Practice Ekgs
EKGs as taken from 150 Practice ECGs:� Interpretation and Review by George J. Taylor. � For all of these images, pretend you are in the ED and have little or no background information about the patient. Make note of all abnormalities present, not just what the question asks for!
Note:��� You might have to click Start twice to get it started.
Note2:� To review the EKG & explanation for each question, look for�the link at the top of the next question.
- 1.
- A.
Acute MI
- B.
Brugada syndrome
- C.
Normal ECG
Correct Answer
C. Normal ECGExplanation
There is a P before every QRS, so the rhythm is sinus. The rate is around 75.Rate this question:
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- 2.
- A.
Right axis deviation
- B.
Left axis deviation
- C.
Left bundle branch block
Correct Answer
B. Left axis deviationExplanation
The axis vector is approximately -35 degrees.Rate this question:
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- 3.
- A.
Normal EKG
- B.
Atrial fibrillation
- C.
Nonspecific T wave changes
Correct Answer
C. Nonspecific T wave changesExplanation
The rate is 105, axis 0 degrees. T waves are flat in the lateral leads and there is minimal ST depression.Rate this question:
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- 4.
- A.
Inferior MI, uncertain age
- B.
Anterior MI, 3 days ago
- C.
Lateral MI, right now
Correct Answer
A. Inferior MI, uncertain ageExplanation
Axis is 90 degrees. Deep Q waves in II, III, and aVF indicate inferior wall scar but is not consistent with an active, current MI.Rate this question:
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- 5.
- A.
Ischemia
- B.
Pericarditis
- C.
Costochondritis
Correct Answer
A. IschemiaExplanation
Sinus tachycardia, axis 70 degrees. Anterior infarction and ST depression are both consistent with ischemia. This could also be called a septal MI.Rate this question:
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- 6.
- A.
Acute MI
- B.
Digoxin toxicity
- C.
J-point elevation
Correct Answer
C. J-point elevationExplanation
J point is the junction between the QRS and the ST segment. The ST segments are elevated V2-V6 but maintain normal shape with upward concavity. Inferior leads show small Q waves but these are too small to be pathologic.Rate this question:
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- 7.
- A.
Ventricular tachycardia
- B.
Supraventricular tachycardia
- C.
Sinus tachycardia
Correct Answer
B. Supraventricular tachycardiaExplanation
The rate is 160/min and this is narrow-complex, ruling out V-tach. It's too fast for sinus tach in an elderly person. There is the presence of a left anterior fascicular block, and the axis is -45 deg or beyond.Rate this question:
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- 8.
- A.
Old anterior MI
- B.
Old lateral MI
- C.
Mobitz type 1
Correct Answer
A. Old anterior MIExplanation
Broad Q waves in V1 and V2 suggest an anterior MI that is uncertain but likely old.Rate this question:
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- 9.
- A.
Yes
- B.
No
Correct Answer
B. NoExplanation
Look for 1st degree AV block, LAFB, incomplete RBBB, LVH, and repolarization changes. Syncope is not likely in someone with 1st degree block.Rate this question:
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- 10.
- A.
1st degree AV block
- B.
Mobitz I block
- C.
3rd degree AV block
Correct Answer
A. 1st degree AV blockExplanation
The P wave is buried in the T wave downslope in II, making the QT appear a bit longer in that lead. I have no idea why she is losing her memory, but it's probably not evident on the EKG.Rate this question:
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- 11.
- A.
Atrial fibrillation
- B.
Second degree heart block
- C.
Right bundle branch block
Correct Answer
A. Atrial fibrillationExplanation
The lack of P waves suggest atrial fibrillation. Inferior Q waves suggest an old inferior MI. There is LAFB.Rate this question:
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- 12.
- A.
Procainamide
- B.
Amiodarone
- C.
Digoxin
Correct Answer
C. DigoxinExplanation
There is underlying AFib and possible LVH. ST segments sag as if you hooked them with you finger and dragged them down, different than what you typically see in ST depression from ischemic or strain. In this patient, the Afib is probably being rate-controlled with digoxin.Rate this question:
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- 13.
- A.
Normal EKG
- B.
