Rhythm Disorders

Question 1

Syncope - Classification

Answer 1

Question 2

Syncope in A&E

Answer 2

• Syncope with low risk features, likely to be reflex or situational, or syncope due to OH, are discharged from A&E
• High risk features, early prompt assessment in A&E observation unit or syncope unit or are hospitalised
• If neither low or high risk features, A&E observation unit or syncope unit preferred to hospitalisastion
• Manage pre-syncope as syncope - prognosis is the same
• Routine bloods and CXR/CTH have low diagnostic yield and impact on prognosis and should only be utilised if specifically indicated
• Cardiac device and syncope –> prompt interrrogation to avoid hospitalisation
  *

Question 3

Syncope - Risk Stratification

Answer 3

Syncopal Event
LOW RISK
* Typical reflex syncope prodrome (nausea, vomiting, warmth, sweating, lightheadedness)
* Associated with prolonged standing in hot / crowded places
* During a meal or post prandial
* Associated with coughing, micturition, defacation
* Associated with head turning or neck pressure
* Standing from sitting / supine position

HIGH RISK - MAJOR
* New onset chest pain, breathlessness, abdominal pain or headache
* Syncope on exertion or when supine
* Sudden onset palpitations immediately followed by syncope

HIGH RISK - MINOR - ONLY HIGH RISK IF ACCOMANIED BY STRUCTURAL HEART DISEASE OR ABNORMAL ECG
* No warning or v short (< 10s) prodrome
* Family history of SCD
* Syncope in sitting position

Past Medical History
LOW RISK
* Long history (years) of recurrent syncope, the same in character as current episode
* Absence of structural heart disease

High Risk
* Severe structural or coronary artery disease (heart failure, low LVEF, previous MI)

Physical Examination
LOW RISK
* Normal examination

HIGH RISK
* Evidence of GI bleeding on PR exam
* HR < 40 unless athletic training
* BP ≤90mmHg
* Undiagnosed systolic murmur

ECG
LOW RISK
* Normal ECG

HIGH RISK MINOR - ONLY IF ASSOCIATED WITH HISTORY CONSISTENT WITH ARRHYTHMIC SYCNOPE
* Pre-excitation
* Paroxysmal AF or SVT
* Mild sinus bradycardia or slow AF (40-50)
* Mobitz 1 second degree AV block or first degree AV block with v prolonged PR
* Atypical Brugada
* Inverted T waves in R precordial leads or Epsilon waves
* Short QTc (≤340ms)

HIGH RISK MAJOR
* Changes consistent with acute ischaemia
* Mobitz 2 2nd degree AV block and 3rd degree AV block]
* Slow AF (< 40)
* Sinus bradycardia (< 40) or sinus pauses >3s in the absence of physical training
* Prolonged QTc (≥460ms)
* BBB or interventricualr conduction delay, LVH, Q waves consistent with ischaemic heart disease or cardiomyopathy
* VT (NSVT or sustatined)
* Type 1 Brugada (coved STE in V1-3)
* Dysfunction of ICD or cardiac device

Question 4

Sycnope Investigation - Carotid Sinus Sensitivity

Answer 4

• Carotid sinus massage recommended in patients > 40 years, who have symptoms consistent with reflext syncope
• Positive test if bradycardia/asystole, or hypotension that reporduces symptoms
• Positive CSM without syncope -> carotid sinus hypersensitivity. Positive CSM with history of reflex syncope -> carotid sinus syndrome
• Do CSM with cuation in patients with history of TIA / stroke / carotid stenosis >70% due to riskof stroke

Question 5

Sycnope Investigation - Active Standing

Answer 5

• Intermittent HR and BP measurement when supine then intermittently when standing for 3 mins
• Beat to beat non invasive BP and HR may be preferred when short lived BP changes are suspected such as in initial OH
• Sycope due to OH confirmed when SBP falls by ≥20mmHg, DBP falls by ≥10mmHg or SBP ≤90mmHg with symptoms reproduced. If BP changes and history consistent with OH, syncope from OH considered likely
• POTS likely when HR increases by > 30bpm or to >120 bpm in 10 minutes active standing in the absence of OH that reporduces spontaneous symptoms

