Cardiology

Question 1

No ST elevation
AND
Troponin is normal

Answer 1

Unstable angina

Non occlusive thrombus

Question 2

No ST elevation
AND
Troponin is raised

Answer 2

Non ST elevation myiocardial infarction

NSTEMI

Occluding thrombus sufficient to cause tissue damage and mild myocardial necrosis

Question 3

ST elevation

Answer 3

ST elevation myocardial infarction

STEMI

Complete thrombus occlusion

(May present new LBBB)

Question 4

Classic symptoms of acute coronary syndrome

Answer 4

Chest pain
Central/left sided/ substernal/ epigastric

May radiate to the jaw, left arm or shoulder

Described as heavy or constricting “elephant on my chest”

Other symptoms> dyspnoea, sweating, nausea and vomiting, may appear pale and clammy

remember that pxs with DM or elderly may not experience any chest pain! = Silent MI

Question 5

Unmodifiable Risk factors of Ischemic Heart Disease

Answer 5

Increasing age
Male gender
Family history

Question 6

Modifiable Risk factors of Ischemic Heart Disease

Answer 6

Smoking
DM
Hypertension
Hypercholesterolaemia
Obesity

Question 7

ST elevation on DII, III and aVF

Answer 7

Inferior MI

Right coronary

Question 8

ST elevation on DI, aVL, V5 and V6

Answer 8

Lateral MI

Left Circumflex

Question 9

ST elevation on V1, V2, V3 and V4

Answer 9

Anterior (anteroseptal) MI

Left Anterior Descending

Question 10

ST elevation on DI, aVL, V4, V5, V6

Answer 10

Anterolateral MI

Left anterior Descending
OR
Left Circumflex

Question 11

Wide spread ST depression

ST elevation in aVR

Answer 11

Left main coronary artery occlusion

EMERGENCY CORONARY ANGIOGRAPHY

Question 12

Management of Acute settings in ST elevation

Answer 12

MONA
Morphine
O2
Nitrates
Aspirin 300mg
\+
Heparin (unfractionated or LMW --> enoxaparin or fondaparinux)

Question 13

If the patient with ACS presents within …… of the onset of the symptoms then a …… can be done

Answer 13

12 hours

PCI/angioplasty (stent) (percutaneous Coronary Intervention)
GOLD STANDARD

Question 14

What should be done if PCI is unavailable or the patient presents after 12 hours of the onset of symptoms?

Answer 14

Thrombolysis

Alteplase is preferred over Streptokinase

Question 15

Chronic/Long term Management of MI

Answer 15

-Aspirin for life
-Ticagrelor or Prasugrel or Clopidogrel for 12 months
-Beta blockers for 12 months (atenolol, bisoprolol)
-ACE inhibitor for life (captopril, enalapril, ramipril)
If intolerant then ARBs (losartan, valsartan, irbesartan)
-Statins for life Atorvastatin 80mg PO OD

**5 drugs= AABC+S
Aspirin, ACE inhibitors, Beta blockers, Clopidogrel, Statins

Question 16

Management of NSTEMI & Unstable Angina

Answer 16

-Aspirin 300mg
+
-Antithrombin>LMWH (enoxaparin, dalteparin or Fondaparinux)
AS SOON AS POSSIBLE

• Nitrates or morphine to relieve pain
• Second antiplatelet (clopidogrel, prasugrel)
• IV glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban)
• Coronary angiography should be considered

Question 17

Who should LMWH be offered to?

Answer 17

Pxs with NSTEMI & Unstable Angina who are not at high risk of bleeding and who are not having angiography in the next 24 hours

If angiography is likely or creatinine is >265 umol/l, unfractionated heparin should be given (UH is IV!)

Question 18

To whom should IV glycoprotein IIb/IIIa receptor antagonists be given?

Answer 18

Epifibatide and tirofiban

Pxs with NSTEMI & Unstable Angina who have intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3%) and who are scheduled to undergo angiography within 96 hours of hospital admission

Question 19

Who should be considered for coronary angiography?

Answer 19

Pxs with NSTEMI & Unstable Angina who have predicted 6-month mortality above 3%.
It should be considered within 96 hours of 1st admission to hospital

It should be performed as soon as possible in patients who are clinically unstable.

Question 20

Px with acute chest pain radiating to jaw and shoulder WITHOUT ST elevation, what should be done next?

Answer 20

Measure cardiac enzymes (troponin)

Question 21

Px with acute chest pain radiating to jaw and shoulder WITHOUT ST elevation, and high troponin levels, what should be done next?

Answer 21

Give subcutaneous LMWH or Fondaparinux + Aspirin 300mg

Question 22

60 YO man with Hx of smoking, HTN and DM complaining of 25 minutes of left side dull aching chest pain radiating to the jaw. He was given 300mg of Aspirin. He is no longer in pain and the ECG is NORMAL. The troponin levels are 202 ng/L (Normal < 5ng/L). What is the next step?

A) Alteplase
B) SC fondaparinux
C) IV Glyceryl trinitrate
D) IV Morphine

Answer 22

Since the ECG is normal, alteplase is WRONG

ECG normal with high troponin levels = NSTEMI

Correct answer: Anticoagulation (LMWH> Dalteparin, Enoxaparin, Fondaparinux)

Question 23

62 YO man with Hx of smoking and HTN complaining of 25 minutes of left side constricting chest pain radiating to his left shoulder. He was given 300mg of Aspirin and trinitrates for the pain. The ECG shows ST elevation in V1-V4. What is the most appropriate next step in management?

Answer 23

PCI- Percutaneous Coronary Intervention

If not among the choices> Atleplase (thrombolysis)

Question 24

59 YO with Hx of HTN, complaining of chest pain for around 4 hours. Vitals are stable. He was given IV morphine for his chest pain. ECG shows T wave inversion in DII, DIII and aVF. What is the next step in management?

Answer 24

Chest pain+T wave inversion = myocardial ischemia

ASPIRIN 300mg
AND
LMWH or Fondaparinux

Question 25

59 YO with Hx of HTN, complaining of chest pain for around 4 hours. Vitals are stable. He was given IV morphine for his chest pain. ECG shows wide spread ST depression and ST elevation in aVR. What is the next step in management?

