Cardiovascular – Part 2 14Mar2009 DO NOT DISTRIBUTE - 1 - Cardiology #1 – Cardiac Function & Circulatory Control 1.1) Which of the following is NOT true regarding cardiac muscle? a) Fibers exhibit cross-striation and densely staining cross-bands b) Large mitochondria and glycogen stores are adjacent to each myofibril c) The cardiac muscle nucleus lies in the center of each cell d) The subendocardial layer has an impulse-conducting system e) The endocardium is the principle component of the cardiac muscle 1.2) Which of the following is considered a lateral, not transverse, component of cardiac muscle? a) Fascia adherens – binds to form the functional cardiac fiber b) Macula adherens – prevents cells from pulling apart c) Gap junctions – provides ionic continuity for syncytium behavior 2.1) Sarcoplasmic reticulum Ca++ ATPase (SERCA) activity is regulated by which of the following? a) Na+ release b) Electrical depolarization c) Phospholamban d) Ca++ binding to troponin C e) Actin/myosin interactions 2.2) Which of the following is most responsible for extruding Ca++ to maintain homeostasis on a beat-to-beat basis? a) SERCA b) Ca++ ATPase proteins c) Cardiac glycosides d) Na+/Ca++ exchanger e) Na+/K+ pump 3) Increased contractility, according to the Frank-Starling Law, is most dependent on: a) Afterload b) Preload c) Heart rate d) Pulse pressure e) Ca++ absorption 4) During which phase(s) of the cardiac cycle is the mitral valve open? a) Isovolumic contraction and filling phase b) Ejection phase and isovolumic relaxation c) Isovolumic relaxation and isovolumic contraction d) Filling phase and ejection phase e) None of the above 5.1) If total peripheral resistance (afterload) is increased, which of the following will also increase? a) Heart rate b) Ejection fraction c) Cardiac output d) Stroke volume e) Peak pressure
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Cardiovascular – Part 2 14Mar2009
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Cardiology #1 – Cardiac Function & Circulatory Control
1.1) Which of the following is NOT true regarding cardiac muscle?
a) Fibers exhibit cross-striation and densely staining cross-bands
b) Large mitochondria and glycogen stores are adjacent to each myofibril
c) The cardiac muscle nucleus lies in the center of each cell
d) The subendocardial layer has an impulse-conducting system
e) The endocardium is the principle component of the cardiac muscle
1.2) Which of the following is considered a lateral, not transverse, component of cardiac
muscle?
a) Fascia adherens – binds to form the functional cardiac fiber
b) Macula adherens – prevents cells from pulling apart
c) Gap junctions – provides ionic continuity for syncytium behavior
2.1) Sarcoplasmic reticulum Ca++ ATPase (SERCA) activity is regulated by which of the
following?
a) Na+ release
b) Electrical depolarization
c) Phospholamban
d) Ca++ binding to troponin C
e) Actin/myosin interactions
2.2) Which of the following is most responsible for extruding Ca++ to maintain
homeostasis on a beat-to-beat basis?
a) SERCA
b) Ca++ ATPase proteins
c) Cardiac glycosides
d) Na+/Ca++ exchanger
e) Na+/K+ pump
3) Increased contractility, according to the Frank-Starling Law, is most dependent on:
a) Afterload
b) Preload
c) Heart rate
d) Pulse pressure
e) Ca++ absorption
4) During which phase(s) of the cardiac cycle is the mitral valve open?
a) Isovolumic contraction and filling phase
b) Ejection phase and isovolumic relaxation
c) Isovolumic relaxation and isovolumic contraction
d) Filling phase and ejection phase
e) None of the above
5.1) If total peripheral resistance (afterload) is increased, which of the following will also
increase?
a) Heart rate
b) Ejection fraction
c) Cardiac output
d) Stroke volume
e) Peak pressure
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5.2) Which of the following is true of the end-diastolic force-length relationship
(EDFLR) and the end-systolic force-length relationship (ESFLR) when a patient is given
epinephrine (positive inotropic agent)?
