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News4Medico.com T opic - Coronary Artery disease Coronary Artery disease onlinembbs.com Cardiology anatomy2medicine.com

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T opic - Coronary Artery disease

Coronary Artery disease

T opic - Coronary Artery disease Coronary Artery disease onlinembbs.com Cardiology anatomy2medicine.com Differential

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Cardiology

disease Coronary Artery disease onlinembbs.com Cardiology anatomy2medicine.com Differential diagnosis of chest pain (

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Differential diagnosis of chest pain ( Commonly asked clinical Vignette in MD Entrance) (MCQ)

 

o

Costochondritis/musculoskeletal:

 

§ Sharp, localized pain and reproducible tenderness

§ oftenexacerbated by exercise

 

o

Myocardial infarction/angina:

 

§ Chest heaviness, pressure

§ pain, typically radiating to left arm, shoulder, or jaw

 

o

Pericarditis:

 

§ Chest pain radiating to shoulder, neck, or back,

§ worse with deep breathing or cough (pleuritic)

§ relieved by sitting up/leaning forward(MCQ)

 

o

Aortic dissection:

 

§ Severe chest pain radiating to the back

§ associated with unequal pulses or unequal blood pressure in right and left arms(MCQ)

 

o

Abscess/mass:

 

§

Often sharp, localized pain, pleuritic(MCQ)

 

o

Pulmonary embolism:

 

§ Often pleuritic.

§ Frequently associated withtachypnea and tachycardia

 

o

Pneumonia:

 

§

Pleuritic, frequently associated with hypoxia(MCQ)

 

o

GERD/esophageal spasm/tear:

 

§

Burning pain, dysphagia, may be similarto pain ofmyocardial infarction (MI)

 

o

Other causes ofchest pain:

 

§

Peptic ulcer disease, biliary disease, herpes zoster, anxiety, pneumothorax

Risk factors for coronary artery disease (MCQ)

 

o

Modifiable:

 

§ Smoking ,Hypercholesterolemia ,Hypertension

§ Obesity (apple-shaped) ,Diabetes mellitus , Physical inactivity

 

o

Nonmodifiable:

 

§

Age ,Male , Family history

 

o

Criteria for family history of coronary artery disease:(MCQ)

 

§

MI before age 40 in men

§

MI before age 55 in women Evaluation ofCAD

o Exercise Stress Testing

1

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News4Medico.com onlinembbs.com anatomy2medicine.com § Patients are asked to walk on a treadmill at increasing levels

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News4Medico.com onlinembbs.com anatomy2medicine.com § Patients are asked to walk on a treadmill at increasing levels of

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News4Medico.com onlinembbs.com anatomy2medicine.com § Patients are asked to walk on a treadmill at increasing levels of

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§ Patients are asked to walk on a treadmill at increasing levels of difficulty to reach a heart rate that is 85% ofpredicted maximum for age.

§ Alternatively, pharmacologic agents such as dobutamine may be administered IV to stimulate myocardial function in a patient who cannot exercise.(MCQ)

§ ECG monitoring during the procedure detects changes.

§ A test is considered positive for coronary artery disease if the patientdevelops:(MCQ)

ST elevation

ST depression > 1 mm in multiple leads

Decreased BP

Failure to exercise more than 2 minutes due to

symptoms

§ Failure to complete the test due to reasons other than cardiac symptoms (i.e., arthritis) is not diagnostic.

o

Stress Myocardial Perfusion Imaging

§ Patients are injected with a radioisotope (thallium 201 or technetium 99m sestamibi) and stressed (with exercise or pharmacologic agent). (MCQ)

§ Nuclear imaging is obtained immediately after exercise and in 4 hours.

§ The test can detect:

 

Myocardial perfusion

Ventricular volume

Ejection fraction

o

Cardiac Catheterization

§ The right heart is accessed by the femoral or internal jugular vein.

§ The left heart is accessed by the femoral or radial artery (from the rightheart).

Acute coronary syndromes (ACS)

o

Classified as non-ST-elevation and ST-elevation events.

o

Non-ST-elevation events include non-ST-elevation MI and unstable angina (UA). ACS is due to an imbalance ofmyocardial oxygen demand and supply.

o

The most common cause of decreased oxygen supply is narrowing of coronary artery by thrombus or plaque that has become unstable.

o

Cardiac enzymes :

§ Myoglobin: (MCQ)

Elevated within 1 hour of MI but is nonspecific

Creatinine phosphokinase (CPK):

Elevated within 4 to 8 hours of MIbut is nonspecific

§ CK MB isoenzyme:(MCQ)

Specific marker for myocardial tissue damage

§ Troponin T or I: (MCQ)

2

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News4Medico.com onlinembbs.com anatomy2medicine.com Very sensitive and specific markers for cardiac muscleinjury.

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News4Medico.com onlinembbs.com anatomy2medicine.com Very sensitive and specific markers for cardiac muscleinjury.

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News4Medico.com onlinembbs.com anatomy2medicine.com Very sensitive and specific markers for cardiac muscleinjury.

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Very sensitive and specific markers for cardiac

muscleinjury. Elevated within 3 hours and can stay elevated for more than a week

Renal insufficiency can lead to erroneously high levels depending on the type of troponin and the cutoff value used.

§ “Serial enzymes”:

Consists of cardiac biomarkers drawn every 6 to 8hours for a 24-hour period(MCQ)

Initial Evaluation ofACS

 

o

Typical symptoms:

 

§ Left-sided/substernal chest pressure with radiation to left shoulder, arm, or jaw

§ Shortness ofbreath

§ Diaphoresis

§ Nausea or vomiting

 

o

Unstable angina is associated with

 

§ increasing frequency and/or severity ofsymptoms

§ symptoms at rest

§ new onset of symptoms.

