IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST, Exams of Nursing

Download IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST and more Exams Nursing in PDF only on Docsity! IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS What does the noise on atrial channel signal? - CORRECT ANSWERS Lead noise during exercise is suggestive for a problem with the atrial lead. When looking closely at the X-ray image, an insulation defect can be detected on two of the three leads. One defect is found on the abandoned atrial lead and the second on the active atrial lead. These findings together with low lead impedance, make diagnosis of atrial lead insulation damage the most likely explanation. Atrial lead conductor problems could also result in atrial noise but impedance would be expected to increase in this situation. There is no indication of a ventricular lead problem. Myopotential oversensing in the context of a unipolar atrial electrode is possible but would not explain the X ray findings and low atrial lead impedance. What is A00 pacing mode? - CORRECT ANSWERS A00 mode in itself causes undersensing. MADIT RIT trial - CORRECT ANSWERS MADIT RIT programming devices implanted for primary prevention with a single zone at 200 bpm with a 2.5 second delay before the initiation of therapy was found to reduce inappropriate shock as well as mortality. This was also found with a three zone system with delayed therapy using a 60 second delay at 170 bpm, and a 12 second delay at 200 bpm and a 2.5 second delay at 250 bpm. A worse outcome was found for conventional programming using a 2 zone system with a 2.5 second delay at 170 bpm and a 1.0 second delay at 200 bpm. In general switching off ATP in VT zones as well as turning SVT discriminators are clearly not recommended. IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS Which drugs have little to no effect on capture threshold? - CORRECT ANSWERS Beta blockers usually have little to no effect on capture threshold. Example: Metoprolol is clearly least likely to have elevated RV pacing thresholds in a patient. Name drugs that can increase pacing thresholds? - CORRECT ANSWERS Both class IC antiarrhythmics (propafenone, but flecainide in particular) as well as class III antiarrhythmics (amiodarone and sotalol) may lead to an increase in pacing thresholds. (Though sotalol can IMPROVE DFT). Name three causes of atrial standstill - CORRECT ANSWERS Myocardial Infarction Digitalis glycosides Hyperkalemia A 59 yo female with ischemic cardiomyopathy presents with palpitations, lightheadedness, insomnia and feels jittery. She has a CRT-D device. Takes Furosemide, potassium, lisinopril, carvedilol and amiodarone. Seeing short runs of VT on her device interrogation. - CORRECT ANSWERS Hyperthyroidism What would be your best next step for ordering tests? - CORRECT ANSWERS Thyroid panel Which antiarrhythmic drug is least likely to increase defibrillation thresholds? - CORRECT ANSWERS Sotalol is least likely to increase defibrillation thresholds and may in fact decrease it. In contrast all other drugs mentioned are likely to INCREASE defibrillation thresholds, which is why DFT testing is sometimes performed on patients newly started on other drugs (Flecainide, Verapamil, Amiodarone, Mexiletine). IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS Female Gender Non ischemic cardiomyopathy as the underlying pathology of heart failure. Less consistently echo signs of dyssnychrony were found to predict response. What is associated with less favorable response to CRT? - CORRECT ANSWERS Coronary artery disease Think presence of ischemic cardiomyopathy as the cause of decreased LV function is clearly associated with a less favorable response to CRT (especially regarding LV reverse remodeling). This is likely due to irreversible myocardial scarring. Which leads represent the lateral wall? - CORRECT ANSWERS Lead 1, AVL, V5 and V6 represent the lateral wall. Which study investigated the efficacy of a single burst of ATP (8 pulses, 88% cycle length) in VT and fast VT? - CORRECT ANSWERS The PainFREE and the PainFREE II. The success rate was 85% and 72%. Acceleration of VT's by a burst of ATP were rarely observed. Based on this data at least one burst of ATP before or during charging should be programmed in virtually all patients. Dependent patients - CORRECT ANSWERS Switch to asynchronous pacing in order to prevent oversensing from both electrocautery and device manipulation. IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS Application of only short bursts of electrocautery or using a bipolar cautery system will reduce the risk of over sensing. Activity sensor should be turned off (for all patients) in order to minimize inappropriate increases in heart rate due to device manipulation. Placement of transthoracic pacing pads. Bipolar (NOT UNIPOLAR) pacing configurations should be used when possible, as once the generator is out of the pocket there is no longer a pacing circuit and loss of capture resulting in asystole in a pacemaker dependent patient. Name a programming change