a) EDFLR and ESFLR will increase
b) EDFLR will increase with little effect on ESFLR
c) ESFLR will increase with little effect on EEFLR
d) EDFLR and ESFLR will decrease
e) There will be little effect on both EDFLR and ESFLR
6) Which of the following determinants of cardiac performance is defined by sarcomere
stretching?
a) Preload
b) Afterload
c) Heart rate
d) Contractility (ventricular)
7) Which of the following is used clinically as a practical means to index the strength of
the heart? TPR = MAP – CVP / CO
a) Stroke volume
b) Ejection fraction
c) Cardiac output
d) Total peripheral resistance
e) Central venous pressure
8) Which of the following is NOT true regarding cardiovascular response to exercise?
a) Oxygen consumption increases about 18-fold and CO increases 6-fold
b) Venous oxygen saturation decreases from 75% to 25%
c) Arterial dilation is a result of released potassium and other vasodilators
d) Preload remains constant throughout exercise
e) Vagal tone is withdrawn and sympathetic drive is increased
9) Which of the following is NOT an age-related change to the cardiovascular system?
a) Sympathetic response to exercise decreases
b) Cellular hypertrophy occurs
c) Coronary perfusion decreases
d) Large arteries stiffen
e) Chronotropic and inotropic response to sympathetic mediation decreases
Cardiology #2 – Osteopathic Considerations in Cardiovascular Medicine
1.1) A patient presents with a myocardial infarction. After pharmacologic treatment has
been started, manipulative procedures can further decrease oxygen and energy demands.
Manipulation at which of the following areas would NOT be helpful?
a) T3
b) T7
c) T4
d) OA
e) AA
1.2) In patients presenting with arrhythmias or palpitations, somatic dysfunctions of what
vertebral areas should be treated?
a) T1-T4
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b) T2-T8
c) T1-L2
d) T1-T6
e) T2-T5
1.3) A patient with an anterior wall myocardial infarction is likely to have paraspinal
musculoskeletal changes at which of the following levels?
a) C2 and the cranial base on the left
b) T1-T4 on the left
c) T5-T7 on the right
d) T9-T12 on the left
e) L1-L2 on the right
1.4) Supraventricular tachyarrhythmias that have been associated with hypersympathetic
activity are most likely to arise from:
a) Right sided sympathetic fibers originating from T1-T4
b) Left sided sympathetic fibers originating from T2-T5
c) Left vagus nerve
d) Pre-ganglionic fibers originating from the cervical chain ganglia
e) Stimulation of the oculocardiac reflex
2) What pattern of somatic dysfunction has been demonstrated in a significant percentage
of hypertensive patients?
a) OA, AA, and T6
b) C2, T1, and T7
c) C6, T2, and T6
d) C6, T1, and T3
e) OA, AA, C2, C6, and T1-T4
Cardiology #3 – Epidemiology of Cardiovascular Disease
1) Which of the following is NOT an immutable (unmodifiable) risk factor for coronary
artery disease (CAD)?
a) Race and gender
b) Family history
c) Homocysteine
d) Older age
2) Which of the following lipid and lipoprotein parameter equations is used to evaluate
dyslipidemia and is the best predictor of coronary artery disease risk in the general
population? VLDL = very-low density lipoprotein, HDL = high density lipoprotein
a) (LDL + VLDL + HDL) / HDL
b) (LDL + VLDL + HDL) / LDL
c) (LDL + VLDL + HDL) / VLDL
d) (HDL – VLDL + LDL) / HDL
e) (HDL – VLDL + LDL) / LDL
3.1) Regarding cardiovascular disease, short-term benefit of intervention is much greater
in ____ prevention and interventions with hazards are of greater importance in ____
prevention.
a) Primary; Primary
b) Primary; Secondary
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c) Secondary; Secondary
d) Secondary; Primary
3.2) Which of the following is considered an atherosclerotic cardiovascular disease?
a) Valvular heart disease
b) Congenital heart disease
c) Myocardial disease
d) Electrophysiologic disorders
e) Peripheral vascular disease
Cardiology #4 – Approach to the Patient with Possible Cardiovascular Disease
1.1) A patent presents with retrosternal squeezing pain. Their pain had been temporarily
relieved by nitroglycerin in the ambulance. Physical exam reveals an S3 sound and a
slight murmur. Which of the following characteristics would differentiate this as either
stable or unstable angina?
