Professional Documents
Culture Documents
Internal Medicine
FACILITATOR: Jose P. Tirona, MD, FPCP, FPCP DATE: December 14, 2016
"The meaning of life is to find your gift. The purpose of life is to give it away." --Anonymous
OUTLINE
Cardiac conduction system of the heart Sudden Cardiac death
ECG Genetic basis
Heart failure
Arrhythmia
Treatment
Automaticity
Trigger activity LEGEND:
Reentry Blue and red – emphasis
Rhythm abnormalities Italicized – recordings 2016
Bradycardia
Purple – HB108 transcription
Tachycardia
Boxed/Green-2018
Antiarrhythmics
recordings
ATRIOVENTRICULAR NODE
At the base of interatrial septum
Spindle shape
Supplied mainly by the right coronary artery
specifically the RIGHT POSTERIOR
DESCENDING CORONARY ARTERY
Any ischemia in the right coronary artery
results to slowing of conduction or
dysfunction of the AV node, leading to
slow heart rates or bradyarrhythmias
Usual beat: 60 to 100
BUNDLE OF HIS
Emerges from the AV node
Courses across the interventricular septum
CARDIAC PACEMAKERS DUAL blood supply (AV NODAL ARTERY and
Structures in the heart that generate LEFT ANTERIOR DESCENDING ARTERY)
impulses producing electrical activity, which Supplied mainly by the left coronary artery
are mechanically converted to contractions Generates 20 – 40 bpm
Sinoatrial node
Atrioventricular node BUNDLE BRANCHES
Bundle of His Left bundle branch
Bundle branches Right bundle branch
Distal His-Purkinje system Also generates 20 – 40 bpm
The conduction system is usually supplied by the
Summary of the conduction system: SA node
left and right coronary artery.
Interatrial tract AV node His bundle Bundle
branches His-Purkinje system
SINOATRIAL NODE The right and left side of the heart
PRIMARY PACEMAKER of the heart contracts simultaneously. Any problem in
Junction of RA & SVC structure could lead to arrhythmias.
Supplied mainly by the SINUS NODE ARTERY
Supplied by right coronary artery in 60% of CARDIAC MYOCYTES
the time and in the left coronary artery in Intercalated disks are anchoring structures
the 40% of the time containing gap junctions.
Obstruction in these coronary arteries result to Cardiac muscle cells are faintly striated branching
dysfunction of SA node mononucleated cells, which connect by means of
Drives the main conduction of the heart intercalated disks to form functional network.
Usual beat: 80-100 The action potential travels through all cells
Blood supply is important because if there is impeded connected together forming a functional
there will be decrease in oxygen leading to syncytium in which cells function as a unit.
dysfunction & disease. Responsible for conduction.
DLSHSI COLLEGE OF MEDICINE 2018 | 1 of 23
CARDIAC ACTION POTENTIAL If its threshold decreases, the heart is prone to
Mainly dependent on ions and the transfer of ions develop arrhythmia such as ventricular
intra and extra-cellularly tachyarrhythmia and atrial arrhythmias
Resting membrane potential: -80 TO -90 MV FIVE PHASES OF ACTION POTENTIAL
Concentration gradient of potassium
ELECTROCARDIOGRAM
Clinical Applications THE ECG MACHINE
☤ Rhythm abnormalities In routine clinical electrochocardiography, 12
☤ Chamber enlargement leads are usually recorded:
☤ Ischemia / Infarction Standard leads: I, II, III
Augmented Leads: avR, avL, avF
WHAT IS AN ECG? Precordial Leads: V1,V2,V3,V4, V5, V6 9 The
Electrocardiogram standard leads and augmented leads
Valuable record of the heart’s electrical are attached to the extremities, while
activity the precordial leads are attached to
Easy to understand! the chest
Attach transthoracically
Tip: Just recognize the waveforms
Clinical applications:
Rhythm abnormalities
Chamber enlargement
Ischemia / infarction
When a patient comes to the
ER with chest pain, the 1st thing thing to do after
the history is to have an ECG
NORMAL VALUES
P WAVE (0.08 to 0.10 seconds) – Atrial
depolarization
P-R interval (0.12 to 0.20 seconds) - Conduction
from Atria to AV node
QRS (0.06 to 0.10 seconds) - Ventricular
depolarization, normally narrow
S-T segment – Ventricular repolarization
U WAVE – seen in some people
Q –Tc interval (< 0.44 seconds) – Ventricular
ECG INTERVALS depolarization and repolarization
Very important because a lot of ventricular
arrhythmias happen in this interval
Life threatening arrhythmias happen because
of changes in Q-T interval
Any disease or drug that prolong the Q-T
interval can render individuals prone to
sudden cardiac death secondary to
ventricular arrhythmias
QTc = QT divided by the Square root of RR
Any alteration or prolongation of these values can
reflect
Ifslowing of conduction
your P wave is prolonged = it can signify
Alterations in P-R interval = defects in the AV
node like the use of calcium channel blockers,
beta blockers, which affect the conduction of
the AV node
Widened QRS complex = Patients with large
hearts, MI, dilated cardiomyopathies or with
Any slowing in conduction cause prolongation in ventricular premature beats
the interval. So if there’s a large atrium, AV node
conduction will slow down and it will reflect as
prolongation of PR interval.