Question 6

Sycnope Investigation - Tilt Testing

Answer 6

• Consider in patients with suspected reflex syncope, OH, POTS, psychogenic pseudosyncope
• Consider to educate patients to recognise symptoms and learn physical manouvres
• Reflex syncope, OH, POTS, PPS likely if symptoms reproduced along with characteristic circulatory patterns
• Tilt table can suggest hypotensive suscpetibility, which can exit in reflex syncope and cardiac syncope - can help guide pacemaker therapy
• Tilt table can help distinguish epilspesy from syncope and syncope from falls

Question 7

Sycnope Investigation - Autonomic Function Testing

Answer 7

Valsava manouvre
* Consider in patients with suspected nueorgenic OH
* Consider to diagnose hypotensive tendency in some forms of situational syncope

Deep Breathing Test and other autonomic function tests
Consider to assess autonomic function in patients with suspected neurogenic OH
* May consider other autonimic function tests (mental arthimetic, cold water, 30:15 ratio) in suspected neurogenic OH

ABPM
* ABPM recommended to diagnose nocturnal hypertension in patients with autonomic dysfunction
* Consider AMBP to monitor degree of OH and supine hypertension in patients with autnomic dysfunction
* May Consider ABPM or HBPM to detect hypotension during episodes of otherostatic intolerance

Question 8

Sycnope Investigation - ECG Monitoring

Answer 8

• Immediate in hopsital ECG monitoring indicated in patients at high risk
• Consider Holter monitor in frequent syncope (≥1 / week)
• Consdier external event recorders early after index syncope event in patients with an inter-symptom interval < 4 weeks
• ILR indicated (1a) in patients with recurrent syncope of uncertain origin and high likelihood of recurrence within the battery life of the device
• ILR indicated (1a) in high risk patients in whom work up did not lead to a specific cause who do not have a conventional indication for PPM or ICD
• Consider ILR in suspsected or certain reflex syncope with frequent episodes
• Consider ILR when epilepsy suspected but treatment ineffective
• May consider ILR in unexplained falls
• Arrhythmic syncope confirmed when correlation between arryythmia (tachycardia or bradycardia) and syncope
• Consider arrhthmic syncope when Mobitz 2 second degree, third degree or V pause of >3 s (except in young trained people)

Question 9

Sycnope Investigation - EP study

Answer 9

• EP study indicated when previous MI or other scarring conditions and syncope remains unexmplained after non-invasive investigation
• Consider in syncope and bifascicular block when no explanation after non-invasive investigation
• Consider in sycope preceeded by brief palpitations when no explanation after non-invasive investigation
• May consider in sinus bradycardia with no symptoms when syncope and bradycardia not clearly related
• PPM indicated in syncope with bifascicular block if either resting H-V interval of >70ms or 2nd or 3rd degree His-Purkinje block during incremental atrial pacing or with pharmacological challenge
• If myocardial scar and inexplained syncope, do VT stim study
• If structural heart disease with syncope precipitated by palpitations, do SVT/VT stimulation study
• Consider PPM in patients with syncope and resting sinus bradycardia with prolonged sinus node recovery time

Question 10

Sycnope Investigation - Echocardiography

Answer 10

• Indicated when structural heart disease suspected
• Exercise 2D and doppler echo in HCM with suspected inducible LVOTO with resting or provoked LVOT gradeint < 50mmHg

Question 11

Sycnope Investigation - Exercise Testing

Answer 11

• Recommended for patients with syncope during or after exercise. During exercsie usually cardiac, after exercise, almonst always reflex syncope
• Sycnope due to AV block is confirmed if AV block develops on exercise (even without syncope)
• Reflex syncope diagnosed if syncope comes on immediately after exercise in the presence of severe hypotension

Question 12

Syncope Treatment - Reflex Syncope

Answer 12

Question 13

Syncope Treatment - Pacing in Reflex Syncope

Answer 13

Question 14

Syncope Treatment - Pacing in Reflex Syncope - Decision Tree

Answer 14

Question 15

Syncope Treatment - Orthostatic Hypotension

Answer 15

Question 16

Syncope Treatment - Cardiac Arrhythmias

Answer 16

SVT syncope - ablation 1a, medications IIa
VT syncope - ablation 1a, ICD 1a/IIa, medications IIa

Question 17

Syncope Treatment - LQTS

Answer 17

• Beta-blockers first line, ICD when unexplained syncope on BB
• Left cardiac sympathetic denervation should be considered when can’t tolerate BB, ICD contraindicated or multiple ICD shocks
• ILR instead of ICD if syncope but low risk of SCD on multiparametric analysis

