Educational Links

PCSK9 Inhibitor for Lipid Disorders

 

What is PCSK9?

 

PCSK9 stands for proprotein convertase subtilisin kexin 9. It is a serine protease, a type of enzyme, mostly produced in the liver.

 

What does PCSK9 do?

 

It helps break down low density lipoprotein (LDL) receptors in the liver, which in turn increases LDL-C (low density lipoprotein cholesterol or “bad cholesterol”) levels.

 

Why would PCSK9 inhibitors work?

 

By blocking the action of the PCSK9 enzyme, LDL-C levels can be decreased.

 

What types are out there?

 

evolocumab from Amgen

 

alirocumab from Regeneron Pharmaceuticals and Sanofi

 

bococizumab from Pfizer

 

All of these PCSK9 inhibitors are monoclonal antibodies to PCSK9 that are given as a subcutaneous injection.

 

Where are PCSK9 inhibitors in the drug development process?

 

They have not yet been approved for use. However, many studies have shown statistically significant reductions in LDL-C!

 

The Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) study includes 22,500 patients. The full results will not be available until 2018 at the earliest.

 

Completed and ongoing studies include:

 

DESCARTES, LAPLACE-2, GAUSS-2, MENDEL-2, and RUTHERFORD-2 with evolocumab

 

studies for alirocumab and bococizumab are currently running

 

SPIRE-1 and SPIRE-2 with bococizumab for 22,000 patients started in October 2013

 

What side effects have been seen so far during the clinical studies?

 

Nasopharyngitis

 

Upper respiratory tract infection

 

Influenza

 

Muscle-related issues

 

Sources:

 

O’Riordan, M. (2014, March 30). Strong results from early studies with PCSK9 inhibitors generating big buzz. Medscape. Retrieved from http://www.medscape.com/viewarticle/822814

 

Rosenson, R.S., de Ferranti, S.D., Durrington, P. (2014, November 14). Treatment of drug-resistant hypercholesterolemia. UpToDate. Retrieved from http://www.uptodate.com/contents/treatment-of-drug-resistant-hypercholesterolemia

 

Emergency Room Management of Atrial Fibrillation

 

Atrial fibrillation is one of the most common arrhythmias encountered in the emergency room. Serious complications from atrial fibrillation include congestive heart failure, myocardial infarction, and thromboembolism. The management of atrial fibrillation in the emergency setting is to first identify the arrhythmia and then to classify it as symptomatic (hemodynamically unstable) or asymptomatic (hemodynamically stable).

 

Atrial fibrillation should be suspected in all elderly patients with shortness of breath, dizziness, or palpitations. Additionally, atrial fibrillation should be ruled out in any patient with acute fatigue or worsening of congestive heart failure. The best way to diagnose atrial fibrillation is through the use of an electrocardiogram, or ECG. On ECG atrial fibrillation typically presents as an irregularly irregular rhythm. Or, in other words, it will present with an irregular rate with an R-R that is not predictable, usually absent P waves, a rapid atrial rate (usually between 150-300 bpm), and the presence of f waves (atrial fibrillation waves).

 

Once atrial fibrillation is diagnosed the next step in the management is to determine the patient’s hemodynamic stability. If the patient has chest pain (angina) or low blood pressure (hypotension) the patient is said to be hemodynamically unstable. In this case electrical cardioversion is indicated and is the treatment of choice. The patient is to be sedated and then shocked until sinus rhythm returns. The practitioner should gradually increase the cardioversion strength by starting at 100 J, increasing to 200 J, then 300 J, and then 360 J.

 

In the case that the patient is hemodynamically stable emergency management for the patient with atrial fibrillation relies around controlling the ventricular rate, The goal of ventricular rate control is less than 100 beats per minute. This is accomplished through the use of 15 mg of diltiazem (Cardizem) intravenously over two minutes, then 5 to 15 mg per hour via continuous IV infusion. Alternatively, esmolol (Brevibloc), propranalol (Inderal), digoxin (Lanoxin), or verapamill (Calan) may be used.

 

If the rate-control drug administered converted the patient’s rhythm back to a sinus rhythm then the patient can be discharged to follow-up with their primary care provider or cardiologist. However, in the case that the rate-control drug used does not convert the patient back to sinus rhythm then the practitioner may consider cardioversion. If there are contraindications to cardioversion then long-term anticoagulation must be considered.

 

Barring any contraindications (such as digitalis toxicity and multifocal atrial tachycardia) the patient should be placed on heparin IV. If the patient’s symptoms have persisted for less than 48 hours medical or electrical cardioversion may be attempted. Electrical cardioversion should follow the same algorithm as stated above. Most commonly, quinidine sulfate (Quinidex) or flecainide (Tambocor) are used for medical cardioversion, however, dofetillide (Tikosyn), ibutilide (Corvert), procainamide, or amiodarone (Cordarone) may be implemented.

If the patient has had symptoms for greater than 48 hours or the duration of symptoms is unknown then the patient must be started on heparin IV, placed on warfarin (Coumadin) for 3 weeks, followed by elective cardioversion. Elective cardioversion is electrical and may or may not include medical cardioversion. If the atrial fibrillation still persists up to this point then long-term anticoagulation therapy must be considered.

All About Pacemakers and ICDs
What Are They?

 

A pacemaker is implanted under the skin usually right underneath the collar bone. The pacemaker is used when the heart’s sinoatrial (SA) node does not work properly and develops a slow heart rate or rhythm or if the electrical pathways are blocked. A new type of pacemaker called a biventricular pacemaker is used for the treatment of ventricular dyssynchrony or heart failure. In heart failure, the two ventricles are not pumping correctly together and will cause less blood to pumped by the heart. The biventricular pacemaker paces both ventricles at the same time causing increase of blood pumped out of the ventricle.