 

o

Presentation may be atypical in diabetics and women.

o

Initial test: ECG

Determining the Type ofACS and Management protocol

 

o

ST-elevation MI (STEMI) or new left bundle branch block (LBBB) on ECG:

 

§

These patients are admitted and managed according to guidelines for STEMI.

 

o

Unstable angina/non-ST-elevation MI: (MCQ)

 

§ These two have similar pathogenesis.

§ Non-ST-elevation MI differs from unstable angina in that the lack ofoxygen is severe enough to cause myocardial damage and enzyme leakage (unlike unstable angina, where there is no enzyme leakage).

 

o

Clinical scenario 1: If normal ECG and normal cardiac enzymes and no recurrence ofsymptoms(MCQ)

 

§

patient can have echocardiogram to assess left ventricular function.

 

o

Clinical scenario 2: If either test is abnormal(MCQ)

 

§

patient should be managed as acute ischemia.

 

o

Clinical scenario 3: If ST depression, inverted T-waves, positive cardiac enzymes, or recurrence ofsymptoms (but no ST elevation on ECG)(MCQ)

 

§

patient should be admitted to the hospital and managed as acute ischemia.

Risk Stratification

o TIMI Risk Score(MCQ)

§ Age>65

§ Presence of 3 or more CAD risk factors

3

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News4Medico.com onlinembbs.com anatomy2medicine.com § Prior coronary stenosis  50% § Presence of ST segment

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News4Medico.com onlinembbs.com anatomy2medicine.com § Prior coronary stenosis  50% § Presence of ST segment

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News4Medico.com onlinembbs.com anatomy2medicine.com § Prior coronary stenosis  50% § Presence of ST segment

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§ Prior coronary stenosis 50%

§ Presence of ST segment deviation on admission ECG

§ At least two anginal episodes in last 24 hours

§ Elevated serum cardiac biomarkers

§ Use of ASA in prior 7 days

o Risk of all cause mortality @ 14 days =

§ 0/14.7% ,2 8.3% ,33.2 %

§ 419.9% , 5 26.2% , 6/740.9%

Initial Treatment for All ACS

 
 

o

Anti-ischemic treatments:

§ Oxygen

 

§ Nitroglycerin (NTG)

 

for chest pain

can be given sublingually

Ifpain persists, can be given intravenously.

 

§ Morphine

 
 

Given if pain persists despite NTG

 

§ Beta blockers(MCQ)

 

decreasecardiac oxygen demand

have been shownto decrease mortality

Aim for a pulse rate of60 .

 

o

Antiplatelet and anticoagulation:

§ Aspirin (chewable preferred).

§ Clopidogrel is an alternative for those with true aspirin allergy.

§ Both unfractionated heparin and low-molecular-weight heparin can be used.

§ GP IIb/IIa inhibitors have shown to be beneficial for(MCQ)

 

high-risk patients

 

o

elevated troponin

o

TIMI risk score > 4

o

ongoing ischemia

 

patients undergoing percutaneous intervention.

 

§ Thrombolytics are not used in unstable angina or non-ST- elevation MI because in 60 to 80% the infarcted artery is not occluded.(MCQ)

Treatment for Unstable Angina and Non-ST-Elevation MI

 

o

General ACS anti-ischemic and antiplatelet treatment

o

Early invasive treatment (cardiac catheterization) ifany ofthe following are present:(MCQ)

§ Elevated troponin

§ Recurrent chest pain despite medical therapy

§ CHF

§ Positive stress test

§ Left ventricular EF < 40%

§ Sustained ventricular tachycardia

§ Cardiac stent within 6 months

4

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News4Medico.com onlinembbs.com anatomy2medicine.com o Early conservative therapy with medical management can be

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News4Medico.com onlinembbs.com anatomy2medicine.com o Early conservative therapy with medical management can be

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News4Medico.com onlinembbs.com anatomy2medicine.com o Early conservative therapy with medical management can be

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o Early conservative therapy with medical management can be considered in patients who respond to medical managementwithout any of the features mentioned above. Treatment for ST-Elevation MI

o

Patients include those with new left bundle branch block.

o

Requires early revascularization with thrombolytics and/or cardiaccatheterization and stent

o

Cardiac catheterization/percutaneous transluminal coronary angioplasty (PTCA):(MCQ)

§ Coronary angiogram can demonstrate the coronary anatomy as well as the specific diseased vessel causing symptoms.

§ The occlusion of the vessel can be reopened by balloon angioplasty and/or coronary stent placement.

§ Success rate as high as 90% compared to 60% with thrombolytics.

§ Preferred over thrombolytics if:(MCQ)

 

Skilled lab is available in < 12 hours from onset of

symptoms and < 30 minutes from entering the ER

High risk of ST-elevation MI (i.e., cardiogenic shock)

Late presentation (> 3 hours after symptoms)

o

Thrombolytics

§ Thrombolytics are preferred (MCQ)

if patient presents within 12 hours ofsymptoms , preferably within 3 hours

if there will be a delay to PTCA or ifcardiac

catheterization is not an option.

§ Thrombolytics work to break up clots.

§ Examples include streptokinase, urokinase, anistreplase, alteplase, and reteplase.

