EHRA 2021 ECG Contest with correct answers

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CLINICAL CASE:
58 year-old patient, previous smoker, with no other relevant past medical history.
5 months of self-limited episodes of palpitations, without any other symptom.
He is admitted in the E.D. due to a new episode of palpitations, presenting with the following ECG:



Which is your diagnosis?

Ventricular tachycardia arising from the left ventricle. There is a capture beat!
Atrial flutter with AV variable conduction, with QRS aberrancy (RBBB).
Atrial fibrillation with aberrant conduction (RBBB).
Pre-excited atrial fibrillation.

CLINICAL CASE:
A 85 year-old patient with implanted pacemaker describes fatigue and palpitations.
He presents to your emergency department with the following ECG:

Picture56

What is your diagnosis?

Atrial tachycardia with appropriate ModeSwitch
Single chamber pacemaker with ventricular lead dysfunction
Dual chamber pacemaker with atrial lead dysfunction
Dual chamber pacemaker with ventricular lead dysfunction

CLINICAL CASE:
73 year-old male patient
Anamnestic data:

  • Previous myocardial infarction treated with angioplasty and stenting
  • PM DDD for sick sinus disease

Which is your diagnosis?

Ventricular tachycardia
Endless loop tachycardia
Atrial flutter
Atrial fibrillation

CLINICAL CASE:
A 70 year-old patient with history of arterial hypertension and vascular disease describes chest pain and palpitations.
He presents to your emergency department with the following ECG:



What is your diagnosis?

Sinus rhythm, AV block IIa
Sinus rhythm, AV block IIb, pericarditis
Sinus rhythm, AV block IIb, STEMI
Sinus rhythm, AV block III, STEMI

CLINICAL CASE:

  • 55 year-old lady
  • Background:
    • WPW syndrome with ablation of overt left anterolateral accessory pathway a few years ago
    • HLA B27 positive spondyloarthritis
    • Psoriasis
    • Monoclonal gammopathy of undetermined significance
    • Fibromyalgia
ECG at the GP surgery post ablation ECG at the GP surgery post ablation
  • Referred to heart rhythm clinic for ongoing palpitations and sinus tachycardia – mean HR on a 3-day Holter was 102 bpm
  • Medicaton: Flecainide, Methotrexate, Amitriptyline, Meloxicam, Folic acid, Sertraline, Pantoprazole

Which of the patient’s drugs could have caused this change in ECG?

Flecainide
Methotrexate
Meloxicam
Amitriptyline
Sertraline

CLINICAL CASE:
79 year-old patient with history of myocardial infarction presents to the ER with wide QRS tachycardia.
Based on the 12 lead ECG which is the most likely diagnosis?

Atrial fibrillation with LBBB
Atrial tachycardia with LBBB
Ventricular tachycardia
AVNRT with LBBB aberration
Antidromic AVRT using left sided accessory pathway

CLINICAL CASE:
47 year-old woman, electrophysiological study for recurrent episodes of palpitations. Normal cardiac echocardiography.



What is your diagnosis ?

Premature atrial contractions
Premature ventricular contractions
Double ventricular response
AVNRT

CLINICAL CASE:
A 75 year-old patient with history of arterial hypertension and vascular disease describes palpitations.
He presents to your emergency department with the following ECG:



What is your diagnosis ?

Ventricular tachycardia
Sinus tachycardia with pre-existing LBBB
Atrial tachycardia with LBBB
Atrial flutter with LBBB

CLINICAL CASE :

  • 47 year-old Iraqi
  • Exertional chest pain and palpitations
  • Not exercising regularly
  • Non-smoker, non-diabetic
  • Slightly overweight (BMI 27 kg/m2)
  • Family history: father died suddenly at the age of 52, assumed heart attack, but no autopsy performed

What is the likely diagnosis?

Hypetrophic cardiomyopathy
Arhythmogenic right ventricular cardiomyopathy with LV involvement
Amyloidosis
Coronary artery disease

CLINICAL CASE:
67 year-old patient with no known history of heart disease presents to the ER with dizzinness and palpitations.
Based on the 12 lead ECG which is the most likely diagnosis?

Atrial fibrillation with LBBB
Atrial flutter with LBBB
Ventricular tachycardia
AVNRT with aberration
Antidromic AVRT

Which is your diagnosis?

Atrial fibrillation
Accelerated junctional rhythm with atrio-ventricular dissociation
Atrial flutter
Third-degree atrioventricular block

CLINICAL CASE:
58 year-old patient with ICD (DDD 50-120 bpm) implanted in primary prevention.
Symptom:  pre-syncope



Which is your diagnosis?

