Cardiac Arrhythmias

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Cardiac Arrhythmias






  1. A 45-year-old woman is admitted with syncope while standing in the mall. No premonitory symptoms, no other significant past medical history, and on no medications except contraceptive pill. Her physical examination, electrocardiogram (ECG), and echocardiogram are normal, as is the tilt table test. What is the most likely cause of her syncope?



    1. Neurocardiogenic
    2. Pulmonary embolism due to hormone-induced hypercoagulable state
    3. Catecholaminergic polymorphic ventricular tachycardia
    4. Long QT syndrome



  2. A 55-year-old man with prior myocardial infarction (MI) and coronary stenting 3 years ago is admitted with sudden loss of consciousness while sitting at a desk. He was on aspirin, statin, angiotensin-converting-enzyme inhibitor, and Coreg®. Heart rate was 65 bpm, blood pressure 110/72 mmHg, normal jugular venous pressure, and no murmurs. ECG showed poor R wave progression, echo showed an ejection fraction (EF) of 30% with anterior and apical akinesis and thinning. Left anterior descending artery stent was patent on coronary angiogram. What is the next logical step?



    1. Discharge with event monitor
    2. Do electrophysiology (EP) testing for inducible arrhythmias
    3. Implant an implantable cardioverter-defibrillator (ICD)
    4. Perform a stress test for ventricular tachycardia (VT)



  3. Carotid sinus hypersensitivity is more common in which of the following?



    1. 20-year-old female
    2. 40-year-old male
    3. 40-year-old female
    4. 75-year-old man



  4. Mortality in long QT syndrome depends upon which of the following?



    1. Specific genetic defect
    2. QT interval
    3. History of syncope
    4. All of the above



  5. In a patient with type I Brugada syndrome presenting with syncope, the 2-year risk of sudden death is which of the following?



    1. 2%
    2. 10%
    3. 30%
    4. 80%



  6. Which of the following statements about Brugada syndrome is correct?



    1. It is a genetically determined sodium channelopathy
    2. Mortality risk is independent of amount of ST elevation
    3. The ECG changes are stable and do not change over time
    4. They have underlying left ventricular (LV) dysfunction



  7. A 78-year-old patient with no prior medical history, not on any medications, is noted to be bradycardic at a routine physical exam. ECG shows complete heart block. Upon further questioning, the patient denies complaining of dizziness, near syncope, or syncope. He admits to noticing a gradual decline in exercise capacity over the last year. What is the next step in the management of this patient?



    1. Holter monitor
    2. EP test
    3. Exercise treadmill test
    4. Dual-chamber pacemaker implant



  8. A 37-year-old patient presents with symptoms of palpitations. Holter monitoring revealed episodes of atrial tachycardia and atrial fibrillation. He was prescribed flecainide 100 mg BID and metoprolol succinate 50 mg daily. He noticed an improvement in symptoms of palpitations but complains of fatigue and inability to return to work as a firefighter. What is the best option for this patient?



    1. Continue present management
    2. Switch to sotalol
    3. EP studies and catheter ablation
    4. Lower dose of flecainide and metoprolol



  9. A 72-year-old woman with history of coronary artery disease, ischemic cardiomyopathy, and paroxysmal atrial fibrillation of 5 years’ duration has noticed an increase in frequency and duration of episodes over the last year. Her medications include Tikosyn® 250 μg BID, Coreg 25mg BID, enalapril 10 mg daily, aspirin 81 mg daily, and rivoroxaban 20 mg daily. She would like to consider pulmonary vein antrum isolation procedure if she will be taken off rivoroxaban after the procedure. What do you tell her?



    1. She can expect to continue taking aspirin and discontinue rivoroxaban
    2. She will need to continue taking rivoraxaban and discontinue aspirin
    3. Both medications can be stopped
    4. Both medications will be continued



  10. An ECG (Figure 22.10) is done on a 35-year-old male who is scheduled to undergo knee surgery. The patient has no symptoms of palpitations. What is the next step in the management?



    1. No further work-up is indicated
    2. Exercise treadmill test
    3. Echocardiogram
    4. EP studies and ablation
    Sheet shows ECG of 35-year-old patient who is scheduled to undergo knee surgery with no symptoms of palpitations, and options.

    Figure 22.10




  11. A 60-year-old patient with history of dilated cardiomyopathy, LVEF 35%, on optimal medical therapy is noted to have frequent premature ventricular complexes (PVCs) on ECG with left bundle branch block (LBBB) morphology and inferior axis. She denies symptoms of palpitations. On a 24-h Holter monitor, the PVC burden is 22%. Which of the following options would you offer next?