 

An implantable converter defibrillator (ICD), is used to deliver two levels of electrical surgery: a low energy shock that can convert a beating heart that is abnormal back into normal rhythm or a high energy shock that is delivered only if arrhythmia is so severe that the heart is quivering and not pumping. Also when the ICD senses that the heart is beating too fast, the ICD will send an electrical signal shock to convert the fast rhythm to a normal rhythm.

 

What Is The Difference Between A Pacemaker And An ICD?

 

The biggest difference between a pacemaker and an ICD is that the latter can

monitor heart rhythm while simultaneously sending low or high-energy pulses to correct an abnormal heart rhythm. Pacemakers continuously monitor and deliver low-energy electrical pulses to restore an individual’s normal heart rate. ICDs also monitor and deliver low-energy electrical pulses however, they have the ability to be programmed to transmit higher-energy shocks. These higher energy pulses are typically used for cardioversion and defibrillation therapies.

 

Who Needs Them?

General Presenting Symptoms (usually bradyarrhythmias 2/2 sinus node dysfunction or conduction abnormalities)

• dizziness, lightheadedness, syncope, fatigue, poor exercise tolerance
• Location of conduction abnormalities
  • AV node dysfunctional abnormalities
    • PR prolongation, second degree abnormalities, normal QRS
  • His Purkinje System
    • Prolonged PR
    • Mobitz II
    • QRS complex abnormality

 

–  Common Indications

Sinus Node Problems

• Class 1 Indications(surefire indication): Symptomatic sinus bradycardia where the symptoms are certainly due to the bradycardia. Symptomatic chronotropic incompetence as determined by Exercise EKG
• Class 2 Indications (possible indication): Sinus Brady where the symptoms MAY be due to the brady. Chronic sinus brady in people who are mildly symptomatic

Acquired AV Block

• Class 1: 3rd Degree AV block. Symptomatic 2nd Degree (Type II>Type I) especially with a widended QRS or chronic bifasicular block.
• Class 2: 1st degree when there is hemodynamic compromise because of a very long PR interval

Special Circumstances

• Neurocardiogenic syncope: Hard to distinguish, but if patient has significant carotid sinus hypersensitivity, defined as syncope and >3sec of asystole post carotid massage
• Congenital complete heart block
• Neuromuscular disease (MS, Kearns Sayre, Erb’s Dystrophy) especially once there is any indication for heart block
• Long QT syndrome

 

What Types Are There? (Diana)

• Single chamber: 1 lead in the right atrium OR 1 lead in the right ventricle
• Dual chamber: 1 lead in the right atrium AND 1 lead in the right ventricle
• Biventricular: 1 lead in the right atrium AND 1 lead in the right ventricle AND 1 lead outside of the left ventricle

 

How Often Do I Need To Get My Device Checked?

 

Your doctor will usually want to check your pacemaker or ICD every three months to insure it is working properly and that the battery life is sufficient. Newer technologies are allowing patients to check their pacemakers or ICDs themselves at home and send these results via a telephone transmitter. If you have this technology you may check your device every three months from the comfort of your home. However, you will still need to come in to the office to have your device checked once a year for a single or dual chamber pacemaker, and every six months for a biventricular pacemaker. Your device will usually last anywhere from 4 to 8 years depending on your condition and the usage of the device.

 

What Else Should I Know About My Device?

 

The American Heart Association and the Food and Drug Administration (FDA) and manufacturers’ guidelines do not support MRI in pacemaker patients, a (except for new MRI-conditional devices).

 

It’s advised to avoid close or prolonged contact with electrical or devices with electrical magnetic devices:

• Cell phones and MP3 players (for example, iPods)
• Household appliances, such as microwave ovens
• High-tension wires
• Metal detectors
• Industrial welders
• Electrical generators

=> Exposure to devices like this can disrupt electrical signaling

 

Things One can do to avoid disruption of the pacemaker:

-Don’t place cellphone over the pacemaker

-Hold cellphone up to the ear opposite to that of the side of the pacemaker device

-Avoid prolonged exposure to household devices

-If you workout with a MP3 player, strap it to opposite arm

-Keep wifi devices at least 6 inches away from you

-Notify TSA staff or security using metal detectors that you have a pacemaker and avoid prolonged exposure with the metal detector wand or the metal detector machine

-Ask your doctor for a card that can be placed in your wallet which states what kind of pacemaker you have

-There is NO limitation to physical activity,but you should AVOID doing contact sports

 

Medtronic Revo Surescan made by Medtronics are actually safe for MRI scans if they meet specific requirements:

 

 

1. Your device has been implanted for more than 6 weeks
2. Your device was implanted in the left or right pectoral regions
3. Your device has been recently interrogated by your cardiologist and the MRI with Revo SureScan Pacemaker form has been completed
4. No other implanted devices, abandoned leads or wires, lead extenders, or adapters are present

 

Sources:

http://www.nhlbi.nih.gov/health/health-topics/topics/pace/lifestyle.html

http://www.novaradiology.com/services/undergoing-an-mri-with-the-medtronic-revo-mri-surescan-pacemaker/

http://my.clevelandclinic.org/services/heart/services/icd/pacemaker

http://www.nhlbi.nih.gov/health/health-topics/topics/pace/

http://www.texasheart.org/HIC/Topics/Proced/icdtopic.cfm

http://www.nlm.nih.gov/medlineplus/ency/article/007370.htm

Hypertension

 

Definition

Hypertension refers to systolic blood pressures greater than 140 mm Hg or diastolic blood pressures greater than 90 mm Hg. Hypertension is diagnosed by two or more elevated blood pressure readings on two or more office visits after an initial screening.

 

 

	Systolic	Diastolic
Normal	< 120 mmHg	and < 80 mmHg
Prehypertension	120-139 mmHg	or 80-89 mmHg
Stage I Hypertension	140-159 mmHg	or 90-99 mmHg
Stage II Hypertension	greater than or equal to 160 mmHg	greater than or equal to 100 mmHg

 

 

Etiologies

 

Hypertension can be primary or secondary. Primary hypertension constitutes 85-95% of cases.

