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Sol's Cardiac Notes
MW Fall 11
| Question | Answer |
|---|---|
| P wave? | atrial depolarization. |
| PR segment? | time required for the impulse to travel through the AV node (where it is delayed) and through the bundle of His, bundle branches, and Purkinje fiber network. |
| PR interval? | represents time required for atrial depolarization, and impulse travel through the conduction system and purkinje fiber network. |
| QRS complex? | represents ventricular depolarization. |
| ST segment? | early ventricular repolarization. |
| T wave? | ventricular repolarization. |
| U wave? | Late ventricular repolarization. |
| QT interval? | total time required for ventricular depolarization and repolarization |
| J point? | Junction where the QRS complex ends and the ST segment begins. |
| Where in the EKG is atrial systole? | Beginning of the P wave to just before the high point of the R wave (QRS complex). |
| Where is isovolumetric contraction in the EKG? | R to S |
| Ventricular ejection occurs where in the EKG? | S wave to 2/3 through the T wave. |
| Isovolumetric relaxation occurs where in the EKG? | Last 1/3 of the T wave. |
| Ventricular filling occurs where on the EKG reading? | End of the T wave to the P wave. |
| Normal heart sounds (2)? | S1 and S2 |
| Abnormal heart sounds (3)? | Splitting of S2, S3, S4. |
| What causes S1? | The closing of the mitral and tricuspid valves (atrioventricular). |
| S1 marks the beginning of… | Ventricular systole |
| S1 occurs where on the EKG? | Just after the QRS complex. |
| What causes S2? | The closure of the aortic and pulmonic valves (semilunar valves). |
| S2 marks the…? | End of ventricular systole |
| S2 occurs where on the EKG? | End of the T wave. |
| S3: aka, what? | Aka ventricular gallop; heard after the normal S2 sound. |
| S3 caused by (2)? | Early heart failure or ventral septal defect |
| S4: aka, what? | Aka atrial gallop; heard before S1. |
| S4 caused by…(7)? | 1.HTN 2.Anemia 3.Ventricular hypertrophy 4.MI 5.Aortic stenosis 6.Pulmonic stenosis 6.Pulmonary emboli 7.Loss of compliance with age |
| Gallops are caused by… | Decreased compliance |
| New S3? | Heart failure |
| New S4? | MI |
| Murmurs: reflect what? | Turbulent blood flow through normal or abnormal valves. |
| Systolic murmurs occur when? | Between S1 and S2 |
| Diastolic murmurs occur when? | Between S2 and S1 |
| Rub: when, sign of (3), 2 conditions? | Occurs with heart beat; sign of infection/inflammation/infiltration; pericarditis, cardiac tamponade. |
| Walls of the heart are made of? | Myocardium |
| Chambers of the heart are lined with? | Endocardium |
| 5 phases of the cardiac cycle in order? | 1.Isovolumetric ventricular contraction 2.Ventricular ejection 3.Isovolumetric relaxation 4.Ventricular filling 5.Atrial systole |
| What do you lose during a fib? | Atrial kick |
| Preload determined by? | Left ventricular end dialstolic volume. |
| 3 conditions that can lower preload? | 1.Dehydration 2.Hypovolemic shock 3.CHF |
| 5 meds to decrease preload? | 1.Diuretics (lasix) 2.Venous/Vasodilators (Nitroglycerin) 3.Cardiac glycosides (Digoxin) 4.Beta blockers (metropolol) 5.Morphine |
| What do you not let your pt due who is on a nitro drip? | Take a hot shower (d/t inc vasodilation) |
| Afterload? | The pressure the LV must overcome to get blood out of the heart. |
| Two meds to decrease afterload? | 1.Diuretics 2.ACE Inhibiitors 3.Other antihypertensives |
| Afterload and septic shock? | Decerase in afterload |
| 5 assessment factors outside of the heart? | 1.Pulses 2.Blood pressure 3.Edema 4.Pain 5.EKG |
