Cardiology Board Review

Jennifer Carlquist PA-C, Central Coast Cardiology, CAQ ER Medicine

 Disclosure
I have a relationship with CME4Life, LLC, and
sell DVDs of my lectures with their company.
 Cardiomyopathy
 Dilated
 Hypertrophic
 Restrictive
Conduction Disorders
 Atrial fibrillation/flutter
 AV Block

Blueprint  Bundle branch block

 PSVT
 Premature beats
 Sick sinus syndrome
 Ventricular tachycardia
 Ventricular fibrillation
 Torsades de pointes
Heart Failure/CAD
 Common arrhythmias and their
treatment
Demystifying Bundle Branch and AV
Blocks
Objectives Coronary Artery Disease: Identify
patients at risk for CAD, prevention and
treatment
 Heart Failure: Identify, manage and
prevent it
“Conduction Disorders”
Things that go bump in the night…
Atrial fibrillation/flutter
Atrioventricular block
Bundle branch block
Paroxysmal supraventricular tachycardia
Premature beats
Sick sinus syndrome
Ventricular tachycardia
Ventricular fibrillation
Torsades de pointes
 Normal
conduction
 Palpitations
tree
Getting to the
root of the
cause
AFIB/Flutter
PVC’s
SVT WPW Sick sinus VT
 Rate: >100 – 160 BPM
Sinus
Regularity: Regular
Tachycardia
P wave: Present, PR interval constant

__________________ and ________________ can cause sinus tachycardia.

 Fever
Pain
Hypovolemia
ST causes
Drugs

How do we treat sinus tach?

 47 year old
syncopal
episode x 2

“ I love to Zumba”
 Rate: Varies
Regularity: Irregular, but PR intervals are the same
P wave: Present intermittently
Sinus
Pause/Arrest Sick sinus syndrome:
- Digitalis, CA ++ blockers, Antiarrhythmic drugs, CAD,
collagen vascular diseases and or mets
- Reversible? Pacer?
Does he need
to go to the
ER?
Supraventricular
Tachycardia

Criteria
Rate: 140 - 220  Etiology
bpm
 Rapid atrial depolarization overrides the
Rhythm: Regular
SA node
QRS: Normal or
prolonged (>.12  Pathway, caffeine, drugs
sec)

Usually starts and

 Clinical Significance
stops suddenly  Decrease in cardiac output = __________
SVT

These patients will most likely have a ___________ blood pressure.

 Stable? Adenosine

SVT

Unstable? Synch
  Stable
 Valsalva

 Unstable
PSVT  Adenosine 6, 12, 12 - (How do we push it?)

 Long term solution:

 BB, ablation
 Rate: Variable, ventricular response can be fast or slow. Atrial
Atrial rate is usually over 350 BPM.
Regularity: Irregularly irregular
Fibrillation
P wave: None; chaotic atrial activity

Patients lose their ___________ in atrial fibrillation.

  Paroxysmal: Atrial fibrillation that lasts from a
few seconds to days, then stops on its own
 Persistent: Does not stop by itself but will stop
if cardioverted
Defining  Permanent (long standing persistent) AFIB
AF begets AFIB wont retain sinus
 Normal LA with structurally normal hearts are
better candidates
 We can fix

•Thyrotoxicosis Things the patient

•High blood can fix
Atrial
Fibrillation pressure
•Heart disease •Obesity
Causes •Smoking
(Valvular)
•High cholesterol •Caffeine
•Alcohol abuse
•Sleep apnea
 Stroke
Complications
CHF
Rate vs Rhythm?
Assess/address
stroke risk
Ablation/Cardiovert
 Rate control is non-inferior to rhythm
control and may be superior in elderly
Rate or co-morbid patients (AFFIRM).
vs
Rhythm Strict rate control may provide no
further benefits (RACE-II)
 Insert chart about this
 1 - strong consideration for AC
“The second 2 and up- “No brainer”
time you want BUT - 1 from female (< 65 years
to be a zero…” old without other risk factors)
NO AC
 Warfarin: needs frequent monitoring
Pradaxa (Direct thrombin inhibitors)
– non valvular $8-12 day
AC choices
No monitoring
No reversal
Pick your poison…
Factor Xa
 No monitoring
 No reversal agents
 Rare medication interactions
 No food interactions
 Renal dosing
 Expensive up to $12/day
Coumadin
 Needs monitoring
 Reversal possible
 Medication interactions
 Food interactions
 Renal insufficiency
 Inexpensive
 The Anticoagulants

Savaysa ASA Coumadin

Eliquis 60 mg qs
Xarelto 81 mg 5 mg qd
5 mg bid
15 mg bid
  Post op, coPd, Partying
 Infiltrative myxoma
 Rheumatic valvular disease
Things to rule  Acute MI
out
 Thyroid
 Toxins

Environmental
 Obese? Sleep apnea
BeerGin
Echo – LAE
Get you
know your Lexiscan – ischemic substrate
customer Bleeding issues?
HRTF?
 How symptomatic?
How long to stay in it –
perioperative?
How do you Bleeder?
choose a drug? How likely to stroke?
How much are they in it?

WHAT DO THEY WANT TO DO

Atrial Flutter
Rate:
Atrial: 250–350 BPM, Vent: 125–175 BPM
Regularity: Regular
P wave: Saw toothed
Does this patient need AC?
  PE
 ETOH
 Ischemic heart disease
Atrial Flutter  Hypoxia
Causes  Digitalis toxicity
 Mitral or tricuspid valve disease
 AMI
Ectopy
The Troublemaker
 Lots of angry cells…

What causes  Atrial

 Ventricular
ectopic beats?
 Come in patterns

This ectopy pattern is called ______________ .

ECTOPY