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1.An urgency of a theme:

Disorders of a cardiac rhythm – are widespread clinical phenomena. Their occurrence can be caused practically by any kind of a cardiovascular pathology. Arrhythmias of heart not only aggravate the basic disease, but also frequently define its prognosis. So, arrhythmias are the most frequent complications of an infarcted myocardium, and at a pre-hospital stage – a main cause of death of such patients.

All this is the basic for studying various aspects of this clinical phenomenon. For mastering this theme knowledge of pathological physiology and anatomy of conduction heart system, and also propaedeutics of internal diseases is necessary. Considering wide prevalence of disorders of a rhythm, patients suffering from this pathology, can meet in practice of the doctor of any speciality, especially the therapist and the cardiologist.

If the urgency of a theme is clear to you, then pass to studying the purposes of training.


The Purpose (general): to be able to spend intrasyndromic differential diagnosis of arrhythmias of heart, to define principles of management the patient and to be able to assist at the urgent conditions caused by disorders of a rhythm.

^ Specific goals

to be able to:

Basic knowledge-skills are necessary for achievement of the purposes of training

To allocate the basic syndromes at disorders of a cardiac rhythm.

1. To collect and appreciate complaints, to spend objective examination of a patient with pathology of cardiovascular system (sub-fac. of Propaedeutic therapy, sub-fac. Faculty therapy).

2. To make the individual plan of diagnostic search in the limits of the basic syndrome and to interpret results of investigational methods.

2. To appreciate and to interpret data of roentgenograms, of echocardiograms, of electrocardiograms, Holter,s monitoring, bicycle exercise (sub-fac. of Propaedeutic therapy, sub-fac. of Faculty therapy).

3. To carry out differential diagnosis of arrhythmias on the basis of differential diagnostic algorithms.

4. To diagnose the urgent conditions at disorders of heart rhythm.

4. To be able to recognize the syndromes, describing urgent conditions, occurring at diseases of cardiovascular system (sub-fac. of Propaedeutic therapy).

5. To prove principles of management patients with disorders of a rhythm.

5. To apply means of pathogenetic and symptomatic medicamental therapy in patients with pathology of cardiovascular system (sub-fac. of Pharmacology).

The information necessary for reviewing and revising the basic knowledge and skills can be found in the following references:

  1. Oxford Handbook of Clinical Medicine. Murray Longmore, Ian B.Wilkinson, Supray Rajagopalan. New York, 2004.

  2. Klabunde R.E. Cardiovascular Physiology Concepts. Lippincott, 2004. 256 pp.

  3. Internal diseases. An introductory course. Edited by V.Vasilenko and A.Grebenev. Moscow, 2006.

Pre-Practice Knowledge and Skills Test Questions

Task 1.

Patient Н., 58 years old, was admitted to the hospital with complaints of tachypnoe, expressed weakness, dizziness, nausea, and sensation of cardiac arrest with the subsequent strong impact in chest. The doctor has suspected the presence the extrasystolic arrhythmia, which was confirmed by electrocardiogram further. Choose a symptom, which has given the basis to the doctor to suspect in the patient the presence of extrasystolic arrhythmia.

А. The increased rate of breathing (tachypnoe);

B. Тhe sensation of heart arrest with the following strong impact in chest;

C. Тhe expressed weakness;

D. Тhe dizziness;

E. Тhe nausea.

Task 2

Patient S., suffering from thyreotoxicosis, has felt the sudden dizziness, weakness, and missing in cardiac activity. On ECG: heart rhythm is irregular with rate 200 beats in a min., no P waves are defined, irregular R-R intervals, ventricular complexes are not widened, chaotic wavy isoline between qrs-complexes.

What rhythm or conduction disorder, probably, takes place in the patient?

А. Paroxysm of atrial fibrillation;

B. III degree (complete) AV block;

C. Ventricular fibrillation;

D. Paroxysm of supraventricular tachycardia;

E. Paroxysm of ventricular tachycardia.

Task 3.

Patient D., 67 years, suffering from IHD, after smoking suddenly experienced palpitation, feeling of discomfort at precardiac zone, dizziness. HR - 140 beats per minute, BP - 120/70 mm Hg. On ECG the paroxysm of ventricular tachycardia was registered.

What medicine should be administered first of all?

А. Cordarone;

B. Lidocain;

C. Verapamil;

D. Obzidan;

E. Ethmozin.

Task 4.