| PMI: where? | Midclavicular, 5th ICS (mitral area at the apex of the heart). |
| 3 reasons why one might have JVD? | 1.Fluid overload 2.CHF 3.Dialysis |
| Auscultation mnemonic? | APE TO MAN: Aortic Pulmonic Erb’s Point Tricuspid Mitral |
| Where is the SA node located? | Wall of the RA |
| Big box numbers 1-8? | 300, 150, 100, 75, 60, 50, 43, 38… |
| Left Main Artery branches into? | Left Anterior Descending and the Left Circumflex Artery. |
| LAD perfuses? | Portions of the LV, Ventricular Septum, Chordae Tendiane, Papillary muscle and to a lesser extent the right ventricle. |
| Left Circumflex perfuses? | LA, lateral and posterior posterior portions of the interventricular septum. |
| Right Coronary Artery perfuses the? | RA, RV, and Inferior portion of the LV. |
| SA Node BPM? | (60-100 bpm) |
| AV Node BPM? | (40-60 bpm) |
| Bundle of His? | (40-60 bpm) |
| Purkinje Fibers? | (20-40 bpm) |
| Systemic vascular resistance? | A component of impedance; a combination of blood viscosity and arteriolar constriction. |
| Posture BP’s? | Check BP/pulse while pt is lying supine (min 3 min). Check sitting pulse w/in 1-2 min. Have pt stand up, check BP and pulse within 1-2 minutes. Compare results. |
| Cause for concern in postural BP’s? | A decrease of more than 20 mm Hg in systolic pressure, 10 mm Hg in diastolic pressure, as well as an increase in HR by 10-20% (10-20 beats) with any of the position changes may be indicative of dehydration or vasodilation. |
| ABI values? | Normal Value: 1.0 or higer. <.80:Moderate Vascular Compromise. <.5:Severe Vascular Compromise. |
| Abnormal ABI’s? | An abnormal ABI indicates vascular compromise and is can help identify peripheral vascular disease, and (more effectively in women) other CV disease such as CAD. |
| Where do you auscultate heart sounds (four anatomical locations)? | Aortic area: 2nd ICS just right of the sternum. Pulmonic area: 2nd ICS just left of the sternum. Tricuspid area: fifth ICS at the lower left of the sternal border. Mitral area: fifth ICS at the apex of the heart/mid-clavicular line. |
| Systolic murmur: causes (2)? | 1.aortic stenosis 2.mitral regurgitation. |
| Diastolic murmur: (2)? | 1.mitral stenosis 2.aortic regurgitation. |
| Holosystolic murmur: what, causes (3)? | Holosystolic murmurs begin with the first heart sound and extend to or through the second heart sound. 1.mitral regurgitation 2.tricuspid regurgitation 3.ventricular septal defect. |
| Friction rub: causes (3), heard in (3)?Caused by inflammation/infection/infiltration. Heard in pt’s with pericarditis resulting from MI, cardiac tamponade, or post-thoracotomy. | |
| 3 main cardiac markers? | Troponin, Creatine Kinase MB, Myoglobin. |
| Most specific cardiac marker? | Troponin |
| Troponin: rises in, peak, returns to normal? | Rises 4-6 hrs after MI. Peaks in 12-14 hours. Returns to normal in 5-9 days. |
| Pt with troponin elevation but no MI on EKG will…? | Still be treated aggressively. |
| CK-MB: specificity, rise, peak, return to normal? | Most specific MI related CK test but not as specific as troponin. Rises in 3-6 hours. Peaks in 12-24 hours. Returns to normal in 3 days. |
| Myoglobin: specificity, rise, declines in..? | Not a specific cardiac marker. Rises quickest of the 3: 2-3 hrs after injury. Declines in 7 hours. |
| When are cardiac markers measured? | On admission, in 6 hrs, and 12 hrs after admission. |
| Non modifiable risk factors for CAD (3)? | 1.Age 2.Heredity 3.Gender (men until age 80) |
| Most importat risk factor for developing CAD in women? | Age |
| Primary factor in developing CAD? | Atherosclerosis |
| Another major risk factor in CAD and PVD? | Smoking |
