Whispers of the Heart
I Stole and got (cardiac) arrested
Be Still My Beating Heart
Squiggly Lines and AI
Fib Around and Find Out
100
Continuous murmur heard beneath left clavicle
What is PDA?
100
Most commonly associated cause of acute severe mitral regurgitation after STEMI
What is Papillary muscle rupture?
While both can occur after myocardial infarction, chordae tendineae rupture can also occur due to other factors like infective endocarditis or connective tissue disorders, while papillary muscle rupture is more commonly associated with MI.
100
Main treatment of cardiac device infection
What is Extraction?
pocket debridement, antibiotics
100
What is Atrial Flutter with 2:1 Block?
This is the classic appearance of anticlockwise flutter:
- Inverted flutter waves in II, III + aVF at a rate of 300 bpm (one per big square)
- Upright flutter waves in V1 simulating P waves
- 2:1 AV block resulting in a ventricular rate of 150 bpm
- Note the occasional irregularity, with a 3:1 cycle seen in V1-3
100
This condition is known for upper extremity hypertension, radial-femoral pulse delay, infraclavicular systolic murmur.
What is Aortic coarctation?
200
This condition causes a holosystolic murmur that is heard along left sternal border, it increases with inspiration.
What is Tricuspid regurgitation?
While a holosystolic murmur can also be caused by other conditions like mitral regurgitation or Ventral Septal Defect, the characteristic enhancement with inspiration is a key clue to TR.
200
The timing of ACE inhibitor initiation after STEMI.
What is within the first 24 hours?
From the ACC/AHA Guidelines for MI:
Class I
1. Patients within the first 24 hours of a suspected acute MI with ST-segment elevation in two or more anterior precordial leads or with clinical heart failure in the absence of significant hypotension or known contraindications to use of ACE inhibitors.
200
Cardiomyopathy associated with apical dyskinesis or ballooning
What is Takotsubo (stress) cardiomyopathy?
200
What is Wolf Parkinson White?
- Sinus rhythm with a very short PR interval (< 120 ms)
- Broad QRS complexes with a slurred upstroke to the QRS complex — the delta wave
- Dominant R wave in V1 suggests a left-sided AP, and is sometimes referred to as “Type A” WPW
- Tall R waves and inverted T waves in V1-3 mimicking right ventricular hypertrophy (RVH) — these changes are due to WPW and do not indicate underlying RVH
- Negative delta wave in aVL simulating the Q waves of lateral infarction — this is referred to as the “pseudo-infarction” pattern
200
Diagnostic test for PAD if ABI >1.4
What is Toe-brachial index?
A potential source of error with a high ABI is that calcified vessels may not compress normally, thereby resulting in falsely elevated pressure measurements. An ABI above 1.3 is suspicious for calcified vessels that may occur in the setting of underlying diabetes mellitus or end-stage kidney disease (ESRD).
The TBI is a more reliable indicator of limb perfusion in patients with diabetes mellitus and ESRD because the digital vessels are frequently spared from medial calcification. (Uptodate)
300
The generally recommended aortic valve type for patients younger than 50 years.
What is a mechanical valve?*
For patients younger than 50 years undergoing aortic valve replacement (AVR), the 2020 ACC/AHA guideline generally recommends a mechanical valve. However, if there's a contraindication to long-term oral anticoagulation with a vitamin-K antagonist (like warfarin), a bioprosthesis can be considered.
300
Your patient presents to hospital discharge clinic with chest pain and pulseless electrical activity 3 days after STEMI.
What is Ventricular free wall rupture?
300
Specific β-blockers associated with reduced mortality in patients with HFrEF
What is Bisoprolol, metoprolol succinate, carvedilol?
300
This ECG was taken from a 30-year old man who presented with exertional lightheadedness and palpitations.
What is Hypertrophic Cardiomyopathy (HCM)?
ECG Features
- Left ventricular hypertrophy with increased precordial voltages and non-specific ST segment and T-wave abnormalities
- Deep, narrow (“dagger-like”) Q waves in lateral (I, aVL, V5-6) +/- inferior (II, III, aVF) leads
Other associated features may include:
- Left atrial enlargement (“P mitrale”) — left ventricular diastolic dysfunction may lead to compensatory left atrial hyertrophy
- Signs of WPW (short PR, delta wave) — ECG features of Wolff-Parkinson-White (WPW) were seen in 33% of patients with HCM in one study, and at least one genetic mutation has been identified that is associated with both conditions
- Dysrhythmias: atrial fibrillation and supraventricular tachycardias are common; PACs, PVCs, VT
- Giant precordial T-wave inversions in apical HCM
This ECG was taken from a 30-year old man who presented with exertional lightheadedness and palpitations. The ECG was misread by the cardiology team as showing “left ventricular hypertrophy, lateral infarct age undetermined”.