a) Location of pain
b) Quality of pain
c) Onset and duration
d) Aggravating and relieving factors
e) Associated symptoms anf signs
1.2) A patient presents with substernal pressing pain and dyspnea. History reveals pain
and dyspnea is aggravated by effort and that the onset was slow. Which of the following
is most likely?
a) Myocardial infarction
b) Pericarditis
c) Aortic dissection
d) Pulmonary embolism
e) Pulmonary hypertension
1.3) A patient presents with knife-like pain over the sternum. Although the pain has
lasted many hours, the patient was reluctant to come to the hospital. Physical exam
reveals pain increases with deep breathing and auscultation reveals a rubbing sound.
Which of the following is most likely?
a) Myocardial infarction
b) Pericarditis
c) Aortic dissection
d) Pulmonary embolism
e) Esophageal reflux
1.4) A patient presents with excruciating pain on the anterior chest that developed
suddenly. History reveals the patient has not been taking their hypertension medication.
Physical exam reveals blood pressure asymmetry and neurologic defect of a lower limb.
Which of the following is most likely?
a) Myocardial infarction
b) Pericarditis
c) Aortic dissection
d) Gallbladder disease
e) Pulmonary hypertension
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1.5) A patient presents with substernal squeezing pain. The ambulance staff notes say the
patient was found diaphoretic, dyspneic, and that nitroglycerin had no effect on pain.
Which of the following is most likely?
a) Myocardial infarction
b) Pericarditis
c) Aortic dissection
d) Pulmonary embolism
e) Pulmonary hypertension
1.6) A patient presents with left-sided substernal burning pain that began immediately
while they were on a business flight. Physical exam reveals pain with deep breathing,
dyspnea, and tachycardia. Which of the following is most likely?
a) Myocardial infarction
b) Pneumonia
c) Pneumothorax
d) Pulmonary embolism
e) Pulmonary hypertension
1.7) Which of the following is true of the distribution of a herpes zoster vesicular rash?
a) Follows hair pattern
b) Follows tension lines
c) Follows dermatome
d) Contained within a bone distribution
e) Contained within a muscle distribution
1.8) A patient presents with sharp, left-sided pain that began during a Judo match.
Physical exam reveals dyspnea, hyper-resonance on the left side, and no jugular vein
distension (JVD). You ask for a chest tube kit since the patient most likely has:
a) Pulmonary embolism
b) Pneumonia with pleurisy
c) Pulmonary hypertension
d) Myocardial infarction
e) Spontaneous pneumothorax
1.9) A patient presents with left-sided pain localized to the area of the 7th rib. Physical
exam reveals a fever, cough, and dull percussion over the localized area. Auscultation
reveals bronchial breath sounds. Which of the following is most likely?
a) Pulmonary embolism
b) Pneumonia with pleurisy
c) Pulmonary hypertension
d) Myocardial infarction
e) Spontaneous pneumothorax
1.10) A patient presents with aching pain over the chest. The area is tender to pressure
and painful with movement. History reveals the patient was helping a friend move when
the episode began. Which of the following is most likely?
a) Musculoskeletal disorder
b) Gallbladder disease
c) Anxiety state
d) Pulmonary embolism
e) Myocardial infarction
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1.11) A patient presents with a substernal burning sensation that lasts for a few hours per
episode. History reveals the symptoms are not associated with food, but drinking milk
helps relieve the pain. Which of the following is most likely?
a) Musculoskeletal disorder
b) Gallbladder disease
c) Anxiety state
d) Peptic ulcer
e) Esophageal reflux
1.12) An obese patient presents with a substernal burning sensation that starts after eating
a large meal. History reveals the symptoms only last for a 30 minutes and sometimes the
patient has water brash. Which of the following is most likely?
a) Pneumonia with pleurisy
b) Gallbladder disease
c) Anxiety state
d) Peptic ulcer
e) Esophageal reflux
1.13) A medical student presents with localized precordial pain. During the physical
exam, the location of the pain changes. Chest wall tenderness is found and sighing
respirations are heard. Which of the following is most likely?