Answer 25

Wide spread ST depression + ST elevation in aVR = Left Main Coronary Artery Occlusion --> EMERGENCY CORONARY ANGIOGRAPHY

Question 26

Cardiac tamponade triad

Answer 26

Beck's triad> hypotension, muffled heart sounds, high JVP (distended neck veins) Other symptoms: dyspnea, pulsus paradoxus, tachycardia

Question 27

How can a cardiac tamponade develop after a MI?

Answer 27

Acute pericarditis >Pericardial effusion >Cardiac Tamponade *Trauma is the most important cause of cardiac tamponade*

Question 28

How does a cardiac tamponade looks in a Chest X-ray?

Answer 28

Enlarged GLOBULAR heart (It can also be a pericardial effusion) Looks like a leather bag filled with water

Question 29

Dx and Rx of a cardiac tamponade

Answer 29

Echocardiogram Urgent pericardiocentesis

Question 30

Initial Rx of a patient in hypovolemic shock and cardiac tamponade.

Answer 30

1-2 L of IV fluids** Oxygenation and ventilation Bedside pericardiocentesis

Question 31

Atrial Myxoma

Answer 31

Benign tumour 75% in the left atrium Tend to grow on the wall (inter-atrial septum) 10% are inherited--> familiar myxoma

Question 32

Mitral valve obstruction caused by atrial myxoma

Answer 32

Mid-diastolic murmur, dyspnea, syncope and congestive HF

Question 33

What happens if small pieces of an atrial myxoma break off and travel to the arteries?

Answer 33

Ischemia Lung- Pulmonary embolism Brain- Stroke Peripheries- Clubbing and blue fingers

Question 34

Px with mid-diastolic murmur, dyspnea, syncope, congestive HF, clubbing and blue fingers with Hx of pulmonary embolism and atrial fibrilation. Dx?

Answer 34

Obstruction of mitral valve--> mid-diastolic murmur, dyspnea, syncope and congestive HF Small pieces may break off and travel to arteries --> PE, Stroke or clubbing and blue fingers Atrial fibrilation =Atrial Myxoma

Question 35

An echocardiogram shows a pedunculated heterogeneous mass typically attached to the region of fossa ovalis (inter-atrial septum) Dx?

Answer 35

Atrial Myxoma

Question 36

Px with Atrial Myxoma with sudden painful swollen limb with a loss of pulse.

Answer 36

Acute limb ischemia Rx> Urgent catheter Embolectomy

Question 37

QRS in lead I is up (+) and lead II is down (-)

Answer 37

Left axis deviation | -30 to -90

Question 38

QRS in lead I is down (-) and in lead II is up (+)

Answer 38

Right axis deviation | 90 to 150

Question 39

QRS in lead I is down (-) and in lead II is down (-)

Answer 39

Right superior axis deviation | 150 to 270

Question 40

QRS positive in lead I and II

Answer 40

Normal axis | -30 to 90

Question 41

Causes of Left Axis deviation

Answer 41

Inferior MI Left ventricular hypertrophy Left Anterior Fascicular block (or hemiblock) Obese Wolff-Parkinson-White syndrome (delta wave)

