SINUS BRADYCARDIA

ATRIAL PREMATURE BEATS

PREMATURE VENTRICULAR COMPLEX

DOUBLE PVC

PVC TRIPLETS

BIGEMINY
WPW

PSVT
MULTIFOCAL ATRIAL TACHY

AFIB
ATRIAL FLUTTER
VENTRICULAR TACHYCARDIAS
MONOMORPHIC VT

POLYMORPHIC VT
VENTRICULAR FIBRILLATION
TORSADES DE POINTES
AV BLOCKS
1ST DEGREE
The PR interval >200 ms indicates first-degree atrioventricular block.
SECOND DEGREE AV BLOCK
Second-degree atrioventricular block: Mobitz I/Wenckebach

MOBITZ 2
THIRD DEGREE AV BLOCK
 1. MCQ 3.074
A 28-year-old man develops rapid palpitations and mild light-headedness following
a 20km run. He is not known to have cardiac disease and a recent cardiovascular
examination was normal. The pulse is rapid and regular. Which one of the following
rhythm strips would be most likely with this clinical picture?
paroxysmal supraventricular tachycardiajm 812

2. Young man developed palpitations after a 15km walk. Had to choose ECG rhythm strip.
a) A fib if bradycardia+irregular,but if tachycardia+regular: PSVT
b) V fib
c) A Flutter
d) VT
Summary of Electrocardiographic Features of hocm

 Left atrial enlargement

 Left ventricular hypertrophy with associated ST segment / T-wave abnormalities
 Deep, narrow (“dagger-like”) Q waves in the lateral > inferior leads
 Giant precordial T-wave inversions in apical HCM
 Signs of WPW (short PR, delta wave).
 Dysrhythmias: atrial fibrillation, supraventricular tachycardias, PACs, PVCs, VT

3. an ecg question of a completely healthy 35 year old man after a jog rapid palpitations and light headedness
asking for the proper ecg
Afib - SVT but its rate was slow 75 - vent tachy -complete heart block

‫ تاخيلىشايعهستن‬٢ ‫بعدورزش‬. Lone af‫و‬pac

4. Patient on polypharmacy, had stopped all his drugs, now comes with and ECG of Atrial Fibrillation, which drug to
start first?????????????
Perindopril
Beta blocker
Digoxin
Frusemide
(acute : rate control,chronic: rhythm control)
5. Pulmonary embolism case with ECG
S1Q3T3 pattern
This 'classic' pattern is often considered the pathognomonic ECG abnormality associated with acute pulmonary
embolism
 Deep S wave in Lead I: ≥1.5 mm
 Deep Q wave in Lead III: ≥1.5 mm
 T wave inversion in Lead III

6. pt arrive from travel. Chest pain sibce 4 hrs which is worsening now, sweating , BP 90/60
Lbbb
Inf mi with rbbb
Pul. Embolism - http://medicine.ucsf.edu/education/resed/Chiefs_cover_sheets/ecg_pe.pdf
pericarditis

7. A 4year child has come with this ECG,Has complained of 4hours lightheadedness & palpitations. HR 200 and PR
20/MIN What’s next step of management:vt
A.Oral Digoxin
B.Immerse face in water
C.IV adenosine
D.IV sotalol

VT , SVT , WPW( ‫ هست‬wide complex tachycardia ‫مهماينهكهيك‬،‫ ولىمهمنيستچيه‬. ‫ هست‬SVT with aberrancy ‫اينبهاحتمالزياد‬
: ‫ باقضيهبرخوردميشه‬VT ‫بودنشاصًالمهمنيستفعًال) ودراينجورمواردمثليك‬
D/C shock ‫ بود‬unstable ‫ اگه‬-
‫ليگنوكايينياسوتالول‬،‫ بودآميودارون‬stable ‫ اگه‬-
‫فقطيكتبصرهدارهداستاناونماينكهدربچههااگهخواستيمدرماندارويىبكنيماوليكدوزآدنوزينميزنيمبعدميريمسراغداروهاىفوق‬

8. young man ( more than 20) was playing football and when was standing alone, without being hit by anyone, lost
consciousness and regain it after 5 minute and was well and started playing again after 30 minutes. What is the
most likely cause
Vasovagal===few minutes
cardiac arthymia===few seconds
hypoglycemia===not gain conscious without giving sugar==gain consciousness gradually

