Part 1 | EP (Clinical)

1. A 24-year-old female presents with recurrent palpitations. There is no pattern to

what triggers the arrhythmia, but she is typically able to terminate it by
performing Valsalva-maneuver. She has no significant past medical history. She
denies alcohol or illicit drug use. There is no family history of arrhythmia, sudden
death, or cardiomyopathy. The baseline ECG and echocardiogram are normal.
The following ECG was obtained when the patient presented to the ED with
persistent palpitations.

What is the most likely diagnosis based upon the clinical history and ECG?
A. Antidromic reciprocating tachycardia
B. Atrial flutter with rapid ventricular response
C. Inappropriate sinus tachycardia
D. AVNRT
E. His-Purkinje extrasystoles

2. The Patients with the tachycardia in Question 1 usually have:

A. Dual AV nodal physiology
B. A concealed accessory pathway
C. Retrograde atrial activation spreading from the free wall of the AV groove to
the septum
D. A wide QRS complex during tachycardia that narrows at lower HR
E. Structural heart disease
3. A 45 year old male patient was presented to the ER with chest pain and
palpitations. ABP was 90/60. He underwent coronary revascularization few years
ago and the echocardiogram revealed that LV systolic function is 30%. His labs
revealed Total CK 600 IU/L, CK MB 6.5 ng/ml and Troponin 0.65 ng /ml.
This is the ECG on admission and after DC shock.

What is your recommendation?

A. Coronary Angiography and ICD implantation as soon as possible.

B. Coronary Angiography and assessment for ICD indication after 40 days
C. Amiodarone and CRT implantation.
D. Conventionel RF Ablation
E. 3D Mapping & RF Ablation
4. A 75-year-old woman is admitted with a pre-syncopal episode.
She denies chest pain and shortness of breath. She has a past history of
hypertension for which she has been taking a diuretic. On examination she is
conscious and has a BP of 85/40 mmHg. Her ECG is shown below:

What is the next step of management?

A. DC cardioversion
B. Intravenous Amiodarone
C. Intravenous Flecainide
D. Intravenous Lidocaine
E. Sotalol
5. A 28-year-old woman, who is 24 weeks pregnant with her first child is referred
to the medical assessment unit with six hour history of palpitations. These
palpitations started suddenly and the patient felt uncomfortable. On arrival
she looks anxious. Her blood pressure is 125/80 mmHg. Her pulse is 140 bpm
and regular. Her ECG is shown below.

What is the most appropriate management plan for this patient?

A. Vagal manoeuvres followed by Adenosine

B. Vagal manoeuvres followed by Amiodarone
C. Vagal manoeuvres followed by Atenolol
D. Vagal manoeuvres followed by DC cardioversion
E. Vagal manoeuvres followed by MgSo4
6. A 39-year-old man presented to hospital complaining of palpitations. He felt
nauseated with dizziness but he did not have any chest pain or breathlessness.
He had been diagnosed with Wolff-Parkinson-White syndrome two years ago
associated with frequent attacks of palpitations that were usually terminated
by carotid sinus massage. However, on this occasion carotid sinus massage had
failed to terminate the palpitations. He had a past history of asthma, treated
with salbutamol and budesonide inhalers.

On examination, his blood pressure was 130/75 mmHg and pulse 160 beats per
minutes. His heart sounds were normal and chest was clear on auscultation.
Abdominal and neurological examinations were unremarkable.

The 12-lead ECG is shown below:

What is the best treatment that should be given to stop his current attack as
carotid sinus massage has been ineffective?

A. Adenosine
B. Amiodarone
C. Digoxin
D. Intravenous beta-blocker
E. Verapamil
7. A 53-year-old man presented to the Emergency department with severe chest
pain. The 12-lead ECG showed inferior ST segment elevation and he was
diagnosed as having an acute inferior myocardial infarction. Thrombolysis was
initiated on the basis of the ECG findings. Thirty minutes later in the coronary
care unit he developed complete atrial and ventricular dissociation, although
he remained haemodynamically stable with the blood pressure recorded as
120/80 mmHg. After a further ten minutes he developed intermittent runs of
ventricular tachycardia (VT) which were associated with a significant fall in the
blood pressure to 85/65 mmHg. Over the subsequent ten minutes his blood
pressure stabilized (110/75 mmHg) and no further episodes of ventricular
tachycardia were recorded.

