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Questions and Answers
Which of the following is NOT part of the right coronary circulation?
Which of the following is NOT part of the right coronary circulation?
- Lateral wall MI (correct)
- Posterior wall MI
- Inferior wall MI
- Right ventricular MI
Left dominant coronary circulation is more common than right dominant coronary circulation.
Left dominant coronary circulation is more common than right dominant coronary circulation.
False (B)
What leads correspond to inferior wall myocardial infarction?
What leads correspond to inferior wall myocardial infarction?
II, III, AVF
Most individuals have a ______ dominant coronary circulation.
Most individuals have a ______ dominant coronary circulation.
Match the following terms with their corresponding descriptions:
Match the following terms with their corresponding descriptions:
What is the primary mechanism of hibernation in myocardium?
What is the primary mechanism of hibernation in myocardium?
Stunning of the myocardium is characterized by chronic ischemic dysfunction.
Stunning of the myocardium is characterized by chronic ischemic dysfunction.
What investigation is preferred to differentiate between ischemia and infarction?
What investigation is preferred to differentiate between ischemia and infarction?
The target LDL cholesterol level for statin therapy is greater than ______ mg/dL.
The target LDL cholesterol level for statin therapy is greater than ______ mg/dL.
Match the following terms with their definitions:
Match the following terms with their definitions:
What consequence is associated with proximal RCA occlusion?
What consequence is associated with proximal RCA occlusion?
Distal RCA occlusion is associated with RVMI.
Distal RCA occlusion is associated with RVMI.
What is the role of the acute marginal artery?
What is the role of the acute marginal artery?
Proximal RCA occlusion can result in _____ arrhythmias.
Proximal RCA occlusion can result in _____ arrhythmias.
Match the following types of RCA occlusions with their effects:
Match the following types of RCA occlusions with their effects:
Which of the following T wave characteristics indicates a potentially serious condition?
Which of the following T wave characteristics indicates a potentially serious condition?
The presence of U waves in an ECG trace is commonly associated with hyperkalemia.
The presence of U waves in an ECG trace is commonly associated with hyperkalemia.
What does ST depression in an ECG typically indicate?
What does ST depression in an ECG typically indicate?
The ECG analysis shows recordings at ____ minutes to observe ST depression changes.
The ECG analysis shows recordings at ____ minutes to observe ST depression changes.
Match each type of T wave characteristic to its description:
Match each type of T wave characteristic to its description:
What is a necessary criterion for diagnosing a myocardial infarction (MI)?
What is a necessary criterion for diagnosing a myocardial infarction (MI)?
ST elevation in leads V1 to V3 should be ≥1.5mm in females to be considered significant.
ST elevation in leads V1 to V3 should be ≥1.5mm in females to be considered significant.
What are the ECG morphologies associated with ST elevation?
What are the ECG morphologies associated with ST elevation?
A significant ST elevation of ≥2.5mm in leads V1 to V3 indicates myocardial infarction in individuals over ______ years old.
A significant ST elevation of ≥2.5mm in leads V1 to V3 indicates myocardial infarction in individuals over ______ years old.
Match the following causes of ST elevation with their descriptions:
Match the following causes of ST elevation with their descriptions:
What is a common trigger for symptoms in chronic stable angina?
What is a common trigger for symptoms in chronic stable angina?
Chronic stable angina typically lasts more than 30 minutes.
Chronic stable angina typically lasts more than 30 minutes.
What type of medication is commonly used to relieve symptoms of chronic stable angina?
What type of medication is commonly used to relieve symptoms of chronic stable angina?
A positive treadmill test indicates a ST segment deviation of ______ mm.
A positive treadmill test indicates a ST segment deviation of ______ mm.
Match the following conditions with their corresponding categories:
Match the following conditions with their corresponding categories:
Which of the following is indicative of pericarditis?
Which of the following is indicative of pericarditis?
Benign early repolarization is characterized by global ST elevation and PR segment depression.
Benign early repolarization is characterized by global ST elevation and PR segment depression.
What is another name for Takotsubo cardiomyopathy?