LEAST likely to improve the likelihood of the device going into mode switch? - CORRECT ANSWERS Decrease PVARP (think shorten) Decreasing PVARP will not increase the detection of atrial fibrillation, as events occurring during PVARP are already registered towards the mode switch count (although no AV delay is started during this period). What would shortening the PVAB do? - CORRECT ANSWERS Shortening the PVAB will potentially result in more atrial events not being blanked, which are counted towards mode switch. Making the atrial channel more sensitive will equally lead to more atrial events being sensed. Reducing the entry count and / or the mode switch rate will also result in a higher likelihood for the device to go into mode switch. IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS A 2.5V battery measurement is indicative of what? - CORRECT ANSWERS Battery nearing ERI Think how beginning of life (BOL) voltage is around 2.8V with a low battery impedance. During life cycle impedance rises resulting in a decrease in voltage. The timing of ERI is usually around 2.4V and 4000-10000 Ohms, but can differ depending on the model and company. Closed loop stimulation (CLS) - CORRECT ANSWERS Sensor rates based on the closed loop sensor are based on measures of myocardial contractility to determine the target heart rate during exercise. The system measures the intracardiac impedance at any given point in time and compares it to the measurements taken at rest, followed by a calculation of the required pacing rate. This system is more effective in some patients with vasovagal syncope by sensing autonomic changes early in the episode. Other sensors types may adapt the HR according to body motion, acceleration, vibration (all estimates of physical motion) and minute ventilation (transthoracic impedance measurement). RV outflow tract position of the RV electrode shows what on ECG? - CORRECT ANSWERS RV outflow tract shows stimulation with an inferior vector (positive QRS in II, III, AVF) and LBBB morphology indicating RV outflow tract position of the RV electrode. An RV apical position would yield a superior stimulation vector, whereas LV apical pacing results in an RBBB like morphology. IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS The best option if patient already has a CRT device is ablation of the AV node. Will lead to significant functional improvement due to 100% CRT pacing, as well as prevent ICD therapies being delivered due to atrial fibrillation and rapid ventricular response. Cardiac Tamponade - CORRECT ANSWERS Think compression on the heart. Cant pump out oxygen to the body. Sac around heart fills with blood. Look for drop in oxygen saturation levels and uneven QRS complexes. Pericardial sac creates pressure on heart, effecting cardiac output. Think low oxygen out to the body. This sac is like a water bed which limits friction as the heart contracts. Restlessness, dizziness (syncope), fatigue and tachycardia are all signs of low cardiac output. Body compensating for reduced oxygen. Think BEC (Beck's Triad) B - Big jugular veins distension (JVD) E - Extreme Low BP (Hypotension) C - Can't hear heart sounds (muffled) Pulses paradoxes (Blood pressure gets pushed lower) Systolic drop by 10 mmHg upon respiration. Narrowed pulse pressure. 120/80-40 pulse pressure 100/90-10 pulse pressure Think DROWNED D - Distended jugular veins R - Respiratory tract and lungs clear O - Oxygen Saturation Low IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS W - Weak rapid pulses (thready pulses) N - No pulse (death is a complication) E - ECG QRS complexes short and even D - Decreased cardiac output During implantation of a pacemaker as the pocket is about to be closed, a fire erupts during the use of electrocautery. Which of the following is the most likely cause? - CORRECT ANSWERS Oxygen pooling under a drape that is tented over the patient. In a patient undergoing implantation of a pacemaker, perioperative use of which of the following drugs is most likely to result in formation of a significant hematoma in a pacemaker pocket? - CORRECT ANSWERS Enoxaparin Think low molecular weight heparin products which have very high rates of bleeding and hematomas. It is rare that "bridging" warfarin with enoxaparin is used any longer given the higher complication rates with that approach. Anti-platelet drugs such as clopidogrel and aspirin are more potent and associated with more bleeding. Dypyridamole is rarely used and is a fairly weak anti-platelet drug. There are a number of studies that show using uninterrupted warfarin in high risk patients is very safe, with only a small increase in hematoma rate over non-anticoagulated patients. What is a relative contraindication for implantation of a transvenous pacemaker or ICD? - CORRECT ANSWERS Secundum atrial defect The main issue is that of a potential shunt in a patient undergoing a device implant that would allow blood to go from the right side (pulmonic) circulation to the left side (systemic). An ASD could allow a clot that might develop on a pacing lead to go across