Cardiology Practice Questions

Q: All of the following must be done for management of a patient whose ECG is shown below except:

Sotalol. ***Sotalol*** - The ECG shows rapid, chaotic electrical activity characteristic of **ventricular fibrillation (VF)**, a life-threatening arrhythmia. - **Sotalol is an antiarrhythmic drug** that is not indicated for the immediate management of VF, which requires rapid defibrillation due to its highly unstable nature. *Defibrillation* - **Defibrillation** delivers an electrical shock to the heart to reset its electrical activity and is the most effective immediate treatment for VF. - This is a critical intervention to restore a perfusing rhythm and prevent sudden cardiac death. *Epinephrine* - **Epinephrine** is a potent vasoconstrictor and cardiac stimulant used during cardiac arrest to improve myocardial and cerebral blood flow. - It is administered during cardiopulmonary resuscitation (CPR) to increase the chances of successful defibrillation and return of spontaneous circulation. *CPR* - **Cardiopulmonary resuscitation (CPR)** is essential for maintaining blood flow to the brain and other vital organs during cardiac arrest. - High-quality chest compressions and rescue breaths are crucial until definitive treatment (defibrillation) can be applied and is effective.

Q: A 56-year-old woman presents with word-finding difficulty and hand weakness for 1 hour. ECG was done to find cause of TIA. ECG shows:

Atrial fibrillation. ***Atrial fibrillation*** - The ECG shows an **irregularly irregular rhythm** with **no discernible P waves**, which are classic features of atrial fibrillation. - The **transient ischemic attack (TIA)** symptoms (word-finding difficulty, hand weakness) in this patient are highly suggestive of an embolic event originating from the fibrillating atria. *Atrial flutter* - Atrial flutter typically presents with a **regular, rapid atrial activity** characterized by a "sawtooth" pattern (F waves) in leads II, III, and aVF, and a regular ventricular response (unless there is variable block). This pattern is not seen on the ECG. - While it can cause TIA due to thrombus formation, the ECG morphology doesn't support this diagnosis. *Paroxysmal atrial tachycardia* - This rhythm is characterized by a **sudden onset and cessation** of a regular, fast heart rate (typically 150-250 bpm) with a **uniform P wave morphology** that differs from sinus P waves. - The ECG in question lacks the regularity and distinct P waves characteristic of paroxysmal atrial tachycardia. *Multifocal atrial tachycardia* - Multifocal atrial tachycardia (MAT) is characterized by **at least three different P wave morphologies** in the same lead, an **irregularly irregular rhythm**, and varying PR and RR intervals. - While it shares irregular rhythm with atrial fibrillation, the presence of distinct, varying P waves is the differentiating factor for MAT, which is absent in this ECG.

Q: Identify the ECG finding shown below:

Irregularly irregular pulse. ***Irregularly irregular pulse*** - The ECG shows a rhythm where the **R-R intervals are inconsistent** and vary unpredictably, a hallmark of irregularly irregular rhythm. - This pattern, combined with the **absence of discernible P waves**, is characteristic of **atrial fibrillation**. *Widespread ST segment depression with HR of 300 bpm* - While there might be some **ST segment changes**, they are not consistently depressed across all leads, and the **rate is not 300 bpm**. - A heart rate of 300 bpm would mean 1 large box (0.2s) between QRS complexes, which is clearly not the case here. *Widespread ST segment depression with HR of 150 bpm* - The calculated heart rate appears to be roughly around **90-110 bpm**, which contradicts 150 bpm. - As mentioned, **widespread ST segment depression** is not the primary and most striking defining feature in this ECG. *Tall T waves in V3-V5* - There are **no prominent tall T waves** in leads V3-V5; in fact, the T waves are difficult to discern clearly due to the rapid and irregular ventricular activity. - The most significant feature is the **marked irregularity** of the ventricular response.

Q: A 75-year-old male patient presents to the AIIMS emergency with retrosternal chest pain for 6 hours. The following ECG was done. What will be the primary management of the patient?

Primary PCI. ***Primary PCI*** - The ECG shows significant **ST-elevation** in leads V1-V5, indicating an acute **anterolateral ST-elevation myocardial infarction (STEMI)**. - For patients presenting within 12 hours of symptom onset with STEMI, **primary percutaneous coronary intervention (PCI)** is the preferred reperfusion strategy, especially when available within recommended timeframes, as it leads to better outcomes and lower mortality compared to thrombolysis. *Thrombolysis* - While thrombolysis is a reperfusion strategy for STEMI, it is generally considered if PCI cannot be performed within 120 minutes of first medical contact or 90 minutes from diagnosis, or if the patient presents early (within 3 hours) and PCI access is significantly delayed. - Given that the patient is at AIIMS (a major medical center likely with PCI capability) and has good timing for intervention (6 hours), **primary PCI** is superior. *Abciximab* - **Abciximab** is a **glycoprotein IIb/IIIa inhibitor** used as an adjunct to PCI to prevent thrombus formation, not a primary reperfusion therapy itself. - It would be administered in conjunction with PCI, but it is not the primary management strategy. *Low molecular weight heparin* - **Low molecular weight heparin (LMWH)** such as enoxaparin is an **anticoagulant** used in STEMI to prevent clot extension and re-occlusion. - While an essential component of STEMI management, it is part of supportive medical therapy and stabilization, not the primary reperfusion strategy for opening the occluded artery.