| Non-modifiable risk factors in the development of CAD (8)? | 1.Smoking 2.Obesity 3.Sedentary 4.Stress 5.Dietary habits 6.Diabetes 7.HTN 8.Hyperlipidemia |
| 4 cigs a day = | 2X the risk |
| 20 cigs a day = | 4X the risk |
| Ideal total cholesterol levels? | <200 |
| Ideal triglyceride levels? | <150 |
| Ideal HDL’s? | >40 |
| Ideal LDL’s? | <70 |
| Stage I HTN? | 140/90 – 159/99 |
| Stage II HTN? | 160/100 – 179/109 |
| Stage III HTN? | >180/110 |
| 1st line tx for HTN? | Diuretics: loop (furosemide/Lasix, Ethacrynic acid) Thiazides (HCTZ, Diuril) Potassim sparing (spironolactone, |
| 2nd line of defense for HTN? | Beta blockers. |
| Beta blocker action? | block adrenergic impulses in the heart and peripheral vessels; lower HR (neg chronotropy), lower contractility (neg inotropy) |
| BB’s contraindicated in whom? | Asthma/respiratory pts. |
| Examples of Beta Blockers? | Propranolol, Atenolol, Nadolol, Metoprolol. |
| Adenosine: pharm class? | Antiarrhymic |
| Uses for adenosine (2)? | 1.Conversion of PSVT to sinus rhythm if vagal maneuvers do not work 2.Chemical stress test |
| Adenosine contraindicated in? | 2nd and 3rd degree heart block |
| Adenosine dose? | 0.5-1.0 mg with the end point being 0.04mg/kg |
| Albuterol classes? | Adrenergic/Bronchodilator |
| Albuterol uses? | Bronchodilator for bronchospasm |
| Albuterol is contraindicated in…d/t SE of…? | Cardiac Dz/HTN: chest pain, palpitations, angina, arrhythmias, hypertension. |
| Amiodarone/Cordarone classes? | ClassIII Antiarrhythmic |
| Amiodarone Uses? | Pulseless Vtach, V Fib (when CPR and defib have failed). SVT (PO) and other lethal tachyarrhythmias. |
| Amiodarone contraindicated in? | 2nd and 3rd deg heart block, cardiogenic shock, bradycardia. |
| Action of amiodarone? | Inhibits adrenergic stimulation; vasodilates; slows sinus rate (prolongs QT and PR intervals). |
| Asprin classes? | Non-opioid analgesic/salicylate |
| Aspirin uses? | Prophalyactic tx of MI; mild to moderate pain. |
| Aspirin dose for suspected MI? | 160mg STAT |
| Digoxin classes? | antiarrhythmic/inotropic/digitalis glycoside |
| Digoxin uses? | Heart failure, Atrial fibrillation/atrial flutter (slows ventricular rate), Paroxysmal atrial tachycardia. |
| Digoxin chronotropic and inotropic qualities? | Slows heart rate (negative chronotropy), increases CO (positive inotropy). |
| Digoxin contraindicated in (2)? | Uncontrolled ventricular arrhythmias, AV Block. |
| Digoxin and electrolyte imbalance? | Can cause hypokalemia and hypomagnasesmia. |
| Hypokalemia during digoxin therapy can…? | Greatly increase risk of digoxin toxicity. |
| Digitalizing dose? | 0.5-1.0 gms given at 50% then 25% doses x2 at 6-12hr intervals. |
| Diltiazem: classes? | Antianginal/antiarrhythmic/antihypertensives/ Calcium channel blocker. |
| Diltiazem antiarrhytmic use (2)? | 1.SVT 2.Rapid ventricular rate of A Fib and A Flutter. |
| 3 actions of Diltiazem? | 1.Systemic vasodilation resulting in decreased BP 2.Coronary vasodilation resulting in decreased frequency and severity of attacks of angina 3.Reduction of ventricular rate in atrial fib/flutter. |
| Diltiazem contraindicated in (5)? | 1. 2nd deg AV block 2. 3rd deg AV block 3.HypoTN 4.Recent MI 5.Pulmonary congestion |
| Enalapril classes? | Anti-hypertensive/ACE Inhibitor |
| Enalapril uses (2)? | Lowering of blood pressure in patients with hypertension. Increased survival and reduction of symptoms in patients with symptomatic heart failure. |
| SE of enalapril? | 1.Cough 2.Hypotension 3.Dizziness |
| Heparin class? | Anticoagulant/antithrombotic |
| Uses of Heparin (2)? | Pulmonary emboli and Atrial fibrillation with embolization. |