QRS complex defect – whether there’s
enlargement or delay in conduction in the
ventricles causing prolongation of conduction will
WIDEN the QRS complex
ST segment defect- any disease or defect that can
happen in ST segment will prolong it and it will
predispose it to a lot of arrhythmias
ST segment:
Primarily used to determine if the patient has an acute injury pattern/acute myocardial infarction (MI) or just an
ischemia; the ST segment is isoelectric meaning there is no electrical activity (kaya straight line lang sya sa ECG,
that’s the baseline voltage). We use the isoelectric point as basis to determine whether there is an ST elevation or
depression.
ST depression – means patient is having an ongoing ischemia or a non-ST elevation MI
ST elevation – patient is having an acute injury pattern or an ST elevation MI
ECG MEASUREMENTS
As you can see in the ECG, there several boxes.
The dark lines are the big boxes. The big boxes
are further divided into smaller boxes which
measure 1 mm each. For each big box, there are 5
smaller boxes horizontally and vertically for a
total of 25 small boxes in one big box.
These boxes represent seconds.
One small box is 0.04 sec (40 msec).
Hence, each big box is 0.2 sec (0.04 x 5).
The ECG paper speed is 25 mm/second.
Therefore, the smallest (1mm) horizontal
division corresponds to 0.04 second. (1mm
divided by 25 mm/second is 0.04 second)
RULE OF THUMB
Smallest square is 0.04
seconds x 5 large box is 1
second
1 large box is 0.2 seconds
10 mm/1 mV Reference
X axis - time
Y axis - amplitude
The paper speed will tell you whether you’re recording correctly or not. The normal paper speed is 25 mm/s. Whenever you look at the
ECG, it’s important to check the paper speed. If the speed is very fast (e.g. 50 mm/s), an actual heart rate of 70 beats may appear as 35
beats only on the ECG. So you might mistakenly interpret it as sinus bradycardia
Measurement of Rate:
Count how many small squares are there from the tip of the QRS to the tip of the next QRS (this is your RR
interval)
Bakit 1500? Kasi there are 1500 small boxes per minute:
1 small box = 0.04 sec
5 small boxes = 1 large box = 0.2 sec
25 small boxes = 5 large boxes = 1 sec
25 small boxes x 60 sec = 1500 small boxes = 1 min
So if you are using the big squares, use the 300 as numerator.
RHYTHM
The heart rhythm can be assessed while the axis can also be assessed. The axis is just the vector of the conduction, the
direction of the conduction.
Normal direction: The Sinus Node can go downwards and laterally, but axis can also change from the normal
cephalocaudal it could be reversed
Determine whether patient is in sinus beat or not. Sinus beat: the impulse is coming from the sinus node.
How to know if it’s a sinus beat?
a. It should always have a P wave preceeding each QRST
b. P wave should be normal looking
c. P waves should have the same contour in one lead. It is always upright in leads I, II and avF. If it’s negative in
I, II, and AVF, that impulse did not originate from the sinus node. Hindi rin pwede na in one lead, one impulse
is upright, and one is negative, or one impulse is mataba, the next is medyo mapayat. Same dapat lahat in one
lead.
MECHANISMS OF ARRHYTHMIA
Automaticity
Triggered Activity
Reentry
Please take note that this mechanisms can overlap. Meaning at one point one mechanism has triggered an arrhythmia and
another mechanism has perpetuated that particular arrhythmia. So pwedeng two mechanisms at the same time is
happening in one patient for example, one arrythmia is triggered by automaticity just like premature beat and then it is
being sustained and perpetuated by another mechanism such as re-entry and one particular example is one patient with
normal sinus rhythm and then being triggered by a premature beat and then develops atrial fibrillation.
