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IBHRE CEPS EXAM WITH {946} QUESTIONS
AND VERIFIED ANSWERS
Type of pause seen after PVC - ANSWER Compensatory pause Type of pause seen after PAC - ANSWER Non-compensatory pause What would lead I look like in BiV pacing - ANSWER small or isoelectric because activating both V at the same time Inferior STEMI best seen in which leads - ANSWER inferiors Large (+) p wave in II - ANSWER Right Atrial enlargement (RAE) Notched P in II; biphasic late (-) p in V1 - ANSWER Left Atrial Enlargement (LAE) Elevated R in V1 - ANSWER Right Ventricle hypertrophy electrolyte imbalance associate with SQTS - ANSWER hypercalcemia electrolyte imbalance associate with LQTS - ANSWER hypocalcemia Which 2 leads are usually similar in configuration because they measure along the same horizontal axis - ANSWER I & v PVC location: (-) II, III, avF - ANSWER low, apex PVC location: (+) II, III, avF - ANSWER high, outflow tract PVC location: transition before v3 - ANSWER Left sided PVC location: transition after v3 - ANSWER Right sided Delta waves: (-) v1 - ANSWER Right sided Delta waves: (+) v1 - ANSWER Left sided Delta waves: (-) II, III, avF - ANSWER posterior Delta waves: (+) II, III, avF - ANSWER anterior Delta waves: (+) v2- 6 - ANSWER posterior septal
Delta waves: transition v1- 2 - ANSWER septal Indication for ablation of AP in pt w/ no SVT - ANSWER shortest pre-excited R-R <220 in AF increased risk of AP through pathway leading to VF Conduction through the AV node with delay or block, resulting in a broader QRS - ANSWER Aberrancy Electrical impulses trigger cardiac muscle contraction by controlling the flux of which ion across membrane - ANSWER Calcium Ventricle activation time measurement - ANSWER Beginning of Q to peak of R cSNRT= - ANSWER cSNRT=SNRT-SCL AVNRT response to adenosine - ANSWER SVT terminates with an A AVRT response to adenosine - ANSWER Ruled out, if SVT continues with AV block VA<AV - ANSWER AVRT Ashman's phenomenon - ANSWER aberration occurring when a short cycle follows a long one in AF RBBB morphology in v6 - ANSWER wide S wave LBBB morphology in v6 - ANSWER opposite of v Heart block type: A, H, no V - ANSWER 2nd type 2 - infranodal block Heart block that resolves during exercise is located in - ANSWER AVN Most rare hemiblock - ANSWER Left posterior Hemiblock Does antidromic AVRT have a delta wave? - ANSWER Yes Does orthodromic AVRT have a delta wave? - ANSWER No (AP conducts retrograde) When would you use precordial thump - ANSWER in pulseless VT when defib is not nearby
Oral drug most similar to Lidocaine - ANSWER Mexiletine Drug that decreases theophylline levels - ANSWER Mexiletine Most common toxic effect of antiarrhythmic drugs - ANSWER proarrhythmic 1st line class 1c drug on symptomatic AF pts w/ recent onset w/ no structural or ischemic heart disease - ANSWER Flecainide 1st line action for pt w/ narrow complex SVT - ANSWER Vagal maneuvers Side effects of amiodarone - ANSWER Acute - AV block, hypotension, bradycardia Chronic - pulmonary fibrosis, peripheral deposition leading to bluish discoloration, arrhythmias, hypo/hyperthyroidism, photosensitivity (corneal deposition) Drugs to avoid in WPW - ANSWER Any drug that blocks the AVN can increase the risk of rapid bypass Adenosine Beta Blockers Calcium Channel Blockers Digoxin Drugs that may be beneficial in WPW - ANSWER Flecainide & Procainamide Rhythm control for AF & AFL - ANSWER 1c & III Rate control for AF & AFL - ANSWER II & IV Cardiac Active Sympathetic catecholamines - ANSWER DINED Dopamine Isuprel Norepinephrine Epinephrine Dobutamine Beta Blocker Contraindications - ANSWER Asthma Heart block COPD Diabetes Extremities PVD Benefits of Vasopressin over Epinephrine in VF/pulseless VT - ANSWER Reduced cardiac ischemia & irritability one-time does to simplify administration