 

Primary hypertension:The mechanism of primary hypertension is unclear and seems to be lifestyle related. Factors such as dietary sodium, obesity, stress and a sedentary lifestyle are responsible for hypertension in genetically predisposed individuals. In patients > 65, high sodium intake is more likely to precipitate hypertension.

 

Secondary hypertension: Causes include primary aldosteronism, renal parenchymal disease such as glomerulonephritis, polycystic renal disease, pheochromocytoma, Cushing syndrome, congenital adrenal hyperplasia, hyperthyroidism and coarctation of the aorta. Use of sympathomimetics, excessive alcohol, corticosteroids, or cocaine worsen blood pressure control.

 

Symptoms and signs

Hypertension is usually asymptomatic until complications develop in target organs. Uncomplicated hypertension usually causes dizziness, flushed facies, fatigue, headache or epistaxis. Severe, untreated hypertension can cause cardiovascular, neurological, renal and retinal symptoms. It is important to treat hypertension early, before it causes damage to the organs.

 

JNC 8 Hypertension treatment guidelines

 

The Joint National Committee (JNC 8) hypertension guidelines were published in the Journal of the American Medical Association in 2013. Compared with previous guidelines, the new guidelines emphasize higher blood pressure goals for systolic blood pressure and diastolic blood pressure and less use of several antihypertensive medications.

 

Goal blood pressures according to JNC 8:

 

Patients 60 years or older who do not have diabetes or chronic kidney disease	<150/90 mmHg
Patients 18-59 years without major comorbidities	<140/90 mmHg
Patients 18-59 years with diabetes or chronic kidney disease	<140/90 mmHg

Interview Questions and Answers for Residency

 

for Dr. Ben-Zur

 

By Edward Lin, Matthew Gill, and Michael Sheflo

 

1. Why do you want to go into this specialty?

 

1. What are you looking for in a residency program?

 

1. What have you learned about yourself during medical school?

 

1. Do you have any teaching experience?

 

1. How do you make clinical decisions?

 

1. How did you deal with a difficult time in your life?

 

1. What do you do to cope with stress and disappointment?

 

1. What kinds of patients are most difficult for you to relate to and how do you overcome this?

 

1. What are your strengths?

 

1. What are your weaknesses?

 

1. How do you establish rapport with patients?

 

1. How do you establish relationships with colleagues and hospital staff?

 

1. What motivates you in medicine?

 

1. What is something that you have learned outside of medicine that has been beneficial to know within medicine?

 

1. What are your interests in research?

 

1. How do you compare to the rest of your medical school class?

 

1. What are your long-term goals?

 

1. How do you deal with disagreement?

 

1. What are you most proud of?

 

1. Who is your role model?

 

1. What other specialties did you consider applying to?

 

1. We have many strong applicants, why should we choose you?

What is Atrial Fibrillation?

 

Your heart is separated into four chambers, a left and right atria and a left and right ventricle. Blood is efficiently pumped through the body as a result of synchronized contraction where the atria will first contract to push blood down into the ventricles and then the ventricles will pump to push blood up and out into either the body or lungs .

 

What allows for this synchrony is ‘electrical coupling’ so that when one heart cell within a chamber fires, it can tell its neighbor to also fire. Your brain isn’t in direct control of this firing, and despite your best attempts, you aren’t consciously making your heart beat nor can you make your heart beat faster or slower.

 

There are groups of specialized cells at specific points within the heart called ‘pacemaker’ cells which do this job for you. This group of specialized cells will fire at regular intervals on their own causing a cascade of firing or depolarization in adjacent heart muscle cells in a very orderly manner. This is very similar to a row of dominos that we might have set up as children where one domino falling causes the ones next to it to also fall. One pacemaker cell firing causes the ones downstream to also fire. It’s all very coordinated and very efficient.

 

Problems arise when points within the heart or even the tubes coming off the heart ‘rebel’ and decide to stop listening to the pacemaker cells and fire on their own. Atrial fibrillation is a result of progressive scarring, or fibrosis, of the atria believed to arise from either the chamber getting too large (called dilatation), genetics, or inflammation. It is hypothesized that scarring is a major factor in the development of these ‘rebellious’ heart cells. Without the control of its pacemaker, the rebel cells of the atria contract whenever they please at a VERY fast rate (150-300 beats a minute).

 

In this situation, there are essentially two bosses in the heart, the pacemaker cells and these rebellious cells. Both are trying to get everyone downstream to listen to them, some do and others don’t. It’s all very chaotic and messy. This loss of beautiful synchrony leads to ineffective pumping of the atria which then results in inefficient filling of the ventricles and finally poor blood distribution to the lungs and body.

 

Your doctor may give your atrial fibrillation a classification. This is meant to help communicate your condition to other doctors as well as help to drive treatment decisions. The classifications can be based on ECG pattern, epicardial or endocavitary recordings, mapping of atrial electrical activity or clinical features.

 

 

Atrial Fibrillation Category	Defining Characteristics
First detected	only one diagnosed episode
Paroxysmal	recurrent episodes that stop on their own in less than 7 days
Persistent	recurrent episodes that last more than 7 days
Permanent	an ongoing long-term episode
Lone	absence of clinical or ECG findings of other cardiovascular disease(including hypertension), related pulmonary disease, or cardiac abnormalities such as enlargement of the left atrium, and age under 60 years
Nonvalvular	no rheumatic heart disease, prosthetic heart valve or mitral valve repair
Secondary	where a pre-existing cardiac condition like a heart attack, heart surgery, pulmonary embolism or pneumonia is the cause of the AF

 

 

Symptoms of Atrial Fibrillation

AFib may be noticeable to some people while others are not aware of the the fibrillating. Symptoms range from mild to difficulty in breathing, shortness of breath, and palpitations. Additional symptoms include fatigue, weakness, dizziness, confusion,  lightheadedness, and chest pain and /or discomfort.

