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Chapter 25 Test — Advanced ECG Techniques: An Introduction for Medical Students
24 questions · 24 min · +4 / -1
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Question 1
Question 1
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A 50-year-old man is set up for a treadmill exercise tolerance test using the Bruce protocol. The cardiologist plans to run the test to 85% of the age-predicted maximum heart rate. What is his maximum predicted heart rate?
A.
150 beats/min
B.
170 beats/min
C.
200 beats/min
D.
160 beats/min
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Question 2
Question 2
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A cardiologist is reviewing referrals for exercise tolerance testing. Which of the following patients does NOT have an absolute contraindication to a treadmill exercise stress test?
A.
A patient with unstable angina, still having rest pain over the past 48 hours
B.
A patient with symptomatic severe aortic stenosis and exertional syncope
C.
A patient with confirmed active infective endocarditis on IV antibiotics
D.
A 68-year-old man with a 5.5 cm abdominal aortic aneurysm
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Question 3
Question 3
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A 55-year-old man with exertional chest pain undergoes an exercise tolerance test. Which of the following findings during the test would NOT raise suspicion of severe multivessel coronary artery disease?
A.
Onset of ST depression early, at a low workload
B.
Persistence of ST changes late into the recovery phase
C.
Achievement of more than 10 METs with no chest pain or ST change
D.
ST-segment elevation in lead aVR during exercise
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Question 4
Question 4
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A 68-year-old man with stable angina and hypertension is being assessed before elective major vascular surgery. His resting ECG is unremarkable, but his functional capacity is poor (less than 4 METs). Which investigation gives the most accurate prognostic information about his perioperative cardiac risk?
A.
Exercise ECG testing
B.
Dobutamine stress echocardiography
C.
Myocardial perfusion scintigraphy
D.
Coronary angiography
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Question 5
Question 5
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During a treadmill exercise stress test, the ST segment must be assessed at a defined point before the test can be called positive. At which point is exercise-induced ST depression measured?
A.
40 milliseconds before the J point
B.
At the peak of the T wave
C.
At the J point itself
D.
80 milliseconds after the J point
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Question 6
Question 6
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The figure shows three morphologies of exercise-induced ST-segment depression. Which of these is regarded as a NON-SPECIFIC finding that does NOT satisfy the criteria for a positive exercise stress test?
A.
Upsloping ST depression
B.
Horizontal ST depression
C.
Downsloping ST depression
D.
Both horizontal and downsloping depression
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Question 7
Question 7
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A 58-year-old man with exertional chest pain undergoes a Bruce-protocol treadmill test. Which of the following results satisfies the criteria for a positive (ischaemic) exercise stress test?
A.
1.5 mm upsloping ST depression at J+80 ms in leads V4 to V6
B.
1.5 mm downsloping ST depression at J+80 ms in leads V4 and V5
C.
2 mm J-point depression in lead aVL alone, with the ST segment back at baseline by J+80 ms
D.
0.5 mm horizontal ST depression at J+80 ms in leads II and III
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Question 8
Question 8
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During an exercise stress test, a 60-year-old man develops 2 mm ST-segment ELEVATION in leads V2 to V4. His resting ECG showed no Q waves in these leads. This finding most likely indicates:
A.
A false-positive result, typical of women and patients on digoxin
B.
A previous transmural infarct with a left ventricular aneurysm
C.
A normal physiological response to exercise
D.
Severe ischaemia from a near-total coronary occlusion
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Question 9
Question 9
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A 35-year-old woman describes clearly defined episodes of palpitations lasting a few minutes, occurring about once a week. Her resting ECG is normal and a 48-hour Holter recorded no arrhythmia. What is the most appropriate next step?
A.
Implantation of an implantable loop recorder
B.
Repeat the 24-hour Holter monitor next week
C.
A patient-activated event recorder
D.
Exercise stress testing on a treadmill
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Question 10
Question 10
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A 68-year-old man has had four episodes of syncope without warning over two years. Examination, echocardiography, a 48-hour Holter and a 4-week event recorder have all been unrevealing. What is the investigation of choice now?
A.
Exercise stress testing
B.
Implantable loop recorder
C.
Signal-averaged ECG
D.
A further 48-hour Holter recording
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Question 11
Question 11
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Which statement about the implantable loop recorder (ILR) is correct?
A.
It is simply another name for a subcutaneous implantable cardioverter-defibrillator
B.
It paces the ventricle whenever it detects a long pause
C.
Its battery lasts approximately 6 months
D.
It is implanted subcutaneously and records the rhythm without delivering therapy
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Question 12
Question 12
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Which of the following can be derived from a 24-hour Holter recording but CANNOT be meaningfully assessed from a standard 10-second 12-lead ECG?
A.
Heart rate variability (SDNN)
B.
The presence of a delta wave
C.
The corrected QT interval
D.