What is the best immediate management?

A. Amiodarone infusion
B. Intravenous aminophylline
C. Intravenous dobutamine
D. Observe under close ECG monitoring
E. Temporary pacing wire insertion
 8. A 26-year-old male came to the Emergency department as he suffered from
sudden onset palpitations at home. He is followed up at the heart care clinic
regularly because of a heart problem but he is unsure of the details. On arrival
his initial pulse rate is 202 irregularly irregular but reverts intermittently to
sinus rhythm 70 beats per minute. During ECG monitoring, there were frequent
paroxysms of tachycardia. His blood pressure is 105/60 mmHg. The ECG of this
arrhythmia is shown below:

What is the most appropriate next step for management?

A. Direct current cardioversion during the sustained tachycardia

B. Intravenous Adenosine
C. Intravenous Digoxin
D. Intravenous Flecainide
E. Intravenous Verapamil
 9. A 70-year-old lady presented with an episode of syncope. Her ECG is shown.

Which of the following describes the site of the lesion in this lady?
A. AV node
B. AV node and Purkinje fibres
C. Purkinje fibres
D. Purkinje fibres and ventricular muscle
E. Ventricular muscle

10. A 38-year-old man underwent radiofrequency ablation in the right atrium for
medically refractive symptomatic atrial tachycardia. He was dismissed on aspirin
325 mg/day. Six days following the procedure he developed left-sided persistent
chest pain and mild dyspnea. His exam is notable only for tachycardia with a HR
of 110 bpm. An ECG discloses sinus tachycardia. What is the next most
appropriate test to request?
a. Echocardiogram
b. CT scan
c. Coronary angiography
d. Arterial blood gas, D-Dimer CT pulmonary angiography
e. Chest X ray
11. Acute success rates for ablation of accessory pathways could be stated as:
a. 50% to 70%
b. 75%
c. 85%
d. 90% to 95%
e. Virtually 100%

12. The following findings are considered abnormal results during EP testing
EXCEPT:
A. >3 seconds pause, a fall in BP >50mmHg with symptoms, or
syncope with carotid sinus massage
B. >3 seconds asystole, hypotension <60 mmHg, syncope with
head up tilt
C. Sinus node recovery time >2 seconds
D. A corrected sinus node recovery time >525 seconds
E. An H—V interval 55 to 75 msec

13. The arrhythmic substrate, that is the least likely to be definitely ruled out with
a negative EP study, is:
a. Sinus node dysfunction
b. Severe His-Purkinje disease
c. Accessory bypass tract
d. VT in a patient with ischemic cardiomyopathy
e. AVNRT

14. A 72-year-old woman is admitted with acute on chronic renal impairment

related to a diarrhoeal illness. She also complains that her vision has turned
yellow. She is treated with digoxin 125 mcg daily for chronic atrial fibrillation,
ramipril, and furosemide.
On examination her pulse is 40, atrial fibrillation, her BP is 135/72 mmHg.
Investigations show: Haemoglobin 115 g/L (115-160) White cell count 7.8 ×10
/L (4-11) Platelets 190 ×10 /L (150-400) Sodium 138 mmol/L (135-146)
Potassium 4.1 mmol/L (3.5-5) Creatinine 2.7 Digoxin 4 mg/L (0.5-2.0).
While she is waiting for a bed on the ward she deteriorates, developing a
regular broad complex tachycardia with a pulse of 190 and a BP of 115/60
mmHg
Which of the following is the optimal way to manage her?
a) Amiodarone
b) Bretylium
c) DC cardioversion
d) Lidocaine
e) Quinidine
15. 70 year old patient, known to have non-obstructive HCM, with recurrent
attacks of Pre-syncope
His 12 lead ECG, comment on ECG?

A- VT due to presence of AV dissociation, Capture Beat and fusion beats.