 

How is it diagnosed?

History and physical exam

To discover signs, symptoms, and risk factors

Electrocardiogram (ECG)

To look at electrical activity of the heart and see the atrial fibrillation

Echocardiogram

To look inside of the heart and see how it is working

Additional testing – exercise testing, Holter monitoring, thyroid testing, complete blood count (CBC), serum creatinine, analysis for proteinuria, test for diabetes mellitus

To look for the atrial fibrillation, causes, risk factors, and baseline

 

**Risk factors:

 

Heart

*Hypertensive heart disease (high blood pressure)

*Coronary heart disease

Heart failure

Heart valve disease (stenosis, regurgitation, prolapse)

Recent heart surgery (coronary artery bypass graft or CABG, cardiac valve surgery)

Rheumatic heart disease

Heart attack

Hypertrophic cardiomyopathy

Congenital heart disease (atrial septal defects, Ebstein’s anomaly, patent ductus arteriosus, etc.)

Venous thromboembolic disease (deep vein thrombosis or DVT, pulmonary embolism or PE)

Endocarditis

 

Other Risks

Long-term binge drinking of alcohol

Hyperthyroidism

Chronic obstructive pulmonary disease (COPD)

Obesity (BMI > 30 kg/m2)

Diabetes

Chronic kidney disease

Family history (1st degree relative with Afib)

Genetics (if present, usually > 1 gene involved)

Male sex

Older age

Low birth weight

Inflammation and infection

 

* Most common in developed countries

** This list does not include every possible risk factor; please refer to your doctor for more information about your risk factors

 

Drug Treatment for New Onset Atrial Fibrillation:

1. In patients who are asymptomatic or mildly symptomatic elderly patients with cardiovascular or hypertensive issues, the first goal is to establish rate control. For rate control, the first line of therapy is typically Beta Blockers and Calcium Channel Blockers.

→ Metoprolol (Beta Blocker) and Diltiazem (Calcium Channel Blocker) are commonly used

If the patient is unresponsive to the first line of therapy, Amiodarone is next suggested.

1. Anticoagulation is another important aspect to medical therapy for atrial fibrillation, due to the risk of forming clots, which may lead to a stroke. The patient is typically started on both Heparin and Warfarin. The patient is subsequently monitored for a therapeutic level of anticoagulation using International Normalized Ratio (INR), which is between 2 and 3.    Other anticoagulation therapy that may be used in substitution of warfarin include the following: Dabigatran, Rivaraxaban, and Apaxiban.  Although more costly, these medications don’t require monitoring of INR levels.

 

 

Surgical vs. Nonsurgical  Treatment

 

1. Electrical cardioversion

• Electrical cardioversion is a procedure where the patient receives a shock outside the chest via paddles or patches; It is used to reset the heart’s normal rhythm. The procedure is similar to defibrillation but uses lower levels of electricity
• Before doing electrical cardioversion, provider will have the patient undergo Transesophageal echocardiography (TEE)
  • This involves using a small ultrasound device that doctors will place down your mouth and looks in and around the heart

 

1. Radiofrequency ablation (RFA)

• Ablation is used when long term medical therapy or electrical cardioversion is not effective or contraindicated in the patient
• Before ablation is performed, electrical mapping is used to identify where the origin of the atrial fibrillation is located. the map tells which areas are creating problematic electrical signal
• A catheter or thin flexible tube is inserted into patients blood vessels and guided to the heart. the physician carefully destroys malfunctioning tissue via extra electrical currents in the pulmonary veins

 

1. AV node ablation and pacemaker placement

• If the trigger for AF occurs in the AV node, then the AV is ablated and pacemaker is implanted
• A pacemaker is a small device implanted with chest with wires that placed in various parts of the heart; used to regulate heart beat
• Implanted under the skin, near the collarbone
• Sends steady, contracting rhythm in the heart
• Pacemaker sense when heart is too fast or too slow

 

1. Open Heart Maze Procedure

• Maze procedure is where the heart surgeon creates small cuts in the upper part of your heart; the cuts are then stitched together and scar tissue forms; the scar tissue interferes with the transmission of electrical impulses that cause AFib.

 

 

Informational Video on Atrial Fibrillation:  http://www.youtube.com/watch?v=HyQjpQf_eME

 

 

References:

 

Cheng, A., & Kumar, K. (2014, October 21). Overview of atrial fibrillation. UpToDate. Retrieved from http://www.uptodate.com/contents/overview-of-atrial-fibrillation

Rosenthal, L. (2014, August 25). Atrial Fibrillation – Practice Essentials  Medscape Emedicine. Retrieved from http://emedicine.medscape.com/article/151066-overview on October 22, 2014.

 

Ganz, L. (2014, September 11). Epidemiology of and risk factors for atrial fibrillation. UpToDate. Retrieved from http://www.uptodate.com/contents/epidemiology-of-and-risk-factors-for-atrial-fibrillation

(2014, September 14). Understand your risk for arrhythmia. American Heart Association. Retrieved from http://www.heart.org/HEARTORG/Conditions/Arrhythmia/UnderstandYourRiskforArrhythmia/Understand-Your-Risk-for-Arrhythmia_UCM_002024_Article.jsp

Tips for Electrophysiologists Performing AVNRT Ablation

 

by Matthew Gill, Edward Lin, and Michael Sheflo

 

1. For slow pathway location, be familiar with Koch’s Triangle which is formed from the Coronary Sinus (CS), Tendon of Todaro, and the annulus of the tricuspid valve. Also, be familiar with the Bundle of His Location.
   1. The His bundle catheter is key in demarcating the landmarks of the triangle of Koch (2)
2. Use the SR0 sheath for stability
   1. The use of a long sheath with slight distal septal angulation can enhance catheter reach and stability (1)

 

image 1:

 

1. for an anterior view of the CS, use the LAO view at the 6 o’clock position (relative to the head) at the CS level. (2)

image 2: Right anterior oblique view (RAO) of right atrial appendage electrode (RAA), Bundle of His electrode (His), coronary sinus electrode (CS), and ablation probe (Abl)

image 3: Left anterior oblique view.