9. patient with ECG of rapid response AF and palpitation ( rate 150) with hypothyroidism on thyroxin what should
be done?
Digoxin
Give metoprolol
 10. Pt. with CHF taking b-blocker , furosemide , perindopril , K supplement , metformin for DM , start amiodarone
due to arrythmic problems , now complain of lightheadednes and palpitation & feeling like syncope , what id the
cause ? Same ecg of Ali nazzari recalls was given
A) perindopril + lasix
B)bblocker + lasix
c) K supplement + bblocker
d)amiodarne + furosemide===torsa de points,tachycardia, hypokalaemia\\\ttt magnesium correct electrolyes

11. an old lady presented to you with early diastolic murmur at apex, mid systolic murmur at right parasternal side
and diastolic murmur at left sternum. What is the lesion?
A)MR===systolic murmur
B)AR ....3 suffles
C)MS===diastolic murmur
D)TR

12. A man presented with lightheadedness with multiple drug interaction, to me the ECG was of long QT syndrome,
not hyperkalemia-
Amiodarone +frusemide
 Amlodipine+ frisemide
Frusemide + thaiazide

Combining Amiodarone +frusemide can increase the risk of an irregular heart rhythm. may need regular monitoring of
your electrolyte (magnesium, potassium) levels. You should seek immediate medical attention if you develop sudden
dizziness, lightheadedness, fainting, or fast or pounding heartbeats during treatment with amiodarone. In addition, you
should let your doctor know if you experience signs of electrolyte disturbance such as weakness, tiredness, drowsiness,
confusion, muscle pain, cramps, dizziness, nausea, or vomiting
http://www.drugs.com/interactions-check.php?drug_list=167-0,1146-0

Risk factors for torsade include the following:

 Congenital long QT syndrome.

 Female gender.
 Acquired long QT syndrome (causes of which include medications and electrolyte disorderssuch
as hypokalemia and hypomagnesemia)
 Bradycardia.
 Baseline electrocardiographic abnormalities.
 Renal or liver failure.

VF
13. ECG of Bradycardia he is sure about it .. patient on polypharmacy what combination causes all
1-amiodaron frusemide (torsa de pointes)
2-amiodarone amlodipine ..(amlodipine causes tachycardia)
3- digoxin and other drug

14. one LBBB ecg but im so sorry cant remember exactly was something like old case of mi , q waves were there too
and now come for follow up .was on polypharmacy acei , beta blocker , furosemide nd few more what would u
do ?
a) reassure and review in 6 months
b) stop the drugs one drug in each option stop BB

Never administer beat blocker in a patient with recent onset LBBB and ACS
Rbbb===m pattern at v1 and w pattern at v6
Lbbb===w pattern at v1 and m pattern at v6

15. ECG hyperkalemia-- K>7.. ask Rx--

a. ca gluconate
b. iv dextrose

manifestations of hyperkalemia: muscle weakness or paralysis, cardiac conduction abnormalities, and cardiac
arrhythmias, including sinus bradycardia, sinus arrest, slow idioventricular rhythms, ventricular tachycardia, ventricular
fibrillation, and asystole
ECG changes: tall peaked T waves with a shortened QT interval; progressive lengthening of the PR interval and QRS
duration; disappearance of the P wave; and widening of the QRS complex to a sine wave pattern

Tall T wave in all leads!

Rapidly acting therapies include the administration of calcium, insulin with glucose, beta-2-adrenergic agonists, and, in
selected patients, sodium bicarbonate . These therapies are primarily used in three settings:
 ECG changes
 serum potassium < 6.5 to 7 meq/L
 A lesser degree of hyperkalemia in patients with a serum potassium that is rapidly increasing
 16. A little todler came with parents because he ate his grandma "white pills" , they don’t know which one he ate cuz
she is taking many drugs for many things , the boy is drowzy has bradycardia by examination and u did an ECG.
Which drug did the boy ingested ?
• beta blocker
• Digoxin
• K supplement
• Metformin
• TCA
Digoxin overdose:
Signs of overdosage include vomiting, salivation and diarrhoea, drowsiness, bradycardia and arrhythmias.