B- Antidromic SVT
C- Pre-excited Afib
D- SVT with Aberrancy

16. What is the recommended treatment for this case in question 15:
A- EPS & Ablation
B- ICD implantation
C- Amiodarone
D- Coronary Angiography
17. Comment on this ECG:

A- Manifest preexciation through Right Posteroseptal accessory pathway

B- Intermittent Right Posterior accessory pathway
C- Left Posterior accessory pathway
D- Left Ventricular hypertrophy

18. A 70-year-old male was receiving amiodarone 200 mg daily for intermittent
atrial fibrillation. However, he was aware of tiredness and lethargy. He
appeared clinically euthyroid with no palpable goitre. Investigations revealed:
Serum T4 23 pmol/L (9-26)
Serum T3 0.8 nmol/L (0.9-2.8)
Serum TSH 8.2 mU/L (<5)

Which of the following statements would explain these results?

a) Abnormal thyroxine binding globulin
b) Amiodarone-induced hypothyroidism
c) ‘sick euthyroid' syndrome
d) Spontaneous hypothyroidism
e) TSH secreting pituitary adenoma
 19. A 48-year-old woman with a history of recurrent ventricular tachycardia has
routine blood tests 3 months after starting amiodarone therapy:
TSH 14.5 mu/l (<5)
Free T4 10 pmol/l (9-26)

How should her thyroid dysfunction be managed?

a) Continue amiodarone and add folic acid
b) Stop amiodarone and start thyroxine therapy
c) Stop amiodarone and add carbimazole and thyroxine
d) Stop amiodarone and repeat bloods in 4 weeks
e) Continue amiodarone and add thyroxine therapy

20. A 26 years old male patient presented to the ER complaining of palpitation.

Patient has no chest pain. He is reporting that his mother had a pacemaker at
the age of 50 years. His lab investigations are normal including cardiac enzymes,
electrolytes and thyroid profile.

ECG at presentation:

ECG after 1 mg of Atropine IV

Describe the ECG:
a- AF with complete heart block
b- Supra hisian 2:1 heart block
c- Infra hisian 2:1 heart block
d- Junctional Rhythm

21. What is your recommendation for this patient in the previous question no 20?
a- Reassurance & follow up
b- Implantation of DDD
c- Ventolin & theophylline
d- Inderal & Cordarone

22. 6 years old boy who is accidently discovered to have abnormal ECG , while he
was seen by a pediatrician for a chest infection
His mother had been diagnosed as to have multiple sclerosis 7 years ago, and his
grandmother was a systemic lupus patient.
Choose the correct answer describing the ECG abnormality
A- Congenital complete heart block
B- Mobitz type I
C- Mobitz type II
D- Frequent PACs
 23. 16 years old female complaining of palpitation for the last 8 months
ECG during symptoms:

What is your diagnosis?

A. Second degree AV block

B. Sino atrial exit block
C. Respiratory sinus arrhythmia
D. Premature atrial beat ( PAC)
 24. 27 years old female patient complaining of palpitation, her ECG is shown below:

Choose the correct answer:

A. Lown Ganong Levein Syndrome
B. Intermittent preexitation of left postero septal AP
C. Manifest right anterior Accessory Pathway
D. Manifest left posterior AP
 25. A 60 yars old male patient admitted to CCU after an episode of syncope.
The ECG on admission is shown below:

The ECG on 2nd day of hospitalization is shown below:

What is the procedure that is done for the patient and resulted in the later ECG
changes?
a- EPS & Ablation
b- Hemodialysis
c- Amiodarone
d- Calcium chloride infusion followed by hemodialysis
26. Where is the most likely site of the accessory pathway based upon the follow-
ing ECG?

a. Left lateral
b. Left posterior/septal
c. Right posterior/septal
d. Right lateral/anterior
 27. A 21-year-old female was referred for an EP study due to recurrent palpitations
that gradually increased in frequency and duration. The following intracardiac
electrograms were obtained during the study when the patient spontaneously
developed a tachyarrhythmia.

The arrhythmia present is best characterized as:

a. VT
b. AF
c. Long RP atrial tachycardia
d. Short RP atrial tachycardia
e. Atrial flutter

28. What is the most likely arrhythmia present in this patient in question no. 27?
a. Antidromic reciprocating tachycardia
b. Atrial flutter with rapid ventricular response
c. VT
d. AVNRT
e. AF with rapid ventricular response
 29. A 62-year-old female presents to the ED with a 2-hour history of severe chest
pain, dyspnea, and diaphoresis. An initial ECG shows ST elevation in leads V2—
V6. She proceeds immediately to coronary angiography where a 100% prox-
imal LAD artery stenosis is discovered. The lesion is successfully opened with
angioplasty followed by stent implantation, with TIMI flow grade III.
An echocardiogram shows a LV EF = 30% and presence of abnormal regional
wall motion along the anterior and lateral walls. In hospital, telemetry reveals
frequent PVCs and infrequent episodes on non-sustained VT (3—5 beats). What is
the next step in her care?
a. Medical therapy and implantation of an ICD
b. Medical therapy and implantation of an ICD if VT is induced by EP study
c. Medical therapy and implantation of an ICD if a signal averaged ECG is
abnormal
d. Medical therapy and defer implantation of an ICD
e. Medical therapy and refer for radiofrequency ablation of the VT

