4.1 K) Cardiovascular Tachycardias

Front 1

ECG Criteria for VT vs. SVT + aberrancy

Back 1

1. Broad Complex > 0.16 msec
2. Tachycardia > 120
3. Absence of typical RBBB / LBBB morphology
4. Extreme Axis Deviation
5. AV dissociation
6. Capture Beats
7. Fusion Beats
8. Chest Lead Concordance
9. Brugada’s Sign {RS length > 100msec}
10. Josephson’s Sign {notching near nadir of S wave}
11. Rsr [ not rsR of RBBB]

See side 3

Front 2

Which is incorrect in regards to Multifocal Atrial tachycardia {MAT}?
1. The rhythm is irregular
2. The R-R interval is chaotic, and the PR intervals vary.
3. The P waves have multiple morphologies
4. It is an unstable rhythm
5. It is associated with COPD/Chronic lung disease

Back 2

4. It is a stable rhythm

Front 3

Causes of Atrial Flutter
"Ship-RACV"

Back 3

S Stimulants {drugs}
H Hyperthyroidism
I Idiopathic
P Pericarditis
RA Respiratory-Acute /
Chronic
C CCF
V Valve dysfunction

Front 4

Prognostic factors in CHADS2 scoring {for Embolic stroke reduction and anticoagulation in AF}

Back 4

Congestive Cardiac Failure
{EF < 35%}
Hypertension
Age > 75 years
Diabetes
Stroke / TIA

Side 3 for Relative risk

Front 5

Anticoagulation Guidelines for CHADS2 {Scores and Rx}

Back 5

0 = aspirin
1 = aspirin OR warfarin
>= 2 = warfarin

Front 6

in comparing AVNRT and AVRT, which is incorrect?
1. AVRT is less common than AVNRT
2. AVRT involves a macro reentry circuit
3. AVNRT involves a micro reentry circuit
4. AVNRT is associated with structural cardiac disease
5. AVRT involves an accessory AV pathway

Back 6

AVNRT is not usually associated with structural cardiac disease

Front 7

In regards to AVRT, which is incorrect?
1. Orthodromic conduction with AVRT is more common than antidromic conduction
2. Orthodromic conduction in AVRT involves retrograde conduction along the normal conducting AV pathway
3. Orthodromic conduction with AVRT tachycardia is difficult to distinguish from AVNRT tachycardia
4. AVNRT tachycardia rates are between 150-250bpm
5. Paroxysmal AVRT is associated with WPW

Back 7

2. Retrograde conduction occurs up the Accessory pathway

Front 8

Causes of completely irregular rhythms {7}

Back 8

1. Atrial Fibrillation
2. Atrial tachycardia with variable conduction
3. atrial flutter with variable conduction
4. Multifocal atrial tachycardia {MAT}
5. Multiple extrasystoles
6. Wandering pacemaker
7 Parasystole
see side 3

Front 9

Which is incorrect regarding narrow complex tachycardias?
1. Atrial fluter is usually via a re-entrant mechanism
2. Normal AV nodal tissues rarely allow a ventricular response rate of more than 170-180 bpm
3. Atrial fibrillation is the result of multiple micro-reentry circuits.
4. Atrial fibrillation limits diastolic filling AND stroke volume of the ventricles.
5. Fibrillation waves are best seen in the inferior leads and V1

Back 9

2. 150-165bpm

Front 10

Which is the association with atrial flutter:
1. Structural heart disease
2. Heart failure
3. Valve dysfunction {mitral}
4. Thyroid disease
5. All of the above

Back 10

5.

Front 11

Ashman Phenomenon rhythm associations {3}

Back 11

1. Atrial fibrillation
2. Atrial ectopy
3. Atrial tachycardia

Front 12

Mnemonic for Causes of Atrial fibrillation:
SHH! I2 C3 VP2W

Back 12

S sick sinus syndrome
H hyperthyroidism
H hypertensive heart disease

Idiopathic
I ischaemic heart disease

C cardiomyopathy
C CCF
C cardiac surgery

V valve disease {mitral*}
P pericarditis
P Pulmonary embolus
WPW

Front 13

IN regards to WPW, which is incorrect?
1. WPW is present in 0.1-0.3% of population
2. Males > females
3. only 25-50% WPW patients become symptomatic
4. 70% WPW patients have no underlying heart disease
5. Presenting rhythm in symptomatic patients is a reentrant tachycardia 50%

Back 13

5. 70-80%

AF seen in 10-30% patients with WPW.

Front 14

In regards to WPW, which is incorrect?
1. Patients with WPW often have one or more classic features MISSING on the ECG.
2. The Kent fibres are the most common accessory pathway
3. Type A WPW = QRS mostly positive in V1.
4.The short PR interval is the result of the absent Av node conduction delay.
5. on the ECG: narrow QRS and no delta wave = ANTIDROMIC tachycardia

Back 14

5. Orthodromic tachycardia = narrow QRS and no delta wave ==> AV node anterograde conduction and retrograde accessory pathway conduction
Antidromic tachycardia = wide QRS and + delta wave = accessory pathway anterograde conduction , and AV node retrograde conduction.