§ Absolute contraindications to thrombolytics:(MCQ)

Any prior intracranial hemorrhage

Stroke within 1 year

Intracranial neoplasm

Active internal bleeding

Suspected aortic dissection

§ Relative contraindications to thrombolytics:(MCQ)

Available cath lab within 90 minutes of presentation

Systolic blood pressure (sBP) > 180

diastolic blood pressure (DBP)> 110

Prior stroke or intracranial lesion other than above

Bleeding disorder

warfarin use with international normalized ratio(INR) > 2

Major surgery within 3 weeks

Age>75

5

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News4Medico.com onlinembbs.com anatomy2medicine.com   Cardiopulmonary resuscitation (CPR) Peptic ulcer

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News4Medico.com onlinembbs.com anatomy2medicine.com   Cardiopulmonary resuscitation (CPR) Peptic ulcer

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News4Medico.com onlinembbs.com anatomy2medicine.com   Cardiopulmonary resuscitation (CPR) Peptic ulcer

anatomy2medicine.com

 

Cardiopulmonary resuscitation (CPR)

Peptic ulcer

Medications at Discharge for Patients with ACS(MCQ)

o

Aspirin indefinitely

o

Beta blocker indefinitely

o

Angiotensin-converting enzyme (ACE) inhibitor indefinitely

 

§

initially recommended for patients with ejection fraction (EF) < 40% or anterior wall MI

 

o

Statin to maintain LDL < 70

Clopidogrelfor 1 to 12 months depending on stent placement and type Postinfarction Complications

o

o

Ruptures (usually occur within 4 to 5 days of a large MI):

o

Free wall rupture

 

o

Acute ventricular septal perforation

o

Acute mitral regurgitation from papillary muscle rupture

o

Arrhythmias:

 

o

Ventricular tachycardia:(MCQ)

 

§ If within 48 hours of MI, usually just from reperfusion of myocardium.

§ If it occurs later than 48 hours, consider implantable defibrillator.

 

o

Bradycardia (usually from inferior wall MI)

o

Atrioventricular (AV) block:(MCQ)

 

§ If inferior wall MI, this will usually reverse

§ ifanterior wall MI, usually will require pacemaker

 

o

Dressler’s syndrome: (MCQ)

 

§ Usually occurs 1 or 2 weeks after cardiac injury (MI or cardiac surgery).

§ It is associated with fever, pericarditis, and sometimes pericardial or pleural effusions; likely a hypersensitivityprocess.

§ Treat with NSAIDs.

Secondary Preventionof unstable angina/non-ST-elevation MI and ST- elevation MI:

o

Smoking cessation

o

Aggressive diabetes management

o

Aggressive control of hypertension (maintain < 140/90)

o

Lipid control with statins as above and dietary modification

§

ANGINA

Unstable angina

o

An acute coronary syndrome diagnosed by the following history:

 

§ New-onset angina

§ Angina that changes or accelerates in pattern , location, or severity

§ Angina at rest

Stable angina:

o A chronic, episodic pain syndrome due to temporary myocardial ischemia.

6

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News4Medico.com onlinembbs.com anatomy2medicine.com o Pattern of pain is similar to that ofacute MI , but

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News4Medico.com onlinembbs.com anatomy2medicine.com o Pattern of pain is similar to that ofacute MI , but resolves

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News4Medico.com onlinembbs.com anatomy2medicine.com o Pattern of pain is similar to that ofacute MI , but resolves

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o Pattern of pain is similar to that ofacute MI , but resolves with rest or medication. Prinzmetal’s angina:

o

Angina due to coronary vasospasm, not linked to exertion.

o

Distinguished from unstable angina by chronic, intermittent nature.

o

Pain usually occurs at a specific hour in the early morning

o

Coronary vessels are angiographically normal.

o

Etiology :Temporary myocardial ischemia

o

Diagnosis

 

§

ECG

 

ST segment depression or elevation

T wave inversion

May be normal

o

Treatment

§ For Stable Angina(MCQ)

Beta blockade: Reduces myocardial oxygen demand

Aspirin: Reduces risk of MI in asymptomatic patients

Morphine: For analgesia, but does not affect outcome

Modify risk factors for coronary artery disease.

Sublingual NTG for episodic pain

Echocardiogram to assess left ventricular function

Exercise stress test

Consider coronary revascularization after aforementioned tests: PTCAor coronary artery bypass graft (CABG).

Clinical Pearls :

§ For Prinzmetal’s Angina

Calcium channel blockers and nitrates to reduce vasospasm

The maximum heart rate is estimated as: [220 patients age].(MCQ)

ECG Changes(MCQ)

 

o

Inferior wall MI:

 

§

ST elevation in II, III, aVF

 

o

Corpulmonale:

 

§

ST depression in II, III, aVF

 

o

Anteroseptal MI:

 

§

ST elevation in V1, V2,

 

o

Lateral wall MI:

 

§

ST elevation in V4, V5, V6

 

o

Posterior wall MI:

 

§

ST depression in V1, V2

Low-molecular-weight heparin

 

o

given sub-Q every 12 hours.

o

PT/PTT does not need to be checked.

7

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News4Medico.com onlinembbs.com anatomy2medicine.com The thrombolytic streptokinase   o highly immunogenic

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News4Medico.com onlinembbs.com anatomy2medicine.com The thrombolytic streptokinase   o highly immunogenic

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News4Medico.com onlinembbs.com anatomy2medicine.com The thrombolytic streptokinase   o highly immunogenic

anatomy2medicine.com

The thrombolytic streptokinase

 

o

highly immunogenic

o

cannot be used in the same patient twice within a 6-month period.

Clinical Vignette in MD Entrance :(MCQ)

 

o

A 64-year-old man who was discharged from the hospital after MI 2 weeks ago presents with fever, chest pain, and generalized malaise. ECG shows diffuse ST-T wave changes

 

§ Diagnosis: Dressler’s syndrome.

§ Treat with nonsteroidal anti-inflammatory drugs (NSAIDs).

Clinical Vignette in MD Entrance :(MCQ)

 

o

A 72-year-old smoker presents complaining of three episodes of severe heavy chest pain this morning. Each episode lasted 3 to 5 minutes, but he has no pain now . He has never had this type ofpain before.

o

Diagnosis: Unstable angina.