Non-specific ST segment changes
- C.
Poor R-wave progression
Correct Answer
B. Non-specific ST segment changesExplanation
Flat T waves and sagging ST segments in V3-V5 aren't quite normal. The Q wave in III is not concerning because it is not present in contiguous leads.Rate this question:
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- 14.
- A.
Left atrial enlargement
- B.
Right atrial enlargement
- C.
Normal atrial sizes
Correct Answer
A. Left atrial enlargementExplanation
Note the notched P wave in the inferior leads as well as the biphasic appearance in V1, which are classic findings in Left atrial enlargement. Other abnormal findings to note are left axis deviation, RBBB, LVH with repolarization abnormalities, and prolonged QT interval.Rate this question:
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- 15.
- A.
Mobitz II heart block
- B.
Non-hypokalemic U waves
- C.
Hypokalemic U waves
Correct Answer
B. Non-hypokalemic U wavesExplanation
In this EKG, there are U waves seen in V3-V6. There are also findings of LVH, poor R wave progression, and possible inferior MI.
DDx for U waves: Sinus bradycardia accentuating the U wave; Hypokalemia (remember the triad of ST segment depression, low amplitude T waves, and prominent U waves); Quinidine and other type 1A antiarrhythmics; CNS disease with long QT intervals (often the T and U fuse to form a giant "T-U fusion wave"); LVH (right precordial leads with deep S waves); Mitral valve prolapse (some cases); HyperthyroidismRate this question:
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- 16.
- A.
Aortic stenosis
- B.
Tricuspid regurgitation
- C.
Patent ductus arteriosus
Correct Answer
B. Tricuspid regurgitationExplanation
Note the Right atrial enlargement (tall P waves in inferior leads) with possible Left atrial enlargement as well. There is Right axis deviation with strain pattern in V1. Of the murmurs that accentuate with inspiration, tricuspid regurgitation is the one most likely to give you RVH. The PDA would give a systolic and diastolic murmur. With a PDA, there is usually only LVH present but you can get biventricular enlargement if pulmonary hypertension develops.Rate this question:
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- 17.
- A.
Cardiac tamponade
- B.
Pneumonia
- C.
COPD flare
Correct Answer
C. COPD flareExplanation
There is striking Right atrial enlargement as well as an axis of 90 degrees. In combination with poor R wave progression, there is likely pulmonary hypertension that developed over time due to COPD. The tachycardia is ominous and this patient ended up on the ventilator a few hours later.Rate this question:
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- 18.
- A.
Atrial fibrillation
- B.
Atrial flutter
- C.
Multifocal atrial tachycardia
Correct Answer
B. Atrial flutterExplanation
There is a ventricular pacemaker with 100% capture, which explains the wide QRS and LBBB pattern. The flutter waves can be seen in inferior leads as well as V1.Rate this question:
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- 19.
- A.
Mitral regurgitation
- B.
Tricuspid regurgitation
- C.
Aortic regurgitation
Correct Answer
A. Mitral regurgitationExplanation
Biphasic P wave in V1 and probably notched P wave in inferior leads indicate Left atrial enlargement. LVH is probable but the typical strain pattern is not seen, which can sometime indicate mildly dilated LV and increased mass without wall thickening. This patient probably had mitral regurgitation although you cannot make the diagnosis by EKG alone.Rate this question:
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- 20.
- A.
Sodium level
- B.
Digoxin level
- C.
Complete blood count
Correct Answer
B. Digoxin levelExplanation
Prolonged QT interval around 550 ms, RBBB, and lack of P waves are concerning. This is a nodal rhythm (HR 58) with retrograde P waves present. You should be concerned about digoxin toxicity especially if there is renal failure present as well. Also check potassium and magnesium, since the patient has been on diuretic therapy.Rate this question:
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- 21.
- A.
Active ischemia
- B.
Heart failure
- C.
Pericarditis with pericardial effusion
Correct Answer
B. Heart failureExplanation
The patient likely had an anterior MI a month ago with persistent ST elevation. His lack of symptoms suggest against active MI currently. New onset of heart failure is by itself an indication for echocardiography. Persistent ST elevation in an infarct zone may indicate LV aneurysm, a consequence of completing an infarct.Rate this question:
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- 22.