Question 18

Atrial Fibrillation - Screening

Answer 18

• Opportunistic screening using pulse taking and ECG rhythm strips recommended in patient ≥65 (1b)
• Interrogate PPM and ICD regularly for AHRE
• Consider systematic screening in patients ≥75 or high risk of stroke
• Formally diagnose AF only when 30s of rhythm strip or 12 lead ECG shows AF

Question 19

Atrial Fibrillation - EHRA Symptom Scale

Answer 19

1- No symptoms
2a - Normal daily activity not affected by symptoms relating to AF
2b - Normal daily activity not affected by symptoms relating to AF, but patient is troubled by symptoms
3 - Normal daily activities are affected by symptoms related to AF
4 - Normal daily activities discontinued

1c - quantify symptoms with EHRA scale before and after initiation of therapy
1c - evaluate symptoms before and after cardioversion to aid rhythm control decisions

Question 20

Atrial Fibrillation - CHADS-2-VASc Score

Answer 20

Mechanical heart valve or mod/severe MS - VKA

If not

CHADSVASC ≥2 in men and 3 in women - NOAC.
Consider when ≥1 in men and 2 in women

Question 21

Atrial Fibrillation - HASBLED

Answer 21

Question 22

Atrial Fibrillation - NOACs - Doses

Answer 22

Dabigatran
* 150mg BD
* Reduced dose 110mg BD
* Criteria for dose reduction:
≥ 80 years
Verapamil use
Increased bleeding risk

Rivaroxaban
* 20mg OD
* Reduced dose 15mg OD
* Criteria for reduced dose
CrCl 15-49ml

Apixaban
* 5mg BD
* Reduced dose 2.5mg BD
* Criteria for reduced dose
2/3 of:
≥80 years old
Weight ≤60kg
Cr ≥1.5mg/dL (>133umol/L)

Edoxaban
* 60mg
* Reduced dose 30mg
* Criteria for reduced dose
CrCl 15-50
Weight ≤60kg
Concurrent use of dronaderone, ciclosporine, ketoconazole, erythromycin

Question 23

Atrial Fibrillation - Rate Control

Answer 23

Question 24

Atrial Fibrillation - Rhythm Control

Answer 24

Question 25

Atrial Fibrillation - Cardioversion

Answer 25

* For pharmacological cardioversion of recent onset AF, IV vernakalant (exlcuding severe heart failure and recent ACS), flecainide or propafenone (excluding patients with severe structural heart disease) recommended (1a) * IV amiodarone recommended for AF cardioversion in patients with severe heart failure if delayed cardioversion appropriate * Cardioversion (electrical or pharmacological) is recommended in symptomatic AF as part of a rhythm control strategy * Pharamcological cardioversion only indicated in haemodynamically stable patients, after consideration of VTE risk * *Consider* pre-treatment with amiodarone, propafenone, flecainide or ibutilide to facilitate success of DCCV * *Consider* pill in the pocket PO flecainide for patients with no strucutral heart disease and recent onset, infrequent, AF "pill in the pocket" * AVOID pharmacological cardioversion in patients with sick sinus syndrome, AV conduction disturbance or QT >500ms unless risks of pre-arrhythmia and bradycardia have been considered

Question 26

Atrial Fibrillation - Rhythm Control Drugs

Answer 26

**Flecainide and Propafenone** * Flecainide: 200-300mg PO, 2mg/kg IV over 10 mins for cardioversion * Propafenone: 450-600mg PO, 1.5-2mg/kg over 10 mins * AVOID in Ischaemic heart disease or significant structural heart disease May induce hypotension and atrial flutter with 1:1 conduction Flecainide may cause mild QRS widening Do not use for cardioversion of Flutter **Vernakalant** * 3mg/kg over 10 mins. Wait 10-15 mins after first infusion then 2mg/kg over 10 mins * AVOID in Hypotension, NHYA III or IV heart failure, Recent ACS, Severe AS, Prolonged QT May cause hypotension, QT prolongation, QRS broadening and NSVT **Amiodarone** * 5-7mg/kg over 1 hour then 50mg/kg over 24 hours * AVOID in Only if no other option in thyrotoxicosis May cause phlebititis - use large cannula in large vein May cause hypotension, bradycardia, AV block, QT prolongation ** Ibutilide** * 1mg over 10 mins (0.01mg/kg if under 60kg), repeat after 10-15mins * Effective for Atrial flutter cardioversion * Should not be used in prolonged QT, severe LVH or low LVEF * Should be used in CCU setting as may cause long QT and TdP * ECG monioring for at least 4 hours following