a) Musculoskeletal disorder
b) Gallbladder disease
c) Anxiety state
d) Peptic ulcer
e) Esophageal reflux
1.14) A patient presents with right upper quadrant pain that presents after eating fast
food. Which of the following is most likely?
a) Anxiety state
b) Peptic ulcer
c) Esophageal reflux
d) Gallbladder disease
e) Liver disease
2) A heart failure patient states, “My goal for the entire day is to be able to get up and use
the bathroom on my own.” Which of the following New York Heart Association
(NYHA) functional classes would this patient be given?
a) NYHA Class I
b) NYHA Class II
c) NYHA Class III
d) NYHA Class IV
Cardiology #5 – Radiology of the Heart
1.1) The superior most “bulge” on the left cardiac border seen on an anteroposterior (AP)
chest x-ray represents which of the following?
a) Right atrium
b) Left atrium
c) Aorta
d) Superior vena cava
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1.2) In the AP radiograph, what is B?
a) Superior vena cava
b) Inferior vena cava
c) Right atrium
d) Left ventricle
e) Pulmonary trunk
1.3) In the AP radiograph, what is D?
a) Right atrium
b) Left atrium
c) Right ventricle
d) Left ventricle
e) Aorta
1.4) In the AP radiograph, what is C?
a) Superior vena cava
b) Inferior vena cava
c) Right atrium
d) Left ventricle
e) Pulmonary trunk
1.5) In the lateral radiograph, what is C?
a) Right atrium
b) Left atrium
c) Right ventricle
d) Left ventricle
e) Aorta
1.6) Using the two radiographs below of a cardiac
resynchronization therapy (CRT) device, which of
the following best describes the location of the tip
of the pacing lead indicated by an arrow?
a) Right atrium
b) Left atrium
c) Right ventricle
d) Left ventricle
e) Coronary sinus
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2) Which of the following variables has the greatest effect on the apparent cardiac size on
a chest radiograph?
a) Race and gender
b) Last oral intake
c) Degree of inspiration
d) Location of 9th rib
e) Size of liver or spleen
3) Although magnetic resonance imaging (MRI) is allowed for pacemakers and
implantable cardioverter defibrillators (ICDs) under very specific guidelines, MRI is
generally contraindicated for which of the following major reasons?
a) Lead heating due to induced current
b) Dislodgement of the device due to magnetic pulling
c) Mode-switching of the device into an asynchronous mode
d) Closure of the device magnetic reed switch leading to multiple shocks
e) Distortion of the image leading to incorrect diagnosis
Cardiology #6 – Electrocardiography
1) Using the electrocardiogram (ECG) image, what is 4?
a) P wave
b) Q wave
c) R wave
d) S wave
e) T wave
2) Using the ECG image, what is E?
a) PR interval
b) PR segment
c) QT interval
d) ST segment
e) QRS interval
3.1) Which of the following corresponds to the rapid repolarization phase of the
ventricles with K+ ions leaving the cardiac myocytes?
a) P wave
b) PR segment
c) QRS complex
d) ST segment
e) T wave
f) PR interval
g) QT interval
3.2) A first degree heart block occurs when which of the following intervals is longer
than 0.2 seconds?
a) P wave
b) PR interval
c) QRS complex
d) ST segment
e) T wave
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3.3) Which of the following represents an electrical pause at the atrioventricular (AV)
node and a mechanical pause as atrial blood fills into the ventricle?
a) P wave
b) PR segment
c) QRS complex
d) ST segment
e) T wave
f) PR interval
g) QT interval
3.4) Which of the following refers to ventricular systole and can lead to serious problems,
such as Torsade de Pointes (TdP), if it is prolonged?
a) QT interval
b) PR interval
c) QRS complex
d) ST segment
e) T wave
4) Bipolar limb lead ____ most closely parallels the electrical system of the heart (toward
the apex) with an upward deflection of the P wave, QRS, and T wave due to electrical
depolarization and repolarization traveling toward the ____ lead.
a) II; Right arm (RA)
b) II; Left leg (LL)
c) III; Left arm (LA)
d) III; Left leg (LL)
e) I; Left arm (LA)
5.1) The 3 augmented unipolar leads and 3 bipolar limb leads lie in the frontal plane.
