Antibiotic prophylaxis questions used to be difficult and confusing (and easy to get wrong), but thankfully the current recommendations are very straight forward. The board will put a bunch of confounding (superficially scary) cardiac histories and exam points, and lead you to “want” to give antibiotic prophylaxis, but don’t be fooled!! If whatever they put doesn’t [...]

Long QT syndrome (or prolonged QT Syndrome) is a congenital disorder characterized by a prolongation of the QT interval on electrocardiogram and a tendency to convert to ventricular tachy-arrhythmias. These arrhythmias will frequently be seen in emergency department questions with younger persons presenting with an arrhythmia and a family history of sudden death in a [...]

Look briefly at the rhythm and name it.  Since time is valuable during the exam, your ability to name the rhythm quickly and decisively will make a difference. Verify your answers with Cardiac Rhythm Review page.

  Grading of murmurs   Grade Description Grade 1 Very faint Grade 2 Soft Grade 3 Heard all over the precordium Grade 4 Loud, with palpable thrill. Grade 5 Very loud, with thrill. May be heard when stethoscope is partly off the chest. Grade 6 Very loud, with thrill. May be heard with stethoscope entirely [...]

Complete heart block, also referred to as third-degree heart block, or third-degree atrioventricular (AV) block, is a disorder of the cardiac conduction system where there is no conduction through the AV node as shown below:    When you see this, emergently place temporay pacing in a hospital setting where plans for permanent pacer and cardiovascular [...]

Second-degree heart block, or second-degree atrioventricular (AV) block, refers to a disorder of the cardiac conduction system in which some atrial impulses are not properly conducted to the ventricles. Some P waves are not followed by a QRS. Second-degree AV block is composed of 2 types: Mobitz I or Wenckebach block, and Mobitz II. The [...]

First-degree heart block, or first-degree atrioventricular (AV) block, is defined as prolongation of the PR interval on the ECG to more than 200 msec.   While the conduction is slowed, there are no missed beats. ECG of a patient with first-degree heart block is shown below. First-degree AV block is more common among African Americans compared [...]

Left bundle branch block (LBBB) occurs when transmission of the cardiac electrical impulse is delayed or fails to be conducted along the rapidly conducting fibers of the main left bundle branch or in both left anterior and posterior fascicles.  Thus, the left ventricle slowly depolarizes by means of cell-to-cell conduction that spreads from the right [...]

Ventricular filling during atrial contraction Due to decreased ventricular compliance  (CAD, AS, MR, HCM, Diabetic Cardiomyopathy) ****No S4 during Atrial Fibrillation The S4 heart sound is associated with any process that increases the stiffness of the ventricle including: –>hypertrophy of the ventricle –>long-standing hypertension (causes ventricular hypertrophy) –>aortic stenosis (causes ventricular hypertrophy) –>overloading of the [...]

May be normal in people under 40 years of age and some trained athletes but should disappear before middle age.   Caused by the oscillation of blood back and forth between the walls of the ventricles initiated by in-rushing blood from the atria. Due to: 1.Rapid ventricular filling   Ventricular decompensation (acutely)   Ventricular Septal [...]

Closure of aortic and pulmonic valves just after systole. Persistently split S2 (widened S2) is due to pulmonic stenosis, PE, or RBBB (all cause delayed function of right ventricle.) A young girl with a split S2 and with RBBB on ECG is Pulmonic Stenosis. Not ASD or VSD. Normally heard as split during inspiration. The split [...]

Normally heard as a single sound, occasionally a narrow split Heard during the onset of systole Due to closure of the mitral and tricuspid valve Loud S1 : pregnancy, anemia, anxiety, thyrotoxicosis, mitral stenosis Soft S1 : heart failure, mitral regurgitation

Diabetes mellitus type 2 is often accompanied by other conditions: hypertension, high LDL, low HDL, obesity. Together it’s called “Syndrome X”. Hyperinsulinemia occurring in response to insulin resistance may play important role in genesis of these abnormalities. There is another “Syndrome X” that consists of anginal chest pain, depression of ST segment on stress test [...]