Question 27

Atrial Fibrillation - Catheter Ablation

Answer 27

* Consider procedural risks and major risk factors for AF recurrence * *Consider* repeat PVI if symptoms improved after initial PVI **Failed Drug Therapy** * Recommended for patients who have 1 failed or intolerant class I or III AAD who have: - Paroxysmal AF (1a) - Persistent AF without major risk factors for recurrence (1a) - Persistent AF with major risk factors for recurrence (1b) * *Consider* if failed on beta-blocker **First Line Therapy** * Selected patients with paroxysmal AF (IIa) or persistent without major risk factors for recurrence (IIb) as an alternative to class I or III AADs considering benefits and risks * Recommended to reverse LV dysfunction in AF patients where AF tachycardia cardiomyopathy is highly probable * *Consider* in selected AF patients with HFrEF to improve survival and hospitalisations * *Consider* as alternative to PPM in patients with AF related bradycardia or symptomatic pre-automaticity pause post cardioversion **Techniques** * Complete PVI recommended * Consider CTI line in patients with history of CTI dependent flutter or inducible CTI flutter in procedure * Consider non PVI LA ablation targets **Lifestyle** * Weight loss in obese patients * Risk factor control **Anticoagulation** * OAC for ≥3 weeks priorto ablation * Consider TOE guidance to exclude thrombus instead of ablation * In patients who are therapuetically anticoagulated, ablation without anticoagulation interruption is recommended (1a) * Anticoagulation for at least 2 months post ablation * Long term anticoagulation based on stroke risk (not on ablation success) ## Footnote IIa - consider surgical AF ablation when concurrent cardiac surgery considering benefits and risk factors for recurrence

Question 28

Atrial Fibrillation - Cardioversion stroke risk

Answer 28

* NOACs recommended with at least the same efficacy and safety as warfarin * ≥3 weeks therapy before cardioversion for AF or flutter * TOE guidance is an alternative to 3 weeks NOAC if early cardioversion planned * If thrombus on TOE, 3 weeks cardioversion before cardioversion. Consider repeat TOE * In patients at risk of stroke, continue anticoagulation long term, irrespective of success of cardioversion, first episode or cardioversion method * Early cardioversion can be performed without TOE if < 48hours onset * If AF for >24 hours, must have anticoagulation post cardioversion for at least 4 weeks. After that, anticoagulation determined by stroke risk * If AF < 24 hours and very low stroke risk (CHADsVASc 0 in men and 1 in women), consider omitting anticoagulation

Question 29

Atrial Fibrillation - Long term rhythm control drugs

Answer 29

* Amiodarone is recommended for long term rhythm control in all patients, including HFrEF but due to side effects, consider other drugs first (1a) * Dronaderone recommended for long term rhythm control for normal LV, mildly reduced (but stable) LV, HFpEF, valve disease, IHD (1a) * Flecainide or propafenone recommended for patients with normal LV function and without significant structural heart disease, ischaemia, LVH (1a) * If on sotalol, monitor QT interval, K levels, CrCl, pro-arrhythmic factors * Consider sotalol in normal LVEF and in IHD if monitoring the above * If long term flecainide, consider long term AV nodal blocking drugs * Avoid if permanent AF or in patients with advanced conduction disturbances unless anti-brady pacing provided

Question 30

Atrial Fibrillation - Antocoagulation management with PCI

Answer 30

* NOACs preferred to VKA when combinded with antiplatelets. If needs VKA, then INR target 20-2.5 ant TTR 70% * If HASBLED ≥3, reduce rivaorxaban to 15mg or dabigatran to 110mg BD * AF and ACS, if uncomplicated PCI, stop aspirin after ≤1 week and continue clopidogrel and NOAC for 12 months, then stop clopidogrel, if stent thrombosis risk lower, or bleeding risk higher than ST risk. For CCS, as above but 6 months clopidogrel and NOAC * If ST risk is higher than bleeding risk, continue triple therapy for >1 week but ≤1 month

Question 31

Atrial fibrillation - cryptogenic stroke

Answer 31

* Ischaemic stroke or TIA and no known AF - 24 hours ECG monitoring initally then 72 hours monitoring * Selected patients - longer term monitoring or ILR

