ABIM Clinical EP cheat sheet

Vascular access: femoral vein lies medial to femoral artery; common femoral artery puncture targets the femoral head midpoint on fluoroscopy.

Pericardiocentesis: subxiphoid approach directed toward the left shoulder, aspirating inferiorly and posteriorly; continuous ECG monitoring detects needle contact with epicardium (ST injury or PVCs).

Transseptal puncture: fossa ovalis located posteriorly and inferiorly in the septum; confirm with pressure, contrast, and echocardiography before dilating.

Radiofrequency ablation lesion depth is limited (~5-7 mm); contact force, power, and duration determine lesion size; irrigated catheters reduce thrombus and allow higher power.

Cryoablation for AVNRT: target ~-30 to -40 C for 2-4 minutes; monitor for AV block during freezing and stop if block persists.

Anticoagulation during left atrial ablation: maintain ACT 300-350 s with heparin; never leave an activated sheath in the left atrium without anticoagulation.

Cardiac tamponade after ablation: abrupt hypotension with echo showing pericardial effusion and right-sided collapse; treat with immediate pericardiocentesis and reversal of anticoagulation.

Phrenic nerve injury risk is highest with right phrenic pacing during right atrial or superior vena cava ablation; monitor diaphragm capture and halt energy on loss of capture.

AVNRT: dual AV nodal pathways; typical (slow-fast) has short RP with pseudo-R' in V1; treat acutely with vagal maneuvers then adenosine.

WPW: short PR, delta wave, wide QRS; risk of pre-excited AF; avoid AV nodal blockers (digoxin, verapamil, adenosine) in pre-excited AF; use procainamide or cardioversion.

Long QT: QTc = QT/sqrt(RR) (Bazett); torsades treated with IV magnesium and overdrive pacing; avoid QT-prolonging drugs.

Brugada pattern: coved ST elevation >2 mm in V1-V2 with T inversion; risk stratification with electrophysiology study and ICD for syncope or spontaneous pattern.

ARVC: epsilon waves, T-wave inversion in V1-V3, ventricular arrhythmias of LV/RV origin; diagnosis by Task Force criteria including imaging and genetics.

Atrial flutter: typical counterclockwise circuit uses cavotricuspid isthmus; sawtooth flutter waves in inferior leads; ablation at CTI is curative.

Ventricular tachycardia: monomorphic vs polymorphic; capture and fusion beats suggest VT; Brugada algorithm and AV dissociation aid diagnosis.

Antiarrhythmic Vaughan-Williams classes: I sodium channel, II beta blockers, III potassium channel (amiodarone, sotalol), IV calcium channel; amiodarone has thyroid, pulmonary, hepatic toxicity.

Track procedure outcomes: fluoroscopy time, complication rates, and success rates should be reviewed against published benchmarks.

Registry participation (e.g., NCDR) provides risk-adjusted comparisons; use data to identify outliers and target quality improvement.

Morbidity and mortality conferences: structured case review identifies systems failures and cognitive errors, not just individual blame.

Simulation-based training improves catheter skills and reduces complications; deliberate practice with feedback is more effective than repetition alone.

Maintain a personal procedure log with outcomes and complications; review annually to identify learning needs.

Critical appraisal: evaluate studies by design, bias, confidence intervals, and applicability to your patient population before changing practice.

Root cause analysis: identify proximate and contributing causes of adverse events; implement system changes and re-measure.

Plan-Do-Study-Act (PDSA) cycles test small changes iteratively before broad implementation.

Informed consent: discuss indication, alternatives, risks, benefits, and the possibility of trainee participation; confirm patient understanding with teach-back.

Breaking bad news (SPIKES): Setting, Perception, Invitation, Knowledge, Empathy, Strategy and summary.

Shared decision-making for ICD implantation: discuss sudden death risk reduction, quality-of-life impact, driving restrictions, and end-of-life device deactivation.

Use plain language and avoid jargon; confirm comprehension by asking the patient to restate the plan.

Document goals-of-care discussions and code status; revisit after major clinical changes.

Interpreter use for limited English proficiency improves outcomes; avoid family members as interpreters for clinical discussions.

Closed-loop communication in procedural teams: verbalize orders and confirm receipt to reduce errors.

Address patient anxiety before procedures with clear step-by-step explanation and expectation setting.

Disclose medical errors to patients honestly and promptly; disclosure supports trust and is an ethical and often legal obligation.

Manage conflicts of interest: disclose industry relationships and recuse from decisions where bias could affect patient care.

Maintain confidentiality per HIPAA; share only minimum necessary information.

Informed refusal: competent patients may decline recommended therapy; document capacity assessment and discussion.

Impaired colleague: report through appropriate channels; patient safety takes priority over collegial loyalty.

Boundary setting with patients and families; avoid dual relationships that compromise objectivity.

Advance directives and surrogate decision-making: follow patient's stated wishes; use substituted judgment when unknown.

Cultural humility: recognize personal biases and adapt communication to patient values and background.

Door-to-balloon time for STEMI: target <90 minutes at PCI-capable centers; <120 minutes including transfer.

Primary prevention ICD cost-effectiveness depends on patient selection; follow guideline indications to avoid low-value implants.

Remote monitoring of CIEDs reduces in-person visits and detects lead failure or arrhythmias earlier; establish alert triage workflows.

Readmission reduction: structured discharge with medication reconciliation, follow-up scheduling, and patient education reduces heart failure readmissions.

Anticoagulation stewardship: use CHA2DS2-VASc for stroke risk and HAS-BLED for bleeding risk; coordinate across prescribers.

Device advisories: systems for patient notification and registry tracking enable rapid identification of affected patients.

Team-based care with advanced practice providers and pharmacists improves guideline-directed medical therapy titration.

Health equity: identify disparities in device access and ablation referral; use standardized pathways to reduce variation.