Front 15

In regards to WPW, which is incorrect?
1. Unstable patients should be cardioverted -synchronised-starting at 50-100J
2. A regular ORTHODROMIC [ narrow QRS] tachycardia is the single most common presentation of an accessory pathway syndrome.
3. Initial treatment for Orthodromic tachycardia {in order} = vagal ; adenosine ; BB; CCB ;digoxin ; amiodarone ; flecainide.
4. Symptomatic patients with an antidromic {wide QRS} tachycardia are at high risk of VT.
5. With a wide complex irregular tachycardic rhythm, adenosine{ and other nodal blockers} are contraindicated.

Back 15

5. VF
A wide complex irregular tachycardia at a ventricular rate > 250bpm is HIGHLY SUGGESTIVE OF AF AND WPW
SEE SIDE 3

Front 16

Diseases associated with WPW {7}

Back 16

1. Idiopathic ***
2. Cardiomyopathy {HOCM}
3. Transposition of the great vessels {TOGV}
4. Ebstein's Disease
5. Mitral valve prolapse {MVP}
6. Tricuspid atresia
7. Endocardial fibroelastosis

Front 17

4 ECG characteristics of Sinus tachycardia

Back 17

1. normal P waves
2. Normal P-R intervals
3.1:1 atrioventricular conduction
4. atrial rate 100-160 bpm

Front 18

3 categories of sinus tachycardia stimuli

Back 18

1. Physiologic
2. Pharmacologic
3. Pathologic

See side 3

Front 19

3 ECG characteristics of AVNRT

Back 19

1. P wave buried in QRS complex-and not visible
2. 1:1 conduction
3. normal QRS complex

Front 20

Which is incorrect regarding management of SVT?
1. vagal manoevres have a success rate of 25%
2. The valsalva manouevre is the most effective vagal manouevre for conversion of reentrant SVT-particularly in supine position
3. early recurrences are seen in 25% patients treated with adenosine
4. adenosine is safe in pregnancy
5. Adenosine is contraindicated in narrow complex WPW

Back 20

5. It is not CI in NARROW COMPLEX WPW

Front 21

which is an incorrect association?
1. WPW and kent bundle
2. Lown-Ganong-Levine (LGL) Syndrome and James fibres
3.James fibres of LGL syndrome connect atrium and proximal HIS bundles
4. James fibres insert directly into infranodal conducting system
5. LGL syndrome ECG: short PR interval and wide QRS

Back 21

5. short PR interval and narrow QRS

Front 22

Mahaim bundles with AVRT originate from:
1. AV node
2. His Bundle
3. Bundle branches
4. All of the above
5. None of the above

Back 22

4.

Front 23

Which is incorrect in regards to Type A WPW:
1. V1 delta wave has + deflection
2. V1 has dominant R wave
3. Q waves present in inferior leads
4. Ventricular activation occurs first occurs in the inferior-posterior region of Left ventricle.
5. Delta wave has initial negative deflection in V1

Back 23

5. V1 delta wave-positive deflection

Front 24

Type B WPW: which is incorrect?
1. V1 delta wave has initial positive deflection
2. May resemble an inferior wall MI
3. Lead V1 can have an RS or QS pattern
4. Delta wave has initial negative deflection in V1
5. Ventricular activation occurs in the inferior-posterior region of the Right ventricle

Back 24

1. V1 delta wave has initial negative deflection

Front 25

In regards to Type C WPW, which is incorrect?
1. Ventricular activation occurs first in the posterior lateral region of the Left ventricle.
2. Leads V5 has negative OR isoelectric pattern
3. Lead V6 can have a negative OR isoelectric pattern
4. Both Type A and Type C WPW have positive initial delta wave deflections
5. Delta wave is negative in lead V1.

Back 25

5. Positive delta wave deflection in V1.

Front 26

Brugada Criteria for VT

Back 26

1. Absent RS complex in all V leads==> VT
2. R to S nadir > 100msec in any V lead==> VT
3. AV Dissociation ==> VT
4. Typical BBB pattern ==> not VT

Front 27

Main causes of VT

Back 27

1. coronary artery disease
2. Cardiomyopathy
3. Myocarditis
4. Valvular heart disease

Front 28

Treatment options for VT

Back 28

1. DC cardioversion
2. pharmacological
- Amiodarone
3. Rapid Right ventricular pacing {Overdrive pacing}

Front 29

Which of the following is incorrect regarding Torsades de pointes?
A. It is more electrically unstable than monomorphic VT
B. It is a depolarisation abnormality
C. Syncope is the usual presenting symptom
D. It can be caused by hypocalcaemia and hypomagnesaemia.

Back 29

B. Repolarisation abnormality

Front 30

List the causes of Torsades de Pointes.

Back 30

1. Hypo-electrolytes
a. magnesium
b. calcium
2. Antiarrhythmic drugs [ I and II ]
3. TCA
4. Antidepressants / Antipsychotics
a. phenothiazines
b. citalopram
5. Congenital prolonged QT syndrome
6. Organophosphates
7. Complete heart Block [CHB]
8 Drug interactions
a. erythromycin-terfenadine

Front 31

Treatment options for Torsades de Pointes?