Clinical Vignette in MD Entrance :(MCQ)

o

A 70-year-old man presents with frequent episodes ofdull chest pain on and off for 8 months. He says the pain wakes him from sleep.

o

Diagnosis: Prinzmetal’s angina.

Serum Markers for MI

ENZYME

ONSET(HRS)

PEAK (HRS)

DURATION

Myoglobin

1-4

6-8

24hrs

Troponin T/I

3-12

18-24

7-10 days

Cratinine kinase

3-12

18-24

3-4 days

Lactate dehydrogenase

6-12

24-48

6-8 days

T opic - Hypertension

Hypertension

8

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News4Medico.com onlinembbs.com anatomy2medicine.com Defined as an SBP  140 or DBP  90 on two

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News4Medico.com onlinembbs.com anatomy2medicine.com Defined as an SBP  140 or DBP  90 on two separate

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News4Medico.com onlinembbs.com anatomy2medicine.com Defined as an SBP  140 or DBP  90 on two separate

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Defined as an SBP 140 or DBP 90 on two separate occasions (MCQ)

25 to 35% of adults have hypertension

Etiology

o

Essential hypertension (primary, idiopathic)

o

Secondary causes:

 

§ Renal parenchymal disease (chronic pyelonephritis)(MCQ)

§ Renal artery stenosis

§ Primary hyperaldosteronism (Cushing’s and Conn’s syndromes)

§ Pheochromocytoma(MCQ)

§ Eclampsia and preeclampsia

§ Coarctation of the aorta (congenital)(MCQ)

Pathophysiology

Usual mechanism is a normal cardiac output with increased peripheral vascular resistance.(MCQ) Risk factors

o

o

Diabetes

o

High-sodium diet (MCQ)

o

Obesity

o

Tobacco use

o

Family history of hypertension

o

Black race

o

Malegender(MCQ)

Signs and symptoms

o

Most patients with hypertension have no symptoms.

o

Patients with severe hypertension may present with:

 

§ Light-headedness

§ Morning occipital headaches

§ Epistaxis

§ Hematuria

§ Blurred vision

§ Angina

§ Congestive heart failure

Diagnosis/evaluation

o

Blood pressure in both arms, repeated ifabnormal

o

Funduscopic examination to look for AV nicking, hemorrhage, papilledema(MCQ)

o

Auscultation for renal artery bruits (MCQ)

o

ECG may show LVH or left ventricular strain.(MCQ)

o

Urinalysis to look for active sediment, hematuria

o

Blood urea nitrogen (BUN)/creatinine, serum potassium (evidence of renal insufficiency)

Treatment

o For repeated elevated blood pressure measurements:

§ Dietary changes: (MCQ)

High fruits, vegetables

9

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News4Medico.com onlinembbs.com anatomy2medicine.com low-fat dairy products, lowtotal and saturated fats, low salt §

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News4Medico.com onlinembbs.com anatomy2medicine.com low-fat dairy products, lowtotal and saturated fats, low salt §

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News4Medico.com onlinembbs.com anatomy2medicine.com low-fat dairy products, lowtotal and saturated fats, low salt §

anatomy2medicine.com

low-fat dairy products, lowtotal and saturated fats, low

salt

§ Weight loss, physical exercise

§ Low-dose thiazide diuretics are first choice for stage 1 hypertension.(MCQ)

§ Low-dose ACE inhibitor, calcium channel blockers, or beta blockers arealso effective.(MCQ)

o Two- or three-drug therapy for patients not initially controlled

Complications ofhypertension (MCQ)

o

Stroke

o

MI

o

Atrial fibrillation

o

Heart failure

o

Peripheral vascular disease

o

Renal disease

Hypertensive emergency

o

Malignant hypertension is characterized by severely elevated blood pressure accompanied by end-organ damage.

o

Features that should alert the physician to the need for rapid blood pressure reduction.(MCQ)

§ New-onset neurologic signs, papilledema

§ chest pain

§ heart failure

§ renal failure

o

Diagnosis

§

Presence of end-organ damage (ECG changes, new-onset renal failure, active urinary sediment, intracranial bleed, etc.)

o

Treatment

o

Reduce the mean arterial pressure by no more than 20%.(MCQ)

o

Common intra- venous agents include:(MCQ)

§ Labetalol

§ Nitroprusside

§ Phentolamine for pheochromocytoma

§ Hydralazine or magnesium for preeclampsia-related hypertension

Clinical Pearls :

Over 90% of hypertension is essential, or idiopathic.

Hypertension due to pheochromocytoma is characterized by ectopic production ofepinephrine and norepinephrine , causing wide swings in blood pressure.(MCQ)

A 29-year-old woman with preeclampsia treated with IV drip ofmagnesium complains of difficulty breathing and has diminished reflexes. What is next step?

o Stop magnesium and give IV calcium.(MCQ)

10

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News4Medico.com onlinembbs.com anatomy2medicine.com An active urinary sediment contains blood, protein, and red and

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News4Medico.com onlinembbs.com anatomy2medicine.com An active urinary sediment contains blood, protein, and red and

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News4Medico.com onlinembbs.com anatomy2medicine.com An active urinary sediment contains blood, protein, and red and

anatomy2medicine.com

An active urinary sediment contains blood, protein, and red and white cell casts.

Use parenteral blood pressure–lowering agents only ifend-organ damage is found, due to the risk of rapid reduction in coronary and cerebral perfusion.