Atrial lead dislocation
Ventricular lead dislocation
Artefacts
Atrial undersensing

Which of the following can be the cause of such ECG appearance:

KCNQ1 mutation, amiodarone, large meal
Fever, SCN5A mutation, sotalol
KCNQ1 mutation, amiodarone, SCN5A mutation
KCNQ1 mutation, sotalol, large meal

CLINICAL CASE:
18 year-old female patient, with family history of sudden cardiac death in a cousin at the age of 20 years old. Past medical history of 3 syncopal episodes, one of them during exercercise. Therefore, an exercise test is performed.
This is the ECG during the test:



Which is the rhythm in this ECG?

Sinus rhythm with ventricular ectopic beats
Bidirectional VT
Sinus rhythm with supraventricular ectopic aberrated beats
JET with 2:1 aberrancy of the his-purkinje system

CLINICAL CASE:
A 39 year-old patient without cardiovascular disease is resuscitated after cardiac arrest.
He presents to your emergency department with the following ECG:



Which is your diagnosis?

Hyperkalemia
STEMI
Idioventicular rhythm
WPW

CLINICAL CASE:
81 year-old man hospitalized for elective replacement of DDD pacemaker. Episode of palpitations with no episode recorded by pacemaker. New episode while monitored.



What is your diagnosis ?

Atrial oversensing
Atrial tahcycardia/flutter
Automatic threshold testing
Pacemaker mediated tachycardia

CLINICAL CASE:

  • 42 year-old female
  • Background:
    • Complex Tetralogy of Fallot with pulmonary atresia, right BT shunt and pericardial graft repair of pulmonary atresia at the age of 10
    • Pulmonary hypertension
  • Presenting complaint:
    • Six episodes of palpitations over 3 months, lasting between 25 minutes and 2.5 hours at approximately 160bpm
    • She does not feel unwell with this but only feels the palpitations. She had to go to A&E once with the longest episode. Otherwise, she has remained stable and able to perform most of her own activities.


The ECG with tachycardia likely shows:

SVT with aberrancy
SVT without aberrancy
Fascicular VT
VT related to anatomical isthmus 3
VT related to anatomical isthmus 4

CLINICAL CASE:
31 year-old patient is referred for ablation due to documented narrow QRS tachycardia.
Tachycardia starts spontaneously as wide QRS tachycardia and spontaneously changes to narrow QRS tachycardia. 12 lead ECG at 50 mm/s recordin speed is shown.
Based on the tracing, which is the most likely diagnosis?

AVNRT
AVRT using right sided accessory pathway
AVRT using left sided accessory pathway
AVNRT and fascicular VT
Atrial tachycardia

CLINICAL CASE:
48 year-old patient presents to the ER with atrial tachycardia.
Based on the 12 lead ECG which is the most likely origin of atrial tachycardia?

Lateral mitral annulus
Coronary sinus ostium
Left atrial appendage
Right inferior pulmonary vein
Right atrial appendage

CLINICAL CASE:
27 year-old patient, no history of cardiovascular disease.
Symptom:  syncope



Which is your diagnosis?

Normal ECG
Right bundle branch block
Brugada pattern
Anterior ST-segment elevation myocardial infarction

CLINICAL CASE:
67 year-old female patient, with past medical history of OSA, COPD and non-filliated stroke one year ago.  She complains of frequent palpitation episodes. This is her ECG:



What catches your attention in this ECG?

Nothing. The ECG is completely normal.
There is a constant artifact after the P wave.
Pre-excitation. WPW Syndrome.
Interatrial block. Bayes syndrome.

CLINICAL CASE:
76 year-old woman, history of myocardial infarction 15 years ago. Preserved LVEF.
Episode of sustained palpitations without hemodynamic compromise.



What is your diagnosis ?

Ventricular tachycardia
Atrial fibrillation
Atrial flutter
Reciprocating tachycardia

CLINICAL CASE:
29 year-old patient presents to the ER with recurrent palpitations and syncope.
Her medical history so far is unremarkable.
Based on the 12 lead ECG which is the most likely diagnosis?

Arrhythmogenic right ventricular cardiomyopathy
Hypertrophic cardiomyopathy
Long QT syndrome
Brugada syndrome

CLINICAL CASE:
36 year-old patient with no estructural heart disease presents to the ER with palpitations.  Tachycardia is terminate with verapamil iv. 12 lead ECG of tachycardia is shown.
What is the most likely diagnosis?

Bundle branch reentry ventricular tachycardia
Left ventricular outlow tract tachycardia
Antidromic AVRT using left sided accessory pathway
Idiopathic fascicular left ventricular tachycardia

CLINICAL CASE:
25 year-old patient presents to the ER with palpitations and dizziness. 12 lead ECG of tachycardia is shown.
What is the most likely diagnosis?

Ventricular tachycardia
Atrial fibrillation and right bundle branch aberrancy
Preexcited atrial fibrillation using right free wall AP
Preexcited atrial fibrillation using left posterior wall AP

Which is your diagnosis?