17. HYPERKALEMIA ECG for a kid who taken his grandparent meds,,which med?
A- verapamil
b- k supplements
c -frusemide
d-digoxin
e-fifth I cannot remember but it was not ace or ARB

digitalis toxicity
 Bradycardia
 hyperkalemia
 arrhythmia (any type with the exception of rapidly conducted atrial arrhythmias)
 Gastrointestinal: anorexia, nausea, vomiting, and abdominal pain
 neurologic signs: confusion and weakness
 Renal dysfunction

Chronic toxicity is more difficult to diagnose, as symptom onset tends to be more insidious. In addition to
gastrointestinal symptoms, visual changes may occur, including alterations in color vision, the development of scotomas,

or blindness
St elevation===hyperkalemia not due to digoxin

Scoppy t wave inversion bcz of===digoxin toxicity

18. another que pt on many medication metoprolol,digoxin,frusemideecg was given mobitz type 1 and nusea
vomiting and abd pain was there,digoxin level was given and it was normal.what to do?
1.cease digoxin
2.cease metoprolol
3.temporary pace making
4.angiogarphy
5.cease metoprolol and commence verapamil
  Toxicity is related to intracellular levels, not serum levels
1-Any patient with clinically significant manifestations of digitalis poisoning should be treated with digoxin -specific
antibody (Fab) fragments. include:
 Life-threatening arrhythmia (eg, ventricular tachycardia; ventricular fibrillation; asystole; complete heart
block; Mobitz II; symptomatic bradycardia)
 Evidence of end-organ dysfunction (eg, renal failure, altered mental status)
 Hyperkalemia (serum potassium >5 to 5.5 meq/L)
2-As temporizing measures or if Fab fragments are not immediately available, symptomatic bradycardia or
bradyarrhythmia can be treated with atropine (0.5 mg IV in adults; 0.02 mg/kg IV in children, minimum dose 0.1 mg) and
hypotension with IV boluses of isotonic crystalloid
 19. Pt. with CHF , DM , HT , mild renal impairement taking perindopril , bblocker , digoxin , aspirin , K supplement,
now have this ecg , what is the next to do ?
A) dec. perindopril
B) stop digoxin
C) inc. K suppl.
D)dec. b blocker

20. A very clear ecg of second degree / type 1, heart block, pt on poly pharmacy, acei, frusimide, digoxin, what to do
next. No option for temp pace,
Stop dig
Stop acei
Stop frusimde
Permanent pace maker

a progressively increasing PR interval until a P wave is not conducted

treatment for Mobitz type I AV block

1-Prior to initiating Tx, excludereversible causes:
 MI
 increased vagal tone (younger persons or athletes)
 medications(ABCD):
 A…amiodarone&adenosine
 B…beta-blockers
 C…calcium channel blockers (especially verapamil and diltiazem )
 D…digoxin
2- If no reversible causes are present:
 asymptomatic no specific therapy
 symptomatic bradycardia implantation of a permanent pacemaker
 21. LBBB ecg was given and the patient was taking perindropilspironolactone..atenolol .what to stop here?

A. Spironolactone
B. Atenolol==ansjm 965
C. perindropil

Hyperkalemia can cause LBBB

patients with heart failure who are taking spironolactone and ACE inhibitorscan develope severe hyperkalaemia in

22. Patient had inf mi two days back. Today in hospital has bradycardia arnd 35/min. ecg strip was given , atropine
was given . no improvement.
A- adenosine
b- temp pacing
c- perm pacing

indications for temporary bradycardia pacing in patients with acute MI:

 Asystole
 Symptomatic bradycardia due to sinus node dysfunction or Mobitz type I that is not responsive to atropine
 Mobitz type II second degree
 Complete AV block
 Bilateral or alternating bundle branch block including RBBB with left anterior fascicular block or left posterior
fascicular block
 A new bundle branch block with first degree AV block
 An old right bundle branch block with first degree AV block and a new fascicular block

23. An old man with congestive heart failure and hypothyroidism. On levothyroxine, digoxin, and other medications
came with light headedness and palpitations. His HR was 140 regular. The ECG was sinus tachycardia as I've
noticed. Wt should you do:

