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Chapter 22 Test — ECG in Special Populations: Pregnancy, Athletes and the Elderly
29 questions · 29 min · +4 / -1
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Question 1
Question 1
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The figure compares the ECG before and during a normal pregnancy. Which combination of changes is the expected physiological pattern?
A.
Sinus tachycardia, right axis deviation and complete right bundle branch block
B.
Sinus bradycardia, first-degree AV block and generalised low QRS voltage
C.
Sinus tachycardia, a leftward axis shift and a small Q wave in lead III
D.
Sinus bradycardia, a rightward shift of the QRS axis and deep Q waves in II, III and aVF
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Question 2
Question 2
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A 30-week pregnant woman attends for antenatal check-up with mild dyspnoea and palpitations. She has pedal oedema and an ejection systolic murmur. ECG shows sinus tachycardia, left axis deviation and occasional premature ventricular beats. Echocardiography shows a small pleural effusion and mild mitral regurgitation, with no other abnormality. What is the next line of treatment?
A.
Start diuretics
B.
Start endocarditis prophylaxis
C.
No treatment needed
D.
Terminate the pregnancy, as the features are diagnostic of heart failure
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Question 3
Question 3
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Regarding the cardiovascular system in normal pregnancy, which statement is TRUE?
A.
Cardiac output falls below pre-pregnancy levels
B.
The QRS axis shifts towards the right
C.
Left ventricular end-diastolic diameter increases
D.
The PR interval lengthens progressively
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Question 4
Question 4
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A 32-year-old woman at 30 weeks' gestation is asymptomatic. Her ECG shows a small Q wave in lead III. Which finding would best confirm that this Q wave is the benign positional change of pregnancy rather than an inferior myocardial infarction?
A.
The Q wave is accompanied by ST-segment elevation of 1.5 mm in lead III
B.
The QRS axis is more negative than -45 degrees
C.
A Q wave of the same depth is also present in leads II and aVF
D.
The Q wave disappears on a tracing taken during deep inspiration
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Question 5
Question 5
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A 28-year-old woman at 32 weeks' gestation has an ECG taken for mild palpitations. She is asymptomatic between episodes, has no family history of sudden death, and her QTc is 462 ms. What is the most appropriate action?
A.
Reassure and continue routine antenatal care
B.
Start oral propranolol immediately
C.
Arrange urgent genetic testing for long QT syndrome
D.
Admit for continuous telemetry and magnesium infusion
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Question 6
Question 6
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What is the most common arrhythmia encountered in pregnancy?
A.
Atrial fibrillation with a rapid ventricular rate
B.
Atrial flutter with 2:1 conduction
C.
Paroxysmal supraventricular tachycardia (PSVT)
D.
Symptomatic bradyarrhythmia
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Question 7
Question 7
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A 27-year-old woman at 34 weeks' gestation has a routine ECG. Which of the following findings is NEVER a normal variant of pregnancy and demands investigation?
A.
QRS axis of -20 degrees
B.
Resting heart rate of 98 bpm
C.
Occasional premature atrial and ventricular complexes
D.
New-onset atrial flutter
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Question 8
Question 8
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A 26-year-old woman at 24 weeks' gestation presents with a regular narrow-complex tachycardia at 190 bpm. Her blood pressure is 112/70 mmHg and she is alert. Vagal manoeuvres fail to terminate the rhythm. Which drug is the most appropriate next step?
A.
Intravenous amiodarone
B.
Intravenous sotalol
C.
Oral flecainide
D.
Intravenous adenosine
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Question 9
Question 9
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Peripartum cardiomyopathy typically occurs within what time frame?
A.
From the last month of pregnancy to within 7 days postpartum
B.
From the last month of pregnancy to within 6 weeks postpartum
C.
From the last month of pregnancy to within 24 months postpartum
D.
From the last month of pregnancy to within 5 months postpartum
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Question 10
Question 10
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Which of the following statements about peripartum cardiomyopathy are correct?
1. It is usually seen in multiparous women.
2. Echocardiography shows an ejection fraction less than 45%.
3. ACE inhibitors are contraindicated during the antenatal period.
4. A history of prior heart disease is usually present.
A.