a) True
b) False, only the augmented unipolar leads lie in the frontal plane
c) False, only the bipolar limb leads lie in the frontal plane
d) False, the 6 chest leads lie in the frontal plane
5.2) Which is true regarding the augmented voltage aVF lead?
a) The left foot is negative and the arms are positive
b) The right foot is negative and the arms are positive
c) The left foot is positive and the arms are negative
d) The right foot is positive and the arms are negative
e) The arms are positive and the foot (either) is negative
5.3) Which of the following augmented leads is a combination of leads I and III?
a) aVF
b) aVL
c) aVR
d) None of the above
5.4) A patient presents with a possible myocardial infarction due to blockage of the left
anterior descending (LAD) artery. This affects the left ventricle (lateral side) of the heart.
ECG changes might be found in which of the following chest leads?
a) V1 and V2
b) V3 and V4
c) V5 and V6
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d) V1 and V6
e) V2 and V5
6.1) Atrial flutter is defined as a heart rate of how many beats per minute?
a) 20 - 60
b) 60 - 100
c) 100 - 250
d) 250 - 350
e) 350 - 450
6.2) An elderly patient presents with palpitations while exercising to Richard Simmons
“Sweatin’ To The Oldies.” Physical exam reveals an irregular and fast pulse. As a
technician sets up the cardiac monitor, you heard the monitor beep at a regularly irregular
rhythm. Which of the following is most likely?
a) Premature atrial contractions (PACs)
b) Premature ventricular contractions (PVCs)
c) Sinus tachycardia
d) Atrial flutter
e) Atrial fibrillation
7) Idioventricular rhythm (ventricular foci) will pace at what inherent rate?
a) 10-20 beats per minute
b) 20-40 beats per minute
c) 40-60 beats per minute
d) 60-80 beats per minute
e) 80-100 beats per minute
8) What is the approximate rate of the ECG below?
a) 275 beats per minute
b) 225 beats per minute
c) 175 beats per minute
d) 125 beats per minute
e) 75 beats per minute
9.1) What is the rhythm of the ECG below?
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a) Premature atrial contraction
b) Atrial tachycardia
c) Atrial fibrillation
d) Atrial flutter
e) Sinus arrhythmia
9.2) What is the rhythm of the ECG below?
a) Atrial tachycardia with 2:1 block
b) Atrial fibrillation
c) Supraventricular tachycardia
d) Junctional tachycardia
e) Torsade de Pointes
9.3) What is the rhythm of the ECG below?
a) Torsade de Pointes
b) Supraventricular tachycardia
c) Junctional tachycardia
d) Ventricular tachycardia
e) Ventricular fibrillation
9.4) What is the rhythm of the ECG below?
a) First degree heart block
b) Second degree heart block type I (Mobitz I, Wenckebach)
c) Second degree heart block type II (Mobitz II)
d) Sinus third degree heart block with ventricular escape
e) Non-conducted premature atrial contraction
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9.5) What is the rhythm of the ECG below?
a) Ventricular tachycardia
b) Ventricular fibrillation
c) Junctional tachycardia
d) Supraventricular tachycardia
e) Torsade de Pointes
10) A patient with chronic atrial fibrillation (Afib) is implanted with a pacemaker. During
an episode, the pacemaker evaluates the atrial rate and then paces the atrium at a higher
rate to terminate the episode. What concept is this device relying on?
a) Automaticity
b) Pre-excitation
c) Overdrive suppression
d) Parasystolic focus
e) Accessory pathway (James fibers, Kent fibers, or Mahaim fibers)
11) Diseased segments of the conduction system can retain the capacity for spontaneous
depolarization (impulse formation) while acquiring protection from passive discharge by
the sinus impulse (entrance block). Under these circumstances, the protected ectopic
pacemaker coexists with the sinus pacemaker and competes with it for control of the
cardiac rhythm. This is known as:
a) Automaticity
b) Pre-excitation
c) Accessory pathway
d) Parasystolic focus
e) Overdrive suppression
12.1) What is the approximate axis in the frontal plane for the ECG below?