1. cease thyroxine
2 . stop digoxin
3. Decrease digoxin
4 . add metoprolol

Sinus tachycardia = Exogenous hyperthyroidism

The symptoms and signs in patients who take excessive doses of thyroid hormone: weight loss, heat intolerance, tremor,
palpitations, anxiety, increased frequency of bowel movements, and shortness of breath
Discontinuation or reduction in the dose of thyroid hormone is usually the only treatment needed. Beta-blockers will
relieve many of the symptoms of hyperthyroidism promptly

24. A 60 y.o. man develops lightheadedness and palpitations. He has hx of thyroid disease and well-controlled heart
failure. He is on thyroxine, ACEI, diuretic. ECG is given – clearly showed AFib.
What is the next step?
a. Cease thyroxine
b. Start digoxine
c. Start b-blocker
d. Start verapamil
 25. Scenerio Of inferior MI within 2 hour what to do next
A. RTpa
B.angiography
C. nitroglycerine
Answer depends on proximity to tertiary center. If close to tertiary center next is coronary angiography from above options
for confirmatory diagnosis and PCI or coronary angioplasty for treatment. If very far from tertiary center and no availability
of PCI, then A.

26. a 50 year old man present with hypertension with asthma and reflux nephropathy .lab inv were given.there was
high urea,high creatinine and proteiuria 900 mg/day.what is the choice of anti HTN?
1.amlodipinejm 966
2.losartan
3.perindropil
4.indapamide
5.BB

ACEi or ARB are first choicein patients with proteinuric chronic kidney disease, The most common side effect of therapy
with ACE inhibitors is cough, so ACE inhibitors are not first-line therapy in patients with asthma or COPD, An alternative
is angiotensin II receptor blocker

27. ECG of complete heart block given. Patient has hypertension with cardiac failure and is on ramipril, verapamil,
statins and diuretics. What is the most appropriate management?
 a)Add adrenaline
b) Stop verapamil
c) Stop diuretic
d) Stop ramipril

Verapamil and, to a lesser degree, diltiazem can diminish cardiac contractility and slow cardiac conduction [3]. As a
result, these drugs are relatively contraindicated in :
 second or third degree atrioventricular block
 patients who are taking beta blockers
 severe left ventricular systolic dysfunction
 ck sinus syndrome

28. pt on many medications , indapamide, verapamil, perindopril , aspirin….. present wth light headedness and
mobitz type 2 ecg given wt to do next
1.valsalva manover
2.cease verapamil
3.temporary pace maker==jm 815
4.ceaseindapamide

29. a pt with heart failure on many drugs stop medication for 2 weeks now came with odemauptoknee,chest was
clear and with sinus tachycardia what to give?
1.digoxin
2.metoprolol
3.commence all drugs again
30. another heart failure scenario pt on many medication and on digoxin .125 mg present with
odema ,crepitation.first what to give
1.40 mg frusemide mane(1st)
2. 0.5 mg digoxin stat
3.metoprolol mane
4.all drugs together
No option for ACEI(1st)

31. A young guy while playing cricket suddenly had syncopal attack without any convulsive features. Soon he
spontaneously recovered and started fielding and continue playing rest of the game.What was the cause?
a)Vasovagal syncope
b)cardiac issue (arrythmia)
c)Epilepsy
 cardiogenic: the patient drops down suddenly and regains consciousness in seconds.
 Neurogenic: goes suddenly and come backs in minutes (vasovagal , seizure , etc)
 Metabolic: the patient goes gradually and come backs gradually

B between these options. if there is post ictal state then SEIZURE otherwise SYNCOPE. If there is prodromal signs then
more with Vasovagal if no prodromal sign and recover immediately(seconds) more with cariogenic (there could be
murmur), no murmur arrhythmic syncope. But there is some rare once too. Here I share a link for differential daignosis
of SYNCOPE it was really help full for me

32. young male who fall suddenly in the field of a match , without being touched , after a few
seconds/minutes he stood without any intervention and continued playing what is the case
a)vasovagal attack
B)Jacksonian seizures
 33. An adolescent boy with episode of sudden fall in the playground regained consciousness with 5 mins and started
playing within 30 mins . diagnosis
a. postural hypotension
b. arythmias
c. vasovagal syncope