1 and 2 only
B.
1, 2 and 3
C.
3 and 4 only
D.
1, 3 and 4
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Question 11
Question 11
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A 31-year-old woman on postpartum day 10 presents with progressive dyspnoea, orthopnoea and leg oedema. Her ECG is shown: sinus tachycardia with non-specific ST-T wave abnormalities. What is the most appropriate next investigation?
A.
Transthoracic echocardiography
B.
Repeat ECG in one week
C.
CT coronary angiography
D.
Thyroid function tests alone
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Question 12
Question 12
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A 32-year-old woman with no cardiovascular risk factors develops severe crushing chest pain on postpartum day 3. Her ECG shows ST-segment elevation in V2-V4. What is the most likely underlying cause?
A.
Rupture of an atherosclerotic coronary plaque
B.
Spontaneous coronary artery dissection (SCAD)
C.
Benign early repolarization
D.
Peripartum cardiomyopathy
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Question 13
Question 13
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Which of the following ECG changes in an asymptomatic athlete's heart should be considered pathological?
A.
Increased amplitude of the QRS complexes
B.
Second-degree (Mobitz I) AV block
C.
Prolonged QTc interval
D.
T-wave inversion confined to lead V1
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Question 14
Question 14
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The routine pre-participation ECG of an asymptomatic 20-year-old endurance athlete is shown. It shows sinus rhythm with tall precordial QRS voltages meeting voltage criteria for left ventricular hypertrophy, with no ST-segment depression and no T-wave inversion. Echocardiography shows symmetrical wall thickening of 12 mm with a dilated LV cavity. What is the most appropriate management?
A.
No further evaluation; clear him for competition
B.
Genetic testing for sarcomeric protein mutations
C.
Disqualify from competitive sport
D.
Cardiac MRI to look for myocardial fibrosis
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Question 15
Question 15
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The figure contrasts the ECG of the athlete's heart with pathological left ventricular hypertrophy. Which finding indicates that hypertrophy is pathological rather than training-related?
A.
A deep S wave in V1
B.
ST-segment depression with T-wave inversion in the lateral leads
C.
SV1 + RV5 greater than 35 mm by the Sokolow-Lyon criteria
D.
A tall R wave in V5 and V6
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Question 16
Question 16
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A 22-year-old asymptomatic marathon runner has an overnight Holter recording for routine screening. The rhythm shown - progressive PR prolongation followed by a dropped QRS complex - occurs several times during sleep and disappears completely during his treadmill test. What is the most appropriate management?
A.
Reassurance; no further cardiac investigation is needed
B.
Permanent pacemaker implantation
C.
Permanent disqualification from competitive sport
D.
Electrophysiological study
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Question 17
Question 17
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Which single ECG finding most strongly favours hypertrophic cardiomyopathy over the athlete's heart?
A.
Deep narrow Q waves in leads I, aVL, V5 and V6
B.
Voltage criteria for left ventricular hypertrophy
C.
Sinus bradycardia at 45 bpm
D.
Incomplete right bundle branch block
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Question 18
Question 18
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A 24-year-old competitive rower has voltage criteria for LVH on ECG and an echocardiogram showing symmetric left ventricular wall thickness of 14 mm. He is asymptomatic with no family history of sudden death. What is the best non-invasive way to distinguish the athlete's heart from hypertrophic cardiomyopathy in this 'grey zone'?
A.
Exercise ECG alone
B.
Repeat echocardiography after 3 months of detraining
C.
Serial high-sensitivity troponin measurement
D.
24-hour Holter monitoring
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Question 19
Question 19
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A 17-year-old sprinter collapses during a 400 m race and recovers fully within a minute. His examination and resting ECG appear normal. What is the most appropriate management?
A.
Advise adequate hydration and allow him to continue competing
B.
Full cardiac evaluation with temporary restriction from competitive sport
C.
Reassure; exercise-induced syncope in the young is vasovagal
D.
Permanent lifelong disqualification from all sport
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Question 20
Question 20
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An asymptomatic 21-year-old footballer has the ECG shown, with J-point elevation and concave ST-segment elevation of 2 mm in the precordial leads. Which additional feature would mean this pattern can no longer be called benign?