Question 32

Atrial Fibrillation - management of bleeding on anti-coagulation

Answer 32

Question 33

Atrial Fibrillation - Post-operative

Answer 33

* Perioperative amiodarone or beta-blocker recommended to reduce incidence of AF in cardiac surgery * OAC in the long term should be considered in patients at risk of stroke in post operative AF after non-cardiac surgery * OAC in the long term may be considered in in patients at risk of stroke in post operative AF after cardiac surgery * AVOID perioperative betablockers to prevent AF in. non cardiac surgery

Question 34

Narrow Complex Tachcardia - Differential Diagnosis

Answer 34

Question 35

Management of a Narrow Complex Tachycardia in the absence of an established diagnosis

Answer 35

Question 36

Management of a Wide Complex Tachycardia in the absence of an established diagnosis

Answer 36

Question 37

Atrial Tachycardia - Management (Acute and Chronic)

Answer 37

Question 38

Macro-re-entrant Atrial Tachycardia - Acute Management

Answer 38

## Footnote Anticoagulate for MRAT with AF - 1a Consider anticoagulation for MRAT without AF (IIa)

Question 39

Macro-re-entrant Atrial Tachycardia - Chronic Management

Answer 39

Question 40

Ventricular Arrhythmias - Management of incidentally found NSVT

Answer 40

Question 41

Ventricular Arrhythmias - First Sustained Monomorphic VT Episode

Answer 41

Question 42

Ventricular Arrhythmias - Management post sudden cardiac death survival

Answer 42

## Footnote Sudden Death - Clinical evaluation of first degree relatives - autopsy - diagnosis made - targetted genetic testing of first degree relatives

Question 43

Ventricular Arrythmias - Acute Management of Regular, Wide Complex Tachycardia

Answer 43

Question 44

Ventricular Arrhythmias - ICD discharges / electrical storm

Answer 44

## Footnote Do not implant ICD in patient with incessant VAs unless VAs controlled

Question 45

Ventricular Arrhythmias - Polymorphic VA

Answer 45

Question 46

Ventricular Arrhythmias - Monomorphic VA

Answer 46

## Footnote Non-selective beta blocker preferred

Question 47

Sustained Monomorphic VT - Management

Answer 47

* SMVT, haemodynamic compromise -> DCCV (1b) * SMVT, no haemodynamic compromise but low anaesthetic/sedation risk -> DCCV (1c) * In haemodynamically tolerated idiopathic VT, betablocker (RVOT), verapamil (fascicular) * Regular BCT suspected to be SVT, consider adenosine (IIa) * Tolerated SMVT with structural heart disease, consider procainamide (IIb) * Tolerated SMVT in the absence of a diagnosis, consider amiodarone (IIb) * Tolerated SMVT and no structural heart disease, consider flecainide, ajmaline and sotalol IIc

Question 48

ICD - Indication and Management

Answer 48

* Recommended with documented VF or haemodynamically not tolerated VT in absence of reversible cause * When ICD indicated, consider CRT * If ICD not available or refused, consider amiodarone or catheter ablation for ectopic provoked VA * If SVTs leading to innapropriate shocks, do SVT ablation * If AF leading to innapropriate shocks, pharmacological management or AF ablation

Question 49

Ventricular Arrhythmias during STEMI

Answer 49

* IV betablockers indicated for recurrent PVT/VF during STEMI unless contraindicated * Then add IV amiodarone if ongoing (IIa) * Then add IV lidocaine (IIb) * Only BB given prophylactically to prevent arrhythmias, no other AA * Assess LVEF prior to discharge in all STEMI * In patients with LVEF ≤40% , reassess in 6-12 weeks ?ICD

Question 50

ICD decision making after MI

Answer 50

Question 51

ICD decision making in chronic CAD

Answer 51

Question 52

Chronic Management of PVCs / Monomorphic VT

Answer 52

## Footnote If VE burden ≥10%, regular LV function assessment Catheter ablation first line for PVCs/VT from RVOT of left fascicles (1a) BB on non-DHP CCBs first line for non RVOT/Left fascicular VT