to the left atrium and embolize to the brain or other organ. Elbows to fingertips - CORRECT ANSWERS Is considered to be a sterile surface. IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS Above the chest, above the elbows and below the waist are ot considered to be sterile. What is the point at which erythema may be expected as a result of radiation burn? - CORRECT ANSWERS 6000 mGy Rate drop response is used for what? - CORRECT ANSWERS RDR is used to help managed patients with vasovagal events and possibly carotid sinus hypersensitivity. The algo look for a sudden drop in HR, then responds by pacing at a higher therapeutic rate for a defined period of time. The algo can be fooled by anything that causes a sudden drop in HR such as a the pause that can follow a ectopic beat. PVC's and PAC's are the most likely culprit. Shortening the AV delay insures what? - CORRECT ANSWERS Insures RV pacing If patient does not have AV block there is no reason to pace the RV. It wastes power and unneeded pacing of the RV has been associated with a higher incidence of atrial fibrillation, heart failure and even mortality. Crosstalk occurs when the atrial output is? - CORRECT ANSWERS Crosstalk occurs when the atrial output is sensed by the ventricular channel inhibiting ventricular output. The MADIT-RIT show greatest support for which of the following strategies? - CORRECT ANSWERS Programming of extended detection times. This study looked at programming long detection times and high rate detection zones, which found that this resulted in fewer shocks and ATP events. The group that had the fewest IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS takes several days to have an effect, and erythromycin and acetaminophen don't affect clotting in any significant way. Name the three categories of blood thinners - CORRECT ANSWERS Anti platelets Anti Coagulants Thrombolytics How many categories of antiplatelets? - CORRECT ANSWERS Cox-1 inhibitor PDE3 inhibitors ADP (P2Y) receptor antagonists Glycoprotein IIb/IIIa receptor antagonists Thrombin (PAR-1) Receptor Antagonists A patient with AF with RVR could be given what? - CORRECT ANSWERS Carvedilol could be increased. The AV node needs to be blocked down either pharmacologically or by performing an AV node ablation. Mode switching in response to paroxysmal tachyarrhythmia is possible during which of the following types of pacing? - CORRECT ANSWERS DDI and DVI can do what to the atrium? - CORRECT ANSWERS DDI and DVI can pace the atrium. Congenital third degree AV block in a newborn with a heart rate of 50 bpm - CORRECT ANSWERS Permanent pacemaker implantation is indicated for Congenital third degree AV IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS block in a newborn with a heart rate of 50 bpm or with congenital heart disease and a ventricular rate less than 70 bpm. Patient with previous ECG showed LBBB. The patient is asymptomatic. New ECG presents with a typical right bundle branch block (RBBB) with a wide, upright complex in V1 and terminal negative complex in lead 1 and V6. - CORRECT ANSWERS Indication for new dual chamber pacemaker. Shortening the AV delay would do what? - CORRECT ANSWERS Force pacing Think this is contraindicated in a patient with normal AV conduction. Think high threshold on ventricular lead in relatively young patient likely experienced a vagal episode in the emergency room. A 75 yo patient with sustained MI, Holter shows 2.5 second pause during waking hours. No syncope but a five second pause observed during carotid sinus massage. Echo shows ejection fraction (EF) of 43%. What is best step? - CORRECT ANSWERS Schedule a routine follow up examination in one year. Given the EF is now > 35% there is no indication for ICD. A 2.5 second pause (asymptomatic) on a Holter is not an indication for a device, nor is a positive carotid sinus massage in asymptomatic patient. What two drugs are contraindicated for a patient with low EF? - CORRECT ANSWERS Verapamil and flecainide are contraindicated for patients with low EF. Which of the following is most likely cause of insulation malfunction of pacing leads inserted into the subclavian vein? - CORRECT ANSWERS Subclavian crush occurs with medial access of the subclavian vein where the lead traverses through subclavius muscle and costo- clavicular ligament. IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS The friction in the area frequently causes insulation and conductor failure. What ECG abnormalities would most likely lead a patient to develop third-degree AV block during manipulation of the ventricular lead? - CORRECT ANSWERS Left Bundle Branch block In a patient with complete LBBB they are living off of the right bundle which courses very superficially in the right ventricle. During pacing lead or catheter manipulation in the RV, if the right bundle is bumped, it can cease to function (usually transiently) causing no bundles to conduct. Complete AV block occurs until bundle recovers from the trauma. When is removal of the pacemaker and extraction of the lead system indicated? - CORRECT ANSWERS