reduced propensity for VF ACE inhibitors reduce - ANSWER vasoconstriction & hypertension Medical therapies indicated for pt in anaphylactic shock - ANSWER IV fluid & epinephrine Cardiotonic drugs like Digitalis - ANSWER Slow HR & increase force of contraction Contrast is filtered out via - ANSWER Kidneys Deg and time of tilt table test - ANSWER 60-90 degrees 20 - 45 min SA node conduction time (SACT) - ANSWER SACT=(return interval-BCL)/ Echo beat - ANSWER impulse travels down to V via slow pathway & back up to A via fast pathway Tach happenings in DDD pacing when the paced V wave passes retrograde up to the AVN which is sensed as an A then the V is paced too soon - ANSWER PMT Type of AP that can conduct both ways - ANSWER manifest Type of AP that can only conduct retrograde - ANSWER Concealed Normal para-hisian response - ANSWER high output: A capture low output: V capture at longer time Epicardial punture location - ANSWER subxyphoid AV dissociation & H before each V - ANSWER BBRVT Criteria for BBRVT - ANSWER HIS precedes QRS HV 55- 160 if PPI-TCL<30 - ANSWER within circuit Phased Array - ANSWER ICE Morady Pacing - ANSWER VAAV=AT VAV=AVNRT PVC @ time of HIS (HIS is refractory), if impulse reaches A - ANSWER pathway
follows A pace, prevents inappropriate inhibition of the ventricular system by the atrial system - ANSWER Ventricular blanking period (VBP) follows v pace, prevents t wave sensing in ventricle - ANSWER Ventricular refractory period (VRP) Pacemaker therapy class indications - ANSWER 1: therapy good 2: conflicting 3: therapy not useful/harmful What class for ppm would a child with congenital heart disease: sinus node dysfunction w/ symptomatic bradycardia - ANSWER Class 1 What call for ppm would a teen w/ post op 3rd deg heart bloc w/ return of normal conduction in a few days - ANSWER Class 3 LBBB + RBBB - ANSWER Complete heart block Patients have LBBB & pacing LV before RV results in syncronization - ANSWER CRT Most common reason for lead removal - ANSWER infection Position 1 of pacer code - ANSWER Chamber that is paced O = none, A = atrium, V = ventricle, D = both A and V Position 2 of pacer code - ANSWER Chamber that is sensed O = none, A = atrium, V = ventricle, D = both A and V Position 3 of pacer code - ANSWER Mode of Response O, T (triggered), I (Inhibited), D Position 4 of pacer code - ANSWER Rate responsiveness: Indicates the programmability of the pacemaker Ability to adjust the HR based on physiologic need O = none, R = rate modulation Position 5 of pacer code - ANSWER Multisite pacing: Indicates that the pacer can pace multiple sites O = none, A = atrium, V = ventricle, D = dual Negative terminal of the pacer should be connected to - ANSWER distal electrode
During DDR pacer change out, new generator is attached to leads, but no pacing happens until generator is placed in pocket. Why? - ANSWER Unipolar leads: positive pole was not connected until pacer generator makes contact w/ tissue Minimum amount of mA required to elicit regular cardiac contractions - ANSWER Pacing threshold Wedensky hysteresis effect - ANSWER stimulation threshold may vary depending on whether turning up or down Rate responsive devices are beneficial in pts w/ - ANSWER SA node dysfunction Normal lead impedance - ANSWER 500 ohm Broken lead impedance - ANSWER 2500 ohm eroded insulation impedance - ANSWER 80 ohm When to not used synchronized cardioversion - ANSWER fast VT, Vflutter, VFib because no distinct QRS PTs w/ DDDR who exhibit retro VA conduction are prone to develop - ANSWER PMT Chronaxie= - ANSWER 2x rheobase is the minimum TIME to cause a contraction @ twice the Rheobase Class of drugs that can significantly raise stimulation threshold and cause LOC - ANSWER 1c Fastest rate that V can be paced in response to sensed A events - ANSWER Max tracking rate When is stimulation threshold usually lowest - ANSWER At time of implant What can reduce the acute rise in thresholds with in the first 2 months after initial ppm implant - ANSWER IV steroids or steroid eluting tip When is stimulation threshold the highest - ANSWER Acute rejection phase (1mo) High sensitivity = - ANSWER less sensitive Lower sensitivity = - ANSWER more sensitive