1. AUTOMATICITY
Property of cardiac cells to undergo spontaneous depolarization and initiate an electrical impulse in the absence of
external electrical stimulation.
Result of net inward ionic current during phase 4 of the action potential
Inward current of sodium and calcium plus slow outward potassium current mainly pertaining to your action
potential.
A. NORMAL AUTOMATICITY
Depolarization is due to ionic currents involved in B. ABNORMAL AUTOMATICITY
impulse generation during physiological conditions. Due to ionic currents not normally involved in the
Drugs, adrenergic and cholinergic stimulation and initiation of spontaneous impulses and may become
hormones can affect normal automaticity (e.g. drugs pacemaker currents
that could make heart beat faster (tachycardia) like This can be exhibited by cells other than the sinus node.
drugs used in treatment of asthma like terbutalin, Predominant pacemaker is the SA node.
salbutamol, duolin nebulisations. On the other side, The atrial tissue can also exhibit abnormal
drugs can also decrease the normal automaticity or automaticity such as in patients with premature
make the patient (bradycardia) such as those atrial depolarization or supraventricular
hypertensive patients being given beta blockers or premature beat.
calcium channel blockers that can slow down heart rate The bundle of His or the junction and the
that could affect your normal automaticity. Adrenergic, ventricular tissue can also exhibit abnormal
cholinergic in the clinics in the hospital we give automaticity.
epinephrine, norepinephrine that can accelerate heart So as side from the normal sinus beat, these
rate. particular sites can also trigger an action
potential assuming that they have fired outside
the refractory period of that myocardium.
REGULARLY IRREGULAR. Regular beats 1-3 (sinus, sinus, sinus) followed by premature beat.
Let’s say this is a narrow complex, so this is a premature beat definitely this is not sinus, it doesn’t have a P wave, must be
coming from a, let’s say QRS complex, a ventricular premature beat and an atrial premature beat. But definitely this is a
premature beat, the question now is whether it is coming from the atria or the ventricle. We have criteria differentiating
which is atrial premature beat which is ventricular premature beat.
If you’re claiming it is ventricular premature beat because QRS complex is wide, BUT you can have a bundle branch in here
which can give rise to a wide QRS complex. The T wave gives us a clincher that this is a supraventricular premature beat
because the T wave is upright also your QRS complex. Normally kasi kapag ventricular premature beat negative yung T
wave and the axis is the same as the premature beats, doesn’t change kasi kapag ventricular nag-iiba yung axis nya
nagiging negative yung QRS complex mo.
Now this is a patient with atrial flutter, which is saw-toothed T-wave. If this particular arrhythmia is sustained, this is an
example of a re-entry mechanism, ito yung sinasabi natin na one mechanism can perpetuate another. This is triggered by an
abnormal automaticity and maintained by a re-entrant mechanism. So basically atrial flutter as we have seen here is a re-entry
mechanism. But the most common trigger is a premature beat, atrial or ventricular, mostly atrial.
From Harrison’s: Triggered activity is related to cellular afterdepolarizations that occur at the end of the action
potential, during phase3, and are referred to as early afterdepolarizations; when they occur after the action potential,
during phase 4, they are referred to as late afterdepolarizations. Afterdepolarizations are attributable to an increase
in intracellular calcium accumulation. If sufficient afterdepolarization amplitude is achieved, repeated myocardial
depolarization and a tachycardic response can occur
AFTERDEPOLARIZATIONS
Oscillations in the membrane potential that follow the upstroke of an action potential.
So nag-iiba iba yung membrane potential. The problem here are still channels, they either open up longer or
close faster due to a disease process. This happens during the repolarization stage.
Harbingers of fatal depolarization, destruction or fatal arrhythmias
Normally the resting membrane potential is -80-80 mV when this oscillations happen it become more positive or
negative then depolarization can happen that can upstroke action potential that can predispose you to fatal
arrhythmias.
Early Afterdepolarization
Sudden change in time course of repolarization of an action potential
Membrane potential does not follow the trajectory of normal repolarization but suddenly shifts in a
depolarizing direction
Can lead to second upstrokes or action potentials that occur before complete repolarization
Occurs during PHASE 2 or 3 of the action potential
*Label retyped: (A) monophasic action potential with a late phase-2 EAD synchronous U wave, causing prolongation of the
QT interval. (B) or left image, EAD of SUFFICIENT amplitude can trigger PVC or premature ventricular contraction, which
in turn can initiate torsades de pointes if preceded by a pause associated with hypokalemia or hypomagnesemia.