Patient D., 28 years old, addressed to physician with complaints of chest pain, palpitation, fever up to 38-39oC. Doctor suspected acute myocarditis. Recorded ECG is presented below.

Lead II. The Recording speed: 25 mm/sec.

hat rhythm disorder has the patient?

А. Supraventricular extrasystoles;

B. Ventricular extrasystoles;

C. Supraventricular paroxysmal tachycardia;

D. Ventricular paroxysmal tachycardia;

E. Atrial fibrillation.

Task 5.

Patient M., 50 years, suffering from arterial hypertension, addressed to physician with complaints of shortness of breath and palpitation. A day before he worked physically at country-house. On examination: pulse rate 144 beats per minute, BP 180/100 mm Hg. On ECG a rhythm disorder was registered.

Lead V2. The Recording speed 25 mm/sec.

hat arrhythmia takes place in patient?

А. Atrial fibrillation;

B. Atrial flutter;

C. Frequent supraventricular extrasystoles;

D. Atrioventricular paroxysmal tachycardia;

E. Ventricular paroxysmal tachycardia.

Task 6.

Patient D., 43 years, suffering from rheumatism, mitral stenosis, 2 weeks ago felt the irregular cardiac rhythm. On ECG – atrial fibrillation. What ECG signs are typical for this rhythm disorder?

А. The presence of P wave before each QRS complex and equal R-R intervals;

B. The presence of P wave before each QRS complex and different R-R intervals;

C. The absence of P waves and equal R-R intervals;

  1. The absence of P waves and different R-R intervals;

  2. The presence of P wave before each second QRS complexand equal R-R intervals.

Task 7.

The 78 years-old female, suffering from cardiomyopathy, was admitted to the cardiologic department with complaints of moderate dizziness and shortness of breath. The physician recorded ECG. What is the cause of patient’s condition worsening?

Lead II. The Recording speed: 25 mm/sec.

А. Ventricular fibrillation;

B. Atrial fibrillation;

C Supraventricular paroxysmal tachycardia;

D. Atrial flutter;

E. Ventricular paroxysmal tachycardia;

Task 8.

The patient A., 45 years old, visited polyclinic because of breathlessness, palpitation, chest pain. During physical examination physician revealed HR 170 beats per minute, pulse "deficiency" and suspected one of enumerated arrhythmias.

А. Sinus tachycardia;

B. Supraventricular tachycardia;

C. Atrioventricular tachycardia;

D. Ventricular tachycardia;

E. Atrial fibrillation, tachysystolic form.

Task 9

62 years-old patient M., being on in-patient treatment at cardiological department because of on unstably angina pectoris, suddenly turned pale and lost the consciousness. Pulse and BP are not revealed. The eye pupils don’t react on light. On monitor ventricular fibrillation was defined. What urgent aid should be given to the patient first of all?

А. Closed-chest cardiac massage;

B. Artificial lung respiration;

C. Precardiac blow;

D. Intracardiac injection of adrenaline;

E. Electric defibrillation.

Task 10

Patient S., 53 years old, who was in the cardiology department with acute myocardial infarction, the sudden cardiac death was developed. On the screen ventricular fibrillation was determined. An intensive care activity was begun. In what ratio should be done closed cardiac massage and artificial respiration if expert in resuscitation is one?

A. 15 pressing: 2 breath;

B. 5 pressing: 1 breath;

B. 4 pressing: 1 breath;

G. 10 pressing: 2 breath;

D. 15 pressing: 1 breath.

Task 11

Patient D., 45 years old, with paroxysm of atrial fibrillation was administered Novocainamid with the aim of restoring sinus rhythm. Some minutes later the patient suddenly lost the consciousness, on monitor screen instead of atrial fibrillation appeared a new rhythm disorder (the fragment of monitor record is given below). What rhythm disorder did occur in the patient?

Lead II. The Recording speed 25 mm/sec.

А. Paroxysm of ventricular tachycardia;

B. Paroxysm of supraventricular tachycardia;

C. Ventricular fibrillation;

D. Atrial flutter;

E. Ventricular flutter.

Task 12

Patient Z., 56 years, suffering from IHD, complains on recurrent attacks of palpitation, associated with dizziness and blackouts. Any of rhythm disorders weren’t recorded on the standart ECG. Which of following methods of testing should be done in the first place to specify the cause of such patient’s complaints?