- A.
Right coronary artery occlusion
- B.
Left circumflex occlusion
- C.
Proximal LAD occlusion
Correct Answer
C. Proximal LAD occlusionExplanation
The T waves seen here are also known as Wellen's T waves, an extremely concerning finding suspicious for a proximal LAD or Left main lesion. This is a patient who should get the usual initial medications (ASA, Plavix, statin, etc) with the addition of a IIb/IIIa inhibitor like eptifibatide.Rate this question:
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- 23.
What is the distribution of his current ischemia?
- A.
Anterior only
- B.
Inferior only
- C.
Anterior and inferior
Correct Answer
C. Anterior and inferiorExplanation
With an MI, you usually don't get ST elevations in multiple distributions. Usually that finding would suggest more pericarditis than acute MI. But pericarditis is unlikely since you have upwardly convex ST segments and T wave inversions concurrently, whereas in pericarditis the ST segments usually normalize before T waves invert.
This patient had a partial inferior MI 2 years ago and was getting collateral flow through the LAD. Now, he has blocked his LAD which knocked out his anterior wall as well as the remaining inferior wall.
His prognosis is bad.Rate this question:
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- 24.
If he were to go into an SVT, what type of SVT might he go into?
- A.
AVRT
- B.
AVNRT
- C.
Atrial fibrillation with RVR
Correct Answer
A. AVRTExplanation
The rate, rhythm, and axis are all normal here. The key finding is the slurred upstroke, also known as pre-excitation or delta waves, on the EKG. Patients with Wolff-Parkinson-White (WPW) who have a fatal arrhythmia can present with AVRT, which is a kind of supraventricular tachycardia (SVT) that involves the accessory pathway. AVNRT, in contrast, does not require an accessory pathway and instead circles around the AV node.Rate this question:
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- 25.
If you gave this patient adenosine, what might you see on the continuous feed EKG?
- A.
Fibrillation waves followed by return of tachycardia
- B.
Sinus rhythm and possibly no return of SVT
- C.
Flutter waves followed by return of tachycardia
Correct Answer
B. Sinus rhythm and possibly no return of SVTExplanation
The HR of 180 with a narrow complex QRS suggests a supraventricular tachycardia (SVT). An SVT from Atrial flutter with 2:1 conduction to the ventricules usually results in a characteristic HR 150, so Aflutter is less likely. The rhythm is highly regular making Afib with RVR less likely due to the rapid HR, although it can sometimes be difficult to detect small variations when the rate is so fast. AVNRT is the likely diagnosis here. With adenosine, you see a sinus rhythm and sometimes adenosine is enough by itself to break the arrhythmia.Rate this question:
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- 26.
- A.
Normal sinus rhythm
- B.
Slow atrial fibrillation
- C.
Normal pacemaker pattern
Correct Answer
C. Normal pacemaker patternExplanation
There are pacing spikes before the P wave and QRS, suggesting a dual-chamber pacemaker. The presence of an apparent LBBB pattern suggests that the pacing lead is in the Right ventricle. This pacemaker's settings were DDD (dual-chamber sensing, dual-chamber pacing).Rate this question:
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- 27.
- A.
3rd degree heart block
- B.
Slow sinus rhythm with PVCs
- C.
Mobitz II heart block with 2:1 conduction
Correct Answer
A. 3rd degree heart blockExplanation
Complete heart block, or 3rd degree block, means no signals are getting from the atria to the ventricles. It can often be hard to distinguish Mobitz II with 2:1 conduction from 3rd degree block. However, to have 2:1 conduction you need to see a believable PR interval, even if it's prolonged. The next-to-last P wave on this strip has such a long PR interval that it's hard to believe it's truly being conducted.Rate this question:
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- 28.
What is the territory of the affected myocardium?
- A.
Inferoseptal
- B.
Anterolateral
- C.
Posterior
Correct Answer
B. AnterolateralExplanation
This is a classic EKG for antero-lateral ischemia with ST elevation. There are depressions in the inferior leads but no ST elevations. This is a monster-sized MI that has caused elevation in V2-V6, plus I and aVL. The preceding episode of chest pain was likely unstable angina that spontaneously resolved. Cardiac catheterization would likely show a high LAD lesion. Note the QT prolongation here as well.Rate this question:
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- 29.