a) -30 degrees
b) 0 degrees
c) +30 degrees
d) +60 degrees
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12.2) What is the mean QRS vector (axis) in the frontal plane for an ECG showing a
negative/downward deflection in lead I and a positive/upward deflection in aVF? (For
more accuracy, the axis is 90 degrees from the most isoelectric lead)
a) Normal
b) Left axis deviation
c) Right axis deviation
d) Extreme right axis deviation
13) Which of the following is most likely true if leads V1 and V2 are isoelectric?
a) No rotation (normal)
b) Leftward rotation; Left ventricular hypertrophy
c) Leftward rotation; Left myocardial infarction
d) Rightward rotation; Left ventricular hypertrophy
e) Rightward rotation; Left myocardial infarction
14.1) What is the rhythm of the ECG below?
a) Premature atrial contraction (PAC)
b) Atrial bigeminy
c) Atrial trigeminy
d) Premature junctional contraction (PJC)
e) Junctional trigeminy
14.2) What is the rhythm of the ECG below?
a) Premature atrial contraction (PAC)
b) Atrial bigeminy
c) Atrial trigeminy
d) Premature junctional contraction (PJC)
e) Junctional trigeminy
14.3) A patient using amphetamines presents with the ECG below. What is the rhythm?
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a) Sinus rhythm with first degree heart block
b) Second degree heart block type I (Mobitz I, Wenckebach)
c) Second degree heart block type II (Mobitz II)
d) Third degree heart block with junctional escape
e) Non-conducted premature atrial contraction
14.4) What is the rhythm of the ECG below?
a) Premature ventricular contractions
b) Ventricular bigeminy
c) Ventricular trigeminy
d) Idioventricular rhythm
e) Junctional escape rhythm
f) Wandering pacemaker
14.5) How many PVCs per minute is considered pathologic?
a) 2
b) 3
c) 4
d) 6
e) 8
15) Using the ECG below, which of the following is the most likely?
a) Premature junctional contraction
b) Acute myocardial infarction
c) Acute pericarditis
d) Brugada syndrome
e) Wolff-Parkinson-White syndrome
16.1) A left bundle branch block (LBBB) would have a wide QRS and produce an R, R’
pattern (letter “M”) in what leads?
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a) V1 or V2
b) V3 or V4
c) V5 or V6
d) V1 or V3
e) II or III
16.2) A right bundle branch block (RBBB) would have a wide QRS and produce an R, R’
pattern (letter “M”) in what leads?
a) V1 or V2
b) V3 or V4
c) V5 or V6
d) V1 or V3
e) II or III
17.1) Which of the following best describes this ECG?
a) RA abnormality (p pulmonale)
b) LA abnormality (p mitrale)
c) Biatrial abnormality
d) Left ventricular abnormality
e) Right ventricular abnormality
17.2) Which of the following best describes this ECG?
a) RA abnormality (p pulmonale)
b) LA abnormality (p mitrale)
c) Biatrial abnormality
d) Left ventricular abnormality
e) Right ventricular abnormality
18) Which of the following best describes the ECG below?
a) RA abnormality (p pulmonale)
b) LA abnormality (p mitrale)
c) Acute pericarditis
d) Left ventricular abnormality
e) Right ventricular abnormality
19.1) When assessing an ECG for “significant” Q waves, what lead can be ignored?
a) V1
b) V6
c) aVL
d) aVR
e) aVF
19.2) Which of the following would be considered a significant Q wave?
a) +1/2 amplitude of QRS, +1mm tall, +0.04s wide
b) +1/3 amplitude of QRS, +1mm tall, +0.04s wide
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c) +1/3 amplitude of QRS, +2mm tall, +0.08s wide
d) +1/2 amplitude of QRS, +2mm tall, +0.08s wide
e) Same amplitude as QRS, +3mm tall, +0.12s wide
20.1) Evidence of myocardial infarction in lead V1 and possibly V2 would most likely
mean what part of the heart is affected?
a) Inferior
b) Anterior
c) Septum
d) Lateral
e) Posterior
20.2) Which of the following best describes the ECG below?
a) Inferoseptal myocardial infarction, age-indeterminate (old)