A.
A first-degree relative died suddenly at the age of 35
B.
The resting heart rate is 50 beats per minute
C.
The J-point elevation measures 2 mm rather than 1 mm
D.
The ST segment is concave ('smiley face') in shape
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Question 21
Question 21
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An asymptomatic 82-year-old man has the routine ECG shown: narrow QRS complexes with marked left axis deviation, a small q wave with tall R in leads I and aVL, and rS complexes in II, III and aVF. What is the diagnosis and the appropriate management?
A.
Left anterior fascicular block - no treatment; periodic follow-up
B.
Complete heart block - permanent pacemaker
C.
Left bundle branch block - urgent echocardiography and cardiology admission
D.
Inferior myocardial infarction - urgent coronary angiography
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Question 22
Question 22
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A 78-year-old woman presents after a syncopal episode preceded by weeks of dizziness. Her ECG shows right bundle branch block with left anterior fascicular block and a PR interval of 260 ms. What is the most appropriate next step?
A.
Reassure - these are expected age-related changes
B.
Start a beta-blocker for the dizziness
C.
Refer for pacemaker evaluation
D.
Repeat the ECG in six months
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Question 23
Question 23
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An 80-year-old asymptomatic man is found to have a PR interval of 230 ms on a routine ECG. Which additional feature most increases his risk of progression to complete heart block?
A.
A resting heart rate of 58 bpm
B.
A QRS duration of 90 ms
C.
A QRS duration of 140 ms
D.
A broad notched P wave in lead II
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Question 24
Question 24
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An 84-year-old hypertensive woman is found on routine review to have the rhythm shown - an irregularly irregular narrow-complex rhythm with no discernible P waves. Her ventricular rate is 88 bpm, she is minimally symptomatic, and her CHA2DS2-VASc score is 4. What is the highest management priority?
A.
Oral anticoagulation
B.
Amiodarone for rhythm control
C.
Electrical cardioversion to restore sinus rhythm
D.
Aspirin 75 mg daily
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Question 25
Question 25
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A 79-year-old man with COPD and kyphosis has an ECG showing QRS amplitudes below 5 mm in all limb leads. He is clinically stable and this is unchanged from a tracing taken two years ago. What is the most appropriate interpretation?
A.
An artefact requiring only a repeat ECG
B.
Diagnostic of previous extensive anterior myocardial infarction
C.
Definite pericardial effusion requiring urgent pericardiocentesis
D.
Low voltage explained by chest wall and lung changes; no acute action needed
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Question 26
Question 26
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A 76-year-old asymptomatic woman has an ECG showing intermittently non-conducted P waves with a constant PR interval in all conducted beats and a QRS duration of 130 ms. What is the most appropriate management?
A.
Annual ECG only
B.
Reassure - this is a vagally mediated benign finding
C.
Trial of atropine and repeat ECG
D.
Referral for permanent pacemaker implantation
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Question 27
Question 27
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Which ECG finding is normal in a healthy 3-day-old term neonate?
A.
QRS axis of -40 degrees with a dominant S wave in V1
B.
QTc of 500 ms
C.
Complete left bundle branch block
D.
QRS axis of +130 degrees with a tall R wave in V1
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Question 28
Question 28
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A 12-year-old boy has an ECG performed before joining a school sports team. Lead V2 is shown: the T wave is shallowly inverted, and a similar pattern is present in V1 and V3. He is asymptomatic, examination is normal, and there is no family history of sudden cardiac death. What is the correct interpretation?
A.
Hypertrophic cardiomyopathy - disqualify from sport
B.
Normal juvenile T-wave pattern - reassure
C.
Anterior ischaemia - urgent stress testing
D.
Arrhythmogenic right ventricular cardiomyopathy until proven otherwise
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Question 29
Question 29
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A 2-day-old neonate presents with cyanosis, a single second heart sound, and a pansystolic murmur best heard at the left sternal border. The ECG shows left axis deviation, right atrial overload and left ventricular hypertrophy. What is the most likely diagnosis?
A.
Tetralogy of Fallot
B.
Tricuspid atresia
C.
Transposition of the great arteries
D.
Total anomalous pulmonary venous connection
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