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Chapter 8 Test — ST Segment and T Wave: Mastering Ventricular Repolarization Patterns
23 questions · 23 min · +4 / -1
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Question 1
Question 1
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A 24-year-old man presents with pleuritic precordial chest pain that is worse lying flat. His ECG shows ST elevation with upward concavity together with PR-segment depression in leads V2 to V6, and the opposite changes (ST depression with PR elevation) in aVR. The ST-segment morphology is shown. The most likely diagnosis is:
A.
Acute anterior wall myocardial infarction
B.
Acute pericarditis
C.
Left ventricular aneurysm
D.
Aortic dissection
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Question 2
Question 2
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A 42-year-old man has had recurrent episodes of chest pain at rest, each lasting 10–15 minutes and settling spontaneously. He is
currently pain-free
. Serial troponins are normal. His ECG shows the pattern illustrated in leads V2–V3, with no ST elevation. What is the most likely diagnosis?
A.
Takotsubo (broken heart) syndrome
B.
Wellens syndrome
C.
Barlow syndrome
D.
Brugada syndrome
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Question 3
Question 3
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A 60-year-old woman presents with sudden severe headache, vomiting and loss of consciousness. CT confirms a subarachnoid haemorrhage. An ECG is recorded as part of her assessment. Which of the following is
NOT
an expected ECG change in this setting?
A.
Deep T-wave inversion with ST depression
B.
Peaked T waves
C.
QT prolongation
D.
Narrow QRS complex
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Question 4
Question 4
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A 62-year-old hypertensive smoker has new exertional retrosternal chest pain relieved by rest. His resting ECG is normal. Exercise ECG shows more than 2 mm of
horizontal
ST depression in V4–V6 at peak exercise, which resolves in recovery. Angiography shows an 80% proximal LAD stenosis with no plaque rupture or thrombus. Which mechanism best explains his symptoms and ECG?
A.
Vasospasm of an angiographically normal coronary segment
B.
Acute plaque rupture with non-occlusive intracoronary thrombus
C.
Coronary microvascular dysfunction with normal epicardial arteries
D.
Demand–supply mismatch beyond a fixed flow-limiting stenosis
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Question 5
Question 5
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The point marked in the illustration is used as the reference for measuring ST-segment displacement. Which statement about it is correct?
A.
It is the junction of the QRS complex and the ST segment, and ST level is read 60 ms after it
B.
It is the beginning of the P wave, and ST level is measured relative to the QT interval
C.
It is the end of the T wave, and ST level is measured relative to the following TP segment
D.
It is the peak of the R wave, and ST level is measured about 60 ms before it
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Question 6
Question 6
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Which segment should be used as the baseline reference when measuring ST-segment elevation or depression?
A.
The QT interval
B.
The R-R interval
C.
The TP segment
D.
The PR segment
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Question 7
Question 7
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A 55-year-old man presents with chest pain. Which of the following ST-segment measurements at the J point is
within normal limits
and does not by itself meet the criteria for ST elevation?
A.
1.5 mm of ST elevation in V2 and V3
B.
2.5 mm of ST elevation in V2 and V3
C.
1.5 mm of ST elevation in leads II, III and aVF
D.
2 mm of ST elevation in leads I and aVL
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Question 8
Question 8
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Two morphologies of ST-segment elevation are shown, labelled A and B. Which statement is correct?
A.
Panel A is convex and typical of STEMI; panel B is concave and typical of early repolarisation
B.
Both shapes are equally likely to represent acute transmural injury, so contour is unhelpful
C.
Panel B is convex ('tombstone') and suggests acute myocardial injury; panel A is concave and benign
D.
Shape is irrelevant; only the height of the ST elevation above baseline determines the diagnosis
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Question 9
Question 9
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A 22-year-old asymptomatic athlete has the ECG shown taken as part of a pre-participation screen. There is J-point elevation with concave ST elevation and prominent upright T waves in the mid-precordial leads, and no reciprocal ST depression. What is the most likely explanation?
A.
Acute anterior STEMI
B.
Acute pericarditis
C.
Benign early repolarisation
D.
Type 1 Brugada pattern
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Question 10
Question 10
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Most early repolarisation is entirely benign. Which combination of features identifies the uncommon
high-risk
variant that has been linked to ventricular fibrillation?
A.
J-wave amplitude <1 mm confined to V4–V6 with a rapidly upsloping ST segment
B.
J-point elevation that disappears completely during exercise testing
C.
J waves >2 mm in the inferior leads with a horizontal or downsloping ST segment
D.
Concave ST elevation in V2–V3 with tall upright T waves in a young athlete
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Question 11
Question 11
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Three patterns of ST-segment depression are illustrated. Which statement correctly ranks their significance for myocardial ischaemia?
A.
Upsloping depression is the most specific for ischaemia; horizontal depression is non-specific
B.
Downsloping depression is always a drug effect and never indicates ischaemia
C.
All three patterns carry identical significance once the depression exceeds 0.5 mm
D.
Horizontal and downsloping depression are significant; upsloping is usually non-specific
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Question 12
Question 12
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A 72-year-old woman with atrial fibrillation on long-term medication has the ST-segment appearance shown in her lateral leads. She is asymptomatic, and the change is present diffusely rather than in one territory. What does this most likely represent?
A.