    1. Start amiodarone
    2. Repeat echo in 6 months
    3. EP studies and catheter ablation
    4. ICD implant



  12. A 40-year-old patient with history of supraventricular tachycardia (SVT) wishes to undergo EP studies and catheter ablation. What is the expected success rate?



    1. 70–75%
    2. 80–85%
    3. 90–95%
    4. 100%



  13. A 65-year-old patient presents with history of prior MI and 5-year history of recurrent palpitations associated with near syncope. He has been on metoprolol and simvastatin. The 12-lead ECG is suggestive of atrioventricular nodal reentrant tachycardia (AVNRT). Which of the following would you recommend next?



    1. Continue metoprolol
    2. Flecainide
    3. Amiodarone
    4. EP study/ablation



  14. A 35-year-old patient presents to the emergency department with 2-h history of rapid heartbeat associated with dizziness. The blood pressure is 90/60 mmHg,; ECG is shows atrial fibrillation with ventricular preexcitation. What is the best treatment option?



    1. Intravenous (IV) metoprolol
    2. IV digoxin
    3. Cardioversion
    4. IV amiodarone



  15. A 60-year-old patient with chronic kidney disease on dialysis has recurrent episodes of palpitations requiring cardioversion. ECG shows counterclockwise atrial flutter. What is the best treatment option?



    1. Metoprolol
    2. Sotalol
    3. Dofetilide (Tikosyn)
    4. EP study/ablation



  16. A 66-year-old female with history of ischemic cardiomyopathy, status post ICD implant, hypertension, and diabetes is detected to have three episodes of paroxysmal atrial fibrillation lasting from 1 to 2 h during a routine device check. She denies symptoms of palpitations. What is the next step in the management of this patient?



    1. Observation
    2. Holter monitor
    3. Echocardiogram
    4. Anticoagulation



  17. A 70-year-old male with history of ischemic cardiomyopathy, hypertension, hospitalized for congestive heart failure exacerbation 3 months ago has four episodes of paroxysmal atrial fibrillation lasting from 8 to 12 h. He reports symptoms of palpitations and fatigue. He has been taking metoprolol and rivaroxaban. What is the antiarrhythmic agent of choice?



    1. Dronaderone
    2. Dofetelide
    3. Flecainide
    4. Propafenone



  18. A 42-year-old patient with no prior medical history presents with palpitations of 5 days’ duration. ECG reveals atrial fibrillation with ventricular rate of 120 bpm. He is placed on IV heparin and undergoes transesophageal echocardiography-guided cardioversion the following day. What does this patient have?



    1. Lone atrial fibrillation
    2. Paroxysmal atrial fibrillation
    3. Persistent atrial fibrillation
    4. Long-standing persistent atrial fibrillation



  19. What is the appropriate anticoagulation management for the patient in Question 22.18?



    1. Aspirin 75 mg daily for 1 month
    2. Aspirin 325 mg daily for 1 month
    3. Warfarin for 1 month
    4. No aspirin or warfarin is needed



  20. A 55-year-old patient who is status post coronary artery bypass grafting 3 days ago is noted to be in atrial flutter. He is placed on metoprolol and warfarin and discharged home. He has been followed by his primary care physician. You see him in the office 3 months later. He feels well. He is in atrial flutter with ventricular rate 90 bpm. What would be the next step in the management of this patient?



    1. Continue rate control
    2. Sotalol
    3. Cardioversion
    4. EP study/ablation



  21. A 68-year-old female patient status post mechanical valve 4 years ago on warfarin develops paroxysmal atrial fibrillation. She would like to pursue anticoagulation with a novel oral anticoagulant because of labile international normalized ratio (INR) after she was started on amiodarone. Which of the following do you recommend?



    1. Pradaxa
    2. Rivaroxaban
    3. Apixaban
    4. None of the above



  22. Which of the following is not a factor Xa inhibitor?



    1. Apixaban
    2. Dabigatran
    3. Rivaroxaban
    4. Edoxaban



  23. A 70-year-old patient with paroxysmal atrial fibrillation was started on flecainide 100 mg BID. She has been doing well. An ECG done 1 week later reveals sinus rhythm with LBBB. Which of the following is the appropriate next step?



    1. No change
    2. Reduce dose of flecainide to 50 mg BID
    3. Discontinue flecainide
    4. Recommend pacer implant



  24. A 72-year-old patient with history of atrial fibrillation is on warfarin and digoxin. He was started on dronedarone. The serum creatinine at baseline was 1.3; 1 week later it was 1.7. Which of the following statements is false?