34. An 80-year-old man developed sudden loss of consciousness for about 1 minute with gradual recover. There is no
significant past medical history. 5ECG tracings given. Choose the most appropriate ECG tracing.
SVT
Atrial fibrillation
Ventricular fibrillation
Ventricular tachycardia
Complete heart bloc*** as a sick sinus syndrome can trigger loss of consciousness with prompt recovery…

35. 18 month old infant noticed by his parents to have a very fast heart rate last for 20 mins. heart rate was about
250-300/min. What would you do? a. Beta blocker b. verapamil c. cold water stimulation d. digoxin e.
reassurance
Svt is the most common arrythmia in children

36. A young pt with repeated dizziness and fall when standing only. Head tilt test lowers BP to 70/50
What advise will you give?
fludrocortisone
increase salt and water intake (dehydration)

 Doctors use tilt-table tests to find out why people feel faint or lightheaded or actually completely pass out.
 Tilt-table tests can be used to see if fainting is due to abnormal control of heart rate or blood pressure. A
very slow heart rate (bradycardia) can cause fainting.

initial intervention is to increase intravascular fluid volume by large daily salt intake, either added to food or as salt
tablets:
Continue with this until weight has increased by 1.3-2.3 kg; then can consider giving fludrocortisone, if necessary, to
increase sodium retention.
Can precipitate heart failure but peripheral oedema alone should not cause cessation of treatment.

37. A young pt with repeated dizziness and fall when standing only. Head tilt test lowers BP to 70/50 What will you
do?
a)Fludrocortisone Can’t remember other options but there was nothing like I/V fluid ***

Initial intervention: increase intravascular fluid volume by large daily salt intake, either added to food or as salt tablets:
Continue with this until weight has increased by 1.3-2.3 kg; then can consider giving fludrocortisone, if necessary, to
increase sodium retention. It Can precipitate heart failure but peripheral oedema alone should not cause cessation of
treatment.
If symptoms still persist consider midodrine (not licensed for use in postural hypotension)!==postural orthostatic
tachycardia syndrome dx
U can see wikkipedia link …1st increase salt and water then medication fludrocortisones

Notes:
Responses to Head-Up Tilt-Table Testing Condition Physiologic response Normal Heart rate increases
by 10 to 15 beats per minute Diastolic blood pressure increases by 10 mm Hg or more Dysautonomia
Immediate and continuing drop in systolic and diastolic blood pressure No compensatory increase in
heart rate Neurocardiogenic syncope Symptomatic, sudden drop in blood pressure Simultaneous
bradycardia Occurs after 10 minutes or more of testing Orthostatic hypotension Systolic blood
pressure decreases by 20 mm Hg or more or Diastolic blood pressure decreases by 10 mm Hg or
more Postural orthostatic tachycardia syndrome Heart rate increases by at least 30 beats per minute
or Persistent tachycardia of more than 120 beats per minute
 38. A lady presented with light headedness and palpitation she has similar episodes in last 3 months. On examination
BP is 85/60 and pulse 98/min and after head tilt BP is 110/72 and pulse 74/min. treatment ?
Atropine
Pacemakers
Fluids

39. A lady in her 20s with lightheadedness (and ECG given – heart block 1st degree, I think). When you
perform a table test (?) – after head tilt for few minutes her pulse drops to 50 and BP
to 70/40. What is the management?
a. Pacemaker***
b. Atropine
c. b-blocker
aaaaaaaaaaaaaaaa because of heart block + tilt +
Neurocardiogenic syncope is a relatively common entity. In the vast majority of people, there are well defined triggers that can be either avoided or appropriate
action taken when avoidance is not feasible. In a smaller number of individuals, there are recurrent syncopal spells without a clear trigger.

