Cardiology 101 > Diagnostic Imaging > Flashcards

Diagnostic Imaging Flashcards

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1
Q

What tumours may cause widened mediastinum

A

germ cell tumors, lymphoma, and thymomas.

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2
Q

What is cardiopulmonary exercise stress test

A

indicated to differentiate cardiac versus pulmonary causes of exercise-induced dyspnea or impaired exercise capacity

*patient’s ventilatory gas exchange is monitored in a closed circuit and measurements of gas exchange are obtained during exercise (i.e., oxygen uptake, carbon dioxide output, anaerobic threshold) in addition to routine EST.

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3
Q

how long does an event monitor usually monitor for?

A

usually 30-60 days

  • only records events when the patient experiences a symptom and presses a button that triggers the event monitor to store ECG data 1-4 mins before and 1-2 mins after the event
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4
Q

what arrhythmias are not necessarily pathological during AECG monitoring??

A
  • sinus Brady during rest/sleep
  • sinus pauses <3 s while sleeping (esp in sleep apnoea)
  • sinoatrial exit block
  • Wenckebach AV block (Type 1)
  • wandering atrial pacemaker
  • junctional escape complexes
  • PVCs/ PACs
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5
Q

what arrhythmias are of concern during telemetry ?

A
  • Second degree AV block type 2
  • Third degree heart block
  • sinus pause >3s
  • marked bradycardia during waking hours
  • tachyarrhythmias
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6
Q

what frequency of PVC is concerning?

A

> 15-20% -> more likely to cause reduction in LVEF and PVC associated cardiomyopathy

Tx: ablation

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7
Q

what can telemetry tell you about prognosis of MI patients?

A
  • frequent PVCs (more than 10/hr)
  • NSVT

Assoc with 1.5-2x increase in death during 2-5 year follow up, independent of LV function

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8
Q

definition of an episode of atrial fibrillation

A

fibrillation episode lasting > 30s

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9
Q

LVEF equation?

A

LVEF = (End diastolic volume - end systolic volume) / End diastolic volume

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10
Q

Impaired LV relaxation as determined by early diastolic filling velocity (e′) of the LV myocardium at the level of the mitral valve annulus

A

when e′ is less than 10 cm/s or 8 cm/s for the lateral and septal walls, respectively

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11
Q

What does E/e’ ratio indicate

A

estimate of the LV filling pressure can be made using the ratio of blood flow velocity across the mitral valve (E) to the velocity of myocardial tissue during early diastole (referred to as the E/e′ ratio)

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12
Q

What is considered a high E/e’?

A

E/e′ >13 averaged between septal and lateral walls

-> high LV filling pressure

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13
Q

cardiac PET viability scan showing area of decreased perfusion with normal/ increased FDG uptake?

A

suggestive of viable hibernating myocardium

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14
Q

what inherited arrhythmia syndromes cause ventricular arrhythmias?

A
  • long QT syndrome: torsades
  • Brugada: VF
  • Catecholaminergic polymorphic VT
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15
Q

what is idiopathic VF

A

when no cause is found (ie. no ischaemia, drugs, electrolyte disturbances) + no inherited arrhythmia syndromes

-> may have monomorphic PVCs that trigger episodes of VF (Which are targets for ablation to reduce recurrence)

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16
Q

mx of idiopathic VF long term?

A
  • ICD
  • ablation if there are monomorphic PVCs that trigger episodes of VF e.g. in idiopathic RVOT VT
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17
Q

definition of VT storm?

A

> /=3 separate episodes of sustained VT within 24 hours

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18
Q

VT storm: what other agents can be added apart from anti arrhythmias to help reduce sympathetic drive

A
  • beta blockers especially non selective e.g. propranolol 40mg Q6H
  • benzodiazepines
  • sympathetic neuromodulation: percutaneous left stellate ganglion block, thoracic epidural anaesthesia
  • general anaesthesia
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19
Q

what surgical management has an established role in preventing recurrent ventricular arrhythmias in Long QT syndrome and catecholaminergic polymorphic VT?