Should he require admission, should he be monitored on telemetry?
- A.
No, the EKG is normal sinus
- B.
No, the EKG shows only left atrial enlargement
- C.
Yes, he is at risk for ventricular arrythmias
Correct Answer
C. Yes, he is at risk for ventricular arrythmiasExplanation
The two main abnormal findings on this EKG are the Left atrial enlargement and long QTc of around 540 ms. Some antihistamines can prolong the QT, especially in combination with erythromycin. He should be monitored on telemetry given the history of syncope and the finding of prolonged QT interval.Rate this question:
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- 30.
- A.
Give the patient IV magnesium, stat!
- B.
Give the patient IV lidocaine, stat!
- C.
Call a cardiology consult, stat!
Correct Answer
A. Give the patient IV magnesium, stat!Explanation
The wide-complex ventricular arrhythmia is a polymorphic ventricular tachycardia, otherwise known as torsade de pointes. The primary treatment is magnesium infusion. Other treatments include over-drive pacing or isoproterenol in an attempt to shorten the QT via tachycardia.Rate this question:
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- 31.
In panel B, what kind of arrhythmia is present?
- A.
Polymorphic ventricular tachycardia
- B.
Monomorphic ventricular tachycardia
- C.
Atrial fibrillation with LBBB
Correct Answer
B. Monomorphic ventricular tachycardiaExplanation
This is monomorphic ventricular tachycardia in panel B followed by ventricular fibrillation in panel C. The underlying cardiomyopathy predisposed her to malignant arrhythmias, and she could have been a candidate for an AICD based on the SCD-HeFT and MAD-IT II studies.Rate this question:
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- 32.
- A.
Progressive conduction system disease and LBBB
- B.
Left ventricular hypertrophy with strain pattern
- C.
Ventricularly-paced EKG
Correct Answer
C. Ventricularly-paced EKGExplanation
The pacer spikes can sometimes be very small and difficult to see, but this EKG in fact shows a paced rhythm. The patient's history of arrythmia could have been Mobitz II block or intermittent complete heart block, for example, requiring a ventricularly-paced pacemaker. While technically this resembles LBBB since the pacer signals originate in the Right ventricle and then head left, the correct interpretation of this EKG would be ventricularly-paced rather than LBBB.Rate this question:
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- 33.
What is the next best step in the management of this patient?
- A.
Admit to cardiac ICU and strongly consider catheterization
- B.
Send him home since the T wave inversions are nonspecific
- C.
Admit to medicine floor with telemetry
Correct Answer
A. Admit to cardiac ICU and strongly consider catheterizationExplanation
In general, T-wave inversions are nonspecific findings and can be seen in a number of disorders. However, these T waves are deep and symmetrically inverted, which is concerning. There is also the hint of ST elevation in V2 and V3 although not absolute. If he had not had chest pain, you could probably ignore these findings. But given the story, you should worry about unstable angina or NSTEMI and consider early angiography.Rate this question:
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- 34.
- A.
H2 blocker or proton pump inhibitor
- B.
Admit to CICU and call the cath team
- C.
Aspirin only, follow up with PMD
Correct Answer
B. Admit to CICU and call the cath teamExplanation
There is ST elevation in the inferior leads as well as V5 and V6, suggestive of an inferolateral ischemia. The reciprocal ST depressions in V1-V3 are consistent with this diagnosis. With a late presentation, you would probably still catheterize her but thrombolysis would carry an unacceptably high risk of myocardial rupture compared to the benefit gained for revascularizing a small MI.Rate this question:
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- 35.
- A.
Anterior myocardial ischemia
- B.
Old right bundle branch block
- C.
Brugada syndrome
Correct Answer
C. Brugada syndromeExplanation
Brugada syndrome was first described in the 1990s. Note the ST elevation in V1-V3 is saddle-shaped. The apparently-wide QRS suggestive of RBBB or incomplete RBBB is actually due to J-point elevation. There is a defect in the cardiac membrane sodium channel which increases risk of sudden VT and death. EP screening is indicated for this patient. See also http://emedicine.medscape.com/article/163751-overview and http://en.ecgpedia.org/wiki/Brugada_Syndrome.Rate this question:
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- 36.