30. A 75-year-old man presents to the ED with sustained palpitations and mild
dyspnea. He has no history of syncope, cardiac arrhythmia, or structural
heart disease. He takes no medications and denies illicit drug use. Other
than the tachycardia, his examination is normal. The following ECG was
obtained.

What is the likely appropriate treatment?

a. Verapamil
b. Flecainde
c. Amiodarone
d. Sotalol
e. Carotid sinus massage
31. All of the following favor VT over paroxysmal SVT except:
a. AV dissociation
b. Fusion beats
c. Precordial non - concordance
d. Lead V1 RBBB with larger left peak (Rsr’)
e. Lead V6 QRS with rS or S morphology

32. A 17-year-old female presents for a routine gynecologic appointment. She

reports no complaints. She has no medical history other than low heart rate
shortly after she was born. She is not using any medications and denies illicit
drug use. Her examination was within normal limits with exception of a low
pulse rate at 36 bpm. The following ECG was obtained.

What is the most likely diagnosis?

a. Third degree AV block
b. Second degree AV block
c. Ectopic atrial tachycardia with variable AV conduction
d. Accelerated junction tachycardia with variable atrial conduction
e. AVNRT

33. An echocardiogram was normal in the patient outlined in the previous

question. What is the most common cause of her rhythm abnormality?
a. Medications
b. Duchenne muscular dystrophy
c. Maternal systemic lupus erythematosus
d. L-TGA
e. Kearns-Sayre syndrome
 34. What is the next step in the evaluation of the patient in the previous question?
a. Holter monitor
b. Reassurance and repeat ECG in 6 months
c. Exercise testing to assess for myocardial ischemia
d. Genetic testing of the patient and her first degree relatives
e. Muscle biopsy

35. Risk factors for stroke in patients with AF include all of the following except:
a. Age >75 years
b. Dyslipidemia
c. HTN
d. Heart failure
e. Stroke or transient ischemic attack

36. Adequate rate control in a patient with AF is defined as:

a. RestingHR < 80, maximal HR < 110 during a 6-minute walk
b. RestingHR < 60, maximal HR < 110 during a 6-minute walk
c. RestingHR < 80, maximal HR < 140 during a 6-minute walk
d. RestingHR < 60, maximal HR < 140 during a 6-minute walk
e. Resting HR < 100, maximal HR < 140 during a 6-minute walk

37. In patients with heart failure, the following antiarrhythmic drug options are
acceptable:
a. Amiodarone
b. Flecainide
c. Dofetilide
d. Both a and c
e. Both a and b

38. Radiofrequency catheter ablation of AF is characterized by all of the following

except:
a. The approach is more successful in patients with PAF in comparison to
persistent AF
b. Risks include pulmonary vein stenosis, cardiac perforation, atrial esophageal
fistula formation, and stroke
c. In the majority of patients, the procedure is successful in restoring sinus
rhythm and improving quality of life
d. Anticoagulation can be stopped in these patients after 3 months if they
remain in sinus rhythm
39. A 45-year-old male with no known cardiac history presents to the ED with
palpitations, dyspnea, and mild chest discomfort. An ECG is obtained as shown.
Due to respiratory distress and mild hypotension, the patient underwent DC
cardioversion, which was successful in restoring his rhythm to sinus and
alleviating his symptoms. He reports frequent episodes of palpitations associated
with dyspnea but less severe.
An echocardiogram is normal. The ECG is shown below:

All of the following are reasonable pharmacologic approaches for his long-
term care except:
a. Flecainide with metoprolol
b. Flecainide with diltiazem
c. Flecainide
d. Metoprolol
e. Dofetilide