 

1. Have the V-signal be greater than A at about 55-60 watts.
2. Obtain a junctional rhythm when possible while performing A-V ablation.
   1. Look for V-A-V response to prove there is no advancement of tachycardia.
   2. Ablation during sinus rhythm is prefered to ablation during tachycardia so there is better accuracy with the ablation tip. (2)

 

 

References

1. https://books.google.com/books?id=-TBZAgAAQBAJ&pg=PA55&lpg=PA55&dq=sr0+sheath+avnrt+ablation&source=bl&ots=JHcIBiQ6a3&sig=wwuLyQzks-Cm70slMkbRVmF0hP0&hl=en&sa=X&ei=xAnmVKPuFIayoQTc74LYDg&ved=0CC4Q6AEwAg#v=onepage&q=sr0%20sheath%20avnrt%20ablation&f=false
2. http://europace.oxfordjournals.org/content/europace/2/1/15.full.pdf

jtramel@med.usc.edu

 

 

PLEASE REMEMBER TO CHECK YOUR ANSWERS IN THE BACK OF THE TEXT BOOK

HW 68. Part I. Page 451 #2a,b AND Page 453 #1a AND Part II. Posting in the discussion board on www.coursesites.com stating what type of math you will use on your project and why.

(Note: If you need help figuring out how to find an unknown angle, you may watch this video… http://youtu.be/vGPzhG3GMxE Finding an unknown angle starts at 7:05)

HW 67. Page 311 #1 and 2 (From the bottom of the page)  

Solutions: Question 1. The mean is 112 (to the nearest integer). Question 2. The standard deviation is 0.193 m

HW 66. (Optional because it was posted on Sunday Morning, but recommended to practice Using the Z Curve)

1. In a room, the mean age is 27. If 36% of the people in the room are over 31 years old, find the standard deviation.
2. On an SAT math test, the standard deviation was 80. If 95th percentile score is 700, what was the mean on the test.

 

Solutions: Question 1. The standard deviation is 11.1 .  Question 2. The mean is 568 (to the nearest integer).

 

HW 65. Review Page 310 until you are completely comfortable with all invnorm questions. Make sure to check your answers.

HW 64. On a test, the average grade was 72 and the standard deviation was 8. Only 20% of students got an A in the exam and 15% of students failed.

1. What is the pass mark for the test?
2. What is the lowest score needed to get an A on the test?

HW 63. Page 310 #6 If you are not sure how to do this, please watch the video linked below.

HW 62…. Page 307 #3a-c, #4

HW 61. Page 307 #2a and b and #6

 

HW 60. 304 #6

HW 59. Page 303 #3 and 4

Project Assignment- Since there is no regular homework tonight, work on your peer assessment.

HW 58. Page 342 #6 (If you need some guidance through end of the Chi Square test, watch the video linked: http://youtu.be/N-j_00u9Z34?t=19m31s from 19:31 to the end) Note: The numbering of the steps is slightly different from what was done in class but the steps are ultimately the same.

HW 57- Page 337 #3d

 

Project Assignment- First draft of introduction entered in group discussion board (www.coursesites.com)

Your introduction should address the following:

• Why did you choose your topic?
• What do you hope to demonstrate?
• How do you plan to carry out the project?
• What Math will be used?

 

The length of the statement of task should be approximately one page.

 

——————————————————————–

HW 56- Find the Chi Square value for the the observed frequency provided in HW 55. If you are unsure of how to calculate Chi Square, watch the video linked in HW 55 starting from 12:30 and ending at 19:30.

 

HW 55- Watch the video linked below starting from 4:40  and ending at 11:41 to review how to calculate expected frequencies and find the expected frequency for the table below. Video: http://youtu.be/N-j_00u9Z34?t=4m40s

 

NOTE: Do not watch the entire video!

	Prefers Facebook	Prefers Instagram	Prefers Twitter
Male	13	7	5
Female	11	16	7

 

 

Project Assignment- One discussion board post AND 2 or 3 project ideas (on www.coursesites.com)

HW 54- Complete the IB packet from class

HW 53- Page 332 #1

Project Assignment- Two discussion board posting on www.coursesites.com

 

HW 52- Use the following values to answer the questions below.

Sx=3.4,  Sxy=31 , The mean of x is 24 and the mean of y is 33.

1. i) Find the equation of the line of best fit. (You may use this video to help you understand i if you are confused: https://www.youtube.com/watch?v=e6kqGWTxF24)

 

1. ii) Sketch the best fit regression line. (You may use this video to help you understand ii if you are confused: http://www.youtube.com/watch?v=IdWyGshvIQI)

 

 

HW 51- Finish the classwork (posted in the downloads section of mydwight)

HW 50- i) Read the table on page 321 and put the table in your notes.

12. ii) Find the equation of the line of best fit if Sx=12.3, Sxy=31, the mean of x is 100 and the mean of y is 130.

Project Assignment- Review the material from week 1 and the survey verifying that you reviewed the material

HW 49- Find the correlation coefficient for the following and state what the value means.

Age	Typing Speed (wpm)
10	30
14	45
31	62
42	50

 

HW 48- Complete the calculation for the correlation coefficient that we started in class.

HW 47- Page 319 #1 and Page 320 #4

HW 46- Page 199 #1 (Please complete part a using the formula and part b using the calculator.)