The mean arterial pressure is :(2DBP SBP)/3(MCQ)

Nitroprusside can cause cyanide toxicity.(MCQ)

Definition ofHypertension (JNC-7)

HYPERTENSION

SYSTOLIC BLOOD PRESSURE

DIASTOLIC BLOOD PRESSURE

Normal

 

< 120

< 80

Prehypertension

120-139

80-89

Stage 1

140-159 or

90-99

Stage 2

>

160 or

> 100

Low potassium intake is associated with higher blood pressure in some patients; an

intake of90 mmol/d is recommended(MCQ) Polycythemia, whether primary or due to diminished plasma volume, increases

blood viscosity and may raise blood pressure. (MCQ) Nonsteroidal anti-inflammatory drugs (NSAIDs) produce increases in blood

pressure averaging 5 mm Hg and are best avoided in patients with borderline or elevated blood pressures. The metabolic syndrome (sometimes also called syndrome X or the "deadly quartet") consists of (MCQ)

o

upper body obesity

o

hyperinsulinemia and insulin resistance

o

hypertriglyceridemia

hypertension Liddle syndrome (MCQ)

o

o

anautosomal dominant condition

o

characterized by

§ early-onset hypertension

§ hypokalemic alkalosis

§ low renin and low aldosterone levels.

11

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News4Medico.com onlinembbs.com anatomy2medicine.com This is caused by a mutation that results in constitutive activation

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News4Medico.com onlinembbs.com anatomy2medicine.com This is caused by a mutation that results in constitutive activation

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News4Medico.com onlinembbs.com anatomy2medicine.com This is caused by a mutation that results in constitutive activation

anatomy2medicine.com

This is caused by a mutation that results in constitutive activation ofthe epithelial sodium channel of the distal nephron, with resultant unregulated sodium reabsorption and volume expansion. Renal artery stenosis (MCQ)

o

o

present in 1–2% of hypertensive patients.

o

Its cause in most younger individuals is fibromuscular hyperplasia, particularly in women under 50 years ofage.

The remainder of renal vascular disease is due to atherosclerotic stenoses ofthe proximal renal arteries Renal vascular hypertension should be suspected in the following circumstances: if the documented onset is before age 20 or after age 50 years(MCQ)

o

o

hypertension is resistant to three or more drugs

o

if there are epigastric or renal artery bruits

o

if there is atherosclerotic disease of the aorta or peripheral arteries (15– 25% of patients with symptomatic lower limb atherosclerotic vascular disease have renal artery stenosis

o

if there is abrupt deterioration in kidney function after administration of ACE inhibitors(MCQ)

o

ifepisodes ofpulmonary edema are associated with abrupt surges in blood

pressure In young patients with fibromuscular disease, angioplasty is very effective, but

there is controversy regarding the best approach to the treatment of atheromatous renal artery stenosis. Although ACE inhibitors have improved the success rate of medical therapy of hypertension due to renal artery stenosis, they have been associated with marked hypotension and (usually reversible) kidney dysfunction in individuals with bilateral disease.(MCQ)

T opic - Bacterial endocarditis

Bacterial endocarditis

is a localized infection ofthe endocardium

characterized by vegetations involving the valve leaflets or walls.

It can also be classified as acute (ABE) or subacute (SBE).

o

ABE

§

Infection of healthy valves by high-virulence organisms

§

Produces metastatic foci

§

Usually fatal if not treated within 6 weeks

§

Most common organism is S. aureus (MCQ)

o

SBE

§

Seeding of previously damaged valves (rheumatic heart disease,

 

con-

 

§

genital valve defects: mitral valve prolapse)

§

causedby low-virulence organisms

§

Does not produce metastatic foci

§

Most common organism is Streptococcus viridans(MCQ)

12

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News4Medico.com onlinembbs.com anatomy2medicine.com § Mitral valve is most often affected (MCQ) Etiology  

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News4Medico.com onlinembbs.com anatomy2medicine.com § Mitral valve is most often affected (MCQ) Etiology  

onlinembbs.com

News4Medico.com onlinembbs.com anatomy2medicine.com § Mitral valve is most often affected (MCQ) Etiology  

anatomy2medicine.com

§ Mitral valve is most often affected(MCQ)

Etiology

 
 

o

Acute: S. aureus, gram negative(MCQ)

o

Subacute:

 

§

Streptococcusviridans,otheroralflora,groupAbeta- hemolyticstrep, enterococci, Staphylococcus epidermidis

 

o

IV drug users: S. aureus, streptococci, enterococci, Candida

o

Prosthetic valves (10 to 20% of cases):

 

§

S. aureus, Streptococcus viridans,gram negative bacilli, fungi(MCQ)

 

o

Nosocomial infections:

§

Indwelling venous catheters, hemodialysis, CTsurgery Signs and symptoms

 

o

ABE

 

§

Acute onset of fever, chills, rigors

§

New cardiac murmur

§

Metastatic infections—meningitis, pneumonia

 

o

SBE

 

§

Gradual onset of fever, sweats, weakness, arthralgia, anorexia, weight loss, and cutaneous lesions

§

New cardiac murmur

§

Splenomegaly

§

Petechiae:

 
 

Multiple nonblanching red macules on upper chest and mu-cous membranes

 

§

Osler’s nodes:(MCQ)

 

Tender violaceous subcutaneous nodules on fingers andtoes

 

§

Splinter hemorrhages:(MCQ)

 

Fine linear hemorrhages in middle of nailbed

 

§

Janeway lesions: (MCQ)

 

Multiple hemorrhagic nontender macules or noduleson palms

 

§

Roth’s spots:(MCQ)

 

Retinal hemorrhages seen on funduscopy

 

§

Conjunctival hemorrhages

Diagnosis

 

o Duke’s criteria(A very High yield MCQ in MD Entrance )

§ Patient must have 2 major, 1 major + 3 minor, or 5 minor criteria for diagnosis):

§ Major Criteria

Two positive blood cultures taken at least 12 hours apart, or 3positive cultures taken at least 1 hour apart

Echocardiography—vegetations are pathognomonic but

their absence does not rule out endocarditis transesophageal echo is more sensitive.