    1. The INR is not affected
    2. The serum digoxin is unchanged
    3. Renal tubular secretion of creatinine is inhibited by dronedarone
    4. Reduction in glomerular filtration rate



  25. When initiating therapy with amiodarone, a reduction in the dose is needed for all of the following agents except which?



    1. Digoxin
    2. Warfarin
    3. Metoprolol
    4. Apixaban



  26. Which of the following statements regarding Tikosyn is false?



    1. The dose is determined by creatinine clearance
    2. It is contraindicated in patients with heart failure
    3. Inpatient monitoring is mandatory while initiating therapy
    4. ECG is monitored for QT prolongation



  27. A 57-year-old patient with no prior cardiac history with symptoms of exercise-induced palpitations undergoes an exercise treadmill test. Sustained wide QRS tachycardia at a rate of 170 bpm occurs during recovery. The ECG is shown in Figure 22.27. The patient is hemodynamically stable. She is given 5 mg of IV metoprolol. Sinus rhythm is restored 5 min later. Echocardiogram reveals normal left and right ventricle function. What is the most likely diagnosis?



    1. Ischemic VT
    2. Idiopathic RVOT VT
    3. Catecholaminergic VT
    4. Idiopathic LV VT
    Sheet shows ECG of 57-year-old patient with no prior cardiac history with symptoms of exercise-induced palpitations undergoes exercise treadmill test.

    Figure 22.27




  28. A 67-year-old female patient with history of atrial fibrillation, hypertension, and St Jude aortic valve replacement is scheduled to undergo hip replacement. What is the best option for management of anticoagulation?



    1. Discontinue warfarin 5 days prior to procedure, bridge with low molecular weight heparin (LMWH) when INR is 2.0, resume warfarin on day of surgery
    2. Discontinue warfarin 5 days prior to procedure, no bridging with LMWH is needed, resume warfarin on day of surgery
    3. Continue warfarin
    4. Discontinue warfarin 2 days prior to procedure, bridge with LMWH after surgery, resume warfarin on day of surgery



  29. A 70-year-old male patient with history of ischemic cardiomyopathy, status post ICD implant, atrial fibrillation, hypertension, and diabetes is scheduled for ICD generator replacement. What is the best option for management of anticoagulation?



    1. Discontinue warfarin 5 days prior to procedure, bridge with LMWH when INR is 2.0, resume warfarin on day of surgery
    2. Discontinue warfarin 5 days prior to procedure, no bridging with LMWH is needed, resume warfarin on day of surgery
    3. Continue warfarin
    4. Discontinue warfarin 2 days prior to procedure, bridge with LMWH after surgery, resume warfarin on day of surgery



  30. A 55-year-old female patient with history of atrial fibrillation, hypertension, and diabetes is scheduled to undergo biopsy of breast mass. Her renal function is normal. She is on apixaban 5 mg BID. What is the best option for management of anticoagulation>



    1. Discontinue apixaban 24 h prior to procedure
    2. Discontinue apixaban 48 h prior to procedure
    3. Continue apixaban
    4. Reduce dose of apixaban to 2.5 mg BID



  31. A 22-year-old patient is hospitalized with abdominal pain. She has no cardiac symptoms. Her ECG is shown in Figure 22.31. What does it demonstrate?



    1. Intraventricular conduction disturbance
    2. Right bundle branch block (RBBB)
    3. WPW syndrome
    4. Right ventricular hypertrophy
    Sheet shows ECG of 22-year-old patient who is hospitalized with abdominal pain and no cardiac symptoms.

    Figure 22.31




  32. A 28-year-old female patient has had symptoms of palpitations since the age of 5. They are infrequent, occurring once a year, and are brought on by physical activity. Her ECG, done in the office, is shown in Figure 22.32. What is the most likely explanation for her palpitations?



    1. AVNRT
    2. Orthodromic atrioventricular reciprocating tachycardia (AVRT)
    3. Atrial tachycardia
    4. Antidromic AVRT
    Sheet shows ECG of 28-year-old patient, which was done in office, who has had symptoms of palpitations since age of 5.

    Figure 22.32




  33. The ECG in Figure 22.33 demonstrates which of the following?



    1. Sinus rhythm with PVC
    2. Sinus rhythm with premature atrial complex with aberrant ventricular conduction
    3. Sinus rhythm, WPW syndrome with PVC
    4. Sinus rhythm, WPW syndrome with two accessory pathways

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Apr 23, 2020 | Posted by in CARDIOLOGY | Comments Off on Cardiac Arrhythmias

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