| Labs to monitor in Heparin use? | aPPT, Platelet count. |
| Isoproteronol classes? | Antiarrhythmic, adrenergic, bronchodilator. |
| Uses of Isoproteronol (and action)? | Bradycardia (positive inotropic and chronotropic effects) |
| Use Iso cautionsly in? | HTN/CAD |
| Furosemide/Lasix class? | Loop diuretic |
| Lasix uses (2)? | Edema due to heart failure, Hypertension. |
| SE of lasix? | Hypotension, electrolyte imbalances (hypokalemia among most others, dehydration, metabolic alkalosis). |
| Morphine class? | Opioid analgesic |
| Morphine use? | Pain associated with MI |
| Magnesium Sulfate use? | Torsades de Pointe, hypomagnasemia, HTN. |
| Metoprolol classes? | Beta blocker/anti-anginal/antihypertensive |
| Metoprolol uses? | Hypertension, Angina pectoris, Prevention of MI and decreased mortality in patients with recent MI, Management of stable, symptomatic (class II or III) heart failure due to ischemic, hypertensive or cardiomyopathc origin. |
| Metoprolol contraindicated in (5)? | Uncompensated CHF, Pulmonary edema, Cardiogenic shock, Bradycardia, heart block. |
| Nitroglycerin class? | antianginal, nitrate |
| Nitro uses? | Angina (acute: SL, chronic: PO, Transdermal), adjunt tx of CHF (PO)/MI(IV). |
| Nitro contraindicated in? | pericardial tamponade, constrictive endocarditis. |
| 4 common SE of nitro? | 1.Dizziness 2.Headache 3.Tachycardia 4.HypoTN |
| Therapeutic uses of Nitro (3)? | 1.Relief or prevention of anginal attacks 2.Increased cardiac output 3.Reduction of blood pressure |
| Procainamide classes? | Class IA antiarrhythmic |
| Procainamide uses? | 1. PAC 2.PVC 3.Vtach 4.PAT 5.Maintenance of normal sinus rhythm after conversion from atrial fibrillation or flutter |
| 3 therapeutic uses of procainamide? | Decreases myocardial excitability, Slows conduction velocity, May depress myocardial contractility. |
| Common SE of procainamide? | diarrhea |
| Pt precautions for IV admin of procanamide? | Have pt remain supine |
| Verapamil classes (4)? | Antihypertensive, antiarrhythic, antianginal, calcium channel blocker. |
| Uses for verapamil (4)? | Management of 1.hypertension 2.angina pectoris 3.vasospastic (Prinzmetal's) angina 4.supraventricular arrhythmias and rapid ventricular rates in atrial flutter or fibrillation. |
| Therapeutic uses for Verapamil (3)? | 1.Systemic vasodilation resulting in decreased blood pressure 2.Coronary vasodilation resulting in decreased frequency and severity of attacks of angina 3.Reduction of ventricular rate during atrial fibrillation or flutter. |
| Verpamil contraindicated in (4)? | 1.2nd- or 3rd-degree AV block 2.Systolic BP <90 mm Hg 3.CHF 4.Concurrent IV beta blocker therapy |
| Pt teaching for new Pacemaker()? | 1.Rpt pulse lower than set on PM 2.Rpt any fever, redness, swelling, or drainage at insertion site 3.Keep cellular phones 6 in from generator w/ handset on ear opposite of PM 4.Avoid magnets/transmitters 5.No MRI’s 6.Medic bracelet/PM ID card |
| PM and pulse? | Take daily at same time for 1 full minute and record rate in PM diary and any times you feel symptoms of a possible pacemaker failure. |
| More PM pt teaching? | Avoid tight clothing/belts over PM (as well as pressure on the generator), inform other MD’s that you have a PM, do not operate electrical applicances over PM, do not lean over electrical/gas engines/motrs, be aware that antitheft devices can trigger PM. |
| MORE PM pt teaching? | Inform airport personnel that PM will set off metal detector, stay away from arc welding equip, if you feel symptoms when near a device more 5-10 ft away and chk pulse, no sudden jerky movement for 8 weeks after PM installation. |