А. Tredmil-test;

B. Holters monitoring;

C. Echocardiography;

D. Bicycle exercise test;

E. Transesophageal electric cardiac stimulation.

Task 13

Patient N., 46 years old, was hospitalized in the clinic with complains on shortness of breath, dizziness, nausea, sensation of cardiac arrest, and a strong blow to the chest, followed after it. On electrocardiogram frequent ventricular extrasystoles were recorded. Select the main indication of extrasystoles which gave reason to the doctor regarded it as ventricular.

A. The presence of P-wave before the complex QRS;

B. Wide (more than 0.12 ms) complex QRS;

C. The absence of P-wave before the complex QRS;

D. Incomplete compensatory pause;

E. Narrow (less than 0.12 ms) complex QRS.

Task 14

The main reason of patients death suffering from heavy CHF (chronic heart failure) is:

A. Thromboembolism

B. Medicamentous complications

C. Cachexia

D. Pulmonary edema

E. Life-threatening

Task 15

In patient D., 56 years old, suffering from rheumatism with mitral stenosis 2 weeks ago, noted irregularity in the heart work. At ECG - atrial fibrillation. What frequency of auricular rhythm is observed in this disorder of rhythm?

A. 350-600 per min;

B. 100-250 per min;

C. 100-150 per min;

D. 100-350 per min;

E. 60-100 per min.

Task 16

In patient D., 67 years old, suffering from ischemic heart disease, the electrocardiogram recorded right ventricular rhythm with a frequency of 80 sp/min, however, instead of P-waves were large serrated F-waves. What the disorder of rhythm was found in the patient?

A. Paroxysm of ventricular tachycardia;

B. Paroxysm of supraventricular tachycardia;

C. Atrial fibrillation;

D. Atrial flutter;

E. Ventricular fibrillation.

Task 17

In a patient S., 53 years old, which is hospitalized in the cardiology department with the acute myocardial infarction, a pattern of sudden cardiac death was developed. On the screen ventricular fibrillation was determined. Intensive care activities were begun. What preparation is necessary to administer for the patient to restore cardiac activity?

A. Korglicon;

B. Novocainamid;

C. VErapamil;

D. Adrenaline;

E. Digoxin.

Task 18

Patient A., 45, comes to consult a doctor with complains on shortness of breath, palpitations, pain in the heart. During examination a physician found the "deficit" pulse. What does this phenomenon mean?

A. Loss of separate pulse waves;

B. Weak pulse filling;

C. Irregular pulse;

D. Different frequency of the pulse at the hands of the individual;

E. Lack of pulse in the peripheral arteries.

Task 19

Patient D., 67 years old, located in the cardiology department with the severe ischemic heart disease, suddenly lost consciousness. On the screen ventricular fibrillation was fixed, after which the doctor immediately started artificial respiration and indirect heart massage. What the electric method of treatment should be used along with the reanimation of these events?

A. Electrical cardioversion;

B. Electrical cardioversion, and then defibrillation;

C. Electrical defibrillation;

D. Transesophageal electrocardiostimulation;

E. Transesophageal electrocardiostimulation and then defibrillation.

Task 20

In a soldier D., 26 years old, during a medical examination on the ECG all signs of normal sinus rhythm were recorded. What is a normal frequency of the rhythm?

A. 80-100 per min;

B. 60-100 per min;

C. 50-90 per min;

D. 60-80 per min;

E. 50-100 per min.

^ IV. Subject Material

For achievement of goals of study it is necessary to master the following theoretical questions:

  1. Etiology and pathogenesis of rhythm.

  2. The classification of rhythm disorders.

  3. The Ways of clinical and instrumental diagnosis of rhythm disorders.

  4. The Differential diagnosis of rhythm disorders.

  5. The Urgent conditions at arrhythmias.

  6. The Principles of the treatment of rhythm disorders, management of the urgent conditions.

You can find the information necessary for study of the theoretical questions in the following references:

  1. Lectures on Hospital Therapy.

  2. Usuf S.Y., Cairns J., Camm J., Fallen E.L. Gersh B. Evidence Based Cardiology. BMJ Publishing Group, 2002. 1024 pp.

  3. Montgomery H., Holdright D. 100 Questions in Cardiology. BMJ Publishing Group, 2001. 222 pp.

  4. Klabunde R.E. Cardiovascular Physiology Concepts. Lippincott, 2004. 256 pp.

  5. Break-down chart on the subject "Arrhythmias" (addition 1);

  6. The diagnostic algorithm at syndrome "Arrhythmias of heart" (addition 2).

  7. The Main clinical forms of the disorders of the rhythm (addition 3);

  8. The Categorization antiarrhythmic drugs (addition 4).

Summary of procedures for the practice on the Subject:


  1. Making assessment of prior-to-practice level of knowledge and skills.

  2. Clinical analysis of patients with the syndromes in question, substantiation of a hypothetical diagnosis, methods and techniques of giving and determining emergency medical service.