HW 45- Complete the IB Packet (2 night assignment)… Handout and Answer Key on the Download section of the class site.

HW 44- Page 182 #4 and 5

HW 43- Page 181 #1 and Page 182 #6 (Note: To calculate key values for a bar graph or histogram, it helps to convert the information to a frequency table first.)

HW 42- Page 188 #1 and 2

HW 41- Page 188 #4 and #5a-c

 

HW 40- Use the cumulative frequency curve below to find: a) the lower quartile b) the upper quartile  c) the interquartile range d) the maximum e) the minimum  f) the range

HW 39- Page 195 #2 c and d and Page 196 #5

HW 38- Find the mean, median, mode, lower quartile, upper quartile, interquartile range and range of the values below.

 

Number of clients	Frequency
1	5
2	29
3	50
4	10
5	6

 

Answer Key:

Mean=  2.83  Median= 3   Mode= 3   Lower Quartile= 2  Upper Quartile= 3  Interquartile Range= 1   Range= 4

 

HW 37- In the Downloads section of mydwight

HW 36- Page 172 #2 (using the calculator) and page 178 #1

HW 35- Page 160 #1 (just write the answers) and Page 184 #1

HW 34- Complete question 5 and try question 2. Note: For question 2, you will need to know that cumulative frequency is the sum of all frequencies in that row and the row before. (Handout link – https://drive.google.com/a/dwight.edu/file/d/0Bzu0vic9bg3ca0VHOThiY2ZSSjA/edit)

HW 33- Complete the Logic IB Handout (Make sure to check your answers with the answer key posted in the download section of the class page)

HW 32- Questions 1-5 on the IB handout

(Answer key posted in the download section of the class page)

HW 31- Page 242 #2, Page 243 #6b, Page 249 #5a

HW 30- Page 253 #1 AND complete truth tables for each of these compound statements.

HW 29-….Page 244 #1 (Period 8 students will need to ALSO watch the video…. http://youtu.be/s0KdD1hA0IY)

HW 28- Page 247 #5a-d, g, h (Period 8 students will need to watch ONLY the first 3 and a half minutes of the video http://youtu.be/L1nf4nzwR0c….)

 

HW 27- Page 242 #1, 2i

 

HW 26- Page 236 #1a,b, Page 238 #1a,b and #3a,b (NOTE: You are not being asked to create truth tables. You are only expected to translate the words to symbols.)

 

HW 25- Complete the Probability Task from class (Task and rubric in downloads section of mydwight)

 

HW 24- Complete the IB Packet from class (linked in downloads)… Make sure to check the answers (also linked)… If you are struggling with any of the questions, we will go over them in class.

 

HW 23- Complete any 5 questions from the IB packet (linked in downloads)

 

HW 22- Page 293 #11

 

HW 21- Page 293 #7, 10

 

HW 20- Watch the video: http://www.youtube.com/watch?v=7v6P6vxUeYc then use the example in the video and find P(rain| You did not walk).

 

HW 19- Page 277 #1, 2, 3

 

HW 18- Page 279 #1, 2

 

HW 17- Page 275 #2, 3

 

HW 16- Page 273 #1, 2, 3

 

HW 15- Page 270 #2 and 3

 

HW 14- Finish today’s class work (Page 260 #1-4)

 

HW 13- Page 288 #8

In addition, if I didn’t see your poll from class and you would like to share it with me, please email the code so I can check it out. Thanks!

 

HW 12- Complete the ‘Set Theory IB Questions’ packet from class and check your answers in the answer key provided in the download section of mydwight.

 

NOTE: Homework 10, 11 and 12 will all be checked on Monday (Sept. 29)

 

HW 11- Complete the first 6 questions of the ‘Venn Diagram Word Problems’ handout from class and check your answers in the answer key provided in the download section of mydwight. (For added practice in preparation for your test, complete all 8 questions).

 

 

HW 10- Page 229 #4, 5, 6, 8

 

HW 9- Page 228 #8, Page 229 #7 and #8 (This assignment was posted on Saturday morning, therefore it is not required. However, to prepare for your quiz on Monday, it is in your best interest that you complete these questions.)

 

HW 8- Page 226 #1, Page 227 #4, Page 228 #5 (Questions and answers posted on the download section of the class page.)

 

 

HW 7- You have already done most (if not all) of the questions listed below… Please look back at each of the questions and compare your answers to the answer keys. Make note of any question(s) that you are not sure of so we can go over them before the quiz tomorrow.

 

Page 222 #1-3, Page 223 #4, Classwork from 9/16 (Answers are posted in Downloads)

———————————————————-

 

HW 6- Page 223 #4

 

HW 5- Page 221 #6 and #7

 

HW 4- Page 221 # 1a,b #2, #3a

 

HW 3- Page 216 #1, 2 #4a-c

 

HW 2- State whether numbers listed below are real, rational, integers and/or natural, then place each number in the appropriate region of the Venn diagram shown in class.

 

5, 2.3, -0.5, -4, 0, pi, the square root of 7, the square root of 9

 

HW 1- Page 214 #1, 2 and 3 (A screenshot of the page is posted on the download page of the class website.)

 

NOTE: Please remember that we will be using the HAESE MATHEMATICS (Mathematics for the international student Mathematical Studies SL book. Third edition)…. The orange book.

 

 

AVNRT

by Matthew Gill, Edward Lin, and Michael Sheflo

 

Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common cause of palpitations in patients with hearts exhibiting no structural abnormality. After consultation with a cardiologist and an electrophysiologist, an ablation may be needed to treat the condition.

 

Electroanatomical mapping utilizes several catheters with sensor tips connected to mapping and navigation software. During the ablation procedure, these catheters measure conduction in electrical pathways of the heart. One catheter is placed in the carotid sinus and another in the bundle of His near the AV node. Electrodes on the catheters are then used to induce the tachycardia. This system is able to map out a three-dimensional image of the associated anatomy and allow easy revisitation of relevant recording sites identified during the study for accurate ablation.

