave is suddenly blocked.

At what anatomical level does the block usually occur in Mobitz Type I (Wenckebach)?

The AV node level.

In Mobitz Type II AV block, what is the status of the PR interval before a QRS complex is suddenly dropped?

The PR interval is fixed and constant.

Why is Mobitz Type II considered more clinically serious than Mobitz Type I?

It carries a high risk of sudden progression to Third Degree (Complete) AV Block.

What is the defining feature of Third Degree (Complete) AV Block?

Complete failure of impulses to conduct from the atria to the ventricles, resulting in AV dissociation.

Describe the relationship between P waves and QRS complexes in Third Degree AV Block.

There is no relationship between them; the atria and ventricles beat independently at their own inherent rates.

What is the hallmark requirement for any escape beat or rhythm to appear on an ECG?

It must appear after a pause that is longer than the normal sinus cycle length.

How does the morphology of the P wave in an Atrial Escape rhythm differ from a normal sinus P wave?

The morphology is different because the impulse originates from an ectopic atrial focus rather than the SA node.

In a Junctional Escape rhythm, what are the three possible appearances for P waves?

Absent (buried in QRS), retrograde (inverted in inferior leads), or hidden.

What is the typical inherent rate range for a Junctional Escape rhythm?

40-60 bpm.

Describe the appearance of the QRS complex in a Ventricular Escape rhythm.

Wide and bizarre (>120 ms) due to slow, aberrant ventricular depolarization.

Which of the three types of escape rhythms has the slowest inherent firing rate (20-40 bpm)?

Ventricular Escape rhythm.

To determine a Normal Axis on an ECG, what must be the polarity of the QRS complexes in Lead I and lead aVF?

Both must be upright (positive).

A QRS complex that is upright in Lead I but negative (downward) in lead aVF indicates which axis deviation?

Left Axis Deviation (LAD).

A QRS complex that is negative (downward) in Lead I but upright in lead aVF indicates which axis deviation?

Right Axis Deviation (RAD).

Name two common clinical causes of Left Axis Deviation (LAD).

Left Ventricular Hypertrophy (LVH) and Left Anterior Fascicular Block (LAFB).

Name two common clinical causes of Right Axis Deviation (RAD).

Right Ventricular Hypertrophy (RVH) and Pulmonary Embolism (PE).

What range of degrees defines a Normal Axis on the ECG frontal plane?

-30° to +90°.

What ECG diagnosis is appropriate when the QRS duration is >120 ms but the morphology fits neither a Right nor a Left Bundle Branch Block pattern?

Intraventricular Conduction Delay (IVCD).

What is the characteristic V1 QRS morphology seen in Right Bundle Branch Block (RBBB)?

An rSR' pattern (often called "rabbit ears").

In Left Bundle Branch Block (LBBB), what specific finding regarding septal Q waves is required in leads I, V5, and V6?

Septal Q waves must be absent.

Describe the QRS appearance in lateral leads (V5-V6) during a Left Bundle Branch Block.

Broad and notched (M-shaped) R waves.

What is a Left Anterior Fascicular Block (LAFB)?

A block of the anterior fascicle of the left bundle branch that results in Left Axis Deviation.

What type of axis deviation is characteristically caused by a Left Posterior Fascicular Block (LPFB)?

Right Axis Deviation (RAD).

In Brugada Syndrome Type 1, how does the QRS duration compare to a typical Right Bundle Branch Block?

The QRS duration in Brugada Syndrome is typically longer than in RBBB.

What is the clinical significance of a "No Man's Land" axis (Extreme Axis)?

It is an axis between -90° and ± 180° where the QRS is negative in both Lead I and aVF.

Which AV block is characterized by a "dropped" QRS complex following a predictable, progressive prolongation of the PR interval?

Mobitz Type I (Wenckebach).

What rare condition is defined by vascular proliferation and remodeling of small pulmonary vessels, leading to increased resistance and right ventricular failure?

Pulmonary arterial hypertension (PAH)

Which clinical classification group is comprised specifically of Pulmonary Arterial Hypertension (PAH)?

Group 1

Pulmonary hypertension associated with *left heart disease* (such as heart failure or valvular disease) is categorized as _____.

Group 2

Which group includes pulmonary hypertension associated with *lung diseases* (like COPD or ILD) and/or *hypoxemia*?

Group 3

Pulmonary hypertension associated with *pulmonary artery obstructions*, such as Chronic Thromboembolic PH (CTEPH), is classified as _____.

Group 4

Which clinical group involves pulmonary hypertension with *unclear or multifactorial mechanisms*, such as sarcoidosis or hematological disorders?

Group 5

What is the term for dyspnea that occurs when a patient bends forward, which is a symptom of pulmonary hypertension?