AFFIRM Study - ANSWER compare rate-control and rhythm-control strategies for the treatment of AF. AFFIRM demonstrated no survival advantage between rate- control (using ß-blocker, calcium channel blocker and/or digoxin) and rhythm-control strategies. What type of rate modulation requires a special lead - ANSWER temperature Effect of smaller electrode on pacing lead impedance - ANSWER increase Protects the pacemaker circuitry from cardioversion/defib energy circuits - ANSWER Zener Diode Plateau at which a normal amount of current is required to excite the tissue regardless of lengthening pulse width - ANSWER Rheobase Advantage of rate responsive or rate adaptive AV delay - ANSWER permits tracking at higher rates Most common cause of pacemaker failure to output - ANSWER oversensing To reduce incidence of safety pacing or functional non-sensing in pts w/ frequent ectopy - ANSWER shorten V blanking period Drug of choice in Afib conducting down bypass tracts - ANSWER Procainimide Drug class that decreases conduction velocity increases refractory period decreases automaticity - ANSWER 1a Class 1a may cause EADs or DADs - ANSWER EADs 1a drug not to use in MI or CHF - ANSWER Disopyramide 1a drug w/o many serious side effects (besides hypotension and QT lengthening) & not likely to increase digoxin levels - ANSWER Procainamide Drug class that suppresses DADs - ANSWER 1B Class that has little effect on conduction velocity decrease ERP decrease AP decrease automaticty - ANSWER 1b
Why 1b have little effect on atrial tissue - ANSWER AP in A is shorter than V 1b drug used in pts with MI w/ frequent PVCs - ANSWER Lidocaine Drug effective for VTs caused by digitalis toxicity - ANSWER Phenytoid Drug class that significantly slows conduction velocity by does not prolong AP or refractory periods - ANSWER 1c Effect of 1c on DFT - ANSWER increases Affects catecholamines, mainly affects SA & AV nodes, blocks epinephrine which slows HR - ANSWER Beta blockers Beta blockers effect on DFT - ANSWER reduces DFT Reduces VF after MI Avoid use in WPW Contraindicated in pts w/ asthma - ANSWER Beta blockers Only class III that only prolong AP (not ERP) - ANSWER Dofetilide Class III affects which phase of the AP - ANSWER prolongs phase 2 Class that increases ERP and prolong AP - ANSWER III Most effective drug for VF and unstable VT - ANSWER Amiodarone Preferred drug for AFib pts in renal failure - ANSWER amiodarone Drug used in cardioversion which may lower energy required and allow for rapid carioversion - ANSWER Ibutilide Slows HR and increases force of contraction in pts in heart failure - ANSWER Digoxin Effective on monomorphic VT involving abnormal purkinje and exercise VT - ANSWER Verapamil Caution of class IV drug in WPW - ANSWER can enhance antegrade conduction through AP Class that decreases automaticity, conduction, and refractory - ANSWER IV
ICD primary prevention - ANSWER prevention of SCD in pts who have not had VA or SCA but increased risk ICD secondary prevention - ANSWER 2nd chance- survivors of SCA/ Prior VA VANISH Study - ANSWER superiority of ablation over escalating medication therapy for pts w/ recurrent VT despite antiarrhythmic medication Most common cause of SCD in individuals under 40 - ANSWER HCM exertion related polymorphic (bi-directional) VT - ANSWER Catecholaminergic polymorphic VT Coved ST elevation in leads V1/2 - ANSWER Brugada Treatment of SQTS - ANSWER Quinidine & ICD Outflow tract more likely occurring in men - ANSWER LVOT Outflow tract more likely occurring in women - ANSWER RVOT
of paps in RV - ANSWER 3
of paps in LV - ANSWER 2
