ECG Test – Mixed Conditions

Welcome to the second ECG test. This test includes both single and multiple choice questions. You can click on ECG recordings to enlarge/zoom. Any provided links will open in new windows, so that you can read relevant topics later. The computer assessment of ventricular rate, atrial rate and time intervals is provided but should be reassessed manually.

12 question(s) with answers and explanations.

Question 1

88-year old male with a previous history of acute myocardial infarction.

• ○ Sinus rhythm
• ✓ Right bundle branch block
• ✓ Abnormal Q-waves
• ✓ STEMI (ST-elevation myocardial infarction)

Question 2

An 88-year old diabetes patient is in the ER due to chest discomfort and dyspnea. His cardiovascular risk profile, duration of diabetes, sex, age and symptoms are all suggestive of myocardial ischemia. Your colleague suggests that the ECG shows right bundle branch block (RBBB), sinus tachycardia and abnormal Q-waves.

• ✓ Sinus tachycardia.
• ✓ PR interval ≈200 ms
• ✓ ST-segment elevations in V1-V4 and reciprocal ST depressions in aVL and I.
• ✓ Abnormal Q-waves in inferior leads (II, aVF, III).
• ✓ There are no signs of right bundle branch block (RBBB).

Question 3

ECG recorded in a 83 year old male with a history of diabetes, hypertension and peripheral artery disease. His diabetologist recently added dapagliflozin to his diabetes treatment and noted significant improvement in blood pressure, glycemic control and exercise capacity. Which two major abnormalities can be seen on the ECG?

• ○ Sinus tachycardia
• ✓ Rapid, irregular ventricular rate and no visible P-waves, indicating atrial fibrillation.
• ✓ Signs of left ventricular hypertrophy (high voltage in chest leads)
• ○ Ischemic ST elevations and hyperacute T-waves in V1-V3.

Explanation. The ECG shows signs of left ventricular hypertrophy (LVH) and atrial fibrillation. There are no signs of ischemia; ST elevations and ST depressions are expected in V1-V3 and V5-V6, respectively, in left ventricular hypertrophy (LVH). These ST-changes are secondary due to abnormal ventricular activation in the hypertrophic myocardium. Likewise, T-waves reflect ventricular repolarization and is also enlarged in LVH.

Question 4

ECG recorded in a 83 year old male with a history of diabetes, hypertension and peripheral artery disease. His diabetologist recently added dapagliflozin to his diabetes treatment and noted significant improvement in blood pressure, glycemic control and exercise capacity. Which two major abnormalities can be seen on the ECG?

• ○ Sinus tachycardia
• ✓ Rapid, irregular ventricular rate and no visible P-waves, indicating atrial fibrillation.
• ✓ Signs of left ventricular hypertrophy (high voltage in chest leads)
• ○ Ischemic ST elevations and hyperacute T-waves in V1-V3.

Explanation. The ECG shows signs of left ventricular hypertrophy (LVH) and atrial fibrillation. There are no signs of ischemia; ST elevations and ST depressions are expected in V1-V3 and V5-V6, respectively, in left ventricular hypertrophy (LVH). These ST-changes are secondary due to abnormal ventricular activation in the hypertrophic myocardium. Likewise, T-waves reflect ventricular repolarization and are also enlarged in LVH.

Question 5

An 88-year old diabetes patient is in the ER due to chest discomfort and dyspnea. His cardiovascular risk profile, duration of diabetes, sex, age and symptoms are all suggestive of myocardial ischemia. Your colleague suggests that the ECG shows right bundle branch block (RBBB), sinus tachycardia and abnormal Q-waves.

• ✓ Sinus tachycardia.
• ✓ PR interval ≈200 ms
• ✓ ST-segment elevations in V1-V4 and reciprocal ST depressions in aVL and I.
• ✓ Abnormal Q-waves in inferior leads (II, aVF, III).
• ✓ There are no signs of right bundle branch block (RBBB).

Explanation. All choices are correct!

Question 6

This ECG, with an irregular ventricular rate around 55 to 65 bpm, shows which of the following?

• ○ Atrial flutter
• ✓ Atrial fibrillation
• ○ Sinus arrhythmia

Explanation. There are no P-waves and the ventricular rate is irregular, but below 100 bpm, which is not typical for atrial fibrillation. This may be explained by use of beta blockers, other drugs or impaired AV conduction. The waves in lead V1 are not flutter waves (F-waves); flutter waves should be seen in multiple leads (notably lead II), display consistent morphology (appearance) and interval, which is not the case here. These waves are referred to as coarse f waves (coarse fibrillatory waves). Hence, atrial fibrillation may be classified as either fine atrial fibrillation or coarse atrial fibrillation.

Question 7

A 71-year-old woman in the Intensive Care Unit (ICU) with Covid-19 (SARS-COV-2) infection produced this ECG. The findings are consistent with all of the following except?

• ○ Right bundle branch block
• ○ Left anterior fascicular block
• ✓ Left posterior fascicular block
• ○ Sinus tachycardia

Explanation. The ECG shows sinus tachycardia, right bundle branch block and left anterior fascicular block. For details, refer to  left anterior fascicular block and left posterior fascicular block.

Question 8

What is the arrhythmia?

• ✓ Atrial flutter
• ○ Atrial fibrillation

Question 9

ECG produced by 59-year-old woman with rheumatic mitral valve disease. The ECG shows which of the following?

• ✓ P-mitrale
• ✓ Left ventricular hypertrophy (LVH)
• ✓ Sinus tachycardia
• ○ Ectopic atrial tachycardia

Explanation. Patients with rheumatic mitral valve disease  typically develop atrial and ventricular enlargement. ECG signs of left atrial enlargement (P mitrale) have low sensitivity but high specificity.

Question 10

Are there any P-waves?

• ○ Yes
• ○ No

Explanation. There are no obvious P-waves, which makes AVNRT the most likely diagnosis in this narrow QRS complex tachycardia.

Question 11

Are there any P-waves?

• ○ Yes
• ✓ No

Explanation. There are no obvious P-waves, which makes AVNRT the most likely diagnosis in this narrow QRS complex tachycardia.

Question 12

This 54-year-old patient with Covid-19 (Sars-Cov-2) has a slightly irregular rhythm. What is the rhythm and should you be concerned about the q-waves in the inferior leads (II, aVF, III)?

• ○ The rhythm is sinus rhythm.
• ✓ The rhythm is sinus arrhythmia.
• ✓ The q-waves are within normal limits (<30 ms duration).
• ○ The q-waves are abnormal.

Explanation. Current criteria for abnormal q-waves states that the duration of the q-wave must be equal or greater than 30 ms.