| Highest mortality rate of CAD associate with which CA? | LAD (also 25% of all MI’s; perfused the aneriro wall and most of the septal wall of the LV. |
| Printzmetal’s angina sx (2), tx (3)? | 1.Chest pain 2.Tachycardia 1.BB 2.CCB 3.Hydration |
| Q wave MI? | More symptomatic than non Q wave MI. |
| Normal ejection fraction? | 55-70% (problems when < 50%) |
| Most direct measure of CO? | BP (takes VS as priority assessment) |
| Absolute contraindications to thrombolytics (7)? | 1.Prior intracranial hemorrhage 2.Known cerebral vascular lesion 3.Known malignant intracranial neoplasm 4.Ischemic stroke w/in 3 months (except w/in 3 hours) 5.suspected aortic dissection 6.Active bleeding 7.closed head/facial trauma within 3 months |
| Glycoprotein inhibitors used for? | continued patentcy of stents and angioplasty. |
| Shockable rhythms? | V Fib, pulseless V Tach. |
| Tx for PSVT? | Adenosine, Beta Blockers, Amiodarone, Cardizem. |
| 3 regular rhythm, narrow QRS complex tachy’s? | 1.Sinus Tachycardia 2.Atrial Flutter 3.PSVT |
| Tachy with wide QRS complex? | Ventricular in origin |
| Tachy with narrow QRS complex? | Atrial in origin |
| PSVT EKG characteristics (3)? | 1.Reg rhythm 2.Narrow complexes 3.No visible P waves (P waves buried in T waves). |
| Interventions for narrow complex tachycardias (PSVT, Aflutter, Afib, Sinus Tachy)? | 1.Assess ABC’s 2.O2 3.Monitor 4.IV Access 5.Vagal maneuvers 5.Adenosine 6.12-Lead EKG 7.Cadioversion |
| Dose of adenosine? | 6-12mg |
| EKG characteristics for PVC’s? | 1.Wide complex 2.come early 3.No p-wave 4.usually a compensantory pause |
| Multifocal PVC’s vs unifocal? | different shapes (- and +) |
| Bigeminy PVC’s? | A PVC every other complex (trigeminy every third) |
| Interventions for V Tach with a pulse? | 1/Assess ABC’s 2.O2 3.Monitor 4.IV access 5.Rx: amiodarone/lidocaine (to calm the ventricular site) 6.Cardioversion |
| Sustained tachycardia? | Longer than 30 seconds |
| Cardioversion used for (5)? | 1.SVT 2.Atrial Tach 3.A Fib 4.A Flutter 5.V Tach w/ a pulse |
| How to identify V Fib? | 1.Pt is unresponsive 2.No breathing, pulse, or BP 3.Disorganized pattern on EKG monitor 4.No P-Wave or QRS 5.No CO 6.Electrical and mechanical fxn’s are ineffective |
| % of LV muscle mass infarced during cardiogenic shock (pump failure)? | >40% |
| ABG’s during cardiogenic shock? | Mixed metabolic/respirtory acidosis, hypoxia |
| Rx for asytole? | Epi |
| Rx for bradycardia? | Atropine |
| Rx for V fib? | Epi, lidocaine (shock, give meds, shock) |
| Causes of bradycardia? | Athlete’s normal rate, excessive vagal stimulation (pain, bearing down), hypoxia, Inferior MI, Beta Blockers, CCBlockers, digitalis. |
| Tx bradycardia only if..? | Symptomatic |
| Atropine doseing? | 0.5-1mg; may repeat q5 min. Not to exceed a total of 2mg, or 0.04mg/kg, |
| Interventions for bradycardia (4)? | 1.Atropine 2.Tx HypoTN w/ fluid or vasopressors (vasopressin, norepi/levophed, epi) 3.Withold bradycardic meds 4.Pacemaker |
| Interventions for PAC’s? | 1.Rx quinidine, procainamide, propranolol, digoxin 2.Avoid stress 3.No cafeeine 4.observe for more serios arrhythmia |
| What’s harder to convert a fib or flutter? | Flutter |
| Which has more hemodynamic consequences: a fib or a flutter? | A fib. |
| Rx for a flutter? | Digoxin, Calcium channel blockers (verapamil, diltiazem, -dipine), Ibutalide. |
| Problem with atrial fibrillation? | No atrial contractions, atrial kick is lost. |
| Conrolled a fib vs uncontrolled? | Controlled: normal range of ventricular beats (60-100). |
| Interventions for A fib? | 1.Rx: heparin/enoxaprin, CCBlockers, digoxin, quinidine 2.Cardioversion 3.Ablation |