Question 42

Causes of right axis deviation

Answer 42

``` Lateral MI Right ventricular hypertrophy Left posterior fascicular block (or hemiblock) Thin, tall, children Chronic lung disease Pulmonary embolism ```

Question 43

Causes of extreme right axis deviation

Answer 43

Congenital heart disease | Left ventricular aneurysm

Question 44

PR interval >0.2 seconds | PR occupies more than 1 large square or 5 small squares

Answer 44

1st degree heart block

Question 45

2nd degree heart block | Mobitz I

Answer 45

Progressive prolongation of the PR interval until a dropped beat occurs

Question 46

2nd degree heart block | Mobitz II

Answer 46

PR is constant but the P wave is often not followed by a QRS complex

Question 47

Complete (third degree) heart block

Answer 47

No association between P waves and QRS complexes

Question 48

1st degree and Mobitz I heart block management

Answer 48

Do not require treatment as long as the patient is asymptomatic

Question 49

Mobitz II and 3rd degree heartblock management

Answer 49

Permanent pacemaker

Question 50

How long is a small square and a big square in an ECG?

Answer 50

small= 0.04 seconds big= 0.2 seconds

Question 51

Agents used to control rate in patients with atrial fibrilation

Answer 51

Beta blockers (atenolol, bisoprolol, metoprolol) --> 1st line but contraindicated in Asthma Calcium channel blockers (diltiazem, verapamil) --> in asthmatic patients Digoxin (less effective controlling rate during exercise, no longer 1st line) Preferred in patients with coexistent HF

Question 52

Patient with atrial fibrillation hemodynamically unstable

Answer 52

Cardioversion

Question 53

Atrial flutter management

Answer 53

Cardioversion

Question 54

Patient conscious or semiconscious with VT and stable

Answer 54

Amiodarone | HE IS STABLE!

Question 55

What is VT?

Answer 55

a broad complex tachycardia originating from a ventricular ectopic focus It can develop into a FV therefore requires urgent treatment! P wave might be present or absent

Question 56

Patient unconscious with VT but with present pulse

Answer 56

Cardioversion! Unstable but HAS A PULSE!

Question 57

Patient unconscious, collapsed, not breathing and no pulse with VT

Answer 57

Defibrillation (asynchronized shock)

Question 58

Most important cause of ventricular tachycardia

Answer 58

Hypokalemia (low K)

Question 59

Atrial Fibrillation symptoms and treatment

Answer 59

Palpitation, tachycardia, dyspnea, fibrillatory waves on the ECG, irregularly irregular rhythm Beta blockers If asthmatic give calcium channel blocker

Question 60

Atrial Flutter symptoms and treatment

Answer 60

Fluttering feeling in the chest Sawtooth waves Cardioversion

Question 61

Ventricular tachycardia symptoms and treatment

Answer 61

Ongoing lightheadness, palpitations, chest pain Amiodarone If unstable--> Cardioversion

Question 62

Ventricular fibrillation symptoms and treatment

Answer 62

Older adult, sudden collapse, not breathing, unconscious, no pulse. Defibrillation

Question 63

Sinus bradycardia symptoms and treatment

Answer 63

Lightheadness, hypotension, vertigo, syncope, dizziness. Symptomatic bradycardia--> atropine

Question 64

The following medications have shown to reduce mortality in pxs with Left Ventricular failure.

Answer 64

- ACE-inhibitors - Beta-blockers - ARBs - Aldosterone antagonists (eplerenone, spironolactone) - Hydralazine with nitrates Loop diuretics and nitrates are key in the acute decompensated HF, but they have no effect on long-term survival.

Question 65

Tx for HF with symptoms What if the px has DM?

Answer 65

Diuretics to relieve symptoms and reduce overload Start with ACEi OR Beta-blocker (ONLY 1) If symptoms persist add the other one (ACEi, BB or ARB) If symptoms still persist add Spironolactone If the px has DM we start with ACEi

Question 66

Spironolactone is a....

Answer 66

Potassium-sparing diuretic AND an aldosterone antagonist

Question 67

What drug should be administered if the patient has HF and AF?

Answer 67

Digoxin! Inhibition of the Na/K ATPase in the myocardium. Personal note: More recent randomized trials have shown an increase in mortality in HF patients with digoxin.

Question 68

Why furosemide + ACEi don't lead to hyperkalemia?

Answer 68

Furosemide= loop diuretic leads to hypOkalemia ACEi and Spironolactone= lead to hypERkalemia

Question 69

Which is the most accurate investigation to demonstrate a patent foramen ovale

Answer 69

Transesophageal echocardiography with bubble contrast

Question 70

What is a patent foramen ovale?

Answer 70

The foramen allows blood to pass from RA to LA. The opening closes soon after birth. In about 1 out of 4 people it never closes. It may cause paradoxical embolism (an embolism that travels from the venous side to the arterial side)

Question 71

Most common cause of death following a MI and treatment

Answer 71

Cardiac arrest due to ventricular fibrillation. Tx= Defibrillation

Question 72

What may occur 48 hours after a MI

Answer 72

Pericarditis Pleuritic chest pain that worsens on lying flat and during inspiration + fever + pericardial rub (extra heart sound, 2 systolic and 1 diastolic that resembles a squeaky leather, described as grating, scratching or rasping)

Question 73

ECG that shows Widespread saddle shaped ST elevation with upward concavity and PR depression

Answer 73

Pericarditis

Question 74

Px with fever + pericardial rub + pleuritic chest pain The X-ray will show...?

Answer 74

Pericardial effusion | An enlarged globular heart can be observed and is confirmed by echocardiography

Question 75

Px with pleuritic chest pain that shows widespread saddle shaped ST elevation with upward concavity and a PR depression. Dx and Rx?

Answer 75

Pericarditis Full dose of NSAID Aspirin 2-4g daily Ibuprofen 1200-1800mg daily Indomethacin 75-150mg daily At least 7-14 days.

Question 76

Px with Hx of MI 3 weeks prior, complains about pleuritic chest pain + fever + and a pericardial rub with ECG that shows widespread saddle shaped ST elevation with PR depression. Dx and Rx?

Answer 76

Dressler's syndrome Thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers Rx> NSAIDs It tends to occur 2-6 weeks following a MI It may show a raised ESR (erythrocyte sedimentation rate)

Question 77

Px with Hx of MI 4 weeks prior, complaining of shortness of breath. The ECG shows ST elevation. Most likely diangosis?

Answer 77

Left ventricular aneurysm The ischaemic damage may weaken the myocardium resulting in a thin muscular layer> aneurysm formation Usually occurs 4-6 weeks post MI High risk of stroke due to a thrombus> anticoagulate!

Question 78

ECG, Chest X-Ray and Echo of a left ventricular aneurysm

Answer 78

ECG> persistent ST elevation CXR> enlarged heart with a bulge at the left heart border Echo> paradoxical movement of the ventricular wall (instead of moving inward, it moves away from the septum during systole)

Question 79

Px with Hx of MI 5 days ago, complaining of dyspnea, orthopnea, chest pain and diaphoresis. A pan-systolic murmur can be heard. Dx and Rx?

Answer 79

Ventricular septal defect (VSD) Presents in the 1st week post MI Only 1-2% Presents with acute heart failure with pan-systolic murmur The echocardiogram is diagnostic and excludes acute mitral regurgitation which is similar. Rx> Urgent surgical correction

Question 80

Acute Mitral Regurgitation ``` Occurs x days after MI Due to... Presents with ... on auscultation Dx is with... Rx? ```

Answer 80

Occurs 2-15 days after MI Due to ischemia or rupture of the papillary muscles of the mitral valve pan-systolic murmur is typically heard May present with hypothension, tachycardia and pulmonary edema Dx> echocardiogram Rx> vasodilator therapy but often requires emergency surgical repair.

Question 81

A px presents with ST elevation and chest pain. Management? What if it's not available?

Answer 81

STEMI MONA and then PCI if not obtainable >Alteplase, if not available >streptokinase

Question 82

A px presents with chest pain and NO ST elevation. Management?

Answer 82

oral aspirin 300mg LMWH or Fondaparinux

Question 83

1st, 2nd and 3rd choice for symptomatic bradycardia

Answer 83

1st- atropine (0.5mg IV push and may be repeated up to 3mg) 2nd- Dopamine 3rd- Epinephrine If the question says "the next best step" or "the initial line" --> O2!!!

Question 84

A patient presents with fever, malaise and rigors, and a new murmur can be heard Dx? Initial step?

Answer 84

Infective endocarditis >Blood culture and then echo

Question 85

Risk factors for infective endocarditis?

Answer 85

A previous episode of IE (strongest RF) Rheumatic valve disease Prosthetic valves Congenital heart defects IV drug user (typically causes tricuspid lesion)

Question 86

Causative organisms of IE?

Answer 86

Staph. aureus is the most common in general Staph epidermis is the most common in prosthetic valve surgery Strept. viridans is the most common in people with poor dental hygiene or following a dental procedure (Strept. mitis and sanguinis)

Question 87

Positive Modified Duke criteria

Answer 87

2 major criteria or 1 major and 3 minor 5 minor

Question 88

Major Duke criteria

Answer 88

1) Positive cultures 2 + blood cultures showing typical organisms (Strep viridans and HACEK group) OR Persistent bacteraemia from 2 blood cultures taken >12h apart or 3 or more + cultures where pathogen is less specific such as Staph aureus and epidermis 2) Evidence of endocardial involvement (+ Echo for IE) + echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves) OR New valvular regurgitation

Question 89

Minor Duke criteria

Answer 89

1) Predisposing heart condition or IV drug use 2) Microbiological evidence that does not meet the major criteria 3) Fever >38C 4) Vascular phenomena--> Major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, Petechiae or purpura 5) Immunologilcal phenomena--> glomerulonephritis, Osler's nodes, Roth spots.

Question 90

Osler's Nodes

Answer 90

painful, red nodules on the hands or feet that can persist for hours to days

Question 91

Janeway lesions

Answer 91

Non-tender, small, erythematous or hemorrhagic macular or nodular lesions on the soles or palms. (they occur due to septic microemboli that deposit the bacteria under skin)

Question 92

IE empirical therapy

Answer 92

Amoxicilin + low dose Gentamicin OR Vancomycin+ low dose Gentamicin (if apenicillin allergic or MRSA Staph Aureus is suspected or severe sepsis) If Hx of prosthetic valve endocarditis--> Vancomycin+low-dose Gentamicin+ Rifampicin

Question 93

A man had dental extraction a few days ago that presents with petechia. His vitals are stable except for his temperature which is 38.9C. On examination he has petechiae, painful nodules on his palms, and a cardiac murmur. Most likely Dx? Next investigating step? Initial management?

Answer 93

IE (fever+new murmur) Blood culture (followed by echo) Amoxicilin+low dose Gentamicin

Question 94

What score should we use in in atrial fibrilation

Answer 94

CHA2DS2-VASc Score

Question 95

What does CHA2DS2-VASc Score determines and what does it measure?

Answer 95

The need to anticoagulants in a patient who has atrial fibrillation ``` C- congestive heart failure - 1pt H- Hypertension (BP>140/90) - 1pt A2- Age >75 years - 2pt D- DM - 1pt S2- Prior stroke or TIA or Thromboembolism - 2pts V- vascular disease (MI, PVD, Aortic plaque) 1pt A- Age 65-74 years - 1pt Sc- Sex category (female = 1 pt) ```

Question 96

A patient with CHA2DS2-VASc Score of 2 pts or more should be given...

Answer 96

Warfarin or DOAC (direct-acting oral anticoagulants) like Apixaban, rivaroxaban, edoxaban, dabigatran Consider warfarin or DOAC to men who score >1 or more

Question 97

What are some advantages and disadvantages of DOAC?

Answer 97

Advantages No need of INR monitoring Faster Onset of action (2-4 hours) Reduces the risk of intracranial hemorrhage Disadvantages No antidote Requires strict compliance by the patients

Question 98

ABCD2 score

Answer 98

Is used to identify the risk of future stroke in pxs who have had a suspected TIA in the following 7 days. (Not advised to use according to recent 2019 CKS guidelines)

Question 99

HAS-BLED score

Answer 99

estimates the risk of major bleeding for patients on anticoagulation for atrial fibrillation

Question 100

DRAGON score

Answer 100

predicts the 3 month outcome in ischaemic stroke patients receiving tissue plasminogen activator (tPA like alteplase)

Question 101

QRISK2 score

Answer 101

determine the risk of a cardiovascular event in the next 10 years.

Question 102

What is the mechanism of a pulmonary edema?

Answer 102

Often caused by congestive heart failure. When the heart is not able to pump efficiently--> the blood may return into the veins --> then the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs.

Question 103

Features of a pulmonary edema

Answer 103