The frontal plane QRS axis
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Question 13
Question 13
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The signal-averaged ECG shown is reported as abnormal. The shaded low-amplitude, high-frequency signal at the terminal portion of the QRS complex represents:
A.
An epsilon wave, which is visible on the standard 12-lead ECG
B.
Late potentials from slowly conducting myocardium within scar
C.
A delta wave of ventricular pre-excitation
D.
Electrical alternans due to pericardial effusion
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Question 14
Question 14
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In which of the following patients would a signal-averaged ECG be technically uninterpretable?
A.
A 60-year-old in permanent atrial fibrillation with left bundle branch block
B.
A 55-year-old in sinus rhythm three weeks after an anterior MI, with a narrow QRS
C.
A 50-year-old in sinus rhythm with a prior inferior MI and a normal QRS duration
D.
A 30-year-old in sinus rhythm being evaluated for suspected ARVC
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Question 15
Question 15
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A signal-averaged ECG performed four weeks after a myocardial infarction shows late potentials. What does this result mean?
A.
It indicates that reperfusion therapy has failed to restore flow
B.
It shows that the patient has developed atrial fibrillation
C.
It indicates a roughly 3-fold higher risk of sudden cardiac death
D.
It confirms an established diagnosis of ventricular tachycardia
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Question 16
Question 16
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The figure illustrates a technique in which beat-to-beat RR intervals are trended over time and analysed by power spectrum into low-frequency and high-frequency components. This technique principally assesses:
A.
Autonomic nervous system control of the heart
B.
Conduction over an accessory pathway
C.
The burden of myocardial scar and fibrosis
D.
Coronary flow reserve
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Question 17
Question 17
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A 60-year-old man is reviewed six weeks after an anterior myocardial infarction. His 24-hour Holter reports an SDNN of 42 ms. What does this indicate?
A.
High heart rate variability — good vagal tone and a favourable prognosis
B.
Physiological sinus arrhythmia requiring no further attention
C.
An artefact, because HRV cannot be measured after a myocardial infarction
D.
Severely reduced heart rate variability — an adverse prognostic sign
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Question 18
Question 18
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Which statement about heart rate variability (HRV) is correct?
A.
HRV is best measured from a standard 10-second 12-lead ECG
B.
High HRV signifies a dangerously irregular heart and predicts sudden death
C.
High HRV reflects flexible parasympathetic control and is a healthy sign
D.
HRV characteristically increases with ageing, diabetes and heart failure
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Question 19
Question 19
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The two QRS complexes shown carry extra notches (circled). What is the accepted diagnostic criterion for fragmented QRS?
A.
A single notch on the upstroke of the R wave in any one lead
B.
Any notching of the QRS complex in a patient with left bundle branch block
C.
An additional R wave (R′) or notching of the R or S wave in ≥2 contiguous leads
D.
A QRS duration exceeding 120 ms in any two contiguous leads
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Question 20
Question 20
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A 62-year-old diabetic man has no Q waves on his ECG, but fragmented QRS complexes are present in leads II, III and aVF. What does this most likely indicate?
A.
Left bundle branch block involving the inferior leads
B.
An acute inferior STEMI requiring immediate reperfusion
C.
A previous silent inferior myocardial infarction
D.
A normal variant with no prognostic significance
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Question 21
Question 21
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A 52-year-old woman with atypical chest pain and ST-T abnormalities on her resting ECG undergoes a treadmill test, which shows 1 mm horizontal ST depression. How should this result be handled?
A.
Report it as diagnostic of obstructive coronary disease and start dual antiplatelet therapy
B.
Report the test as uninterpretable and recommend an imaging stress test
C.
Report it as positive and refer for immediate thrombolysis
D.
Repeat the same treadmill test after 48 hours
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Question 22
Question 22
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Which of the following patients is MOST likely to have a false-negative exercise stress test?
A.
A woman with left ventricular hypertrophy and resting ST-T changes on her baseline ECG
B.
A patient with a Wolff-Parkinson-White pattern and a delta wave on the resting ECG
C.
A patient taking digoxin whose resting ECG shows scooped ST depression
D.
A man with single-vessel disease on a beta-blocker who stops early
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Question 23
Question 23
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Artificial intelligence algorithms trained on millions of ECGs have been validated to identify which of the following from a standard 12-lead ECG — a diagnosis a human reader cannot reliably make from the ECG alone?
A.
Reduced left ventricular ejection fraction
B.
Atrial fibrillation present at the moment of recording
C.
First-degree atrioventricular block
D.
The frontal plane QRS axis
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Question 24
Question 24
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Which ECG monitoring modality is correctly paired with its usual recording duration?
A.
Implantable loop recorder — 3 to 4 years
B.
Event recorder — 10 seconds
C.
Holter monitor — 3 to 4 years
D.
Standard 12-lead ECG — 24 to 48 hours
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