13

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News4Medico.com § Minor Criteria onlinembbs.com anatomy2medicine.com Predisposing lesion on valve or intravenous drug

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News4Medico.com § Minor Criteria onlinembbs.com anatomy2medicine.com Predisposing lesion on valve or intravenous drug

§ Minor Criteria

onlinembbs.com

News4Medico.com § Minor Criteria onlinembbs.com anatomy2medicine.com Predisposing lesion on valve or intravenous drug

anatomy2medicine.com

Predisposing lesion on valve or intravenous drug use

Fever > 38 ̊C

Arterial emboli (Janeway lesions)

Osler’s nodes, Roth’s spots

Positive blood cultures not meeting major criteria

Echocardiogram suspicious for endocarditis but not meeting major criteria

Treatment

 

o

Streptococci: Penicillin G or ceftriaxone 4 weeks(MCQ)

o

Staphylococci:Nafcillin or oxacillin4 weeks(MCQ)

o

MRSA: Vancomycin4 weeks(MCQ)

Clinical Pearls :

o

Endocarditis prophylaxis is given to patients with ValvularHD and those with previous history of endocarditis 30 minutes prior to:(MCQ)

§ Dentalprocedures

§ GIprocedures

§ Urologicprocedures

o

There is a strong association between Streptococcus bovis endocarditis and colonic neoplasms.(MCQ)

o

IV drug users: (MCQ)

§ Right-sided ABE most often affects the tricuspid valve

§ septic pulmonary emboli are common.

T opic - Heart Sounds

Heart Sounds

§ S, is loud in short PR interval

§ S 2 is heard due to closure ofA V values

§ The intensity of S 1 depends upon

§ Position ofmitral leaflets at the onset of ventricular systole

14

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News4Medico.com onlinembbs.com anatomy2medicine.com o In short PR interval mitral leaflets are at a greater\ distance

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News4Medico.com onlinembbs.com anatomy2medicine.com o In short PR interval mitral leaflets are at a greater\ distance

onlinembbs.com

News4Medico.com onlinembbs.com anatomy2medicine.com o In short PR interval mitral leaflets are at a greater\ distance

anatomy2medicine.com

o In short PR interval mitral leaflets are at a greater\ distance than normal due to decreased interval between atrial contraction and ventricular systole

§ The rate of rise ofthe left ventricular pressure pulse

o In VSD & MR rate ofrise ofpressure is low leading to

soft S1

§ Pressure or absence of structural disease ofmitral valve (defective closure in MR, leading to soft S p calcified valve in MS leading to soft S,).

§ Causes of soft S1

§ Long PR interval

§ Mitral regurgitation

§ Immoble mitral leaflet because ofrigidity and calcification as in MS*

§ Left bundle branch block

§ VSD

§ Tricuspid regurgitation

§ Causes of loud S 1

§ Shortened diastole due to tachycardia*

§ Short PR interval

§ Mitral stenosis ifthe valve is pliable*

§ Third Heart sound (S3) is a low pitched sound produced 0.14 to 0.16 S after A 2 at the termination ofRAPID FILLING.

§ S3 usually (in age > 40 yrs) indicates.

§ Impairment ofventricular function.

§ AV valve regurgitation.

§ Conditions that increase rate or volume ofventricular filling.

§ Causes ofS 3

§ Physiological

§ Healthy young adults.

§ Athletes.

§ Pregnancy

15

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News4Medico.com § fever § Pathological onlinembbs.com anatomy2medicine.com § Large, poorly contracted early LV ,

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News4Medico.com § fever § Pathological onlinembbs.com anatomy2medicine.com § Large, poorly contracted early LV ,

§ fever

§ Pathological

onlinembbs.com

News4Medico.com § fever § Pathological onlinembbs.com anatomy2medicine.com § Large, poorly contracted early LV ,

anatomy2medicine.com

§ Large, poorly contracted early LV , Mitral reflux.

§ An S 3 that is 'pericardial knock' present in constrictive pericarditis.

§ In pure MS, S 3 is never heard as rapid filling is not possible due to stenosed AV valve.

§ S 4 is low pitched, presystolic sound, produced in ventricle during 2nd rapid filling phase

§ It is associated with effective atrial contraction.

§ S4 is seen in following conditions;

§

Hypertension

§

Aortic stenosis

§

Hypertrophic cardiomyopathy

§

Ischaemic heart disease

§

Acute mitral regurgitation

T opic - Pericardial tamponade Pericardial tamponade

Tamponade is the physiologic result of rapid accumulation of fluid in the in-

elastic pericardial sac. It impairs cardiac filling and reduces cardiac output.

Etiology

o

Pericarditis

o

Trauma (accidental or iatrogenic)

o

Ruptured ventricular wall (post MI)

Aortic dissection with rupture into pericardium Signs and symptoms

o

o

Beck’s Triad (MCQ)

 

§ Hypotension

§ Muffled heart sounds

§ Jugular vein distention (JVD)

Other Symptoms/Signs

o

Dyspnea

o

Tachycardia

o

Pulsusparadoxus—decrease by > 10 mm Hg ofsBP with inspiration(MCQ)

16

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News4Medico.com onlinembbs.com anatomy2medicine.com   o Narrow pulse pressure o JVD Diagnosis

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News4Medico.com onlinembbs.com anatomy2medicine.com   o Narrow pulse pressure o JVD Diagnosis

onlinembbs.com

News4Medico.com onlinembbs.com anatomy2medicine.com   o Narrow pulse pressure o JVD Diagnosis

anatomy2medicine.com

 

o

Narrow pulse pressure

o

JVD

Diagnosis

 

o

Auscultation may demonstrate distant heart sounds. (MCQ)

o

ECG may show low voltage or electrical alternans.(MCQ)

o

CXR may show enlarged cardiac silhouette.(MCQ)

o

Echocardiogram will show large pericardial effusion.

