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Chapter 18 Test — Bundle Branch Blocks: RBBB, LBBB, Fascicular Blocks and MI Diagnosis
26 questions · 26 min · +4 / -1
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Question 1
Question 1
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A QRS duration between 100 and 120 milliseconds suggests all of the following, EXCEPT:
A.
Normal / borderline QRS duration
B.
Left anterior fascicular block
C.
Left posterior fascicular block
D.
Complete left bundle branch block
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Question 2
Question 2
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A wide QRS complex (≥120 ms) is typically seen in:
A.
Bundle branch block
B.
Sick sinus syndrome
C.
Mobitz type I second-degree AV block
D.
Mobitz type II second-degree AV block
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Question 3
Question 3
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All of the following are recognised causes of right bundle branch block, EXCEPT:
A.
Occurrence in a structurally normal heart, as a normal variant
B.
Acute pulmonary embolism
C.
Cor pulmonale
D.
Severe aortic stenosis
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Question 4
Question 4
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A 45-year-old man presents with sudden chest pain radiating to the left arm and jaw with profuse sweating. His ECG shows a QRS of ≥120 ms with a broad monophasic R wave in V5–V6 and a QS/rS pattern in V1. Which of the following best describes this ECG pattern?
A.
Right ventricular hypertrophy
B.
Right bundle branch block
C.
Left bundle branch block
D.
Ventricular tachycardia
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Question 5
Question 5
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A 68-year-old hypertensive man with a recent anterior STEMI has a broad QRS with a notched, M-shaped R wave in the lateral leads. Which of the following is associated with a RIGHT bundle branch block pattern rather than left bundle branch block?
A.
Acute myocardial infarction
B.
Aortic valve disease
C.
Lev disease
D.
Ashman phenomenon
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Question 6
Question 6
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Right bundle branch block occurring together with left anterior hemiblock is called:
A.
First-degree heart block
B.
Complete heart block
C.
Mobitz type II block
D.
Bifascicular block
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Question 7
Question 7
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A 54-year-old hypertensive man presents with three weeks of exertional dyspnoea. His ECG shows a QRS of 140 ms, an rSR’ ('rabbit-ear') complex in lead V1 and broad slurred S waves in leads I, V5 and V6. P waves are normal and the PR interval is 0.16 s. Which condition is MOST commonly associated with this pattern when it is newly acquired in an adult?
A.
Coronary artery disease
B.
Hyperkalaemia
C.
Wolff-Parkinson-White syndrome
D.
Hypothyroidism
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Question 8
Question 8
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A 58-year-old man develops a new right bundle branch block after radiofrequency catheter ablation for right ventricular outflow tract tachycardia. The catheter had damaged the muscular band that crosses the right ventricular cavity from the interventricular septum to the base of the anterior papillary muscle. Which conduction element does this band carry?
A.
Right bundle branch
B.
Left bundle branch
C.
Sinoatrial nodal fibres
D.
An internodal pathway to the AV node
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Question 9
Question 9
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The 12-lead ECG shown is from a 62-year-old man with exertional breathlessness. The QRS is broad, lead V1 shows an rSR’ complex and leads I and V6 show wide slurred S waves. The most likely diagnosis is:
A.
Left anterior fascicular block
B.
Complete left bundle branch block
C.
Left ventricular hypertrophy with strain
D.
Complete right bundle branch block
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Question 10
Question 10
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The two leads shown come from a patient whose QRS duration is 140 ms. The morphology illustrated is best described by which mnemonic and which diagnosis?
A.
WiLLiaM — left bundle branch block
B.
MaRRoW — right bundle branch block
C.
MaRRoW — left bundle branch block
D.
WiLLiaM — right bundle branch block
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Question 11
Question 11
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A patient has a QRS duration of 150 ms. Which single finding is MOST specific for left bundle branch block rather than right bundle branch block?
A.
An RSR’ (‘rabbit ear’) complex in lead V1
B.
A wide slurred S wave in leads I and V6
C.
Absence of the septal q wave in I, aVL, V5 and V6
D.
ST depression with T-wave inversion in leads V1–V2
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Question 12
Question 12
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A 19-year-old competitive footballer has a routine pre-participation ECG. He is completely asymptomatic with no family history of sudden death. The ECG shows sinus rhythm, a QRS duration of 110 ms and an RSR’ pattern in V1 with a small R’. The rest of the ECG is normal. What is the most appropriate next step?
A.
Start amiodarone and restrict him from all sport
B.
Arrange urgent coronary angiography
C.
Reassure him; no further cardiac investigation is required
D.
Refer for permanent pacemaker implantation
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Question 13
Question 13
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A 70-year-old woman with an established right bundle branch block has an ECG showing ST depression with T-wave inversion in V1 and V2. She is asymptomatic and troponin is normal. How should these changes be interpreted?
A.
Evidence of acute anteroseptal ischaemia requiring angiography
B.
Evidence of digoxin toxicity
C.
Evidence of posterior myocardial infarction
D.
Expected secondary (discordant) repolarisation changes of RBBB
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Question 14
Question 14
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A 66-year-old man with a left bundle branch block documented on ECGs for the last four years presents with 40 minutes of crushing chest pain. Which of the following findings on his current ECG most strongly suggests an acute myocardial infarction?
A.
T-wave inversion in leads I, aVL and V6
B.
ST elevation of 1.5 mm in V5, where the QRS is a broad positive R wave
C.
ST depression of 1 mm in V6
D.