Bendopnoea

An accentuated pulmonary component of the second heart sound (S2) is a physical sign of _____.

Pulmonary Hypertension

Distended pulsating jugular veins, hepatomegaly, and peripheral edema are clinical signs of _____ failure.

Right ventricular (RV) backward failure

Which WHO functional class describes a patient with *marked* limitation of activity who is comfortable only at rest?

Class III

Which WHO functional class is assigned to a patient who has symptoms at rest and is unable to perform any physical activity without discomfort?

Class IV

What is the hemodynamic definition of pulmonary hypertension regarding the mean pulmonary artery pressure (mPAP)?

mPAP > 20 mmHg

Pre-capillary PH is hemodynamically defined by an mPAP > 20 mmHg and a pulmonary artery wedge pressure (PAWP) of _____.

≤ 15 mmHg

Which diagnostic procedure must *always* be performed to confirm a diagnosis and characterize hemodynamics before beginning treatment?

Right heart catheterization (RHC)

Which imaging study is recommended to screen for Chronic Thromboembolic Pulmonary Hypertension (CTEPH) in the diagnostic algorithm?

V/Q scan

Which clinical group of pulmonary hypertension is the primary target for most FDA-approved medical therapies?

Group 1 (PAH)

Which specific cause of pulmonary hypertension is considered the only "curable" form of the disease?

Chronic thromboembolic PH (CTEPH)

Sildenafil and Tadalafil belong to which pharmacological class used in PH treatment?

Phospho-diesterase (PDE) 5 Inhibitors

Bosentan, Ambrisentan, and Macitentan are examples of which class of medications?

Endothelin Receptor Antagonists

Which specific prostacyclin derivative is only available for intravenous (IV) administration?

Epoprostinol

Riociguat belongs to which class of PH therapies?

Guanylate Cyclase Stimulators

What is the mechanism of the 2024-approved drug *Sotatercept*?

It inhibits the activin signaling pathway to restore balance between growth-promoting and growth-inhibiting pathways.

On an echocardiogram, what does the measurement TAPSE evaluate?

Right ventricular (RV) function

Which clinical groups of pulmonary hypertension currently have *no* FDA-approved treatments?

Group 2 and Group 5

What clinical condition is defined as substernal chest discomfort provoked by exertion or emotional stress and relieved by rest or sublingual nitroglycerin?

Angina (specifically associated with cardiac ischemia).

List three common locations for anginal equivalent pressure or tightness other than the chest.

Shoulders, arms, neck, back, upper abdomen, or jaw.

Which two non-pain symptoms are frequently identified as anginal equivalents?

Fatigue and shortness of breath.

During the physical examination of a patient with suspected cardiac chest pain, where should blood pressure be measured?

In both arms.

What is the primary mechanism of a Type 2 Myocardial Infarction (Demand Ischemia)?

An imbalance between myocardial oxygen supply and demand unrelated to acute coronary atherothrombosis.

List four clinical states that can precipitate Demand Ischemia (Type 2 MI).

Anemia, sepsis, pulmonary embolism, or tachycardia.

What imaging tool is utilized for asymptomatic patients above age 40 with intermediate risk to guide preventative management?

Coronary artery calcium (CAC) scoring.

What three findings on a baseline ECG would preclude a patient from undergoing an Exercise Tolerance Test (ETT)?

ST Depression, Left Ventricular Hypertrophy (LVH), or Left Bundle Branch Block (LBBB).

What is the clinical term for the procedure colloquially known as a "heart cath"?

Invasive Coronary Angiography.

Which form of Acute Coronary Syndrome (ACS) is characterized by plaque rupture and a thrombus causing 100% obstruction of the lumen?

ST-Elevation Myocardial Infarction (STEMI).

How is Unstable Angina distinguished from NSTEMI in terms of cardiac biomarkers?

Unstable Angina presents with normal biomarkers, whereas NSTEMI presents with elevated biomarkers.

What ECG finding is required for a diagnosis of STEMI in contiguous leads?

ST-segment elevation of ≥ 1 mm.

Which specific form of angina is caused by coronary artery vasospasm rather than atherosclerosis and typically occurs at rest?

Vasospastic (Prinzmetal) Angina.

What is the etiology of a Type 1 Myocardial Infarction?

Acute coronary atherothrombosis precipitated by atherosclerotic plaque disruption (rupture or erosion).

In the acute management of chest pain, oxygen should be administered to maintain a saturation above what level?

90%.

Name two P2Y12 inhibitors that are preferred over Clopidogrel when Percutaneous Coronary Intervention (PCI) is indicated.

Prasugrel or Ticagrelor.

What is the preferred reperfusion strategy for a STEMI if the patient is at a capable center and first medical contact was within 90 minutes?

Percutaneous Coronary Intervention (PCI).