Treatment

 

o

Immediate pericardiocentesis for unstable patients(MCQ)

o

Infuse fluids to expand volume.

o

Pericardial window (surgery) for meta-stable and stable patients

Clinical Pearls :

 

o

Pulsusparadoxus is a transient fall in measured blood pressure > 10 mm Hg associated with inspiration (due to reduced stroke volume during inspiration).(MCQ)

o

Tamponade physiology:

 

§ During inspiration, venous return to the right atrium increases.

§ In tamponade, the transiently enlarged right atrium bulges leftward, reducing left ventricular volume and output, causing BP to fall with inspiration.

 

o

Pericardiocentesisyielding clotting blood probably came from the right ventricle, not the pericardial sac.

Swan-Ganz Catheterization

 

o

In tamponade, near equalization (within 5 mm Hg) of the right atrial, right ventricular diastolic, pulmonary arterial diastolic, and pulmonary capillary wedge pressure (reflecting left atrial pressure) occurs. (MCQ)

o

The right atrial pressure tracings display a prominent systolic x descent and abolished systolic y descent.(MCQ)

o

Boltwood et al described the diastolic equalization ofpulmonary capillary and right atrial pressures as predominantly inspiratory ; this is known as the inspiratory traction sign. It results from inspiratory traction of the taut pericardium by the diaphragm. (MCQ)

With a 12-lead electrocardiogram (see the image below), the following findings suggest, but are not diagnostic for, pericardial tamponade:

Sinus tachycardia

Low-voltage QRS complexes

17

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News4Medico.com onlinembbs.com anatomy2medicine.com Electrical alternans - Also observed during supraventricular and

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News4Medico.com onlinembbs.com anatomy2medicine.com Electrical alternans - Also observed during supraventricular and

onlinembbs.com

News4Medico.com onlinembbs.com anatomy2medicine.com Electrical alternans - Also observed during supraventricular and

anatomy2medicine.com

Electrical alternans - Also observed during supraventricular and ventricular tachycardia

PR segment depression

Electrical alternans(MCQ)

o

Alternation of QRS complexes, usually in a 2:1 ratio, on electrocardiographic findings is called electrical alternans.

o

It is caused by movement of the heart in the pericardial space.

Electrical alternans is also observed in patients with myocardial ischemia, acute pulmonary embolism, and tachyarrhythmias Chest radiography

o

o

Shows cardiomegaly , a water bottle–shaped heart , pericardial

calcifications, or evidence of chest wall trauma (MCQ) A bowed catheter sign on chest radiography in children after central venous

catheter insertion may be suggestive of tamponade (MCQ) Echocardiography signs

o

An echo-free space posterior and anterior to the left ventricle and behind the left atrium –

o

After cardiac surgery, a localized, posterior fluid collection without significant anterior effusion may occur and may readily compromise cardiac output

o

Early diastolic collapse of the right ventricular free wall (MCQ)

o

Late diastolic compression/collapse of the right atrium (MCQ)

o

Swinging of the heart in its sac (MCQ)

o

LV pseudohypertrophy(MCQ)

o

Inferior vena cava plethora with minimal or no collapse with inspiration(MCQ)

o

A greater than 40% relative inspiratory augmentation ofright-side flow (MCQ)

o A greater than 25% relative decrease in inspiratory flow across the mitral valve(MCQ) Most important table based on which lot ofMCQs are tested in MD Entrance exam

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News4Medico.com onlinembbs.com anatomy2medicine.com Charecteristic Tamponade Constrictive Restrictive RVMI

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News4Medico.com onlinembbs.com anatomy2medicine.com Charecteristic Tamponade Constrictive Restrictive RVMI

onlinembbs.com

News4Medico.com onlinembbs.com anatomy2medicine.com Charecteristic Tamponade Constrictive Restrictive RVMI

anatomy2medicine.com

Charecteristic

Tamponade

Constrictive

Restrictive

RVMI

Pericarditis

Cardiomyopathy

Clinical

       

Pulsus paradoxus

Common

Usually

Rare

Rare

absent

Jugular veins

       

Prominent y descent

Absent

Usually

Rare

Rare

present

Prominenty x descent

Present

Usually

Present

Rare

present

Kussmaul’s sign

Absent

Present

Present

Present

Third heard sound

Absent

Absent

Rare

May be

present

Pericardial knock

Absent

Often

Absent

Absent

present

Electrocardiogram

       

Low ECG voltage

May be

May be

May be present

Absent

present

Electrical alternans

May be

Absent

Absent

Absent

present

Echocardiography

       

Thickened

Absent

Present

Absent

Absent

pericardium

Pericardial

Absent

Often

Absent

Absent

calcification

present

Pericardial effusion

Present

Absent

Absent

Absent

RV size

Usually

Usually

Usually normal

Enlarged

small

normal

Myocardial thickness

Normal

Normal

Usually increased

Normal

Right atrial collapse and RVDC

Present

Absent

Absent

Absent

Increased early filling, mitral flow velocity

Absent

Present

Present

May be

present

Exaggerated respiratory variation

Present

Present

Absent

Absent

CT/MRI

       

Thickened/calcific

Absent

Present

Absent

Absent

pericardium

Cardiac

       

catheterization

Equalization of diastolic pressures

Usually

Usually

Usually absent

Absent or

present

present

present

Cardiac biopsy

No

No

Sometimes

No

helpful?