A

permanent surgical cardiac sympathetic denervation

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20
Q

which kinds of PVCs is catheter ablation first line for?

A

RVOT

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21
Q

causes of sick sinus syndrome?

A
  • intrinsic cause: replacement of nodal tissue with fibrous tissue
  • drugs
  • electrolyte imbalances
  • hypothyroidism
  • hypothermia
  • hypoxaemia
  • increased ICP
  • sleep apnoea
  • excessive vagal tone
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22
Q

mx of sick sinus syndrome?

A
  • Identify transient or reversible causes
  • Permanent pacemaker if no reversible cause
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23
Q

what is a bifasicular block?

A
  • located below AV node
  • combination of blocks at the level of the right bundle and blocks within one of the fascicles of the left bundle (ie left anterior or left posterior)
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24
Q

what is trifascicular block?

A

prolonged PR interval + bifascicular block

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25
when is pacing indicated in bifascicular or trifascicular block?
Assoc with - complete heart block and symptomatic bradycardia - alternating bundle branch block - intermittent type 2 second degree block - symptoms suggestive of bradycardia and an HV interval >100ms on invasive EP study or evidence of infra-His block - Neuromuscular disease e.g muscular dystrophy or erb dystrophy
26
bradycardia during sleep?
if bradycardia only present during sleep, even if extreme, pacing is not indicated
27
what is neurocardiogenic syncope?
- triggering of a neural reflex -> self limited episode of systemic hypotension characterised by both bradycardia and peripheral vasodilation
28
mx of neurocardiogenic syncope?
- patient education, pharmacologic trials, prevention strategies - PPM may not be completely helpful as often there is a prominent vasodepressor (peripheral vasodilation) component to their syndrome > PPM considered if syncope without provocative event + ventricular pauses >/=3s or pronounced bradycardia reflex (<40bpm)
29
when is pacing indicated after acute MI?
- persistent complete 3rd degree block or advanced 2nd degree block Assoc block in his-purkinje system (wide complex ventricular rhythm) after STEMI or if pt - transient advanced 2nd or 3rd degree block with a new BBB
30
Pacing nomenclature: Letter 1
Chamber that is paced (A = atria, V = ventricles, D = dual chamber)
31
Pacing Nomenclature: what is Letter 2?
Chamber that is sensed (A= atria, V = ventricles, D = dual chamber, 0= none)
32
Pacing nomenclature, what is letter 3?
Response to a sensed event (I = pacing inhibited, T = pacing triggered, D = dual, 0= none)
33
Pacing nomenclature: Letter 4?
rate-responsive features, is an activity sensor in the pulse generator that detects bodily movement and increases the pacing rate according to a programmable algorithm (R = rate responsive pacemaker, 0= none)
34
Pacing nomenclature, Letter 5?
Chamber that is paced in multisite pacing (A= atrial, V = ventricles, D= dual chamber)
35
what is pacemaker syndrome?
progressive worsening of symptoms (congestive heart failure) after single chamber ventricular pacing - due to asynchronous ventricular pacing -> inappropriately timed atrial contractions Rx: dual chamber pacing and appropriate pacing mode selection
36
37
what is pseudo pacemaker syndrome?
when a patient without a pacemaker has PR prolongation so severe that p waves closer to the preceding QRS complex, leading to atrial contractions during the preceding ventricular systole
38
what is twiddlers syndrome?
rare complication of pacemaker implantation caused by repetitive and often unintentional twisting of the generator in the pacemaker pocket -> lead dislodgement or fracture and subsequent pacemaker failure
39
what is pacemaker-mediated tachycardia?
a form of reentrant tachycardia that can occur in pts with dual chamber pacemaker ie if AV node retrogradely conducts a ventricular paced beat or a PVC back to atrium -> then pacemaker will pace ventricle again