``` Desaturation Dyspnea Orthopnea Crepitations (crackles-rales) Tachycardia ```

Question 104

Investigation of pulmonary edema

Answer 104

Chest X-ray is the single most appropriate investigation BUT the underlying cause requires echocardiogram (HF, complication of MI, ventricular aneurysm) "The most appropriate investigation" = Chest X-ray "The investigation needed to identify the underlying cause" = Echocardiogram

Question 105

Management of pulmonary edema

Answer 105

MONF (MONA but the A is replaced by Furosemide) Morphine O2 Nitrates Furosemide Sit the px up and give O2 (>95% or >90% in COPD) Spray 2 puffs of sublingual GTN (Glyceryl TriNitrates) Give furosemide 40mg IV (SLOWLY) Diamorphine (2.5-5mg IV slowly) or Morphine (5-10mg IV SLOWLY) to relieve pain, anxiety and distress

Question 106

Difference in the diagnosis between Pulmonary Edema and Pulmonary Embolism

Answer 106

Pulmonary edema can be diagnosed by chest x ray (Kerley Lines> expansion of the interstitial space by fluid; + Bat's wings hilar shadow) Pulmonary embolism needs CTPA (CT pulmonary angiogram)

Question 107

Dissecting Aneurysm or aortic dissection may present as a MI However, name some clinchers that could direct us towards a DA and not a MI

Answer 107

Unequal pulses in upper limbs Hx of Marfan Syndrome Hx of Ehlers-Danlos syndrome or Turner syndrome Severe tearing chest pain that radiates to the back HTN is the most important risk factor The pxs present with hypotension, dyspnea, tachycardia, and sweating. Symptoms caused by low blood supply to organs like a stroke or mesenteric ischemia

Question 108

Aortic dissection pathophysiology

Answer 108

Tear in the tunica intima of the wall of the aorta. | The injury allows blood to flow between the layers of the aortic wall, forcing the layers apart.

Question 109

What is the best diagnostic test for aortic dissection?