Back 31

1. Magnesium ***
2. Cardioversion
[ haemodynamically compromised ]
3. Overdrive pacing [ rate 90-120]
4. isoprenaline infusion

Front 32

Which is incorrect regarding Torsades de Pointes (TdP)
A. TdP may degenerate into VF
B. The commonest cause of Polymorphic Ventricular tachycardia (PVT) is drugs
C. TdP can be treated with Isoprenaline
D. TdP is a specific form of PVT

Back 32

B. Ischaemia

Front 33

Which is incorrect regarding the pathophysiology regarding TdP?
A. A prolonged QT interval reflects prolonged myocyte depolarisation.
B. Bigeminy, in the presence of a prolonged QT, can herald imminent TdP
C. The sequence of progression from prolonged QT interval to TdP = EAD --> PVC --> 'R on T' --> TdP
D. The prolonged repolarisation period gives rise to early after-depolarisations (EADs)

Back 33

D. Prolonged repolarisation

Front 34

Which is incorrect regarding Long QT Syndromes?
A. The normal QT interval is from the BEGINNING of the q, to THE END of the T wave.
B. The Correct QT (QTc) via Bazett's Formula, corresponds to a QT duration at a Heart Rate of 60.
C. The QT should be roughly < 50% of the R-R interval at any rate.
D. The aim of External pacing for Torsades is to Overdrive the bradyarrhythmia.

Back 34

C. rate should be less than 90.

Front 35

In regards to overdrive pacing in Torsades de Pointes, which is incorrect ?
A. In the ED, it refers to setting the pacing greater than the rate of the bradyarrhythmia.
B. There is little actual data to support its efficacy in the ED
C. Monomorphic VT can also be directly overdrive paced-but requires transvenous pacing.
D. Pacing occurs continuously, in the asynchronous mode.

Back 35

D. It actually occurs as brief trains of 6-10 beats of asynchronous pacing.

Front 36

Which is incorrect regarding Long QT and Torsades?
A. Prolonged QT can result in polymorphic VT or Mono-morphic VT
B. Prolonged QT can result in VF.
C. The arrhythmia of TdP is usually initiated by an 'R on T' ventricular extrasystole.
D. The Romano-Ward Congenital Syndrome is associated with deafness.

Back 36

D. Lange-Nielson is associated with nerve deafness.

Front 37

Which electrolyte abnormality is least associated with Increased QT interval?
A. Decreased potassium
B. Decreased magnesium.
C. Decreased calcium.
D. Increased calcium.

Back 37

D.

Front 38

Which is an unlikely drug cause of Long QT interval ?
A. Non-sedating antihistamines
B. Organophosphates
C. Class I and II Anti-arrhythmics
D. Antipsychotics Typical and Atypical.

Back 38

C. Class Ia , Ic and III.
Not Class II

Front 39

Which of the following Clinical conditions is least likely to cause a prolonged QT interval?
A. Severe bradyarrhythmias eg CHB.
B. Subarachnoid Haemorrhage
C. Hypothermia
D. Hyperthermia

Back 39

D.

C. "Severe" Hypothermia does prolong QT interval

Front 40

Which of the following is incorrect regarding the immediate Treatment for TdP?
A. Arrested = Defibrillate
B. Conscious + Sustained = Cardiovert
C. Conscious and non-sustained = External pacing
D. Correct bradyarrhythmia and underlying cause ( MgSO4 ; atropine ; isoprenaline )

Back 40

C. External pacing only after correcting bradyarrhythmia and underlying cause ( Hypokalaemia ; Hypocalcemia ; Hypothermia )

Front 41

List the 5 main ECG phenomena (Types) associated with Syncope in the young adult / athlete.

Back 41

1. HOCM
2. ARVC [ arrhythmogenic right ventricular cardiomyopathy]
3. Brugada Syndrome
4. Long QT Syndrome
5. WPW

Front 42

In regards to the ECG of HOCM, which of the following is incorrect?
A. It has peaked P waves, representing Left atrial enlargement.
B. Pathological Q waves exist in the lateral leads.
C. High precordial voltages are present.
D. There are ST-T wave abnormalities- particularly deep T wave inversion laterally / pre cordially.

Back 42

A. Left atrial enlargement = broad bifid P waves

Front 43

which is incorrect regarding HOCM?
A. It is the leading cause of sudden cardiac death in healthy athletes < 35 years.
B. Its murmur is increased with valsalva and standing.
C. It has Epsilon waves present.
D. Handgrip reduces the murmur of HOCM.

Back 43

C. No -this is present in ARVC

Front 44

In regards to Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC), which of the following is incorrect?
A. The epsilon waves present are similar to the Osborn waves of Hypothermia.
B. It is the second most common cause of sudden cardiac death in young athletes.
C. There is precordial WRS prolongation > 0.14 seconds.
D. There is T wave inversion.

Back 44

C. QRS > 0.11 seconds in V1-3.