Q: A 52-year-old male diabetic patient presents with palpitations to the AIIMS emergency. Urgent ECG was performed. What is the immediate next step in the management?

Adenosine. ***Adenosine*** - The ECG shows a **regular narrow-complex tachycardia** with a rate of approximately 150 bpm, consistent with **supraventricular tachycardia (SVT)**. - **Adenosine** is the drug of choice for hemodynamically stable SVT because it temporarily blocks the AV node, often revealing or terminating the underlying rhythm. *Electrical cardioversion* - This is indicated for **unstable tachyarrhythmias** (e.g., hypotension, altered mental status, acute heart failure, ischemic chest pain), which are not explicitly mentioned in the patient's presentation as immediate signs of instability. - While it can terminate SVT, pharmacologic management with adenosine is usually tried first in a stable patient to avoid a more invasive procedure. *Amiodarone* - Amiodarone is primarily used for **ventricular tachyarrhythmias** and **atrial fibrillation/flutter**, especially when other antiarrhythmics fail or in patients with structural heart disease. - It is not the first-line treatment for stable narrow-complex SVT due to its slower onset of action and potential side effects compared to adenosine. *Primary PCI* - **Primary percutaneous coronary intervention (PCI)** is a procedure to open blocked coronary arteries, indicated for **acute ST-segment elevation myocardial infarction (STEMI)**. - Although the patient is diabetic and presents with palpitations, the ECG evidence of SVT does not directly point to an acute coronary event requiring immediate PCI.

Q: A 65-year-old elderly male has history of sweating and chest pain for last 24 hr with the following ECG. Which of the following is not given in managing the patient?

Thrombolytic therapy. ***Thrombolytic therapy*** - **Thrombolytic therapy** is contraindicated in this patient due to the **24-hour delay** from symptom onset, as fibrinolytic therapy is generally not recommended beyond **12 hours** and absolutely contraindicated after **24 hours**. - The **risk-benefit ratio** becomes unfavorable after this time window, with increased bleeding risk and minimal myocardial salvage potential, making **primary PCI** the preferred reperfusion strategy if available. *Aspirin* - **Aspirin** remains indicated in STEMI regardless of presentation timing as an **antiplatelet agent**. - It provides ongoing **secondary prevention** benefits and helps prevent further thrombotic events even in delayed presentations. *Statin* - **High-dose statin therapy** is recommended immediately in all ACS patients, including those with delayed presentation. - Statins provide **plaque stabilization** and **anti-inflammatory effects** that are beneficial regardless of symptom onset timing. *Morphine* - While **morphine** is generally avoided in STEMI due to potential **delayed absorption** of oral antiplatelet agents and possible increased mortality, it may still be considered for **severe refractory chest pain**. - It can be used cautiously when **nitroglycerin** fails to provide adequate pain relief, especially in delayed presentations where reperfusion options are limited.

Q: Identify the ECG given in the figure below.

Normal sinus rhythm. ***Normal sinus rhythm*** - The ECG shows regular **P waves** followed by **QRS complexes**, with a consistent PR interval and a heart rate between 60-100 beats per minute, which are all characteristics of a normal sinus rhythm. - The QRS complexes are narrow, indicating normal ventricular depolarization, and the T waves are appropriately configured. *Paroxysmal supraventricular tachycardia* - This rhythm would typically show a **very rapid heart rate** (150-250 bpm) with narrow QRS complexes and often obscured or absent P waves. - The rate in this ECG is clearly within the normal range, and P waves are distinctly visible before each QRS. *Atrial fibrillation* - Atrial fibrillation is characterized by an **irregularly irregular rhythm**, absence of distinct P waves, and an erratic baseline due to chaotic atrial activity. - This ECG clearly shows a regular rhythm with discernible P waves. *Ventricular fibrillation* - Ventricular fibrillation is a life-threatening arrhythmia characterized by completely **chaotic and irregular electrical activity** in the ventricles, resulting in no identifiable P waves, QRS complexes, or T waves. - The ECG in the image shows clearly defined, organized waveforms, making ventricular fibrillation incorrect.

Q: A 25-year-old woman presents with complaints of recurrent episodes of sudden onset palpitations. What does her ECG tracing show?

Paroxysmal Supraventricular Tachycardia (PSVT). ***Paroxysmal Supraventricular Tachycardia (PSVT)*** - The ECG shows a **narrow QRS complex tachycardia** with a regular rhythm and a heart rate around 150 bpm, consistent with PSVT. - The sudden onset and termination of symptoms described by the patient are characteristic features of **re-entrant tachycardias**, such as AVNRT or AVRT, which fall under the umbrella of PSVT.