 

After the ablation, the catheters in the carotid sinus and bundle of His are used to try to induce the tachycardia once again, along with administration of isoproterenol. The ablation is successful if the original induced rhythm is not reproduced.

 

The most common type of AVNRT is slow-fast.  The fast pathway takes longer to repolarize, so the short pathway current can go up the fast pathway in a retrograde direction causing the reentry circuit that is causing the tachycardia. The slow pathway needs to be located and ablated in order to correct the slow-fast AVNRT.

 

The image below is an example of the three dimensional mapping. The anatomy focuses on the Triangle of Koch which is composed of the coronary sinus (CS), the tendon of Todaro, and the annulus of the tricuspid valve.  The slow pathway is most commonly located towards the posterior aspect of the triangle, between the tricuspid annulus and the coronary sinus. The red dots on the map are sites that have been ablated. Once sites have been ablated, the electrode data will confirm if the pathology is corrected by demonstrating a junctional rhythm.

 

Quiz 30- Using SOHCAHTOA to find unknown sides and angles in a right triangle

 

Quiz 29- Using the Z curve and equation to find standard deviation or mean

 

Quiz 28- Using invnorm

 

Quiz 27- Using Normalcdf

 

Quiz 26- Using the Normal Distribution Curve

 

Quiz 25- The formal Chi Square Test

 

Quiz 24- Calculating Chi Square (given observed and expected frequencies)

 

Quiz 23- Calculating Expected Frequencies

 

Quiz 22- Interpreting r and the line of best fit

 

Quiz 21- Finding and sketching the line of best fit

 

Quiz 20- Finding the correlation coefficient and determining what it tells us about the strength of the relationship between two variables

 

Quiz 19- Finding the standard deviation for a frequency table

Quiz 18- Finding the standard deviation of a list of numbers

 

Quiz 17- Finding key values and groups from grouped (discrete and continuous) data

 

Quiz 16- Box and Whisker Plot

 

Quiz 15- Finding quartiles and median from a cumulative frequency table

 

Quiz 14- Finding key values (mean, mode, median, quartiles and range) from a frequency table

 

Quiz 13- Classification of data (Quantitative Discrete, Quantitative Continuous our Qualitative/Categorical) and Finding the mean, mode, median, upper quartile, lower quartile and interquartile range of a list of numbers.

 

Note: Interquartile Range = Upper Quartile – Lower Quartile

 

Quiz 12- Logic Definitions (Tautology, contradiction, logically equivalent, logically valid, converse, inverse and contrapositive)

 

Quiz 11- Two and three proposition truth tables using all symbols

 

Quiz 10- Fill in a truth table using basic logic symbols with two propositions

 

Quiz 9- Conditional Probability (with Tree Diagrams)

 

Quiz 8- Tree Diagrams

 

Quiz 7- Independent Probability

 

Quiz 6- Basic Probability

 

Quiz 5- Venn Diagram word problems

 

Quiz 4- Shading Venn Diagram Regions

 

Quiz 3- Venn Diagram Regions (placing elements in the right part of a venn diagram and listing elements in a given region… similar to HW 4 and 5)

 

Quiz 2- Set Notation

 

Quiz 1- Number Sets (Real, natural, rational and integers)

 

 

Intracardiac ECHO Integration With Three Dimensional Mapping

Electrophysiological Study & Catheter Ablation

Avoiding Complications During Atrial Fibrillation Ablation – Dr. Munger, Mayo Clinic

Overview of the heart
http://www.vhlab.umn.edu/atlas/device-tutorial/catheters/index.shtml

Difficult Cannulation of the Coronary Sinus
Interventional Cardiac Electrophysiology
Interventional Electrophysiology and Cardiac Resynchronization Therapy
http://circ.ahajournals.org/content/115/16/2208.long

Chapter 6: Cannulation of the Coronary Ostia

EMERGING TECHNIQUES
Left Ventricular Lead Placement for Cardiac
Resynchronization Therapy
http://www.innovationsincrm.com/cardiac-rhythm-management/2013/june/464-left-ventricular-lead-placement

Copied from a book
http://books.google.com/books?id=y9U4QAqRM-kC&pg=PA139&lpg=PA139&dq=enlarged+right+atria+difficult+cannulation&source=bl&ots=xAguSrJm2o&sig=21iw1vqSpc2S8zv1xhREgrUfEWg&hl=en&sa=X&ei=jzp_VIaJHcn2iQL9-oCACQ&ved=0CDgQ6AEwBA#v=onepage&q=enlarged%20right%20atria%20difficult%20cannulation&f=false

Atrial Flutter:
Description:Atrial flutter (AFL)

Atrial Flutter ablation : Activation pattern in both Atria

Electrophysiological Study & Catheter Ablation

Broadcast
Electrophysiological Study & Catheter Ablation w/3D Mapping
http://www.orlive.com/mercyhospital/videos/electrophysiological-study-and-catheter-ablation-w/3d-mapping1
Atrial Fibrillation
Good: Rhythm Management Of The Atrial Fibrillation Patient
http://www.incathlab.com/EN/lives/15-crm/62-crm/394-rhythm-management-of-the-atrial-fibrillation-patient

AVNRT
Atrioventricular reentrant tachycardia (AVRT) & AV nodal reentrant tachycardia (AVNRT)

How to ablate typical ‘slow/fast’ AV nodal reentry
tachycardia
http://europace.oxfordjournals.org/content/europace/2/1/15.full.pdf

AVNRT ABLATION- www.hamilyon.com – tachycardia

AVNRT by Dr. Mervat Aboulmaaty P2.wmv

Intravascular Ultrasound
Novel Pathophysiological Insights and Current Clinical Applications
http://circ.ahajournals.org/content/103/4/604.full.pdf+html

