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What are the features of right, left and balanced dominant circulation?
- Right: posterior interventricular artery ans at least one posterolateral branch arise from rigth coronary artery (80%)
- Left: posterior interventricular artery and at least one posterolateral branch arise from left circumflex artery (15%)
- Balanced: dual supply of posterioinferior left ventricular from right coronary artery and left circumflex artery (5%)
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Which artery supply the sinoatrial node?
- SA nodal artery:
- -60% from right coronary artery
- -40% from left coronary artery
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Most of venous blood of the heart goes to the right atrium via the coronary sinus. What is the other way the venous blood of earth goes bach to the circulation?
Thebesian veins and the blood goes in all four chambers, contributing to the physiologic R →L shunt
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Wich valve has only 2 cuspids (all the others have 3)
Mitral valve
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ddx cardiac murmur
- valvular valve disease
- atial/ventricular septal defect
- patent ductus arteriosus
- arteriovenous fistula
- functional murmur
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ddx claudication
- vascular:
- - atherosclerotic disease
- - vasculitis (ex. Buerger's disease, Takayasu's disease)
- - diabetic neuropathy
- - venous disease (e.g. DVT, varicose veins)
- - popliteal entrapment syndrome
- neurologic:
- - neurospinal disease (e.g. spinal stenosis)
- - reflex sympathetic dystrophy
- msk:
- - osteoarthritis
- - rhematoid arthristis /connective tissue disease
- - remote trauma
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ddx syncope
- hypovolemia
- - blood loss
- - decreased fluid intake
- - increased fluid losses
- - third spacing
- Cardiac:
- - structural of obstructive cause (SCA, aortic stenosis, caridac tamponade, constrictive pericarditis, HOCM)
- - Arrhythmias (sss, sinus node ischemia, AV block, pacemaker dysfunction)
- - Tachyarrythmias (SVT, ventricular fibrillation, torsade de pointe)
- Respiratory:
- - massive PE
- -pulmonary hypertension
- hypoxia
- hypercapnia
- Neurologic:
- - stroke (TIA)
- - migraine
- - seizure
- - vasovagal
- Metabolic:
- - anemia
- - hypoglycemia
- Drugs:
- - antihupertensives
- - antiarrhythmics
- - beta blockers, CCB
- Psychiatric:
- -panic attack
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ddx generalized edema
- increased hydrostatic pressure:
- - increased fluid retention (cardiac causes CHF, hepatic causes cirrhosis, renal causes acute and chronic renal failure)
- - vasodilatators (CCB)
- - refeeding edema
- Decresaed oncotic pressure
- - hypoalbuminenia
- Hormonal:
- - hypthyroidism
- - exogenous steroids
- - pregnancy
- - estrogens
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ddx chest pain
- pulmonary:
- - pneumonia
- - pulmonary embolism (PE)
- - neumothorax / hemothorax
- - empyema
- - pulmonary neoplasia
- - bronchiectasis
- - TB
- cardiac:
- - MI/angina
- - myocarditis
- - pericarditis/ Dressler's syndrome
- - cardiac tamponade
- Gastrointestinal:
- - esophagial (spams, GERD, esophagitis, ulceration, achalasia, neoplasm)
- - PUD
- - gastritis
- - pancreatitis
- - biliary colic
- mediastinal:
- - lymphoma
- - thymoma
- vascular:
- - dissecting aorting aneurysm
- Surface structures:
- - costochondritis
- - rib fracture
- - skin (bruising, shingles)
- - breast
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ddx palpitation
- cardiac:
- - arrhythmias (PAB, PVB, SVT, VT)
- - mitral valve prolapse
- - valvular heart disease
- - hypertrophic cardiomyopathy
- endocrine:
- - thyrotoxicosis
- - pheochromocytoma
- - hypglycemia
- Drugs:
- - tobacco, caffeine, alcohol, epinephrine, ephedrine, aminophylline, atropine
- Psychiatric:
- - Panis attack
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ddx ST segment elevation
- STEMI
- ventricular aneurysm
- LBBB
- acute pericarditis (diffuse ST changes)
- ischemia with reciprocal changes
- post myocardial infarction
- vasospastic angina (Pinzmetal's)
- hypthermia (Osborne waves)
- early repolarization (normal variant correlate with old ECGs)
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ddx ST segment depression
- NSTEMI
- LVH of RVH with strain
- post MI
- STEMI with reciprocal changes
- digitalis effect (scooping)
- LBBB or RBBB
- Wolff-Parkinson-White syndrome
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ddx dyspnea
- cardiovascular:
- - acute MI
- - CHF/LV failure
- - aortic stenosis
- - mital stenosis
- - elevated pulmonarys venous pressure
- respiratory:
- - airway disease (asthma, COPD exacerbation, upper airway obstruction by anaphylaxis, foreign body of mucus plugging)
- - parenchymal lung disease(ARDS, pneumonia, interstitial lung disease)