40
how to tx pacemaker mediated tachycardia?
increase of the post ventricular atrial refractory period (PVARP) -> pacemaker ignores atrial events occurring shortly after ventricular events
41
how can RV pacing be bad?
- can lead to worsening of ventricular function due to intraventricular dyssynchrony mostly in pts with preexisting LV dysfunction and HF symptoms -> leading to new onset/ worsening heart failure
42
what is cardiac resynchronisation therapy?
simultaneous pacing of Both RV and LV -> aim is to improve ventricular synchrony and improve efficiency of contraction
43
benefits of CRT in appropriate candidates?
- improve QoL - decrease HF symptoms - reduce mortality
44
factors favouring a good response to CRT?
- female - NICMP - LBBB - wider QRS
45
what is multipoint pacing in CRT?
multipoint LV pacing from a quadripolar lead -> delivers 2 pacing pulses, allows more capture of LV tissue *has been shown to increase CRT response by improving LV electrical activation, reducing LV dyssynchrony, decreasing ESV and improving LV fn
46
what is permanent para-hisian pacing?
- direct His bundle activation by pacemaker -> ventricular activation *need healthy intrinsic conduction system
47
what is permanent left bundle branch pacing?
direct left bundle activation by pacemaker -> subsequent LV activation *meant for patients with LBBB: corrects dyssynchrony and negative inotropic effects * need healthy intrinsic conduction system
48
what is anodal stimulation?
phenomenon of activation of the myocardium close to the anode when CRT is programmed from LV tip electrode (cathode) to RV lead coil ring (anode) -> surrounding tissue around anode may be depolarised -> assoc with decreased CRT response
49
types of ICDs?
- transvenous ICD (one or multiple leads) - subcutaneous lead (only one subcutaneous lead)
50
what is a subcutaneous ICD able to do?
- has a lead that runs under the skin but outside of the ribcage - only used for defibrillation and not for pacing
51
what can transvenous ICD be used for?
- can have transvenous or epicardial leads - can act as pacemaker or cardiac resynchronisation therapy
52
what is anti tachycardia pacing?
when ICD transiently paces the ventricle faster than VT in attempt to restore normal rhythm
53
how do ICDs detect arrhythmias?
- based on beat to beat intervals - shortest intervals: VF zone - VT zone - slower arrhythmias: monitor zone -> once classified into a zone, discrimination algorithm employed to distinguish if rhythm is more likely VT or SVT in origin
54
class 1 indications for ICD implantation for primary prevention
post MI: - NSVT + LVEF <40% + inducible VF or sustained VT at EP study - LVEF <35% + NYHA 2-3 (>40 days post MI or >90d post revasc) - LVEF <30% + NYHA 1 - non ischaemic dilated CMP with LVEF<35% + NYHA 2-3 - other special populations
55
class 1 indications for ICD implantation for secondary prevention of SCD?
- survivor of sudden cardiac arrest not due to reversible cause - have structural heart disease with spontaneous sustained VT - syncope of unexplained aetiology with clinically relevant inducible sustained VT or VF on EP study
56
what other special populations may benefit from ICD therapy?
- HOCM with 1>= risk factor for SCD - Brugada syndrome - awaiting heart transplant - noncompaction of LV - long/short QT syndrome - catecholaminergic polymorphic VT - ARVD with 1>/=risk factor for SCD - infiltrative cardiomyopathies - certain muscular dystrophies
57
when is ICD indicated in HOCM?
HOCM with 1 or more risk factor of SCD: VF, VT, FHx SCD, unexplained syncope, LV thickness >/=30mm, abnormal BP response to exercise
58
indications for ICD in Brugada syndrome?
history of previous cardiac arrest, documented sustained VT, unexplained syncope
59
indications for ICD in long and short QT syndromes?
previous cardiac arrest or unexplained syncope
60
indications for ICD in catecholaminergic polymorphic VT?
syncope and /or VT while receiving beta blockers
61
what is the typical energy level delivered by transvenous pacing?
35-40 J
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