Causes include neoplastic disease, idiopathic pericarditis, uremia; less common causes include cardiac perforation, pericardial tuberculosis, and hemopericardium due to anticoagulation. Principal features include Pulsus paradoxus, electrical alternans, and equalization of end-diastolic pressures. Treatment requires Pericardiocentesis; small catheter should be left in place for further drainage.

Causes include idiopathic (most commonly), viral, renal failure, sepsis, cancer, rheumatic diseases, and pericardectomy. ECG shows ST elevation unaccompanied by reciprocal changes. A P-R segment depression can also be seen. CPK elevation is frequently seen. Treatment involves NSAIDS and analgesics.

On ECG, a polymorphic ventricular tachycardia is seen usually due to congenital abnormality or drug effect. Commonly due to QT prolongation The arrhythmia is associated with Procainamide, quinidine, amiodarone, tricyclic antidepressants, disopyramide, hypocalcemia, hypokalemia, hypomagnesemia, severe bradycardia, low protein diet. Treatment includes isoproterenol, overdrive pacing, and magnesioum sulfate. Correct any electrolyte abnormality.

Acute Myocardial Infarction Hyperthyroidism Acute pulmonary embolism Hypertension and coronary artery disease Valvular Heart Disease Alcoholism “Holiday Heart” Cardiomyopathy COPD

Mid systolic murmur, increased with Valsalva and decreased with hand grip Genetic disease of cardiac sarcomere (autosomal dominant) Prevalence is about 0.17% with only 14% symptomatic. Symptoms are related to degree of LV outflow tract obstruction. Symptoms: dyspnea on exertion, orthopnea or paroxysmal nocturnal dyspnea, chest pain, presyncope or syncope, postural lightheadedness, fatigue, and edema. [...]

Rumbling diastolic murmur with a diastolic opening snap. A ‘snapping’ S1. Symptoms include progressive dyspnea and cough, pulmonary edema, atrial arrhythmias, and hemoptysis. Severe mitral stenosis occurs when the opening is reduced to 1 cm. With progressive stenosis, critical flow restriction reduces left ventricular preload and output. Complications include pulmonary infections, infective endocarditis, pulmonary and [...]

Results from healing of fibrinous pericarditis or chronic pericardial effusion when granulation tissue obliterates pericardial space. Tuberculosis, purulent infections, histoplasmosis, trauma, cardiac surgery, irradiation, RA, SLE, chronic renal failure, and neoplastic processes are described as causes. Important to distinguish from tamponade. Echocardiogram is most suitable diagnostic procedure to differentiate between those conditions, but cannot always [...]

Associated with Marfan’s syndrome, osteogenesis imperfecta, and Ehler-Danlos syndrome More common in females (usual age 14-30 years) Encompasses broad range of severities (most patients are asymptomatic for entire life) ranging from systolic click and murmur and mild prolapse to severe mitral regurgitation Most important finding is mid to late systolic click (may be multiple). The [...]

Caused by infective endocarditis, aortic dissection and trauma. Stroke volume declines and ventricular diastolic pressure rises. Premature closure of mitral valve may be seen by echocardiography. The first heart sound is soft or absent. Diastolic murmur is characteristically brief. Patient presents with pulmonary congestion, edema and hypotension. Severe acute regurgitation requires prompt surgical treatment. This [...]

Inflammatory and stenotic disease of medium and large arteries with predilection for aortic arch Subclavian artery -93%, common carotid -58%, aorta -47% Affects adolescent girls and young women Symptoms include arm claudication, Raynaud’s phenom., visual changes, TIA, HTN, renal failure, etc. Prednisone (40-60 mg/day) alleviates symptoms (impact on survival is unclear). Methotrexate is an alternative. [...]