Answer 109

``` Transoesophageal echocardiogram (TEE) Sens 98% and Spec 97% ``` CT scan with contrast is also good or MRI In emergency use US or CT scan

Question 110

Stanford classification of aortic dissection

Answer 110

Type A> ascending aorta, 2/3 of cases Type B> descending aorta, distal or left subclavian origin. 1/3 of cases

Question 111

Management of Type A Standford classification

Answer 111

Ascending aorta dissection. Surgical management, but blood pressure should be controlled to a target systolic of 100-120mmHg whilst awaiting intervention

Question 112

Management of type B Stanford classification

Answer 112

Descending aortic dissection Conservative management, bed rest, reduce blood pressure. IV labetalol to prevent progression

Question 113

Left Brundle Branch Block (LBBB) features on ECG

Answer 113

Notched (M shaped) broad complex QRS usually in lead I, aVL and V6 but not always. Deep inverted QRS usually in V1 Left axis deviation

Question 114

Patient complaining of chest pain and dyspnea. The ECG shows a notched broad complex QRS in DI and aVL and deep negative QRS in V1. He has no cardiac Hx. Management?

Answer 114

New onset of LBBB! Myocardial infarction! Thrombolysis or PCI (and MONA)

Question 115

A px presents with sudden severe abdominal pain, hypotension and sweating, and has no lower limb pulse. Dx?

Answer 115

Ruptured abdominal aortic aneurysm (AAA) Triad> pain, hypotension, pulsatile tender abdominal mass. Sudden onset of severe abdominal pain ± lower back ± flank pain. Shock (hypotension, sweating and fainting) Absent lower limb pulse and mottled skin.

Question 116

A px presents with sudden severe abdominal pain, signs of shock and has no pulse on lower limbs. Management?

Answer 116

Surgical emergency! The initial investigation is an ultrasound If not available then CT scan.

Question 117

Screening for abdominal aortic aneurysm in the UK

Answer 117

Men only Once only In 65th year by ultrasound.

Question 118

A px with Hx of 5 years with dyspnea, orthopnea, lower limb edema that has DM Management?

Answer 118

Symptomatic relief--> furosemide (loop diuretics) Start with ACEi instead of BB (DM patients) If the symptoms persist add BB If still symptomatic add spironolactone (potassium sparing diuretics)

Question 119

Coronary artery dominance

Answer 119

The artery that supplies the posterior descending artery (PDA) determines the coronary dominance In 85% of the population, the right coronary artery (RCA) gives off the PDA (right dominant) In 15% of the population, the left circumflex gives off the PDA (left dominant) Hence, the artery dominance is the RCA, as it gives off the PDA in 85% of people.

Question 120

Px with furosemide that presents with muscle weakness and cramps and the ECG shows a U-wave. Dx and management?

Answer 120

U-wave and muscle weakness and cramps = hypOkalemia Thiazide like diuretics and loop diuretics are the main cause NOT potassium sparing diuretics like Spironolactone (hypERkalemia) Rx> oral or IV Potassium chloride (based on severity> K <2.5 = IV) Stop/treat the cause (thinking about diuretics, vomiting and diarrhea, Cushing syndrome and Conn's disease)

Question 121

Causes of hypokalemia

Answer 121

Loop diuretics Thiazide like diuretics (bendroflumethiazide, indapamide) Vomiting and diarrhea Villous adenoma Renal tubular failure Cushing syndrome Primary hyperaldosteronism (Conn's disease)

Question 122

Causes of hyperkalemia

Answer 122

ACEi ARBs Potassium sparing diuretics (spironolactone or eplerenone) CKD/acute renal failure Addison's (primary adrenal insufficiency) Congenital adrenal hyperplasia (CAH)

Question 123

20 YO px complaining of palpitations and light headedness. Hx of asthma. Presents with 130 HR, rest of vitals stable. The ECG shows narrow-complex ventricular Tachycardia. Dx and management?

Answer 123

Paroxysmal supraventricular tachycardia Rx Valsalva manouver or carotid massage IN ASTHMATIC> Verapamil! (CCB) (adenosine is contraindicated) Adenosine 6mg IV Adenosine 12mg IV Adenosine 12mg IV Cardioversion To prevent future episodes> B blockers or radio frequency ablation.

Question 124

Broad QRS Prolongued QT Fainting episodes May be young px who is an athlete

Answer 124

Polymorphic Ventricular Tachycardia (Torsades De Pointes) Tx if pulse! IV Magnesium Sulphate. (Verapamil SHOULD NOT BE USED in VT)

Question 125

Stage 1 Hypertension

Answer 125

Clinic BP>140/90mmHg and subsequent ABPM daytime average or HBPM average BP≥135/85mmHg

Question 126

Stage 2 hypertension

Answer 126

Clinic BP ≥ 160/100mmHg and subsequent ABPM daytime or HBPM average BP ≥ 150/95mmHg

Question 127

Stage 3 hypertension | "Severe hypertension"

Answer 127

Clinic systolic BP ≥ 180mmHg or clinic diastolic BP ≥ 110mmHg

Question 128

Lifestyle management of hypertension

Answer 128

``` Low salt diet Caffeine intake should be reduced Stop smoking Drink less alcohol Eat a balanced diet rich in fruits and vegetables Exercise more Lose weight ```

Question 129

When to treat stage 1 hypertension?

Answer 129

``` <80 years old AND any of the following Target organ damage Established CV disease Renal disease DM A 10-year CV risk equivalent of >20% ``` If not = Lifestyle modification and follow up

Question 130

What should be done in stage 2 hypertension patients before drug management?

Answer 130

Record either ABPM or HBPM

Question 131

What should be done in px <40 years old with stage 2 or 3 hypertension?

Answer 131

Consider specialist referral to exclude secondary causes of HTN.

Question 132

When should we ALWAYS treat HTN patients?

Answer 132

If ABPM or HBPM ≥ 150/95mmHg (confirmed stage 2 or higher)

Question 133

White + <55 YO | with HTN, Rx?

Answer 133

Start with ACEi/ARBs

Question 134

White + >55YO with HTN, Rx?

Answer 134

Start with CCB | Calcium channel blocker

Question 135

Afro-caribbean + any age with HTN, Rx?

Answer 135

start with CCB | Calcium channel blocker

Question 136

Step 2 in HTN management in a px who is still hypertensive after the 1st step and lifestyle changes.

Answer 136

Add ACEi/ARBs Add CCB A+C (ACEi + CCB)

Question 137

Step 3 in a HTN management who is still hypertensive

Answer 137

Add D (Thiazide Diuretic) ACEi+CCB+Thiazide like Diuretic (A+C+D) Examples of Thiazide like Diuretics Chlorthalidone 12.5-25mg OD Indapamide 1.5mg modified release OD or 2.5mg OD Bendroflumethiazide is NO LONGER recommended by NICE as an hypertensive.

Question 138

Step 4 in HTN management in pxs who are still hypertensive?

Answer 138

A+C+D consider further diuretic treatment If K<4.5mmol/l add spironolactone 25mg OD (K sparing) If K>4.5 mmol/l add higher dose thiazide like diuretic If diuretic therapy is not tolerated or is contraindicated or ineffective consider an alpha or beta-blocker

Question 139

HTN patients who fail to respond to step 4 of HTN management

Answer 139

A+C+D + further diuretic or alpha/beta blocker If optimal tolerated doses of four drugs is not enough --> seek expert advice!

Question 140

BP targets in HTN+DM

Answer 140

If end organ damage <130/80mmHg | If not <140/80mmHg

Question 141

BP targets for >80 YO pxs with HTN without DM

Answer 141

Clinic BP <150/90mmHg ABPM/HBPM 145/85mmHg

Question 142

BP targets for <80 YO pxs with HTN without DM

Answer 142

Clinic BP < 140/90mmHg ABPM/HBPM 135/85mmHg

Question 143

Why are ACEi used for DM and HTN pxs?

Answer 143

It is reno-protective (unless eGFR is low <30= advanced CKD) It has protection against diabetic retinopathy It has positive effect on glucose metabolism

Question 144

Management of HTN | 52 YO px with Hx of DM and who is African-British

Answer 144

ACEi+CCB! If he was only diabetic start with ACEi regardless of age as it is reno-protective (unless eGFR < 30) as he is Afro-Caribbean start with both ACEi and CCB!

Question 145