Neurocardiogenic syncope has been divided into three types (5,6). Type 1 is mixed characterized by a combination of both vasodepression and cardioinhibition. In this
group, the hypotension develops prior to the bradycardia and the bradycardia is generally not severe. The heart rate either does not fall below 40 bpm or remains
below 40 bpm for less than 10 seconds. Type 2 is cardioinhibitory with a major period of asystole and is subdivided into (a) and (b). In type 2a, the hypotension
precedes the bradycardia but the bradycardia is marked with sustained periods of asystole (Figure 1). On tilt table testing, the asystole is > 3 seconds. In Type 2b, the
bradycardia either precedes or coincides with the development of hypotension. Again, the bradycardia is severe. Type 3 is pure vasodepression where there is
minimal to no decrease in the heart rate associated with the hypotension. In each case, there is usually a transient initial increase in heart rate either coincident or
following the onset of the hypotension.
If just tilt was the issue, B-b or mitodrine for neurocardiogenic shock (vasovagal) was good. But here….
Interpretation of table test in hypotension evaluation .....
Normal test -: heart rate increase and bp decrease ......
Neurocardiogenic OR vasovagal snycope-:symptomatic sudden drop of bp and simultaneous bradycardia.....
Orthostatic/postural hypotension-: bp significantly decrease more than 20mmhg and heart rate no significant
change.....,
 40. A young athlete presents with palpitations after marathon. What ECG would you expect? (5 ECG strips given)
a. sunis arrhythmia (not SVT, as different RR intervals, and P wave is presentbefore every QRS)**
b. atrial flutter with variable block
c. VTach
d. AFib
e. 1st degree heart block
Aaaaaaaaaaaaaa
Arrhythmia in athletes HB 3.074

41. pt with hypertension ,DM, well controlled congestive heart failure presents with palpitation and irregular pulse
which one is appropriate first
a.digoxin …….choice for arrhythmia in CHFjm 981
b.warfarin
c.metoprolol
d.aspirin
The most important thing to look at here is The co-existing DM. You dont give B blockers to DM
patients so it is A

Picture of atrial fibrillation ecg with the ff scenario pt with hypertension ,DM, well controlled congestive heart failure
presents with palpitation and irregular pulse which one is appropriate first
a. digoxin
b. verapamil
c. metoprolol
d. Ramipril
e. Amlodipine

42. MI recent patient suddenly breasthlessness bp droped 80/50 ecg VT mx?

DC cardioversio –DC defibeliator –IV adenosine

 VT unstable= dc
 stable = iv lidocaine or procainamide
 treatment= beta blocker

Paroxysmal supraventricular tachycardia (PSVT) occurs in less than 10 percent of patients after an acute MI, Mx:
1- Carotid sinus massage or a valsalva maneuver
2- Intravenous adenosine or verapamil
3- Intravenous beta blockade with metoprolol or esmolol or amiodarone
4- Intravenous digoxin
5-If the arrhythmia persists ………Cardioversion

43. patient collapsed and CPR started first step?

Cardioversion
Defibrillation
IV lignocaine
IV adrenaline

 VF pulseless unstable =defib

 without reversible or transient cause= ICD

44. A 4year child has come with this ECG,Has complained of 4hours lightheadedness & palpitations. What’s next step
of management:
A.Oral Digoxin
B.Immerse face in water
C.IV adenosine
D.IV sotalol

45. ecg showing AFIB asking what youll find in examination

prominant a wave - completely normal heart - idont remember the rest of choices

46. A patient presents with chest pain of 2 hours onset in the metropolitan hospital. ECG given showing lateral STEMI
in I, AVL and V5,V6. Morphine, Oxygen, Nitrates, Aspirin given. What is the next step?
a. tPA
b. Coronary angiography

 <1h symptomacceptible delay of 60min

 1-3hors of symp90min ====
 3-12hours of symp120 min delay
 After 12 hPCI not recommended
 47. young guy while playing cricket suddenly had fallen without any convulsive features. Soon he spontaneously
recovered and started fielding and continue playing rest of the game.What was the cause?
a)Vasovagal syncope
b)Heart block
c)Epilepsy

48. 3 year old man took some of his grandma medications,she's been taking medications for CHF and herpetic
neuralgia. The ECG was 2nd degree heart block. What would be the cause :

1. digoxin
2.amitryptiline
3. Metoprolol
HEART SOUNDS AND MURMURS
INFECTIVE ENDOCARDITIS
RHEUMATIC FEVER