CVS Flashcards

Question

List 4 indications and 4 contraindications for starting DOAC with newly diagnosed AFIB

Answer 1

Canadian EM-Specific Rule: CHADS-65 - Start long term AC if any of the following: 1. CHF (any history) 2. Hypertension (treated or untreated) 3. Age ≥ 65 ❗️(automatic DOAC if met) 4. Diabetes 5. Stroke or TIA history (highest risk) ➡️ One or more = start anticoagulation Contraindications to DOACs 1. Mechanical heart valves (warfarin) 2. Moderate-to-severe mitral stenosis 3. Severe renal failure (e.g. CrCl < 15 mL/min) 4. Active bleeding or high bleeding risk 5. Pregnancy or breastfeeding

Answer 2

1. Unstable hemodynamics 2. Symptomatic New-Onset AF (<48 Hours) 3. Persistent AF (>48 hrs or unknown) with Anticoagulation - After ≥3 weeks of therapeutic anticoagulation Contraindications: 1. AF > 48h with no anticoagulation 2. Active bleeding or contraindication to anticoagulation 3. Asymptomatic stable AF 4. Digitalis toxicity 5. Severe underlying comorbidities

Answer 3

STEMI equivalent critical stenosis of the LAD Type A = Biphasic T waves with the initial deflection positive and the terminal deflection negative (25% of cases) Type B = T-waves are deeply and symmetrically inverted (75% of cases)

Answer 4

1. Concordant STE ≥ 1 mm in ≥ 1 lead 2. Concordant STD ≥ 1 mm in ≥ 1 lead of V1-V3 3. Discordant STE in ≥ 1 lead anywhere with ≥ 1 mm STE or ≥ 25% of the depth of the preceding S-wave

Answer 5

1. Posterior STEMI 2. LBBB + Smith-modified Sgarbossa criteria 3. Ventricular-paced rhythm with Smith-modified Sgarbossa criteria 4. De Winter Sign 5.Hyperacute T-waves

Answer 6

The likelihood of VT is increased with: 1. Age > 50 (PPV 85%) 2. Structural heart disease 3. IHD 4. Previous MI 5. Family history of sudden cardiac death 6. Regular WCT 7. Chest discomfort during angina 8. QRS >140ms if LBBB or >160ms if RBBB

Answer 7

1. Previous ECGs show a BBB pattern with identical morphology to the broad complex tachycardia 2. Previous ECGs show evidence of WPW (short PR < 120ms, broad QRS, delta wave) 3. The patient has a history of paroxysmal tachycardias or palpatations 4. Younger age 5. Family history of SVT

Answer 8

1. Hypo K 2. Hypo Mg 3. Hypoxia 4. Hypercarbia 5. Acidosis/alkalosis 6. Valvular disease 7. IHD 8. CM 9. Trauma 10. Drugs - TCA - Digoxin - Ethanol -Class 1 antidysrythmic drugs

Answer 9

1. Hypo Mg 2. Hypo K 3. Hypo Ca 4. QT prolonging medications - Class 1a/1c, - TCA - Haldol, ondansetron - antihistamines - antimalarials - antibiotics 5. Hypothermia 6. Hypothyroid 7. MI 8. CVA

Answer 10

Unstable > defibrillation 1st line *** MgSO4 2g IV (can repeat q 15 min or start an infusion if recurrence) Over drive pacing: 1. Isoproterenol 2–10 mcg/min IV infusion 2. Lidocaine 1–1.5 mg/kg IV x1 then 0.5–0.75 mg/kg every 5–10 min (max total = 3 mg/kg) 3. Transvenous or transcutaneous pacing (if drug-induced QT prolongation) **Goal HR: 90–110 bpm

Answer 11

1. Monomorphic VT 2. V. flutter 3. Pacemaker tachycardia 4. Na channel blockade/ toxicity 5. Hyper K 6. Post electrical cardioversion 7. SVT with abberancy 8. Accelerated idioventricular rhytm

Answer 12

1.V fib 2. Irregular VT 3. A. fib / flutter w/ pre-excitation syndrome 4. Polymorphic VT - Torsades -Bidirectional VT (digoxin toxicity)

Answer 13

1. Sinus node dysfunction - symptomatic bradycardia 2. AV node -3rd (complete) AV block, -2nd AV block (Mobitz type II) - AV block with alternating bundle branch block - AV block after anterior MI 3. Post-MI Indications - New CHB after anterior MI - Persistent high-grade AV block after inferior MI 4. Post-Cardiac Surgery or TAVR - Persistent high-grade AV block 5. Neuromuscular Diseases

Answer 14

1. Hyperkalemia 2. BBB or CCB toxicity 3. Hypothyroidism 4. hypothermia 5. ischemia 6. medications 7. Lyme disease

Answer 15

1st Letter= Chamber Paced: A = Atrium (SSS) V = Ventricle (V.fib) D = Dual (CHB) 2nd Letter= Chamber Sensed A = Atrium V = Ventricle D = Dual 3rd Letter – Response to Sensing: I = Inhibited T = Triggered D = Dual 4th Letter – Rate Modulation R = Rate responsive blank = no rate modulation