``` Postural hypotensiob (Orthostatic Hypotension) definition and dx? ```

Answer 145

A drop in systolic BP of at least 20mmHg within 3 minutes of standing OR drop of diastolic BP of at least 10mmHg within 3 minutes of standing Dx> monitor BP

Question 146

Postural hypotension is most common in which people?

Answer 146

Elderly people especially those who take multiple drugs (polypharmacy) Pxs with HTN due to drugs. Remember that baroreflex mechanisms that control HR and Vascular resistance decline with age, specially in pxs with HTN

Question 147

An elderly man complains of difficult mobilization. He often feels dizzy upon trying to stand ± he has Hx of recurrent falls. Management?

Answer 147

BP monitoring and assess and review the pxs medications.

Question 148

Px presents with palpitations. His ECG shows absent P wave and irregularly irregular rythm. Dx and Management?

Answer 148

Atrial Fibrillation 1st line> beta-blockers If asthmatic> avoid B-blockers and give CCB If associated HF> digoxin Calculate CHAD2S2-VASc-Score and give Warfarin, DOAC or nothing

Question 149

Px with a sense of a skipped beat, unsustained palpitation, dyspnea and dizziness. What will the ECG most likely show?

Answer 149

An early and broad QRS complex = Ventricular ectopic If it has 3-beat patterns= Ventricular trigeminy 50% of all the population has silent/asymptomatic ventricular ectopics which are discovered incidentally on a routine ECG

Question 150

Causes of ventricular ectopics

Answer 150

``` Ischemic heart disease (MI) Cardiomyopathy Stress Alcohol Caffeine Cocaine Medications or-------> naturally ``` If these Ventricular ectopics are due to ischemic heart disease or cardiomyopathy > may precipitate life-threatening arrhythmias like VF

Question 151

A px with chronic HF developed gout. A medication for his gout is prescribed. A few days later the patient comes back complaining of worsening of his heart failure symptoms (shortness of breath and orthopnea). What is the cause of this worsening?

Answer 151

Gout> NSAIDs. Never give NSAIDs nor selective COX-2 inhibitors to CKD, CHD, IHD. NSAIDs inhibit synthesis of prostaglandins--> decrease the eGFR, retain more salt and water (worsening HF) Thiazide like diuretics and loop diuretics decrease the clearance of uric acid --> leading to gout (hyperuricemia) NSAIDs are used to treat gout.

Question 152

In-hospital Cardiac Arrest algorithm

Answer 152

1. Collapsed patient > SHOUT for help and assess the patient 2. No signs of life (no pulse and not breathing) > ring bell/code blue 3. Start CPR 30 compressions and 2 ventilations ASK FOR THE DEFRIBILLATOR 4. Use defibrillator Advanced Life Support Team arrives.

Question 153

Why do DM patients may die suddenly and silently without feeling any chest pain when having a MI?

Answer 153

Autonomic neuropathy | >painless MI or silent MI

Question 154

UK guidelines on alcohol A person should drink...

Answer 154

No more than 14 units a week (1 unit= 10mL or 8g= amount of alcohol that can be processed in an hour by an adult) No more than 3 units a day at least 2 alcohol-free days a week (a pint of strong lager is 3 units; a low strength lager has just over 2 units)

Question 155

A px drinks 7 units of alcohol a week and smokes 20 cigarettes a day. We should refer him to an Alcohol Cessation Clinic or a Smoking Cessation Clinic or both?

Answer 155

Smoking Cessation Clinic No more than 14 units of alcohol a week His alcohol intake is insignificant as per NICE guidelines.

Question 156

Pre-hospital analgesia (while in ambulance) for MI

Answer 156

GTN> Glyceryl Trinitrate sublingual or spray ±opioids IV> 2.5-5mg Diamorphine or 5-10mg morphine Remember 1/3 of pxs have nitrate resistant chest pain, therefore, morphine is given additionally to relieve chest pain.

Question 157

Why should we give IV analgesia and not IM in the ambulance in the case of a MI?

Answer 157

IM absorption is unreliable If the px receives thrombolysis later on, the site of injection IM might bleed.

Question 158

An ECG showing broad complex tachycardia in a still conscious patient ± atrial activity

Answer 158

Ventricular tachycardia GIVE IV AMIODARONE

Question 159

Most important cause of ventricular tachycardia clinically

Answer 159

Hypokalemia

Question 160

Tall tented T wave in ECG is...

Answer 160

hyperkalemia

Question 161

U wave in ECG is...

Answer 161

hypokalemia

Question 162

Causes of hyperkalemia

Answer 162

``` ACEi Spironolactone NSAIDs Renal Failure Acidosis Adrenal insufficiency Addison's disease ```

Question 163

Rx of hyperkalemia

Answer 163

First protect the cardiac membrane by giving IV calcium gluconate (or calcium chloride) Then reduce the serum potassium by giving Insulin with dextrose or Salbutamol

Question 164

M shaped QRS in leads I, aVL, V6 AND Negative inverted QRS in V1

Answer 164

LBBB Left Bundle Branch Block Associated with acute MI!!!

Question 165

A px with an ejection systolic murmur heard on the right ICS just lateral to the sternum that radiates to the carotid artery.

Answer 165

Aortic Stenosis Symptoms> dyspnea on activity, anginal chest pain, syncope.

Question 166

Px with early diastolic murmur heard on the right ICS just lateral to the sternum and symptoms of HF

Answer 166

Aortic regurgitation

Question 167

Px with ejection systolic murmur on the left 2nd ICS just lateral to the sternum that radiates to the left shoulder of infraclavicular area.