BBB and axis of Fasicular VT - ANSWER RBBB & superior axis retrograde leg in Fasicular VT - ANSWER Left posterior fascicle Drug choice in IST - ANSWER Ivabradine Charge (Q) formula - ANSWER Q=It Unit of absorbed dose - ANSWER RAD (gray) Unit of does equivalent or occupational exposure - ANSWER REM Normal function in dual chamber pacing. Occurs when sensed P rate is fast than the programed maximum tracking rate (or URL) - ANSWER Pacemaker wenkebach When might automatic mode switching fail - ANSWER A flutter When pacing mode switches from atrial tracking to non tracking mode upon tach detection - ANSWER automatic mode switching
SCD-HeFT trial - ANSWER * NYHA II/III, CM, EF 35%
- Endpoint - mortality placebo vs. amnio vs. ICD *23% risk of death for ICD therapy CASH trial - ANSWER randomized patients to ICD, amiodarone, and metoprolol. Mortality in the metoprolol group was similar to amiodarone. The benefit of ICD therapy is more evident during the first five years after the index event CIDS trial - ANSWER randomized patients with VF or VT to treatment with an ICD or amiodarone. mean follow up 3 years in a subset a CIDS, the benefit of ICD over amiodarone increased over time Most common infection agents - ANSWER Staphylococcus areus & epidermis All factors that cause an increase in contractility cause an increase in what intracellular concentration - ANSWER Calcium Determinates of myocardial performance - ANSWER HR Conduction velocity Preload Afterload Contractility Voltage amplitude most common in PFA - ANSWER 2kV Constant current device - ANSWER small load (low impedance) Constant voltage device - ANSWER large load (-) inotropic drugs like beta blockers, verapamil, and disopyamide are beneficial in - ANSWER HCM APAF-CRT trial - ANSWER AVN abl to slow V rate plus CRT reduced overall mortality Difference in transseptal stick in cryo versus RF - ANSWER Cryo stick low and anterior septal to help get into RIPV Drug class best for flutters - ANSWER 1a & III
Tachycardia type: digitalis toxic arrhythmias, Torsades, VTs that respond to Ca blocking agents - ANSWER Triggered Treatment is to reverse underlying metabolic abnormality - ANSWER Automaticity Afterdepolarizations of sufficient magnitude may engage the rapid sodium channels - ANSWER Triggered m and h gates - ANSWER control ionic fluxes of sodium across membrane Class 1 subset that decreases conductivity - ANSWER 1a or 1c Drug class that has little effect of AP; works by decreasing sympathetic tone - ANSWER beta blockers Drug class that decreases sympathetic input causing more parasympathetic influence - ANSWER 4 Drug classes that effects mostly SA and AV nodes - ANSWER II, IV, V Drug class that can convert unidirectional block into bidirectional by increasing the long refractory of the fast pathway - ANSWER Class I Typical lateral, inferior, and anterior leads monitored for an EP study - ANSWER I, II, V IEGM typically records which phase of the AP - ANSWER Phase 0 Programmed impulses allow you to assess - ANSWER Refractory periods Automaticity of a focus Characteristics of reentry circuits HRA catheter position - ANSWER High lateral wall near the junction of the superior vena cava The smallest possible time interval between 2 impulses that can be conducted through that tissue - ANSWER Functional refractory period Occurs during phase 3 of the AP before the cell is fully repolarized - ANSWER Effective refractory period Longest coupling interval where a premature impulse will fail to propagate through tissue - ANSWER Effective refractory period
Catecholamine dependent VT can be tested in the EP lab with the infusion of - ANSWER Sympathomimetic agents Reentry termination depends on - ANSWER - Refractoriness of the tissue between the catheter and circuit
- Conduction velocity of the tissue between catheter and circuit