- - pulmonary vascular disease ( PE, pulmonary HTN, pulmonary vasculitis)
- - pleural disease (pneumothorax)
- - pleura effusion
- neuromuscular and chest wall disorder:
- - C-spine injury
- - polymyositis, myasthenia gravis, Guillain-Barré syndrome
- - kyphoscoliosis
Anxiety / psychosomatic
severe anemia
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When can it be usefull to use the additionnal leads V3R ad V6R with the ECG? (2)
- RV infarction
- dextrocardia
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ddx of left axis deviation
- Left anterior hemiblock
- inferior MI
- WPW
- right ventricular pacing
- normal variant
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ddx of right axis deviation
- right ventricular hypertrophy
- left posterior hemiblock
- PE
- COPD
- lateral MI
- WPW
- dextrocardia
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Criteria complete RBBB
- QRS duration more than 120 msec (mora than 3 littles squares)
- positive QRS in lead V1 (rSR or occasionnaly bread R waves)
- broad S waves in leads I, V5-V6 (more than 40 msec)
- usually secondaray T wave inversion in leads V1-V2
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Criteria complete LBBB
à compltéer
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criteria left ventricular hypertrophy
- S in V1 + R in V5 or V6 more than 35 mm (if more than 40-year-old: 40 mm for 31-40 and 45 mm if 21-30 year-old)
- R in aVL more than 11 mm
- R in I + S in III more than 25 mm
- additional criteria:
- - left atrial enlargement
- - LV strain pattern (ST depression and T wave inversion in leads I, aVL, V4-6)
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Criteria right ventricular enlargement
- - right axis deviation
- - R/S ratio more than 1 in qR in lead V1
- - RV strains pattern (ST depression and T wave inversion in leads V1-2)
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Criteria left atrial enlargement
- negative component of P wave in lead V1 more than 1 mm wide and more than 1 mm deep
- P wave notch in lead II and more than 120 msec
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Criteria right atrial enlargement
P wave more than 2,5 mm in height in leads II, III or aVF
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A Q wave is pathological if:
- more than 40 msec
- or
- more than 25% height of R
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ECG change in hypercalcemia
Shortened QT interval
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ECG change in hyporcalcemia
prolonged QT interval
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We can find U waves on the ECG wirh:
hypokalemia
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Osborne J waves are found on the ECG with:
hypothermia
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Signs of pericarditis on ECG
- early: diffuse ST segment elevation and PR segment depression, upright T waves
- later: isoelectic ST segment, flat of inverted T waves
- tachycardia
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ddx of low voltage on ECG
- mycardial disease (ischemia, infiltative or dialted cardiomyopathy, myocarditis)
- pericardial effusion
- thick chest wall/barrel chest (COPD, obesity)
- generalized edema
- hypthyroidism /myxedema
- inapropriated voltage standardization
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Sign of massive pulmonary embolism on ECG
S1Q3T3
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transthoracic echocardiography indications
- evaluation of left ventricular ejection fraction
- wall motion abnormalities
- mycocardial ischemia and complication of MI
- chamber size
- wall thickness
- valves morphology
- promixal great vessel
- pericardial effusion
- unexplained hypotension
- murmurs
- syncope
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transoesophagial echocardiography indications
- intracardia trombi
- tumours
- valvular vegetations
- aortic dissection
- aortic atheromas
- prosthetic valve function
- shunts
- technically inadequate transthoracic studies
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What is the gold standard for localizing and quantifying CAD?
coronary angiography
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Complication of diagnostic catheterization
- Vascular injury
- renal failure
- stroko
- MI
- mortality rate 0,1-0,2%
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What % is a hemodynamically significant stenosis in coronary arteries?
70%
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ddx sinus bradycardia
- increased vagal tone or vagal stimulation
- vomiting
- episode of myocardial ischemia or infacrction (inferior MI)
- sick sinus syndrome
- increased intracranial pressure
- hypthyroidism
- hypthermia
- drugs (b-bloqueurs, calcium bloqueurs, etc)
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