- A.
Long QT interval
- B.
Long QT and RBBB
- C.
Complete heart block
Correct Answer
A. Long QT intervalExplanation
The QTc is 700 ms, which probably explains the history of arrythmias. There is also Left atrial enlargement (probably), and there is definitely LBBB. QT prolongation is hard to interpret sometimes if there is gross conduction system abnormalities. But with a QTc this long, it wouldn't hurt to look over his meds list and check simple electrolytes and magnesium.Rate this question:
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- 37.
- A.
Left ventricular hypertrophy
- B.
Right ventricular hypertrophy
- C.
Normal EKG
Correct Answer
B. Right ventricular hypertrophyExplanation
The axis is key to decoding this EKG. Notice that it's rightward at about 120 degrees. The tall R waves in V1 and deep S in V6 make RVH likely. She probably has cor pulmonale given the history of emphysema. The Left atrial enlargement is unexpected as you typically would see Right enlargement instead. Maybe she has hypertension.Rate this question:
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- 38.
- A.
Left bundle branch block
- B.
Inferior myocardial ischemia
- C.
Antero-lateral myocardial ischemia
Correct Answer
C. Antero-lateral myocardial ischemiaExplanation
The QRS is definitely wide enough for a bundle-branch block, but the dominant findings here are the ST-segment elevations present V1-V6, in an antero-lateral distribution. Pericarditis is a cause of ST-segment elevations across multiple distributions but typically does not cause such large elevations. This is a large MI with ST elevations spanning 9 leads, probably affecting the proximal LAD.Rate this question:
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- 39.
- A.
Wolff-Parkinson-White
- B.
Left bundle branch block
- C.
Brugada syndrome
Correct Answer
A. Wolff-Parkinson-WhiteExplanation
This looks like LBBB but the key finding is the short PR interval due to a delta wave. The diagnosis here is Wolff-Parkinson-White (WPW) syndrome. This patient needs an EP study and likely radiofrequency ablation of the accessory pathway. Note, conduction through an accessory pathway can come and go. However, a bundle branch block should be persistent and is usually invariable.Rate this question:
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- 40.
- A.
Low serum potassium level
- B.
High serum potassium level
- C.
High serum magnesium level
Correct Answer
B. High serum potassium levelExplanation
This patient was on potassium supplements, and her diuretics were HCTZ and spironolactone. This is an EKG consistent with mild hyperkalemia. The patient's potassium was around 6. As potassium level goes higher, the T waves become as tall or taller than the QRS. Eventually you get widening of the QRS and prolonged PR interval, resembling a sine wave. Arrythmias tend to be bradyarrhythmias in hyperkalemia.Rate this question:
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- 41.
- A.
Retrograde P waves from SVT
- B.
Mobitz II with 2:1 conduction
- C.
Myocardial ischemia
Correct Answer
C. Myocardial ischemiaExplanation
This is a paced rhythm, but the pacer spikes don't look like typical spikes. Here, they're tall and biphasic, making them look like QRS complexes. But they're actually followed by low-voltage QRS complexes and ST-elevations in the inferior leads. This pattern is typical of an older-style unipolar lead, whereas most pacers these days tend to use bipolar leads.Rate this question:
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- 42.
- A.
Digoxin effect
- B.
Normal EKG
- C.
Septal ischemia
Correct Answer
A. Digoxin effectExplanation
This patient's Afib was probably rate-controlled with digoxin, although she is in sinus with 1st degree block here. The QTc is nearly 500 ms, and there is ST-segment sagging in V2-6. Women are more likely to have atypical symptoms of ischemia compared to men, so it is important to be vigilant and rule-out ischemia.Rate this question:
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- 43.
- A.
NSAIDs
- B.
Thrombolytics
- C.