In this ECG: this shows as a premature ventricular contractions which usually happens in the ST segment
There are also problems in the repolarization, due to an alteration in K+ channels wherein the QT lengthens, hence,
early after depolarization usually occurs in phase 3.
You have an action potential, then all of a sudden you have a wave there, (as shown by the triggered beat label). Note
in Picture B that in the ECG, the wave was strong enough to be able to produce a QRS complex.
From Harisson’s: With increasing amplitude of afterdepolarizations, threshold can be reached and repetitive activity
produced). The danger is if you have an afterdepolarization that produces a QRS complex, this may cause
ventricular arrhythmia.
Delayed afterdepolarizations
Occur in conditions where there is INCREASE in CA 2+ in the myoplasm and the sarcoplasmic
reticulum above normal levels (CA OVERLOAD)
Digitalis, catecholamines
After phase 3 of the action potential
This is where ventricular arrythimias happens, Vtach or fibrillations
REFRACTORINESS
The phase in which any amount of stimulation the heart is relatively refractory,
cannot trigger a response! afterdepolarizations can produce a lot
Absolute refractory period (seen as the 0 in the of new arrhythms and patient can go
graph below.) into arrhythmia).
Portion of action potential during which no
stimulus can evoke response
Equivalent to Phase 0 (rapid influx of
sodium)
Coincides with the QRS. When you have QRS,
you cannot produce another QRS no matter
how much you stimulate it because the
ventricle has just depolarized
DISCLAIMER (From batch 2016): This large amount of text that you are about to read was briefly discussed. According to
the previous trans, Doc Tirona does not expect us to master this part at our current level (which frustrated the past-trans’
transcriber, as I am now), BUT STILL, NGUNIT SUBALI’T DATAPWAT, here’s the explanation. (correct me if I’m wrong na
lang).
The impulse conduction of the heart is normally uni-directional, it comes from the sinus node to the AV node to
the His-bundle. It usually just goes down.
But sometimes, in the area of the AV node, there are 2 pathways that may be present, one fast and slow.
The normal pathway conducts fast but recovers slow (longer refractory period). The other pathway conducts
slow but recovers fast.
Game! For example, you have an impulse, conduction will proceed normally one pathway (usually the
fast conduction slower recovery pathway). This pathway is then considered BLOCKED (or
UNIDIRECTIONALLY
BLOCKED PROPERTY).
Typical example of reentry. You have a PQRST, then all of a sudden, you have a premature atrial beat/P wave (small
bump). Also notice that the PR interval is prolonged, compared to the others, so you know that the impulse actually
passed through the slow pathway and this caused the rhythm to go very fast = arrhythmia. This particular arrhythmia
is called AV nodal reentrant tachycardia.
1. BRADYARRHYTHMIAS
Sinus node dysfunction – abnormal automaticity AVnode dysfunction – abnormal conduction
Sinus bradycardia (slowing of conduction in the AV node.)
Sinoatrial block 1st degree AV block
Bradycardia – Tachycardia syndrome 2nd degree AV block
3rd degree AV block
A. SINUS BRADYCARDIA
Regularly occurring PQRST
Rate < 60 / min (If you’ll zoom in and measure the HR, 48 beats per minute. It is slow and therefore is sinus bradycardia.)
The QRS and T waves are all normal.
Sinus Bradycardia.
The PR interval is prolonging (21, 31, 35), until hindi na ma-conduct ang Atrial impulse. Second degree AV block (Type I).
Constant PR interval followed by dropped beat. Second degree AV block (Type II).
E. HIGH-GRADE AV BLOCK
3 or more “p” waves for every 1 QRS.
Most impulses not conducted.
F. THIRD-DEGREE AV BLOCK
No more impulse from atrium reaches the ventricle.
QRS is not from atria or sinus but is coming from ventricle already.
If no more conduction from the atria, you have backup generators. What happens is that when there is no more
impulse, it is sensed by the junction or ventricles then these latent pacemakers would fire. Clue is that if you have
a narrow QRS (junctional galing). If wide, it is from the ventricle.