Answer 167

Pulmonary stenosis Symptoms of systemic cyanosis

Question 168

Px with early-diastolic murmur heard on the left 2nd ICS just lateral t the sternum

Answer 168

Pulmonary regurgitation Symptoms of right sided heart failure

Question 169

Px with mid-late diastolic murmur, with opening click on the apex.

Answer 169

Mitral stenosis Symptoms of heart failure

Question 170

Px with pan-systolic murmur on the apex that radiates to the axilla.

Answer 170

Mitral regurgitation Symptoms of Congestive HF (edema and ascites)

Question 171

Px with diastolic rumble murmur on the 4-5th ICS over the left sternal border and discomfort on the neck.

Answer 171

Tricuspid stenosis Fluttering and discomfort on the neck

Question 172

Px with pan-systolic murmur heard on the 4th-5th ICS over the left sternal border.

Answer 172

Tricuspid regurgitation Symptoms of right-sided heart failure.

Question 173

Pathogenesis of mitral stenosis

Answer 173

Stenosis impedes left ventricular filling --> increased left atrial pressure which leads to left atrial hypertrophy (CXR shows straight left side heart border) --> blood returns back to lungs --> pulmonary congestion --> right ventricular failure (hepatomegaly, ascites, oedema)

Question 174

Features of Mitral stenosis

Answer 174

Mid-late diastolic murmur (best heard on expiration) "low-pitched" Loud S1, opening snap Atrial fibrillation Low volume pulse Malar flush

Question 175

Left heart murmurs are better heard on... Right heart murmur are better heard on...

Answer 175

LEft on Expiration (mitral and aortic) | rIght on Inspiration tricuspid and pulmonary

Question 176

How does dilated cardiomiopathy affects ejection fraction and wall thickness?

Answer 176

↓ ejection fraction | ↓ septal wall thickness

Question 177

How does hypertrophic cardiomiopathy affects ejection fraction and wall thickness?

Answer 177

↑ Ejection fraction | ↑ Septal Wall Thickness

Question 178

Causes of dilated cardiomyiopathy

Answer 178

Alcohol (improves with tiamine) Postpartum Hypertension Inherited (1/3 of pxs; autosomal dominant) Previous MI Infections (Coxsackie B, HIV, diphtheria, parasitic) Endocrine (hyperthyroidism) Infiltrative (haemochromatosis, sarcoidosis) Neuromuscular (Duchenne muscular dystrophy) Nutritional (Kwashiorkor, pellagra, thiamine/selenium deficiency) Drugs (doxorubicin)

Question 179

Patient with SOB, severe dizziness, chest pain and HR > 150 with tachycardia

Answer 179

UNSTABLE! Any unstable tachycardia = Cardioversion

Question 180

Stokes Adam attack

Answer 180

Intermittent complete heart block that causes a slow or absent pulse resulting in syncope.

Question 181

Preterm baby with continuous or machinery murmur

Answer 181

PDA | Patent Ductus Arteriosus

Question 182

Cyanotic baby with ejection systolic murmur

Answer 182

TOF Tetralogy of Fallot The systolic murmur is due to pulmonary stenosis which is one of the 4 major features of TOF

Question 183

The four major defects in Tetralogy of Fallot

Answer 183

VSD (ventricular septal deffect) Pulmonary stenosis Right ventricular hypertrophy Overrriding aorta

Question 184

Progressive (severe) cyanosis + poor feeding + holosystolic (pansystolic) murmur along the left sternal border

Answer 184

Tricuspid Atresia

Question 185

Acyanotic with pan-systolic murmur

Answer 185

VSD (ventricular septal deffect) May present poor feeding and poorly gaining weight.

Question 186

Cyanotic Congenital Heart Disease (R→L)

Answer 186

5 Ts, 1 to 5 Truncus arteriosus, vessels join to make 1 Transposition of great vessels, 2 major vessels switched Tricuspid atresia, 3=tricuspid Tetralogy of Fallot, 4 defects Total anomalous pulmonary vascular return, 5 letters TAPVR

Question 187

Acyanotic Congenital Heart Disease (L→R)

Answer 187

Atrial septal defect (ASD) Ventricular septal defect (VSD) Patent ductus arteriosus (PDA) Coarctation of aorta (CoA)

Question 188

Causes of falls (4)

Answer 188

Cardiac cause (arrythmia) > Stokes Adam attack, hot and flushed after recovery = 12 lead ECG Postural (Orthostatic) hypotension > follow a standing position from a sitting position, dizziness before the fall Hypoglycemia> sweaty and dizzy before the fall, does not recover until glucose is administered Seizure> post ictal features like confusion and drowsiness, a witness describes the episode, recovers completely.

Question 189

Preterm baby with continuous or machinery murmur

Answer 189

PDA (persistent ductus arteriosus)

Question 190

Cyanotic baby with ejection systolic murmur

Answer 190

TOF (tetralogy of fallot) The ejection systolic murmur is due to pulmonary stenosis

Question 191

Progressive (severe) cyanosis + poor feeding + holosystolic "pansystolic" murmur along the left sternal border

Answer 191

Tricuspid atresia

Question 192

Acyanotic + pansystolic murmur

Answer 192

VSD (ventricular septal defect) or poor feeding and poorly gaining weight

Question 193

Patent ductus arteriosus (PDA)

Answer 193

Congenital heart defect Acyanotic Connection between pulmonary trunk and descendeing aorta Common in premature babies May close spontaneously

Question 194

Features of PDA (patent ductus arteriosus) and dx

Answer 194

Left subclavicular thrill (sometimes rough systolic murmur along the left sternal border) Continuous machinery murmur Large volume, bounding, collapsing pulse Wide pulse pressure Dx> echocardiogram

Question 195

Management of PDA (permanent ductus arteriosus)

Answer 195

Indomethacin/ibuprofen (NSAIDs) inhibits prostaglandin synthesis, closes the connection in the majority of cases Remember ind/end= closes the duct If associated with another congenital heart defect amendable to surgery then prostaglandin E1 is useful to keep the duct open until surgery.

Question 196

Tetralogy of Fallot presents typically at around...... months

Answer 196

1-2 months The most common cause of cyanotic congenital heart disease. However at birth, transposition of the great arteries is more common lesion as patients with TOF present symptoms later. Can be picked up until the baby is 6 months old. TOF is a result of anterior malalignment of the aorticopulmonary septum.