| Main characteristic of 1st degree AV block? | PR interval of 0.20 or greater |
| Difference between Mobitz I (winkeback) and Mobitz II? | In mobitz I the PR interval is progressively lengthened until a beat is dropped. In Mobitz II the PR remains constant (when it appears). |
| Characteristics of junctional rhythms (2)? | 1.HR of 40-60 bpm w/ reg rhythm 2.Absent P wave |
| Causes of junctional rhythms (5)? | 1.Sick sinus syndrome 2.Vagal stimulation 3.Digitalis toxicity 4.Inferior infarction 5.Rheumatic heart disease |
| What measurement can indicate mitral regurgitation? | PAWP |
| Interventions for Junctional rhythm (5)? | 1.Correct underlying cause 2.Tx symptomatic pts 3.Improve CO 4.Atropine 5.PM |
| Characteristics of an Idioventricular rhythm? | 1.Regular rate of 20 to 40 bpm 2.Very wide QRS complex |
| 5 causes of an idioventricular rhythm? | 1.Myocardial ischemia 2.Myocardial infarction 3.Digitalis toxicity 4.Pacemaker failure 5.Metabolic imbalances |
| Tx for an idioventricular rhythm? | Transcutaneous Pacing |
| Atrial kick accounts for how much % of ejection fractions? | 30% |
| Three things to note on a paced rhythm? | 1.Note the spike prior to QRS 2.Note what percentages are paced 3.Note wide QRS complexes |
| What is happening during PEA? | Electrical conduction system is intact but mechanical pumping of the heart is not. |
| Tx for PEA? | PEA: Problem-search for probable cause, Epi-1mg q 3-5 min, Atropine-if rate is slow up to 0.04 mg/kg |
| PATCH MD mneumonic for causes of PEA? | Pulmonary embolus, Acidosis, Tension pneumothorax, Cardiac Tamponade, H(4) (Hypovolemia, Hyperkalemia, Hypothermia, Hypoxia), Massive MI, Drug overdose |
| Interventrions for PEA (7)? | 1.Establish responsiveness 2.Assess ABC’s 3.Initiate CPR 4.Ensure IV access 5.Intubate 6.Underlying problem intervention 7.Drugs |
| Asystole: shockable? | No |
| Interventrion s for asystole? | 1.Chk in another lead 2.Transcutaneous pacing 3.Epi 4.Atropine (use meds to get a shockable rhythm). |
| Causes of Asystole (7)? | 1.Acute MI 2.Severe electrolyte disturbances 3.Massive pulmonary emboli 4.Prolonged hypoxemia 5.Severe Acid-base disturbances 6.Electrical shock 7.Drug OD |
| 8 interventions for Asystole? | 1.Establish unresponsiveness 2.Assess ABCs 3.Initiate CPR 4.IV access 5.Intubation 6.Chk another lead 7.Transcutaneous pacing 8.Drugs |
| What is an aortic aneuresym? | dilation or outpouching of the aorta. |
| Superior AA =? | thoracic AA |
| Inferior AA? =? | Abdominal AA (more common) |
| Risk factors for AA(8)? | 1.Male 2.Adv age 3.HTN 4.Smoker 5.Connective tissue disorders 6.Diabetes 7.Trauma 8.Atherosclerosis |
| Sx of AA (3)? | (most are asyptomatic until rupture is imminent) 1.Steady/gnawing pain of the abd, flank/back pain 2.Pulsation in the upper abd slightly left of the midline between xiphoid process and umbilicus 3.can auscultate a bruit |
| Sx of thoracic aortic dissection/rupture (7)? | 1.Back pain 2.SOB/hoarseness 3.Sudden excruciating back pain 4.Neuro chgs 5.JVD 6.New murmur 7.Hypovolemic/hemorrhagic shock |
| Post op care for an AA (7)? | 1.Assess for bleeding 2.Keep BP in normotensive range 3.Assess urine output 4.Monitor CO 5.Doppler of all extremities 6.Meticulous pulmonary hygiene |
| Risk factors for Arterial Occlusive Dz (7)? | 1.Male 2.Smoking 3.Aging 4.HTN 5.Hyperlipidemia 6.Diabetes 7.Family Hx |
| Sx of acute occlusion (5)? | Pain, Pallor, Pulseless, Paresthesia, Paralysis |
| Interventions for Arterial Occlusive Dz (6)? | 1.Restore circulation 2.Embolectomy 3.Graft 4.Bypass graft 5.Balloon angioplasty 6.Stents |
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