Prednisone
Correct Answer
B. ThrombolyticsExplanation
The key finding here is an inferior MI with ST-elevations in II, III, and aVF with a hint of depression in I and aVL. There are also lateral T-wave inversions. Data published in 2007 showed that peri-infarct use of NSAIDs was associated with increased 30-day mortality. Prednisone use is discouraged during an infarct because of the increased chances of free wall rupture.Rate this question:
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- 44.
- A.
Right bundle branch block only
- B.
Left bundle branch block only
- C.
Right ventricular hypertrophy
Correct Answer
C. Right ventricular hypertrophyExplanation
Rhythm is unclear but likely not sinus. It could be Aflutter or a nodal rhythm but most leads are low-voltage. Axis is probably 110 degrees. To diagnose her RVH, look for the R in V1, S in V6, and RAD. She has cor pulmonale.Rate this question:
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- 45.
- A.
Thrombolytics
- B.
Med-evac for cardiac catheterization
- C.
Thrombolytics followed by cardiac catheterization ASAP
Correct Answer
A. ThrombolyticsExplanation
This patient should get thrombolytics for an inferior ischemia (II, III, aVF) with reciprocal depressions in I and aVL. Cardiac catheterization would likely be delayed due to the need to travel to the regional cardiac center. Since time is myocardium, the patient should get treated ASAP with whatever is available. Facilitated PCI where thrombolytics are followed by catheterization has not been shown to be any more effective than thrombolytics alone and probably adds the risk of procedural complications.Rate this question:
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- 46.
- A.
Hyperkalemia - give Miralax
- B.
Lateral ischemia - cardiac catheterization
- C.
Old posterior infarct - no further intervention necessary
Correct Answer
B. Lateral ischemia - cardiac catheterizationExplanation
The QRS is nearly isoelectric with a tall R wave in V1-2. If you were to look at this backwards and upside down, it would resemble a Q wave in the posterior distribution. In that orientation, the tall deep T waves might resemble deep T wave inversions like you see in Wellen's T waves. The ST-elevation in V6 is unmistakable and requires intervention. This may have started as a posterior infarct that has an acute lateral infarct component. You CAN miss lateral infarcts on an EKG that would only be seen if you did an 18-lead EKG.Rate this question:
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- 47.
- A.
Acute pericarditis
- B.
Digoxin effect
- C.
Afib-induced ischemia
Correct Answer
C. Afib-induced ischemiaExplanation
The lack of P waves with a HR 130 in an older patient raises the possibility of ischemia, since the heart is probably working against fixed coronary obstructions. There are multiple territories with ST-depression. Tachycardia can aggravate pre-existing ST-depressions as well. This patient had a pulmonary embolus as the etiology of the Afib with RVR.Rate this question:
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- 48.
- A.
Inferior ischemia
- B.
Anterior ischemia
- C.
Frequent PVCs
Correct Answer
A. Inferior ischemiaExplanation
There is ST depression in the anterior leads and ST elevation in the inferior leads. The anterior leads look more dramatic, and it can be easy to miss ischemia in another territory if you don't read all leads of the EKG carefully. The ST elevations define the location of the MI however, not the ST depressions. This patient had only an occluded Rt coronary without any other significant obstructions.Rate this question:
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- 49.
What EKG features would most strongly suggest monomorphic ventricular tachycardia?
- A.
Rate >100 bpm, narrow QRS, AV dissociation
- B.
Rate >120 bpm, wide QRS, fusion beats, AV dissociation
- C.
Rate >120 bpm, wide QRS, capture beats, duration >30 s
Correct Answer
B. Rate >120 bpm, wide QRS, fusion beats, AV dissociationExplanation
There are no absolute criteria for the diagnosis of Ventricular Tachycardia. The HR should generally be tachycardic (although there is an entity that resembles a slow VT seen in post-MI patients). The pattern should be wide-complex by definition. If you're lucky, you might see fusion or capture beats which suggest a still functioning sino-atrial system. The corrolary to this is the presence of AV dissociation, since the atrial beats are fairly unaffected by the Vtach. In this case, this EKG might actually represent 2:1 flutter given the rate of 150, suspicious P waves in V2, and a nonconducted P in V4 near the last beat.Rate this question:
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Jan 25, 2013Quiz Edited by
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May 12, 2011Quiz Created by
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