  3. Carrying out test-questions. Final testing. Summing up the results.

Addition 1

Break-Flow Chart on the Subject:


Addition 2

The Diagnostic algorithm at syndrome
"Arrhythmias of heart"

Enumeration of the nosologycal units

  1. Sinus tachycardia

  2. Sinus bradycardia

  3. Extrasystoles
  4. Atrial fibrillation and flutter
  5. Supraventricular tachycardia
  6. Ventricular tachycardia
  7. Fibrillation of ventricle

Addition 3

The Main clinical forms of

rhythm disorders

(Е.I.Chazov, Y.N.Belenkov, 2005. – p.357)

The disorders of generation of the impulse (disorders of the automatism)

  1. Change of automatism of the sinus node

  • sinus arrhythmia

  • sinus bradycardia

  • sinus tachycardia

  • sick sinus syndrome (SSS)

2. Ectopic contractions and rhythms (formation of electric impulse in secondary and tertiary sources of automatism – pacemakers), depending on localization:

  • supraventricular (sources of automatism located in atriums and АV-node)

  • ventricular (sources of automatism located in ventriclular myocardium)

2а. Passive (ectopic contractions and rhythms (impulses, replacing from secondary and tertiary sources of automatism with rate reduction, when impulsation from SA-node is absent, аnd also with block of impulses conduction from SA-node)

  • replacing contractions (isolated)

  • replacing rhythms (three or more impulses of nonsinus origin – from atrium’s pacemakers, АV-node’s or ventricles)

  • migration of pacemaker

2б. Active ectopic contractions and rhythms:

  • extrasystoles

  • ectopic rhythms (rate of ectopic rhythm exceeds sinus rhythm rate; ectopic rhythm usually depresses SA-node activity)

    • supraventricular tachycardias (atrial, АV)

    • atrial fibrillation and flutter

    • ventricular tachycardia

    • ventricular fibrillation and flutter




Blockers of Na-channels of cell membranes (remedies, which stabilise the membranes)


With moderate effect duration; which slow down the repolarisation





With minimum effect duration, which quicken the repolarisation




With maximum effect duration, which don’t change the repolarisation






Blockers of -adrenergic receptors


Propranolol Methaprolol



Remedies, which prolong the duration of action potential





Blockers of Са-channel of cell membranes




Addition 4

The Categorization of antiarrhythmic DRUGS

At the end of the practice class, you should solve final tests, so pay attention to the following example tests.

^ FINAL test control

Task № 1

In patient who was in the cardiology department with the acute myocardial infarction paroxysm of atrial fibrillation developed.

What is the pathogenic basis of revealed disorder?

a) increased activity of SA-node cells-pacemakers;

b) decreased activity of SA-node cells-pacemakers;

c) appeared centres of pathologic impulse generation in myocardium;

d) “re-entry” mechanism;

e)presence of accessory AV conduction pathway.

Task №2

Patient I., 56 years, complains of palpitation. At ECG monitoring 10 days after coronary bypass grafting the extrasystolic arrhythmia was revealed.

^ What is the class of ventricular extrasystoles (according to V.Lown’s and M.Wolf’s classification) in this patient?

Lead II. The Recording speed 25 mm/sec. Scale: 1 square - 0,1 sеc.

a) І class;

b) ІІ class;

c) ІІІ class;

d) ІV class;

e) V class.

Task №3

Patient P., 50 years, suffering AH, CHD (exertional angina pectoris FC II), complaints on frequent irregularities in the heart work, which are accompanied by retrosternal pain. On ECG (monitoring leads) there is fixed rhythm disturbance.

What from these preparations will be most effective for the treatment of such arrhythmia?

а) cocarboxylase

b) propranolol

c) nifedipine

d) adenosine triphosphate, ATP

e) inosine

Task №4

For an engineer P., 45 years, by chance, during physical examination was determined rhythm disturbance. ECG (presented below). At the further careful inspection of patient with the use of laboratory and instrumental methods, and also functional cardiologic tests was not found some deviations from a norm.

^ What tactic must a doctor choose in this case?