Question 53

Management of VE burden ≥10%

Answer 53

Question 54

Idiopathic VF Management

Answer 54

Question 55

Long QT Syndrome - diagnostic criteria

Answer 55

Mutations in repolarising K channels LQT1 - Loss of function mutations in KCNQ1 - major determinant of phase 3 of the action potential - Critical for AP adaptation in tachycardia - Also relevant in AR form of LQTs - Trigger - swimming /exercise - ECG - broad, peak T wave LQT2 - Loss of function mutation in KCH2 (hERG) and reduced rapidly activating K current - Trigger - loud noise/emotional stress - Biphasic T wave LQT3 - Gain of function mutation in SCN5A resulting in increased Na activity during plateau at late phase of the action potential - Trigger - rest Risk: LQT2/3 >risk than LQT1 Highest risk: JLN syndrome, Timothy Syndrome, Anderson-Tawil syndrome QTc> 500 high risk, >600 very high risk T wave alternans Early onset life threatening arrhthmia

Question 56

Long QT Syndrome - management

Answer 56

Rx - Nadolol - if cant get, Propranolol

Question 57

CPVT - Management

Answer 57

* Ryanodine receptor (RYR2) and calsequestrin gene (CASQ2) mutations Diagnosis: - Positive genotype or - Normal heart, normal ECG, bidirectional or polymorphic VT on exercise * Normal heart structure, normal ECG, VAs with emotion and exercise * Avoid exercise and stress * Non-selective BB (nadolol or propranolol) * ICD in survivors of CA

Question 58

Anderson-Tawil Syndrome

Answer 58

* 1:1000,000 genetic disease * Triad: frequent ventricular arrhythmias (bidirectional VT), dysmorpholgies and periodic paralysis * Reduced inward rectifier current (Ik1). Loss of function of KCNJ2 * Increased U wave amplitude rather than QT prolongation * ICD in most patients - recommended after non-tolerated VT or cardiac arrest * Flecainide and BB reduce VA

Question 59

Brugada Syndrome

Answer 59

* Diagnosis: - Spontaneous Type 1 Brugada Pattern (J point elevation with >2mm coved ST elevation and TWI in at least 1 right precordial lead (V1 and V2)) and no other heart disease - Induced Type 1 Brugada pattern with fever or Na channel blocker and survived VF or PVT cardiac arrest, no other heart disease Consider diagnosis if: - Induced Type 1 Brugada pattern and 1) Arrhythmic syncope or nocturnal agonal respiration 2) FHx Brugada 3) FHx Sudden Death with negative autopsy and suspicious circumstances for BrS May consider diagnosis if: - Induced type 1 Brugada syndrome only * May occur spontaneously or only with Na channel blockers or fever. Need to exclude phenocopies * SCN5A is causative gene - gene testing recommended in probands * Triggers - fever, cocaine, alcohol, some anaesthetic drugs, selected anti-arrhythmic drugs * Recommendations General - Avoid provoking drugs - Avoid cocaine, cannabis and excessive alcohol - Treat pyrexia Risk stratification, SCD prevention - ICD for BrS who are survivors of SCD or previous sustained VT - Consider ICD for BrS with previous arrhythmic syncope - Consider loop recorder in BrS with unexplained syncope - If qualify for ICD but refuse/contraindication or reccurent shocks - Quinidine - Electrical storm - isoprotenerol - Recurrent appropriate shocks - consider VE/RVOT ablation

Question 60

Early Repolarisation Syndrome

Answer 60

* Diagnosis: resuscitated VF or PVT without any other heart disease and early repolarisation pattern on ECG (J point elevation >1mm in adjacent inferior or lateral leads) * ERP is usually benign finding but over-represented in SADS * ICD for survived CA and ERS. Quinidine for recurrent ICD shocks. Isoprotenerol for electrical storm

Question 61

Short QT Syndrome

Answer 61

* Rare genetic syndrome characterised by short QT interval, premature AF and VF with structurally normal heart * Gain of function mutations in KCNH2, KCNQ1 and loss of function in SLC4A. * Diagnosis - QTc ≤360ms PLUS pathogenic mutation OR FHx SQTS OR survived VF/VT episode in absence of structural heart disease - Consider if QTc ≤320ms alone - Consider if QTc 320-360 PLUS arrhythmic syncope - Consider if QTc 320-360 PLUS FHx SCD <40 * Survival of cardiac arrest of cardiac arrest or documented sustained VT - ICD * ICD indicated but refused or CI - quinidine

Question 62

Relatives of Sudden Arrhythmic Death Syndrome

Answer 62

Question 63

Athlete ECG interpretation

Answer 63

Question 64

Pathway ablation guidelines

Answer 64