Right bundle branch block
Left lateral accessory pathways
Posteroseptal accessory pathway
Left posterior accessory pathway

CLINICAL CASE:
78 year-old patient, ischemic cardiomyopathy.
Symptoms:  palpitations and pre-syncope



Which is your diagnosis?

Atrial tachycardia
Ventricular tachycardia arising from the anterior wall of the left ventricle
Ventricular tachycardia arising from the inferior wall of the left ventricle
Pre-excitated atrial fibrillation

CLINICAL CASE:
71 year-old male patient, with ischemic dilated cardiomiopathy recently diagnosed, with 3-vessel disease and undergone a bypass surgery.
During and after the surgery, dobutamine infusion is required.
This is the ECG recorded at the ICU:



Which is the rhythm in this ECG?

Atrial fibrillation
Sinus rhythm with atrial extrasystoles
Junctional rhythm with constant retrograde VA conduction.
Junctional rhythm with dissociated sinus rhythm and some sinus beat-captures.

CLINICAL CASE:
72 year-old female patient with paroxysmal atrial fibrillation and diagnosed of bradicardia-tachycardia syndrome. Dual-chamber pacemaker was implanted for this reason.
The following ECG is recorded at the pacemaker clinic:



What can be seen on this ECG?

Normal functioning
Ventricle oversensing
Ventricular noncapture and undersensing
Ventricular undersensing

CLINICAL CASE:
40 year-old female patient, with past medical history of non-documented palpitations of 5-10 minutes duration. During one of these episodes she goes to the E.R., and an ECG is recorded right at the end of the tachycardia.



Which statement is true about the tachycardia?

This is atrial flutter with 2:1 conduction
AVNRT and AVRT can be ruled out.
Atrial tachycardia can be ruled out.
The tracing shows inappropiate sinus tachycardia and a sudden sinus pause

CLINICAL CASE:
44 year-old woman, hypertrophic cardiomyopathy. Episodes of palpitations and syncope.



What is your diagnosis ?

Ventricular tachycardia from the base of the LV
Ventricular tachycardia from the base of the RV
Ventricular tachycardia from the apex of the LV
Ventricular tachycardia from the apex of the RV

CLINICAL CASE:
17 year-old patient presents to the ER with recurrent palpitations and dizziness. His 12 lead ECG is shown. What is the most likely diagnosis?

AVNRT
Atrial flutter
Atrial fibrillation
Complete AV block
2nd degree AV block type Mobiz II

CLINICAL CASE:
74 year-old female patient with arterial hypertension.
12 months of self-limited episodes of palpitations, no angina, no (pre-)syncopes.
Based on a holter ECG recording, she was diagnosed with atrial fibrillation and submitted for evaluation of coronary angiography.
She presents at clinic with the following ECG*:

*paper speed is 50 mm/s

*paper speed is 50 mm/s


Which is your diagnosis?

Atrial fibrillation
Pre-excited atrial fibrillation
AVRT
Ventricular tachycardia

CLINICAL CASE:
A 16 year-old patient with implanted pacemaker presents to your outpatient clinic with the following ECG:



What is your diagnosis?

Selective His bundle pacing
Ventricular fusion beats
Lead switch
Ventricular lead displacement

CLINICAL CASE:
A 25 year-old lady with Wolff-Parkinson-White syndrome returned to the arrhythmia clinic after 12 years of absence. She had previously undergone unsuccessful ablation of a para-Hisian accessory pathway (AP) as an 11-year-old girl and was observed for mild/moderate left ventricular (LV) impairment. Since then she had been off drugs, she gave birth and recently had experienced palpitations for which she was prescribed flecainide.
Two days later she presented to the emergency department with severe palpitations, then suffered multiple VF arrests thus was given amiodarone. After last VF arrest she was resuscitated into complete heart block (CHB).
Electrophysiological study confirmed conduction via the AP and surprisingly no underlying atrio-ventricular nodal (AVN) activity. Therefore, the conclusion was that she has relied on her AP and when it became blocked by flecainide and then amiodarone, she arrested and went into CHB. Another ablation attempt was only transiently successful in eliminating the AP, so a biventricular defibrillator was implanted and she was discharged on a low dose of angiotensin receptor blocker. At 6-month follow-up no further arrhythmia was observed and the AP was still functional.

A
A

B
B

C
C

D
D

Task: put the ECGs in the chronological order (paper speed 25 mm/s in all tracings)

A, B, C, D
C, D, B, A
D, C, B, A
D, B, C, A
C, B, D, A

CLINICAL CASE:
80 year-old man, pacemaker (VVI) for permanent complete AV block without escape rhythm. Asymptomatic. Recording during continous monitoring after elective non-cardiac surgery:



What is your diagnosis?

Lost of ventricular capture
Ventricular tachycardia with undersensing
Atrial fibrillation with undersensing
Pacemaker-mediated tachycardia
0
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