Answer 16

Dual pacing Dual sensed Dual response R = Rate-responsive pacing based on activity or demand

Answer 17

Failure to pace (no output when needed) Failure to capture (spike present, but no myocardial response) Failure to sense (spike delivered inappropriately) Lead displacement or fracture

Answer 18

Pacing spike not followed by a QRS complex

Answer 19

REACTIVE ICD (Secondary Prevention) After a life-threatening arrhythmia or cardiac arrest 1. Survivor of cardiac arrest due to VT/VF (not transient/reversible) 2. Sustained VT (≥30s) with: - Hemodynamic instability - Structural heart disease 3. Inherited arrhythmia syndromes with a prior VT/VF episode ***Always include no reversible cause*** PREVENTATIVE ICD (Primary Prevention) - High risk of sudden death, but no prior sustained VT/VF 1. Ischemic cardiomyopathy: - HEFrEF ≤35% - NYHA II–III, ≥40 days post-MI - on GDMT ≥3 months 2. Non-ischemic cardiomyopathy: - HEFrEF ≤35%, NYHA II–III, on meds ≥3 months - HEFrEF ≤30% post-MI with NYHA I symptoms 3. Inherited arrhythmia syndromes (e.g., LQTS, CPVT, Brugada) with high-risk features

Answer 20

1. Life expectancy <1 year due to non-cardiac illness 2. Arrhythmia due to reversible cause (e.g. acute MI, electrolyte abnormality)

Answer 21

1. Oversensing - leads t inappropriate shocks 2. Under sensing - can present with syncope or cardiac arrest 3. Lead malfunction - Lead fracture or noise - Lead displacment - scar tissue at tip of lead 4. Battery or Hardware Issues 5. Failure to Pace or Capture - Device doesn’t pace the ventricle when needed, or pacing doesn’t result in depolarization - Lead dislodgement - Battery or hardware failure - Exit block (high pacing threshold due to fibrosis) - Electrolyte disturbance (e.g., hyperkalemia)

Answer 22

1. Angina with strenuous exertion 2. Angina with moderate exertion 3. Angina with mild exertion 4. Angina with rest CCS Class III–IV → Consider cath or revascularization

Answer 23

1. Asymptomatic w/ normal activities 2. Symptoms with normal activities 3. Symptoms with less than normal activities 4. Symptoms at rest NYHA Class II–IV → Determines eligibility for ICD/CRT, medications (ARNI, MRA)

Answer 24

Chest pain due to myocardial ischemia at rest or with minimal exertion, without myocardial necrosis **No troponin rise, no STE Diagnosis= 1 or More of the Following: 1. New-onset angina (Class III or IV) 2. Rest angina lasting >20 mins (even if resolved) 3. Increasing frequency, duration, or severity of previously stable angina 4. Angina after MI (post-infarction angina)

Answer 25

1. Ongoing/recurrent pain at rest (CCS III/IV) 2. Dynamic ECG changes 3. Hemodynamic instability 4. Hx IHD- Prior MI, PCI, CABG 5. Co- existing comorbidities Diabetes, CKD, heart failure

Answer 26

1. Dyspnea (most common) 2. Nausea or vomiting 3. Diaphoresis 4. Syncope or pre-syncope 5. Epigastric pain or discomfort 6. Fatigue or weakness (especially in elderly) 7. Neck, jaw, or back pain 8. Palpitations or dizziness

Answer 27

1. Elderly 2. Women 3. Diabetics 4. Patients with prior CABG or MI 5. Dementia 6. Non white

Answer 28

1. Elevated trop > 99th percentile + one of the following - Ischemic symptoms (e.g. chest pain) - New ischemic ECG changes (ST/T changes, new LBBB) - Development of pathological Q waves - Imaging evidence of new loss of viable myocardium or new wall motion abnormality - Identification of coronary thrombus by angiography or autopsy

Answer 29

1. Primary coronary event (plaque rupture, thrombosis) 2. Mismatch of O₂ supply-demand 3. Sudden death before biomarkers obtained 4. MI related to PCI 5. MI related to CABG surgery

Answer 30

Structural heart Ds 1. Heart failure (acute/chronic) 2. Myocarditis 3. Takotsubo (stress cardiomyopathy) 4. Cardiomyopathies (e.g. HCM, amyloidosis) Infiltrative 1. Sarcoidosis 2. SLE 3. Kawasaki in children Arrhythmias - AF with RVR - VT/VF arrest Pulmonary - Pulmonary embolism -Pulmonary hypertension Renal - ESRD Critical Illness / ICU - Sepsis - Burns - Post-cardiac arrest - post defibrillation