40. Which of the following summarizes the best approach for anticoagulation
in a patient with persistent cavo-tricuspid isthmus dependent atrial
flutter?
a. Aspirin 325 mg daily
b. Plavix 75 mg daily
c. Warfarin therapy with a goal INR of 2.0 to 3.0 when risk factors for throm -
boembolic events are present
d. Aspirin 81 mg daily and warfarin therapy with a goal INR of 2.0 to 3.0 when
risk factors for thromboembolic events are present
e. Anticoagulation is not necessary in patients with flutters that originate
from the RA since they are not associated the a high risk of arterial
thromboembolism
41. The following ECG is suggestive of which type of atrial flutter?

a. Cavotricuspid isthmus-dependent counterclockwise atrial flutter

b. Cavotricuspid isthmus-dependent clockwise atrial flutter
c. Left atrial flutter along a surgical scar
d. Left atrial flutter along the mitral annulus

42. Which of the following situations can result in SVT with a wide QRS in the
absence of a preexisting or rate-related bundle branch block?
a. Orthodromic AVRT
b. Antidromic AVRT
c. Atypical AVNRT
d. Typical AVNRT

43. A useful general approach for the assessment of a supraventricular

arrhythmias includes all of the following except:
a. AVNRT: short RP tachycardia with P waves seen within or just after the QRS
complex
b. AVRT: short RP tachycardia with P waves 110 msec or more after the QRS
complex
c. Atrial tachycardia: long RP tachycardia
d. AVNRT: termination with a P wave
e. Atrial tachycardia: P-wave variation with subsequent beats during the tachy-
cardia acceleration (warm up)
 44. Atrio-esophageal fistula after PV ablation for AF is likely to
occur with:
a) Focal PV ablation
b) Lasso guided segmental ostial PV ablation
c) Wide area circumferential PV ablation (WACA) guided by 3D mapping
d) Surgical Maze procedure
e) Right atrial compartmentalization

45. All are true about myocardial sleeves around the pulmonary veins
EXCEPT:
a) Contain focal triggers of AF
b) Are complex in architecture
c) Longer in inferior veins than superior veins
d) Rich in autonomic fibers

46. What is the false statement about cardiac memory after ablation of accessory
pathway?

a) Cardiac memory is a phenomenon characterized by transient T-wave

abnormalities occurring during normal sinus rhythm, after a period of
altered ventricular depolarization.
b) This phenomenon is characterized by T-wave changes on surface
electrocardiogram (ECG) where the T-wave vector has the same
direction as the vector of the previously altered QRS complex.
c) T wave changes are persistent and this phenomenon is called Wellens
syndrome
d) It can be considered as a sign of successful ablation of accessory
pathway
 47. A 40 year old man suffers from exercise related broad QRS complex
tachycardias. He presents for catheter ablation. On admission he has
frequent monomorphic PVCs. Tracing shows the12-lead ECG morphology
and a cardiac MRI scan.

Which statement is incorrect?

a) The PVC exit site is located in the right ventricular outflow tract
b) The arrhythmia may cause SCD in young athletes
c) Focal activity is the most likely underlying arrhythmia mechanism
d) VTs with a superior axis are also common in such patients
e) The patient may qualify for ICD therapy
 48. A 45 years male patient known to have AFib. CHA2DS2-VASc score
is 2 and he has a high risk of GI bleeding, what is the best Noval oral
anticoagulant (NOAC) in this patient:

A- Rivaroxaban 20 mg once daily

B- Apixaban 5 mg twice daily
C- Dabigatran 150 mg twice daily
D- Edoxaban 60 mg once daily

49. The following ECG is for a 7 years old male patient, what is the
diagnosis?

A. AVNRT then AVNRT with RBBB aberrancy

B. Orthodromic tachycardia degenerated into run of ventricular tachycardia
C. Preexcitation pattern during sinus rhythm followed by orthdromic tachycardia then
antidromic tachycardia.
D. Preexcitation pattern during sinus rhythm followed by orthodromic tachycardia then
pre- exited AF.
 50. A 62 year old male. He had palpitation for 40 years, fast regular not
associated with dyspnea or syncopal attack. In the last 2 years, this
tachycardia progressively increased with frequent hospital admission

Resting ECG:

Tachycardia ECG:
 Diagnosis?
a) AVNRT
b) Atrial tachycardia
c) Atrial flutter
d) AVRT
e) Atrial fibrillation
f) Sinus tachycardia

End of Part 1