What is another name for Takotsubo cardiomyopathy?
The presence of an Osborne wave is associated with ______.
The presence of an Osborne wave is associated with ______.
Match the following ECG features with their corresponding conditions:
Match the following ECG features with their corresponding conditions:
Which of the following is a correct indication for myocardial perfusion scintigraphy (MPS)?
Which of the following is a correct indication for myocardial perfusion scintigraphy (MPS)?
Intravascular ultrasound is the gold standard for ejection fraction measurement.
Intravascular ultrasound is the gold standard for ejection fraction measurement.
Which radionuclide is commonly used in myocardial perfusion scintigraphy?
Which radionuclide is commonly used in myocardial perfusion scintigraphy?
The primary treatment to decrease heart rate and blood pressure after myocardial infarction is ______.
The primary treatment to decrease heart rate and blood pressure after myocardial infarction is ______.
Match the following drugs with their primary action:
Match the following drugs with their primary action:
Which statements accurately describe Prinzmetal Angina features? (Select all that apply)
Which statements accurately describe Prinzmetal Angina features? (Select all that apply)
Diastolic current in injury indicates current flow towards ischemia.
Diastolic current in injury indicates current flow towards ischemia.
What are the names of the three glycoprotein IIb-IIIa inhibitors used for periprocedural stenting?
What are the names of the three glycoprotein IIb-IIIa inhibitors used for periprocedural stenting?
The Kingmaker segment is also known as the __________.
The Kingmaker segment is also known as the __________.
Match the current types with their characteristics:
Match the current types with their characteristics:
What does ST depression in an ECG typically indicate?
What does ST depression in an ECG typically indicate?
De Winter T Waves are considered a normal finding in an ECG.
De Winter T Waves are considered a normal finding in an ECG.
What condition does the presence of Left Bundle Branch Block indicate in an ECG?
What condition does the presence of Left Bundle Branch Block indicate in an ECG?
Horizontal ST Depression is associated with __________.
Horizontal ST Depression is associated with __________.
Match the ECG findings with their implications:
Match the ECG findings with their implications:
Which of the following is a potential diagnosis associated with ECG findings?
Which of the following is a potential diagnosis associated with ECG findings?
Evolving to MI implies a progression towards a myocardial infarction.
Evolving to MI implies a progression towards a myocardial infarction.
What is the significance of 'scoop' in an ECG analysis?
What is the significance of 'scoop' in an ECG analysis?
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Study Notes
Coronary Circulation
- Right coronary circulation supplies the inferior, posterior, and right ventricular walls of the heart.
- Left coronary circulation supplies the anterior, septal, and lateral walls of the heart.
Surfaces of the Heart
- Anterior sternocostal surface is primarily composed of the right ventricle.
- Inferior diaphragmatic surface is comprised of both the right and left ventricles.
- Posterior surface is primarily the left atrium.
Coronary Dominance
- Dominance is determined by the artery supplying the posterior interventricular sulcus (posterior descending artery).
- Right dominant: 85% of the population.
- Left dominant: 15% of the population.
Right Coronary Artery
- Origin: Right AV sulcus.
- Branches: SA nodal branch, atrial branches, acute marginal artery, branch to AV node, terminal branches.
- Proximal RCA occlusion: Can cause sinus bradycardia, atrial arrhythmias, and right ventricular MI.
- Distal RCA occlusion: Can cause right ventricular MI depending on the relationship to the acute marginal artery.
Left Coronary Artery
- Origin: Left AV sulcus
- Branches: Left anterior descending artery (LAD)...
Acute Coronary Syndrome (ACS)
- ACS is a spectrum of conditions involving a sudden blockage of coronary arteries, including unstable angina, non-ST-elevation MI, and ST-elevation MI.
Hibernation vs. Stunning of Myocardium
- Hibernation: Chronic ischemia, persistent ischemic dysfunction, diagnosable via FDG-PET or MRI.
- Stunning: Acute ischemia, transient post-reperfusion segmental dysfunction.
Management of ACS - Pharmacological Intervention
- First-line drugs:
- Nitrates: Increase heart rate and lower blood pressure; Tolerance can be a limitation.