TREATMENT OF BRADYARRHYTHMIAS:
Drugs/pharmacologic
Device therapy: Pacemaker
2. TACHYARRHYTHMIAS
Supraventricular Arrhythmias Ventricular Arrhythmias
Sinus tachycardia Ventricular tachycardia
Atrial tachycardia Ventricular fibrillation
Atrial flutter/fibrillation
Junctional tachycardia
AV nodal reentrant tachycardia
AV reentrant tachycardia
1. SUPRAVENTRICULAR ARRHYTMIA
A. SINUS TACHYCARDIA
Regularly occurring PQRST
Rate: > 100 / min
Heart Rate of more than 100 bpm. Sinus Tachycardia. Sinus kasi regular yung PQRST sequence.
Sinus, sinus, and another sinus, tapos may premature contraction bigla!
C. SINUS ARRHYTHMIA
Normal in young individuals. All of them are coming from the sinus.
Identical but irregularly occurring PQRST
Longest PP or RR > the shortest by 0.16 seconds or more
From the book: The P wave is upright in leads II, III, and aVF and negative in lead aVR. The P---wave morphology
in lead V1 characteristically has a biphasic, positive/negative contour.
The longest RR interval is 94, the shortest is 60. 94 – 60 is 34. If more than 16, Sinus Arrhythmia.
It is common in patients with chronic lung problems such as COPD, emphysema. Sa atria nang-gagaling ung P wave but the
P waves are different. (Refer to the blue circles: Eto si juan, eto si pedro, eto si juancho.) Iba-iba yung itsura nila di ba?
Different morphologies of the P wave. This is because iba iba yung pinanggagalingan niya. PR interval also is different.
Irregularly irregular heart rhythm.
E.
ATRIAL FLUTTER (MACRO REENTRANT AT)
Atrial rate: 220 – 300 /min (P as flutter waves)
Variable degree of AV block (irregular RR interval)
Take note of the saw-toothed appearance of the P waves in ECG leads II, III, and aVF. ECG in AF is
characterized by the lack of organized atrial activity and the irregularly irregular ventricular response
Usually, flutter waves conduct in an even number. Example, atrial flutter with 4: 1 conduction or 4 flutter waves for 1
QRS. Or atrial flutter with 6:1 conduction. But sometimes, you may have an atrial flutter with varying conduction.
But always remember the sawtooth or picket fence appearance. Do not mistake this for an atrial fibrillation
because the rhythm is still organized. You can still see a normal P wave
DLSHSI COLLEGE OF MEDICINE 2018| 16 of 26
Typical example of reentry. You have a PQRST, then all of a sudden, you have a premature atrial beat/P wave (small
bump). Also notice that the PR interval is prolonged, compared to the others, so you know that the impulse actually
passed through the slow pathway and this caused the rhythm to go very fast = arrhythmia. This particular arrhythmia
is called AV nodal reentrant tachycardia
G. ATRIAL FIBRILLATION
MOST COMMON SUPRAVENTRICULAR Note that atrial fib can have a rate as high as 300,
ARRHYTHMIA IN CLINICS so pag pumasok lahat yan, mamamatay ka
No discernible P waves talaga. But remember the AV node beats at only
Irregular RR interval 60-100, so despite the fast rhythm from the
Irregularly irregular atrium, AV node will try to block it, so di lahat ng
There is a multiple foci of re-entry and the AV impulse pumapasok.
node conducts slower From the book: Although typically the rate will
A problem of reentry: there are impulses vary between 120 and 160 beats per minute, in
coming from several parts of the atrium. So some patients it can be >200 beats per minute.
Occasionally, AF appears to have a well---defined
instead of having a synchronized atrial
etiology, such as acute hyperthyroidism, an acute
contraction, the atrium is quivering. This is why
vagotonic episode, or acute alcohol intoxication.
there is no discernible P wave. Also, some
impulses are getting into the ventricle, some are Acute AF is particularly common during the
not, which is why the rhythm is irregular. acute or early recovery phase of major vascular,
abdominal, and thoracic surgery, in which case
Some impulses can still conduct to the ventricles
autonomic fluxes and/or direct mechanical
because there is no AV block. However, some
irritation potentiate the arrhythmia.AF also may
impulses can’t pass, kasi otherwise pag
be triggered by other supraventricular
pumasok lahat ng impulse, your patient will die
tachycardias.
of tachycardia.
AF is quite rapid, it can reach 500 bpm. BUT NGUNIT SUBALIT DATAPWAT, the AV node can only accommodate only one at
a time. (Di gaya ng iba, 2 or more (dapat isa lang! :P)). There is thus a physiologic slowing, as a protective mechanism for this
kind of arrhythmia.