The patient was discharged home and subsequently died of a VF arrest while running to catch a bus. Autopsy showed septal hypertrophy consistent with HCM.
Teaching Point: In a young patient presenting with exertional symptoms and an ECG that looks this this, think HCM — not “prior lateral infarction“!
300
Treatment of recurrent or autoimmune pericarditis
What is Glucocorticoids?
400
Bounding peripheral pulses, diastolic decrescendo murmur along the sternal border
What is Aortic regurgitation?
400
In the setting of an inferior wall ST-elevation myocardial infarction, this triad suggests a right ventricular (RV) infarction
What is hypotension, clear lung fields, and jugular venous distention?
400
Drug therapy for inherited long QT syndrome
What is a β-Blocker?
For long-term management in congenital Long QT syndrome, beta-blockers are the first line choice, and they help prevent ventricular arrhythmias by stabilizing ventricular action potential and helping block sympathetic surges associated with arrhythmias.
400
What is LBBB with AF?
Note deep S waves in leads V1-3 and tall broad R waves laterally. Appropriate discordance is present.
LBBB Criteria
- QRS duration ≥ 120ms
- Dominant S wave in V1
- Broad monophasic R wave in lateral leads (I, aVL, V5-6)
- Absence of Q waves in lateral leads
- Prolonged R wave peak time > 60ms in leads V5-6
400
P2Y12 inhibitor with dyspnea as side effect
What is Ticagrelor?
500
Physical finding in chronic mitral regurgitation (3 key characteristics)
What is Blowing, holosystolic murmur best heard at the apex?
*Will also accept best heard when lying in lateral decubitus
500
In a young, otherwise healthy woman with no known atherosclerotic cardiovascular disease risk factors, _____ is the most common cause of pregnancy-associated myocardial infarction and occurs most commonly in the first month postpartum.
What is Spontaneous coronary artery dissection?
SCAD involves development of a nontraumatic and non-iatrogenic intramural hematoma with or without intimal dissection with luminal communication. The enlarging hematoma in the false lumen compresses the true lumen of the coronary artery and in potential combination with obstructing dissection leads to chest pain, ischemia, and/or infarction. The diagnosis requires coronary CT or coronary angiography to confirm the characteristic imaging features.
500
This bridging therapy may be used in patients with hemodynamic instability in cardiac tamponade while they await a pericardiocentesis.
What is a normal saline infusion?
Medical management is only a temporary measure for tamponade patients while waiting for pericardiocentesis.
Hypotensive patients (systolic arterial pressure <100 mmHg) with hypovolaemia can be treated with a low volume (250-500 ml) of normal saline as it has been demonstrated to improve haemodynamic parameters. However, the infusion of higher volumes may increase wedge pressure and intrapericardial pressure, and reduce cardiac output. (European Society of Cardiology)
500
This ECG abnormality must be associated with one of the following clinical criteria to make the diagnosis:
- Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT).
- Family history of sudden cardiac death at <45 years old .
- Inducibility of VT with programmed electrical stimulation .
- Syncope.
- Nocturnal agonal respiration.
What is Brugada Syndrome?
Diagnostic Criteria
Type 1
- Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave.
- This is the only ECG abnormality that is potentially diagnostic.
- It is often referred to as Brugada sign.
Brugada Syndrome Key Points
- Diagnosis depends on a characteristic ECG finding AND clinical criteria.
- Definitive treatment = ICD.
- Brugada sign in isolation is of questionable significance.
500
Concentric ventricular wall thickness with low QRS voltage
What is Cardiac amyloidosis?
Increased wall thickness on the echocardiogram in symptomatic cardiac amyloidosis is often incorrectly described as “hypertrophy”, leading to a misdiagnosis of hypertensive heart disease or hypertrophic cardiomyopathy. However, wall thickening in amyloidosis is due to infiltration, and, unlike true left ventricular hypertrophy, in which ECG voltage is increased, the voltage in amyloidosis is low, providing a strong clue to the presence of an infiltrative myocardial disorder.