Answer 31

Anything that causes right heart strain 1. COPD 2. Hypoxia 3. PE 4. Pulmonary HTN 5. OSA Reduced clearance - ESRD -AKI Other cardiac causes 1. ACS 2. AFIB 3. CMs 4. Myocarditis Sepsis/ critical illness -Due to myocardial strain and cytokine-mediated BNP release

Answer 32

NEW STE in 2+ contiguous leads >1mm Exception is V2-V3 STE >1.5 mm female STE>2 mm male >40 STE >2.5 male <40 Have to use modified scarbossa for paced rhythm and LBBB

Answer 33

Anterior STEMI LAD Hyperacute T waves in precoridal leads Upsloping ST segment depression > 1mm at the J point in the precordial leads Absence of ST elevation in the precordial leads Reciprocal ST segment elevation (0.5mm – 1mm) in aVR

Answer 34

- Horizontal ST depression in V1-3 - Tall, broad R waves in V2-3 - Dominant R wave (R/S ratio > 1) in V2 - Upright T waves in V2-3 Posterior MI 15 lead = STE > 0.5mm in V7-V9

Answer 35

Anterior STEMi (Antero septal) Anterior MI STE V1-V6 LAD Reciprocal changes in inferior leads

Answer 36

High lateral MI STE I, aVL, V5-6 Coronary artery= LCx Reciprocal changes: inferior leads

Answer 37

Inferior STEMI + CHB and slow junctional escape rhythm STE II, III, aVF Coronary artery: RCA Reciprocal changes: Lateral leads

Answer 38

In patients with inferior STEMI, RV MI is suggested by: -STE in V1 and STD in V2 (highly specific for RV infarction) - STE in III > II - Diagnosis is confirmed by the presence of STE in the right-sided leads V4R (V3R-V6R) Right sided 12 lead

Answer 39

Predicts 6 week MACE 1. History 0- not sus +1- mod sus +2- highly sus 2. ECG 0- Normal +1- non specific repolarization +2- ST chnages 3. Age 0 <45 +1 45-65 +2 >65 4. Risk factors 0 = 0 +1- 1-2 +3 >2 5. TnT +1 1-3x ULN +2 >3x ULN 0-3 = 2.5% MACE – d/c home 4-6 = 20% MACE – admit for observation 7+ = 73% - early invasive strategy

Answer 40

FMC to Dx > 10 min - ECG acquired and interpreted Dx to cath lab activation < 10 min Door to ballon time in ED < 30 min Transport for inter-facility transfers or STEMI diagnosed in field <60 min FMC to PCI <120 min FMC to fibrinolysis <30 min Time from fribinolysis to cCath < 24 hr

Answer 41

Consider fibrinolysis if ALL of the following are met: 1. Diagnosis of STEMI: - ST elevation ≥1 mm in 2 contiguous leads OR - New/presumed new LBBB with ischemic symptoms 2. Symptom onset within ≤12 hours (Best benefit <6 hours) 3. PCI not available within 120 minutes of first medical contact 4. No contraindications to lysis

Answer 42

Absolute: 1. any prior ICH 2. Known brain AVM 3. Active bleeding 4. GIB < 1 mo 5. Bleeding diathesis 6. Ischemic stroke < 3 mo 7. Suspected aortic dissection 8. Major surgery < 3mo (esp head and spine) Relative: 1. BP >180/110 (uncontrolled) 2. Pregnancy 3. Recent internal bleed (GI/GU <4 weeks) 4. Prolonged or traumatic CPR (>10 mins) 5. Anticoagulation (e.g. INR >2) 6. Dementia

Answer 43

1. Resolution of CP 2. Reperfusion arrythmia 3. > 50 decrease in STE - in the lead with maximum elevation 4. Improved hemodynamics

Answer 44

MOA: - Irreversible inhibition of COX-1 enzyme - Irreversibly inactivates PLTs/ inhibits PLT aggregation ACS ED dose 160–325 mg PO (non-enteric coated, chewed) Maintenance 81 mg daily PO indefinitely (unless contraindicated)

Answer 45

MOA: P2Y₁₂ receptor inhibition on platelets. Irreversible inhibition of PLT aggregation Loading: 300–600 mg PO once Maintenance: 75 mg PO daily **600 mg preferred if PCI planned

Answer 46

Reversible P2Y₁₂ receptor blocker *faster onset and offset then cplavix Loading: 180 mg PO once Maintenance: 90 mg PO BID

Answer 47

MOA: Binds antithrombin III→ deactivates thrombin→ ↓ fibrinogen conversion to fibrin – prevents clot formation/propagation Initial IV bolus: 60–70 units/kg (max 5,000 units) IV infusion: 12–15 units/kg/hr (commonly ~1,000 units/hr) Adjust to target aPTT 1.5–2.5× control Monitor aPTT q6h initially; antidote = protamine sulfate

Answer 48

If heparin given within past 30–60 minutes: ~1 mg of protamine neutralizes ~100 units of heparin For 5,000 units of heparin, give 50 mg protamine IV Max total dose 50 mg Adverse effects: - hypotension - bradycardia -allergic reaction

CVS Flashcards

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