Gram positive infection (Staph or Strep) SIR stands for what? - CORRECT ANSWERS Sensor indicated Rate Extended Max tracking rate and shorten PVARP in order to allow higher rates and prevent the loss of P-wave tracking from happening Integrated bipolar RV leads are more prone to what? - CORRECT ANSWERS Integrated bipolar systems are more prone to oversensing of myopotentials. Especially of the diaphragm and in the context of long R-R intervals where the automatic gain control algorithm becomes very sensitive to even very small signals. The sensing vector is between RV tip to an distal RV-coil as opposed to a true bipolar lead that uses the tip to a small anode ring. IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS Closed loop sensor (CLS) is based on what measurement? - CORRECT ANSWERS Closed loop sensor (CLS) is based on measures of myocardial contractility to determine the target heart rate during exercise. The system measures the intracardiac impedance at any given point in time and compares it to the measurements taken at rest, followed by calculation of the required pacing rate. System proven to be effective with vasovagal patients with syncope by sensing autonomic changes early in the episode. RV outflow tract yields? - CORRECT ANSWERS Inferior vector (positive QRS in II, III, aVF) and LBBB morphology indicating a RV outflow tract position of the RV electrode. RV apical position would yield a superior simulation vectors LV apical pacing results in what morphology? - CORRECT ANSWERS LV apical pacing results in RBBB-like morphology. Pacing from a lateral or posterior CS branch would typically lead to a RBBB as well with a pronounced S wave in lead I. Reed switch was replaced by what modern component? - CORRECT ANSWERS Hall sensor The reed switch is to close when a magnet is placed over it, thus causing a pacemaker or ICD to inhibit shock therapy and enter asynchronous mode. When are single pass VDD leads used? - CORRECT ANSWERS Frequently in ICD applications, they have a pair of electrodes (bipolar) that are free floating in the right atrium. They can sense P waves but cannot pace the atrium. IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS This is useful to track the atrium when there is complete AV block (VDD mode) and to sense atrial signals to determine if AV disassociation is present when classifying ventricular rates. High impedance electrodes meet delivered pacing energy requirements because of? - CORRECT ANSWERS Small lead tip surface area. High impedance leads were designed with a small pacing surface area which creates a high charge density are the tip for efficient use of the battery. However this charge concentration also increases polarization at the tip. Inverted T waves in V1-V3 and high risk of death would be associated with what? - CORRECT ANSWERS ARVC Arrhythmogenic right ventricular cardiomyopathy Septal thickness > 3cm + VF = What class indication? - CORRECT ANSWERS Class 1 Disopyramide is what class of drug? - CORRECT ANSWERS Antiarrhythmic drug that reduces inotropy and may reduce the outflow gradient in patients with obstructive HCM. Think reduces force of contractions. There are 2 kinds of inotropes: positive inotropes and negative inotropes. Positive inotropes strengthen the force of the heartbeat. Negative inotropes weaken the force of the heartbeat What is the underlying cause of vasovagal syncope? - CORRECT ANSWERS Neurocardiogenic reflex IBHRE QUESTIONS AND ANSWERS NEWEST UPDATE 2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST COMPLETE EXAM SOLUTION GRADED A+ FOR PASS Think the most common cause of syncope in young adults is vasovagal in nature. Name a low molecular weight heparin product? - CORRECT ANSWERS Enoxaparin Think very high probability of bleeding and hematomas in patients undergoing procedures. Secundum atrial septal defect is a indication or contraindication for implantation of a transvenous pacemaker or ICD? - CORRECT ANSWERS The main issue here is that of a potential shunt in a patient undergoing a device implant that would allow blood to go from the right side (pulmonic) circulation to the left side (systemic). An ASD could allow a clot that might develop on a pacing lead to go across to the left atrium and embolize to the brain or other organ. 6000 mGy is that point at which? - CORRECT ANSWERS Erythema may be expected as a result of radiation burn. Divide total by radiation level is 200 mGy/min / 6000 = 30 minutes If tracing shows both intermittent failure to output and failure to capture what is the most likely cause? - CORRECT ANSWERS A fractured lead is the most likely cause. Polarization forces are essentially? - CORRECT ANSWERS Polarization forces are essentially noise making it difficult for the device to detect the actual cardiac signal it is looking for. High polarization leads are generally not suitable for systems using this type of capture confirmation algorithm. In a patient with LBBB which of the the ICD detection features is most helpful in differentiating VT from sinus tach? - CORRECT ANSWERS Dual chamber detection algorithm