19

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News4Medico.com T opic - Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy onlinembbs.com anatomy2medicine.com §

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News4Medico.com T opic - Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy onlinembbs.com anatomy2medicine.com §

T opic - Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy

onlinembbs.com

cardiomyopathy Hypertrophic cardiomyopathy onlinembbs.com anatomy2medicine.com § Hypertrophy of the

anatomy2medicine.com

§ Hypertrophy of the interventricular septum narrows the LV outflow tract

§ High-velocity systolic flow draws the anterior leaflet ofthe mitral valve into the tract (via the Bernoulli effect) .(MCQ)

§ causes a dynamic left ventricular outflow tract obstruction.

§ Etiology

o

50% idiopathic

o

50% familial (autosomal dominant, with variable penetrance).(MCQ)

§ Conditions that increase the LV end diastolic volume decrease the obstruction .(A frequently asked MCQ in MD Entrance )

o

increased blood volume

o

negative inotropic drugs

o

rest

o

increased peripheral resistance

§ Outflow obstruction can result in left atrial dilatation, atrial fibrillation, CHF , right heart failure, etc.

§ Signs and symptoms

o

Angina.(MCQ)

§ Occurs at rest and during exercise

§ Frequently unresponsive to nitroglycerin

§ May respond to recumbent position (pathognomonic but rare)

o

Syncope

§

Most often occurs following exercise

o

Arrhythmias: Atrial fibrillation, ventricular tachycardia

o

Signs ofCHF

o

Sudden death is usually due to an arrhythmia (MCQ)

§ Diagnosis

o

Systolic ejection murmur.(MCQ)

§ heard best along the left sternal border

§ decreases with increased LV blood volume (squatting)

§ increases with

 

increased blood velocities (exercise)

decreased LV end-diastolic volume (V alsalva)

o

Paradoxical splitting ofS2

§ ECG: .(MCQ)

o

LVH, PVCs, atrial fibrillation

o

inferiorlateral Q waves

o

nonspecific ST segment and T wave abnormalities

§ Echocardiography:

o Septal hypertrophy, LVH, small LV

§ Treatment

o

Patient should refrain from vigorous exercise.

o

Beta blockers–first line agents.(MCQ)

§ reduce heart rate

20

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News4Medico.com onlinembbs.com § increasing LV filling time § decreasinginotropy anatomy2medicine.com o calcium

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News4Medico.com onlinembbs.com § increasing LV filling time § decreasinginotropy anatomy2medicine.com o calcium

onlinembbs.com

§ increasing LV filling time

§ decreasinginotropy

§ increasing LV filling time § decreasinginotropy anatomy2medicine.com o calcium channel blockers

anatomy2medicine.com

o

calcium channel blockers considered second-line agents.

o

The roles of antiarrhythmics, septal myomectomy, pacemaker, and

defibrillator are all controversial.

§ Avoid anything that decreases preload(nitrates, diuretics, volume depletion) as this will worsen obstruction by allowing left ventricular collapse (MCQ)

§ Clinical Vignette in MD Entrance :.(MCQ)

o

A18-year-old athlete from Bihar becomes severely dyspneic and collapses while running laps. His father had died suddenly at an early age.

o

Diagnosis :Hypertrophic cardiomyopathy.

§ Very few murmurs decrease with squatting (HCM does)

T opic – ECG

ECG Rate

(MCQ)

The usual paper speed is 25mm/sec

1mm (small square) = 0.04 sec

5mm (big square) = 0.2 sec

Calculate atrial and ventricular rates separately if they are different (e.g. complete

heart block). For regular rhythms: Rate = 300 / number of large squares in between each

consecutive R wave. (MCQ) For very fast rhythms: Rate = 1500 / number of small squares in between each

consecutive R wave. (MCQ) For slow or irregular rhythms: Rate = number of complexes on the rhythm

strip x 6 (this gives the average rate over a ten-second period). Interpretation (adults)

o

60–100beats/min -Normal

o

>100beats/min -Tachycardia

o

<60beats/min –Bradycardia

Normal Heart Rates in Children (MCQ)

o

Newborn: 110 – 150 bpm

o

2 years: 85 – 125 bpm

o

4 years: 75 – 115 bpm

o

6 years+: 60 – 100 bpm

ECG Rhythm

Rhythm strip - On a 12 lead ECG this is usually a 10 second recording from Lead II.

A useful 7 step approach to rhythm analysis

1. Rate —

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News4Medico.com a. Tachycardia or bradycardia? b. Normal rate is 60-100/min. 2. Pattern ofQRS complexes —

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News4Medico.com a. Tachycardia or bradycardia? b. Normal rate is 60-100/min. 2. Pattern ofQRS complexes —

a.

Tachycardia or bradycardia?

b.

Normal rate is 60-100/min.

2. Pattern ofQRS complexes —

onlinembbs.com

60-100/min. 2. Pattern ofQRS complexes — onlinembbs.com anatomy2medicine.com a. Regular or irregular? b.

anatomy2medicine.com

a.

Regular or irregular?

b.

If irregular is it regularly irregular or irregularly irregular?

3. QRS morphology —

a.

b.

Narrow complex — sinus, atrial or junctional origin.

Wide complex — ventricular origin, or supraventricular with aberrant conduction.

4. P waves —

a.

b.

Absent — sinus arrest, atrial fibrillation

Present — morphology and PR interval may suggest sinus, atrial,

junctional or even retrograde from the ventricles.

5. Relationship between P waves and QRS complexes —

a. A V association (may be difficult to distinguish from isorhythmic dissociation)

b. A V dissociation

i.

complete — atrial and ventricular activity is always independent.

ii.