Salvatore JA Sclafani, MD [The Rol of IVUS/CCSVI Symptosium 20011 – 15 of 46

Intravascular Ultrasound – Left carotid artery bifurcation stenting.
http://www.incathlab.com/EN/videos/2-endovascular/34-carotid-artery/68-intravascular-ultrasound-evaluation-left-carotid-artery-bifurcation-stenting

Left common carotid stenting post-radiotherapy
http://www.incathlab.com/EN/videos/2-endovascular/34-carotid-artery/239-left-common-carotid-stenting-post-radiotherapy

Radial Artery Access Tutorial: Multiple videos on this page
Radial access is generally very simple, but sometimes it can be more challenging. Watch these videos to become more confident and improve your performance in this technique. The course follows a logical sequence, from patient selection, to puncture and navigation, to ostia vessel cannulation; but it is also possible to jump straight to the section that is most relevant to your immediate need.
http://www.pcredu.com/courses/radial-approach-the-essentials

Right Coronary Sinus Stent

IMPLANTATION: TIPS AND TRICKS – THE CARDIOLOGIST’S VIEW
http://eurheartjsupp.oxfordjournals.org/content/6/suppl_D/D47

Overview of the heart
http://www.vhlab.umn.edu/atlas/device-tutorial/catheters/index.shtml

Difficult Cannulation of the Coronary Sinus
Interventional Cardiac Electrophysiology
Interventional Electrophysiology and Cardiac Resynchronization Therapy
http://circ.ahajournals.org/content/115/16/2208.long

Chapter 6: Cannulation of the Coronary Ostia

EMERGING TECHNIQUES
Left Ventricular Lead Placement for Cardiac
Resynchronization Therapy
http://www.innovationsincrm.com/cardiac-rhythm-management/2013/june/464-left-ventricular-lead-placement

Copied from a book
http://books.google.com/books?id=y9U4QAqRM-kC&pg=PA139&lpg=PA139&dq=enlarged+right+atria+difficult+cannulation&source=bl&ots=xAguSrJm2o&sig=21iw1vqSpc2S8zv1xhREgrUfEWg&hl=en&sa=X&ei=jzp_VIaJHcn2iQL9-oCACQ&ved=0CDgQ6AEwBA#v=onepage&q=enlarged%20right%20atria%20difficult%20cannulation&f=false

Atrial Flutter:
Description:Atrial flutter (AFL)

Atrial Flutter ablation : Activation pattern in both Atria

Electrophysiological Study & Catheter Ablation

Broadcast
Electrophysiological Study & Catheter Ablation w/3D Mapping
http://www.orlive.com/mercyhospital/videos/electrophysiological-study-and-catheter-ablation-w/3d-mapping1

Atrial Fibrillation
Good: Rhythm Management Of The Atrial Fibrillation Patient
http://www.incathlab.com/EN/lives/15-crm/62-crm/394-rhythm-management-of-the-atrial-fibrillation-patient

AVNRT
Atrioventricular reentrant tachycardia (AVRT) & AV nodal reentrant tachycardia (AVNRT)

How to ablate typical ‘slow/fast’ AV nodal reentry
tachycardia
http://europace.oxfordjournals.org/content/europace/2/1/15.full.pdf

AVNRT ABLATION- www.hamilyon.com – tachycardia

AVNRT by Dr. Mervat Aboulmaaty P2.wmv

Atrial Fibrillation Ablation
Electrophysiological Study & Catheter Ablation

Pulmonary Vein Radiofrequency Catheter Ablation Therapy for Atrial Fibrillation

Catheter Ablation For Atrial Fibrillation (AFIB)

Catheter Ablation Animation Video

Pulmonary Vein Ablation Cardiac CT

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
http://www.jove.com/video/3818/catheter-ablation-combination-with-left-atrial-appendage-closure-for

TRANSSEPTAL PUNCTURE

Links to understand the steps involved in the procedure:

http://www.heartrhythmuk.org.uk/files/file/Docs/Guidelines/How%20to%20perform%20a%20transeptal%20puncture%20EiH.pdf

http://www.innovationsincrm.com/cardiac-rhythm-management/2011/june/87-transseptal-access-for-electrophysiologist

Links to videos of the procedure:
http://www.pcronline.com/Videos/Clinical-videos/LTT/Live-in-a-box-R-AsiaPCR-Transseptal-puncture-techniques

http://www.jove.com/video/3818/catheter-ablation-combination-with-left-atrial-appendage-closure-for

The following are educational EKG videos.

Mitral Valve Prolapse and Mitral Regurgitation – Animation and Narration by Cal Shipley, M.D. Animated Portrayal of MVP

Echo-Web – Mitral Valve Prolapse Echo Images with MVP
https://www.youtube.com/watch?v=h6aJSuUTVb0&feature=youtu.be

Cardiologist (Heart Doctor) explains Mitral Valve Prolapse and Regurgitation MVP Explanation and Animation

Bicuspid Aortic Valves Bicuspid aorta surgery expolanation

What’s a Bicuspid Valve? Introduction to BAV

Bicuspid Aortic Valve Echo images and what they mean

Echo Features of a Bicuspid Aortic Valve Characteristics of BAV

4D MRI of BAV 4D MRI of BAV
http://heartvalvedisease.nm.org/diagnosis.html

Kevin Austin Testimonial Testimonial, UPenn

Bicuspid Aortic Valves – Genetics & Heredity With Dr. Patrick McCarthy BAV Henetics/Heredity

Bicuspid Aortic Valve Repair Discussion With Dr. Lars Svensson Bicuspid Aortic Valve Repair Discussion

HCM
Hypertrophic Cardiomyopathy (HCM) Cleveland Clinic (Intro)

What Is Hypertrophic Cardiomyopathy? Mayo Clinic (Intro)

Hypertrophic Cardiomyopathy Overview – Mayo Clinic