Q: A 42-year-old male with poorly controlled diabetes presents with stuttering chest pain for up to 15 minutes at a time over 24 hours. He is pain-free at the time of this ECG. ECG shows:

Unstable angina. ***Unstable angina*** - The patient presents with **new-onset chest pain** that occurs at rest and is prolonged (up to 15 minutes) and "stuttering" over 24 hours, which is characteristic of unstable angina. - The ECG shows **deep inverted T waves** in leads V2-V6 which are indicative of **myocardial ischemia**, even though the patient is currently pain-free. *Stable angina* - Characterized by **predictable chest pain** that is relieved by rest or nitroglycerin and occurs with exertion. - The patient's pain is prolonged, occurring at rest, and is new/worsening, which is inconsistent with typical stable angina. *Silent ischemia* - Refers to myocardial ischemia that occurs **without symptoms of chest pain**, often seen in patients with diabetes due to neuropathy. - While the patient has diabetes, he is actively presenting with chest pain, ruling out silent ischemia as the primary current diagnosis. *Aortic dissection* - Typically presents with **sudden onset, severe, tearing chest pain** that often radiates to the back or neck. - While aortic dissection is a life-threatening condition, the ECG findings of T-wave inversions strongly point to myocardial ischemia rather than dissection.

Q: Which of the following finding is shown in the chest leads?

Digoxin. ***Digoxin*** - The ECG shows a characteristic **downward sloping ST segment depression** with a "sagging" or "scooped" appearance, often referred to as a **"Salvador Dali mustache"** appearance, which is typical of digoxin effect on the ECG. - This pattern is due to the drug's effect on **myocardial repolarization**, specifically shortening the QT interval and inducing these ST changes, even in the absence of toxicity. *Myocardial ischemia* - Myocardial ischemia typically manifests as **ST segment depression** that is **horizontal** or **downsloping** but usually not with the characteristic "scooped" appearance seen with digoxin. - T-wave inversions may also be present, which are not the primary finding here. *Myocardial injury* - Acute myocardial injury is characterized by **ST segment elevation** (in acute myocardial infarction) or **significant ST depression with T-wave inversions** (in NSTEMI) which differs from the morphology seen in this ECG. - The morphology of the ST segment in myocardial injury is usually more abrupt and not "scooped" like a digoxin effect. *Digoxin toxicity* - While this ECG shows a digoxin effect, **digoxin toxicity** usually presents with **arrhythmias** (e.g., ventricular premature beats, bradycardia, AV blocks) in addition to altered ST-T wave morphology. - The ECG alone, showing only repolarization changes characteristic of digoxin, does not confirm toxicity without clinical correlation or evidence of arrhythmias.

Question 1

All of the following must be done for management of a patient whose ECG is shown below except:

Accepted Answer

Sotalol

Answer

Defibrillation

Answer

Epinephrine

Answer

CPR

Question 2

A 56-year-old woman presents with word-finding difficulty and hand weakness for 1 hour. ECG was done to find cause of TIA. ECG shows:

Accepted Answer

Atrial fibrillation

Answer

Atrial flutter

Answer

Paroxysmal atrial tachycardia

Answer

Multifocal atrial tachycardia

Question 3

Identify the ECG finding shown below:

Accepted Answer

Irregularly irregular pulse

Answer

Widespread ST segment depression with HR of 300 bpm

Answer

Widespread ST segment depression with HR of 150 bpm

Answer

Tall T waves in V3-V5

Question 4

A 75-year-old male patient presents to the AIIMS emergency with retrosternal chest pain for 6 hours. The following ECG was done. What will be the primary management of the patient?

Accepted Answer

Primary PCI

Answer

Thrombolysis

Answer

Abciximab

Answer

Low molecular weight heparin

Question 5

A 52-year-old male diabetic patient presents with palpitations to the AIIMS emergency. Urgent ECG was performed. What is the immediate next step in the management?

Accepted Answer

Adenosine

Answer

Electrical cardioversion

Answer

Amiodarone

Answer

Primary PCI

Question 6

A 65-year-old elderly male has history of sweating and chest pain for last 24 hr with the following ECG. Which of the following is not given in managing the patient?

Accepted Answer

Thrombolytic therapy

Answer

Aspirin

Answer

Statin

Answer

Morphine

Question 7

Identify the ECG given in the figure below.

Accepted Answer

Normal sinus rhythm

Answer

Paroxysmal supraventricular tachycardia

Answer

Atrial fibrillation

Answer

Ventricular fibrillation

Question 8

A 25-year-old woman presents with complaints of recurrent episodes of sudden onset palpitations. What does her ECG tracing show?

Accepted Answer

Paroxysmal Supraventricular Tachycardia (PSVT)

Answer

Ventricular Tachycardia

Answer

Atrial Fibrillation

Answer

Atrial Flutter

Question 9

A 42-year-old male with poorly controlled diabetes presents with stuttering chest pain for up to 15 minutes at a time over 24 hours. He is pain-free at the time of this ECG. ECG shows:

Accepted Answer

Unstable angina

Answer

Stable angina

Answer

Silent ischemia

Answer

Aortic dissection

Question 10

Which of the following finding is shown in the chest leads?

Accepted Answer

Digoxin

Answer

Myocardial ischemia

Answer

Myocardial injury

Answer

Digoxin toxicity

Cardiology — MCQs

Cardiology — MCQs

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