- Beta-blockers: Decrease heart rate and lower blood pressure, prolong life post MI.
- Calcium channel blockers: Decrease heart rate and lower blood pressure.
Stenting
- Drug-eluting stents: Coating of drugs (tacrolimus/paclitaxel) for prolonged drug release.
- Bare metal stents: Not as effective as drug eluting stents.
Prinzmetal Angina
- Characterised by rest angina rapidly relieved by nitrates.
- Transient ST elevation.
- Normal coronary angiography.
- Beta-blockers are avoided in this condition due to vasospastic angina.
Kingmaker Segment
- Also known as the ST segment.
- Starts at the end of the J point and ends at the onset of the T wave.
ECG Analysis
- ECG waveform descriptions: RR interval, P wave duration, PR segment, QRS duration, ST segment duration, QT interval, U interval.
- Waveform types: Non-concave (convex shaped), Concave (saddle shaped).
ST Elevation MI (STEMI)
- ECG morphologies: Convex, Coved, Horizontal/Plateau, Oblique, Concave.
- Sequence of changes in STEMI:
- Hyperacute T wave
- Hyperacute T waves with ST Elevation
- Development of pathologic Q waves, decreased amplitude of the R waves, and further ST and T wave changes
Other Causes of ST Elevation
- Prinzmetal angina
- Hyperkalemia
- Left Bundle Branch Block
Normal Variant/Benign Early Repolarization
- Can be mistaken for ST elevation.
- Often seen in patients with left ventricular aneurysm.
ECG Interpretations
- Left Ventricular Hypertrophy: Indicated by ECG findings.
- Left Bundle Branch Block: Another finding from the ECG.
- ST Depression: Showing possible ischemia, various types of ST depression are noted, with probable ischemia being the primary interpretation.
- De Winter T Waves: Identified as a type of T wave abnormality.
- Evolves to MI: Implies progression towards a myocardial infarction (heart attack).
Other ECG Findings
- Pericarditis
- Pseudoinfarction
- Acute Antero-Septal Infarction
- Brugada Syndrome
- Horizontal ST Depression
- Sloping ST
- Scoop
Myocardial Perfusion Scintigraphy (MPS)
- Done with Tc99m or Thallium.
- Useful in patients with resting symptoms or abnormal baseline ECG.
- Helps differentiate between ischemia and infarction, localize ischemia, assess revascularization completeness.
Miscellaneous Points
- FDG PET: Distinguishes between stunned and scarred myocardium.
- Electron beam CT: Quantifies cardiac calcification.
- MRI: IOC for myocardial fibrosis/ejection fraction, gold standard for ejection fraction.
- Intravascular USG: IOC for ostial left main lesion/coronary dissection.
Investigations
- Exercise stress test/Treadmill test:
- Indications: Chronic stable angina, asymptomatic patients with risk factors.
- Contraindications: Rest symptoms, aortic stenosis, hypertrophic cardiomyopathy (HOCM).
Bruce Protocol
- Positive treadmill test: Indicates 2 mm horizontal or down sloping ST segment depression.
Benign Early Repolarization
- ST elevation
- Notching of J point (hook effect).
- Differential diagnosis: Pericarditis.
- No PR segment depression.
Pericarditis
- Clinical Features: History of acute illness
- Global ST elevation.
- Concave upward ST segment.
- PR segment depression.
- No reciprocal changes.
Post-DC Cardioversion
- Related to electrical shock therapy.
Hypothermia
- Characterized by Osborne wave.
Takotsubo Cardiomyopathy
- AKA Broken heart syndrome.
- Catecholamine induced cardiac failure.
- Most common in middle-aged females.
Chronic Stable Angina
- Presentation: Middle-aged to elderly patient with risk factors.
- Symptoms: Chest tightness/squeezing/burning.
- Location: Behind/left of mediastinum.
- Radiation: Any dermatome from C4 - T.
- Duration: 30 minutes suggest ACS.
- Treatment: Excellent response to sublingual or oral NTG.
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