Digoxin toxicity requiring immediate Fab fragments
B.
Reciprocal change from a posterior STEMI
C.
The digoxin effect at therapeutic levels
D.
Subendocardial ischaemia requiring urgent angiography
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Question 13
Question 13
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A 24-year-old woman with fever and dehydration has a heart rate of 155/min. Her ECG shows 1 mm of
upsloping
ST depression in several leads. She has no chest pain and no cardiac history. A repeat ECG after fluids, at a rate of 80/min, is completely normal. What is the best interpretation?
A.
Digoxin effect at therapeutic levels
B.
Rate-related ST change from the tachycardia
C.
Secondary ST-T change from left ventricular hypertrophy
D.
NSTEMI requiring dual antiplatelet therapy and heparin
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Question 14
Question 14
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A 68-year-old woman is admitted a few hours after the sudden death of her husband, with chest pain and the ECG shown, which demonstrates anterior precordial ST elevation. Urgent coronary angiography shows
no obstructive coronary disease
, and the left ventriculogram shows apical ballooning. What is the diagnosis?
A.
Takotsubo (stress) cardiomyopathy
B.
Benign early repolarisation
C.
Acute anterior STEMI with spontaneous reperfusion
D.
Acute pericarditis
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Question 15
Question 15
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Which of the following describes a
normal
T wave?
A.
Symmetric, with equal upslope and downslope, and always upright in aVR
B.
Peaked and narrow-based in all precordial leads, with a symmetric contour
C.
Asymmetric, upright in I, II and V4–V6, and inverted in aVR
D.
Always upright in every lead, including III, aVL, V1, V2 and aVR
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Question 16
Question 16
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Referring to the panel of T-wave morphologies, which description matches a
biphasic
T wave?
A.
A T wave that begins positive and then becomes negative within the same beat
B.
A broad, deeply negative T wave with a symmetric contour
C.
A low-amplitude T wave that is barely visible above the baseline
D.
A tall, narrow, sharply pointed T wave
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Question 17
Question 17
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The illustration shows the temporal evolution of ECG changes in ST-elevation myocardial infarction. Which change appears
earliest
, within minutes of coronary occlusion?
A.
T-wave inversion
B.
Hyperacute T waves
C.
Pathological Q waves
D.
Convex ST elevation
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Question 18
Question 18
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A 54-year-old man presents with 40 minutes of crushing chest pain. His ECG shows
upsloping ST depression ≥1 mm at the J point in V1–V6, followed by tall, peaked, symmetric T waves
, with slight ST elevation in aVR. There is no ST elevation elsewhere. What is the correct action?
A.
Give oral potassium — this is hypokalaemia
B.
Treat as a STEMI equivalent and activate the catheterisation laboratory immediately
C.
Arrange an outpatient exercise stress test
D.
Reassure and discharge — upsloping ST depression is non-specific
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Question 19
Question 19
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A 19-year-old asymptomatic man has a routine ECG before joining a gym. Lead V2 is shown; the same shallow T-wave inversion is present in V1–V3 and is unchanged from a tracing taken two years ago. The rest of the ECG is normal. What is the correct interpretation?
A.
Right ventricular hypertrophy
B.
Anterior myocardial ischaemia requiring troponins and admission
C.
Wellens syndrome, type B
D.
Persistent juvenile T-wave pattern
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Question 20
Question 20
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A 58-year-old woman is admitted with a sudden thunderclap headache and a reduced conscious level. Her ECG is shown: there are deep, symmetric, widespread T-wave inversions with a prolonged QT interval. Troponin is mildly raised. What is the most likely explanation?
A.
Acute anterior STEMI requiring immediate thrombolysis
B.
Secondary repolarisation change from left bundle branch block
C.
Digoxin effect
D.
Cerebral T waves from an acute intracranial event
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Question 21
Question 21
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The panel illustrates ST-T changes seen in LBBB, LVH, RBBB, pre-excitation and RVH. What do all of these changes have in common?
A.
They occur only during exercise and resolve completely at rest
B.
They are secondary changes, expected whenever the QRS complex is abnormal
C.
They are all caused by an electrolyte disturbance of some kind
D.
They are primary repolarisation changes and always require exclusion of ischaemia
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Question 22
Question 22
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The figure shows ST-T patterns in left bundle branch block. Panels A.1 and A.2 show ST-T deflections in the
same
direction as the main QRS deflection; panel B shows ST-T deflection
opposite
to the QRS. Which interpretation is correct?
A.
All three panels are normal findings in LBBB and none needs further assessment
B.
Panel B is abnormal and suggests ischaemia; panels A.1 and A.2 are the expected finding
C.
Panels A.1 and A.2 are abnormal and suggest superimposed ischaemia; panel B is expected
D.
All three panels are diagnostic of acute STEMI in the presence of LBBB
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Question 23
Question 23
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A monitor strip in a patient with frequent ventricular ectopy shows marked ST elevation and T-wave inversion
within the premature ventricular complexes
, while the sinus beats have a normal ST segment and T wave. What is the correct interpretation?
A.
The ST-T changes within a PVC are secondary and cannot indicate ischaemia
B.
This confirms hyperkalaemia and needs urgent treatment
C.
This is the digoxin effect and needs no action
D.
This is diagnostic of an acute STEMI and the cath lab should be activated
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