ST elevation of 3 mm in V2, where the QRS is a deep QS complex 20 mm in depth
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Question 15
Question 15
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In the ORIGINAL Sgarbossa scoring system for diagnosing acute myocardial infarction in the presence of left bundle branch block, which single criterion scores 5 points and is on its own sufficient to activate the catheterisation laboratory?
A.
Concordant ST depression ≥1 mm in V1, V2 or V3
B.
T-wave inversion in leads V5 and V6
C.
Concordant ST elevation ≥1 mm in a lead with a positive QRS
D.
Excessively discordant ST elevation ≥5 mm in a lead with a negative QRS
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Question 16
Question 16
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A patient with an old left bundle branch block and ongoing chest pain has 4 mm of ST elevation in lead V3, where the preceding S wave is 12 mm deep. How should this be interpreted?
A.
The modified Sgarbossa criterion for excessive discordance is met, so acute MI is possible
B.
This is concordant ST elevation and therefore diagnostic of acute MI
C.
This is a normal degree of discordance and needs no further action
D.
No Sgarbossa criterion is met, because discordant ST elevation must be at least 5 mm
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Question 17
Question 17
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A 72-year-old man with chest pain has a left bundle branch block that is identical to an ECG filed three years ago. His Sgarbossa score is 0 and the first troponin is normal. What is the most appropriate management?
A.
IV adenosine to unmask the underlying rhythm
B.
Serial troponins and an echocardiogram
C.
Immediate thrombolysis on the basis of the LBBB alone
D.
Discharge home with a follow-up outpatient appointment
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Question 18
Question 18
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The ECG shown is from a 63-year-old hypertensive man. The QRS duration is under 120 ms, the frontal axis is about −55°, leads I and aVL show a qR pattern and leads II, III and aVF show an rS pattern. There is no evidence of LVH or inferior infarction. The most likely diagnosis is:
A.
Right bundle branch block
B.
Left anterior fascicular block
C.
Complete left bundle branch block
D.
Left posterior fascicular block
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Question 19
Question 19
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The ECG shown demonstrates right axis deviation with a qR pattern in leads II, III and aVF, an rS pattern in leads I and aVL, and a QRS duration under 120 ms. Before this can be reported as left posterior fascicular block, which of the following must be excluded?
A.
Left atrial enlargement
B.
Right ventricular hypertrophy
C.
Left ventricular hypertrophy
D.
First-degree atrioventricular block
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Question 20
Question 20
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The ECG shown is from a 74-year-old man with an old anterior myocardial infarction. It shows a QRS of 130 ms with an RSR’ complex in V1, together with left axis deviation and rS complexes in leads II, III and aVF. The most accurate description is:
A.
Complete left bundle branch block
B.
Right bundle branch block with left posterior fascicular block
C.
Right bundle branch block with left anterior fascicular block
D.
Isolated left anterior fascicular block
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Question 21
Question 21
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An 80-year-old man has RBBB with left anterior fascicular block on ECG. Over the past two months he has had three episodes of sudden loss of consciousness without warning, with rapid full recovery. Ambulatory monitoring has not yet captured an episode. What is the most appropriate management?
A.
Permanent pacemaker implantation
B.
Reassurance and annual follow-up
C.
Repeat ambulatory monitoring in one year
D.
Start a beta-blocker
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Question 22
Question 22
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A 78-year-old woman is investigated for dizziness. An ECG on Monday shows a typical right bundle branch block; an ECG taken on Thursday from the same patient shows a typical left bundle branch block. What does this indicate, and what is the appropriate management?
A.
Lead misplacement on one of the two recordings — simply repeat the ECG
B.
Alternating bundle branch block — an indication for urgent pacing
C.
Bifascicular block — observe with annual review
D.
Rate-dependent aberrancy — reassure and discharge
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Question 23
Question 23
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A 62-year-old man undergoes an exercise treadmill test. At rest and up to a heart rate of 88/min the QRS is narrow. Above 95/min the QRS abruptly widens to 140 ms with an LBBB morphology, and it narrows again during recovery as the rate falls. There is no chest pain and no ST deviation beyond that explained by the wide QRS. What is the most likely explanation?
A.
Intermittent Wolff-Parkinson-White pre-excitation
B.
Exercise-induced ventricular tachycardia
C.
Developing hyperkalaemia during exercise
D.
Tachycardia-dependent (rate-related) left bundle branch block
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Question 24
Question 24
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A 58-year-old woman becomes acutely breathless four days after a hip replacement. She is tachycardic at 118/min and hypotensive. Her ECG shows sinus tachycardia, an S wave in lead I with a Q wave and T-wave inversion in lead III, and a new right bundle branch block. What is the most likely diagnosis?
A.
Hyperkalaemia complicating acute kidney injury
B.
Massive pulmonary embolism with acute right heart strain
C.
Acute inferior wall myocardial infarction
D.
Brugada syndrome unmasked by postoperative fever
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Question 25
Question 25
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A 60-year-old man presents with an acute anterior STEMI due to proximal LAD occlusion. His admission ECG shows a new right bundle branch block that was not present on an ECG taken last year. What does this new RBBB signify?
A.
A benign normal variant of no prognostic importance
B.
That the infarct is confined to the inferior wall
C.
A large infarct with extensive septal damage, carrying high mortality
D.
That the ST elevation is artefactual and no reperfusion is required
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Question 26
Question 26
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A 45-year-old woman with long-standing pulmonary hypertension has an ECG showing a tall R wave in V1 with a single peak and no second (R’) deflection, right axis deviation, and a QRS duration of 95 ms. Which diagnosis best fits?
A.
Right ventricular hypertrophy
B.
Left posterior fascicular block
C.
Incomplete right bundle branch block
D.
Complete right bundle branch block
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