Question 197

Features of TOF (tetralogy of Fallot)

Answer 197

Cyanosis (the severity is determined by the right ventricular outflow tract obstruction) Causes right to left shunt Ejection systolic murmur due to pulmonary stenosis (VSD doesn't usually cause a murmur) A right sided aortic arch is seen in 25% of pxs Chest X ray shows a boot-shaped heart ECG shows right ventricular hypertrophy.

Question 198

Management of TOF

Answer 198

Surgical repair is often undertaken in 2 parts (shunt then surgical repair) Cyanotic episodes may be helped by beta blockers to reduce infundibular spasm

Question 199

Familiar hypercholesterolemia genetics

Answer 199

Autosomal dominant

Question 200

When to suspect familiar hypercholesterolemia?

Answer 200

Cholesterol > 7.5 (normal <5mmol) Family history of MI in 1st degree relative before the age of 60 or 2nd degree below 50 1st degree parents and siblings 2nd degree grandparents aunts and uncles

Question 201

While in a hospital, an elderly patient was found unresponsive, no pulse and no breathing. Management?

Answer 201

IN THIS ORDER! Ring the emergency bell and call the resuscitation team Start CPR 30:2 Get defibrillator Commence ALS when resuscitation team arrives.

Question 202

Acute treatment of congestive heart failure with pulmonary oedema (desaturation, dyspnea, orthopnea, crepitations)

Answer 202

``` MONF Morphine Oxygen Nitrates Furosemide ```

Question 203

History of Rheumatic fever and pansystolic murmur at the apex

Answer 203

Mitral regurgitation Secondary to rupture of papillary muscles or rheumatic fever It leads to right sided heart failure (ascites, pulmonary oedema)

Question 204

Difference between mitral stenosis and mitral regurgitation?

Answer 204

Stenosis- Mid late dyastolic murmur, with opening click At the apex (5th ICS MCL) Symptoms of HF Regurgitation- pansystolic murmur At the apex (5th ICS MCL) radiates to the axilla Symptoms of congestive HF (oedema, ascites)

Question 205

An elderly px presented a syncope, he is transferred to A&E and is now fully conscious. ECG shows irregular rhythm. What is the next BEST investigation?

Answer 205

Echocardiogram Holter ECG is not beneficial as the ECG already shows irregular rhythm (no point in using it again) Echo will identify the underlying cause of the irregular rhythm. Aortic stenosis is the most common valvular heart disease that causes syncopal attacks. If the syncope was during or shortly after exertion then Exercise ECG This px likely has AF causing TIA (syncope+ irregular rhythm)

Question 206

Causes of AF

Answer 206

Endocardium- endocarditis, mitral valve disease Myocardium- cardiomyopathy Pericardium- Constrictive pericarditis HF, HTN and MI Hyperthyrroidism, excessive alcohol intake, chronic lung disease.

Question 207

What should be done prior prescribing amiodarone?

Answer 207

Request serum electrolytes and urea It is a class III antiarrhythmic agent used in the tx of atrial, nodal and ventricular tachycardias. It blocks potassium channels which inhibit repolarisation and prolongs the action potential. Thyroid and liver functions prior and every 6 months ECG every 12 months

Question 208

Adverse effects of amiodarone

Answer 208

Thyroid disfunction (hypothyroidism and hyperthyroidism) Corneal deposits Pulmonary fibrosis (the most serious pneumonitis!) Liver fibrosis/hepatitis Peripheral neuropathy, myopathy Photosensitivity Slate-grey appearance (grey skin) Thrombophlebitis and injection site reactions (usually given via central veins) Bradycardia Prolonged QT interval

Question 209

A px with history of alcholism presents with a racing heart. Management?

Answer 209

Reassurance It is not serious or harmful and it is a common phenomenon in alcoholics.

Question 210

A px with history of TOF who underwent surgery in his childhood will present with what murmur decades later and why?

Answer 210

The corrected pulmonary stenosis can be complicated into PULMONARY REGURGITATION (diastolic murmur at the left upper sternal border)

Question 211

Young adult with history of asthma presents recurrent palpitations, light headedness and tachycardia and paroxysmal supraventricular tachycardia in the ECG. Management?

Answer 211

ADENOSINE IS CONTRAINDICATED IN ASTHMATICS! Valsalva manoeuvre and carotid massage Verapamil (CCB) Cardioversion

Question 212

Digoxin toxicity features

Answer 212

GIT (most common)- nausea, vomiting and anorexia Neurological- Hallucinations and confusion Visual- Yellow green vision (yellow haloes) and blurred vision Arrhythmias- bradycardia, V tach, premature contractions.

Question 213

Digoxin toxicity management

Answer 213

Order digoxin level Digibind (DigiFab) = digoxin immune FAB Correct arrhythmia monitor K

Question 214

Aspirin toxicity features

Answer 214

Earliest symptoms include ringing ears (tinnitus) and impaired hearing More clinically significant signs and symptoms include hyperventilation, vomiting, fever, dehydration, double vision and feeling faint.

Question 215

Common adverse effects of Thiazide like diuretics?

Answer 215

Postural hypotension Hypokalemia and Hyponatremia Gout (hyperuricemia) Dehydration impaired glucose tolerance Impotence Thiazide diuretics can cause hypercalcaemia and hypocalciuria

Question 216

Side effects of calcium channel blockers (CCB)

Answer 216

Ankle swelling and Gingival hyperplasia Diltiazem, amlodipine, verapamil, nifedipine.

Question 217

Heart disease in alcoholics?

Answer 217

Ankle swelling and orthopnea Alcoholic cardiomiopathy (enlarged on x ray) which causes AF may cause flutter but AF is more common. (holiday heart syndrome= irregular heartbeat after bouts of acute bringe drinking) Palpitations, dyspnea, dizziness, syncope, chest discomfort or pain, stroke or TIC, irregularly irregular pulse.

Question 218

Blood transfusion is indicated if...

Answer 218

Hb <80g/L + symptoms of anemia OR Hb < 70g/L + with or without symptoms of anemia

Question 219

``` Recurrent fainting episodes + Prolonged QT intervals on ECG + History of similar ECG during childhood ```

Answer 219

Congenital long QT syndrome The most common arrhythmia associated is V tach Risk of VF so some use long term beta blocker treatment