2.VENTRICULAR ARRHYTHMIAS
In general, these have WIDENED QRS complexes due to the duration of the conduction across the ventricles is
slower.
A. PREMATURE VENTRICULAR CONTRACTION
Among the most common arrhythmias; occur in persons with or without heart disease
No P wave
Bizaare looking QRS
The impulse is coming from the ventricles, either left or right, such that one ventricle is depolarized before the
other, producing a wide QRS. (*usually narrow ang QRS because the right and left ventricles are contracting at
the same time.
Thus, the contraction you are predominantly seeing is actually that of the left ventricle because it’s the bigger
muscle. However, if right ventricle is stimulated earlier, contractions will separate. The right will contract earlier
and will block the left producing a left bundle branch block morphology. Kung mauna naman ung left, you have
right bundle branch block)
PVCs are associated with a "fully compensatory pause" = i.e., the duration between the last QRS before the PVC and
the next QRS complex equal to twice the sinus rate.
Narrow QRS,
Wide QRS,
Tas narrow ulit. PVC
2. Trigeminy
Every 3rd beat is a PVC; two normal beats, then an abnormal beat
Two sinus beats are followed by a VPC or every third beat is PVC
3. Couplets
2 Consecutive PVCs
Sinus rhythm then 2 PVC’s in succession
4. Triplets
3 consecutive PVCs
3 or more consecutive PVC’s are also called a Non-sustained Ventricular tachycardia when the rate exceeds
100 beats/min
Very chaotic rhythm, no recognizable P wave, no organized QRS contraction. All Chaos.
TREATMENT OF TACHYARRHYTHMIAS
Medical
Electrical
Ablative procedures
ANTI-ARRHYTHMICS
x Vaughan-williams classification table
SCD ETIOLOGY
1-13 years old: 1 out of 5
14 to 21 years old: 30%
Middle age to elderly: 88%
----------------end -------------------------
When the toxicity of being med school is really taking its toll
Think about the ones who did not make it to med school
The ones who were not lucky to be there
Your folks, who are scrounging up every centavo they have to keep you there
Think about the future patients who will benefit from the hell you’re going through
And think about the fact that you are aiming for the noblest profession of all
Noblest then, noblest now, and noblest forever will be.
-Anonymous
Notes:
Basically a mash up of 2016 and 2018 transes! HEHE remix
Removed parts of the ECG if you want to read about it see the 2016 tranx. Doc removed a lot of slides that’s why it’s shorter.
12. A 20---year---old male consulted because of 17. A phenylalkylamine calcium channel blocker that
palpitations. You did an ECG, which revealed sinus causes significant delay in AV nodal conduction:
rhythm with wide QRS complex and the presence of a.) Nifedipine
the delta wave. This finding is consistent with which of b.) Diltiazem
the following? c.) Amlodipine
a.) Ventricular Tachycardia d.) Felodipine
b.) Wolff---Parkinson White syndrome
c.) Long QT syndrome (ventricular 18. Antiarrhythmic drug used in patients with accessory
arrhythmias) d.) None of the above pathway And could trigger hypo/hyperthyroidism
a.) Amiodarone
13. The most common supraventricular tachyarrhythmia b.) Sotalol
seen in clinical Practice is which of the following? c.) Verapamil
a.) Atrial fibrillation d.) Flecainide
b.) Sinus arrest
c.) Junctional tachycardia 19. A 25---year---old female, known case of toxic goiter
d.) Ventricular tachycardia presented to the ER with palpitations. Her ECG showed
rapid heart rate with irregularly irregular rhythm and
14. Exhibits automaticity and regarded as the absent P waves. What is your ECG diagnosis?
predominant pacemaker of the heart a.) Atrial fibrillation
a.) Sinus node b.) AV node reentrant
b.) AV node c.) tachycardia c.) Sinus tachycardia
HIS bundle d.) d.) Sinus arrhythmia
Left bundle
20. A 28---year old male, asymptomatic consulted
15. Which of the following is primarily a disorder of for work clearance as a chief in a hotel. His ECG
impulse conduction? showed constant PR interval from beat to beat of 0.26
a.) Sick sinus syndrome b.) seconds. What is your ECG diagnosis?
Complete heart block c.) a.) First degree AV block b.)
Junctional tachycardia d.) AV Wenkebach block c.)
AV reentrant tachycardia Mobitz Type II AV block d.)
Complete heart block