- Distance from electrode and circuit Upper limit of CSNRT - ANSWER 525 SACT= - ANSWER (RCL-BCL)/ A drug commonly used to induce parasympathetic block in order to assess sinus node function - ANSWER Atropine Block that is infra nodal - ANSWER Mobitz II & 3rd HV interval of 120 would be - ANSWER indication for pacemaker Split HIS - ANSWER indication for pacemaker Functional refractory period of AVN can be obtained during extra stim pacing by measuring the shortest - ANSWER H1-H2 interval As the S1-S2 shortens the conduction in the AVN becomes prolonged, the coupling interval that produces block in the AV node is - ANSWER ERP Block in HPS at an H1-H2 interval greater than 400 ms would be - ANSWER indication for pacer Autonomic maneuvers would do what to the refractory of AVN - ANSWER Decrease Approximately what % of patients with SA nodal disease also have AV conduction disease - ANSWER 33% Most characteristic of automatic tachycardia - ANSWER non-inducible What is most necessary for initiation of a reentrant SVT - ANSWER Slow pathway, unidirectional block SVT rhythm characterized by afterpotentials and cycle length being key initiators - ANSWER Triggered
Energy
- definition
- unit
- formula - ANSWER - Ability to do wok
- Joule (J) J= V x I x t = (V^2/R)t Power
- definition
- unit
- formula - ANSWER - Quantity of energy applied per unit of time
- Watt (W) W = J/t = V x I Voltage - ANSWER Electrical pressure or electromotive force causing current to flow Current - ANSWER Flow of electrons or ions 1 Amp = 1 coulomb/sec Resistance - ANSWER Opposition to current flow (-) signal deflection indicates signal is moving away from _____ towards _______ - ANSWER (-) signal deflection indicates signal is moving away from (+) towards (-) (+) signal deflection indicates signal is moving away from _____ towards _______ - ANSWER (+) signal deflection indicates signal is moving away from (-) towards (+) biphasic signal deflection indicates signal is moving _______ - ANSWER biphasic signal deflection indicates signal is moving perpendicular High pass & low pass filter settings for ECG - ANSWER 0.5 Hz 100 Hz High pass & low pass filter settings for intracardiac - ANSWER 30-40 Hz 400 - 500 Hz 1st deg heart block - ANSWER A condition of abnormally slow conduction through the AV node. It is defined by ECG changes that include a PR interval of greater than 0.20 without disruption of atrial to ventricular conduction. PR > 200 msec 2nd deg heart block type 1 - ANSWER Wenckebach - electrical signals get slower & slower until a beat eventually skips
2nd deg heart block type 2 - ANSWER Some electrical signals get to ventricles and some don't 3rd deg heart block - ANSWER Electrical signals do not go from Atria to Ventricles at all Signal Average ECG
- uses
- values (HFQD, LAS, RMSA) - ANSWER Looks for late potentials in pts vulnerable to Sustained VT (pts post MI) Normal Ranges
- HFQD: <110- 114
- LAS for QRS <40 uV: <30-38ms
- RMSA: >20-35uV (+) result = 2/3 abnormal 2 types of ICE - ANSWER - Radial (Boston Scientific)
- Phased Array (BWI) T Wave Alterna (TWA)
- uses
- pitfalls
- most significant result - ANSWER SCD risk stratifier Measures microscopic changes in T wave amplitude on beat by eat basis Criteria
- HR must exceed 110 bpm
- <10% ectopic beats, low noise, absence of AF 1/4 of TWA are indeterminate due to failure to meet criteria If test is (-) 99% predictive probability where as (+) only has 20% predicative probability Vasodepressor Tilt Table Response - ANSWER HR increases progressively & does not fall more than 10% from peak at time of syncope BP decreases dramatically to cause syncope Cardio-inhibitory Tilt Table Response - ANSWER HR increases initially then falls to <40 bpm for more than 10 sec or asystole >3 sec BP increases initially and then falls Mixed Response Tilt Table Response - ANSWER HR increases initially then falls but not <40 bpm (or if <40 bpm, not for more than 10 sec) BP increases initially and then falls before HR drops Most common response