а) to prescribe a digoxin

b) to prescribe an ATP

c) to prescribe procainamide hydrochloride

d) to prescribe a cordarone

e) don’t prescribe medicines

Task №5

For patient D., 44 years, suffering CHD, aterosclerotic cardiosclerosis, the chronic form of arrhythmia remoteness of which about 3 months is diagnosed. Presented ECG of patient (monitoring leads) is below.

^ What preparation can be used for the removal of such arrhythmia?

а) quinidine

b) verapamil

c) АТP

d) digoxin

e) cocarboxylase

Task №6

Patient K., 42 years with paroxysm of tachycardia has intravenous stream injection (during 1 sec 10 mg) of ATP that at once removed arrhythmia and recovered a sinus rhythm (SR). ECG was written during paroxysm of tachycardia, in the moment of injection of ATP and SR recovery. Paroxysm of what tachycardia did a patient have?

а) ventricular

b) atrioventricular

c) cardiac fibrillation

d) auricular

e) sinus

Task №7

Patient P., 45 years, delivered in a clinic with the picture of unstable angina pectoris and heart failure III FC (NYHA). On ECG (monitoring leads) rhythm disturbance is fixed.

^ What from preparations is it impossible to appoint this patient?

а) aspirin

b) nitroglycerine

c) verapamil

d) heparin

e) нитросорбид

Task №8

At patient T., 44 years with the transient syndrome of WPW appeared palpitations, shortbreathing and rapid fatigue. On ECG arrhythmia is exposed.

^ What preparation is dangerous to prescribe?

а) cordarone

b) digoxin

c) procainamide hydrochloride

d) furosemide

e) capoten

Task №9

On two presented EСG, which are written synchronously (monitoring leads), rhythm disturbance is registered.

^ What kind of rhythm disturbance is it?

а) supraventricular extrasystole

b) ventricular premature beats

c) ciliary arrhythmia

d) sinus arrhythmia

e) sinus bradycardia

Task №10

What antiarrhythmic drug, except cordarone (amiodarone), at the protracted taking able to increase life-span patients with ventricular premature beats against the background of postinfarction aterosclerotic cardiosclerosis??

а) flecainide

b) encanide

c) ethmosin

d) propranolol

e) quinidine

Task №11

Patient C., 55 years, businessman, and being in a cardiologic department took quinidine concerning ventricular premature beats. After taking 600 mg of preparation suddenly fallen down and lost consciousness. Two overhead ECG are written synchronously (monitoring leads) before the beginning of treatment, 2 lower ECG – in the moment of loss of consciousness.

^ What is the reason of loss of consciousness?

а) ventricular fibrillation

b) ventricular tachycardia

c) supraventricular tachycardia

d) asystole

e) electromechanical dissociation


Task №12

Patient K., 40 years, before by nothing being ill, consuled in the morning to the policlinic with complaints about a shortbreathing and palpitation. The day before he celebrated a birthday. At examination pulse rate is about 150 in minute, AP - 120/80 mm of merc. On ECG is rhythm disturbance.

What kind of rhythm disturbance is it?

а) auricular fibrillation

b) atrial flutter

c) supraventricular extrasystole

d) atrioventricular paroxysmal tachycardia

e) ventricular tachycardia

Task №13

On Holter monitoring for patient Z., 44 years, who complaints about irregularity in heart work, rhythm disturbance was exposed (short fragment of record of ECG in two monitoring leads).

^ What kind of rhythm disturbance is it?

а) auricular fibrillation

b) sinus

c) supraventricular extrasystole

d) ventricular premature beats

e) atrioventricular tachycardia

Task №14

In connection with frequent paroxysm of ciliary arrhythmia a cardiologist recommended a patient the protracted taking of cordarone.

^ What is the effective half-life?

а) 4 – 6 hours

b) about 1,5 days

c) 1 – 2 weeks

d) about 1 month

e) 1,5 month

Task №15

During the examination of a patient with rhythm disturbance and disorder of impulse conduction a Jackson's symptom was exposed. What rhythm disturbance and disorder of impulse conduction can be attended by this symptom?

а) sinus tachycardia

b) sinus bradycardia

c) atrioventricular heart block 2

d) left bundle-branch block

e) auricular fibrillation

Task №16

According to classification of antiarrhythmic drug of Williams (E. Vauqhan Wiliams, 1969) of procainamide hydrochloride attribute to the class:

а) 1А b) 1B c) 1С d) 2 e) 3

Task №17

On Holter monitoring of ECG for patient S., 60 years, ventricular premature beats was exposed(the fragment Holter monitoring is presented).

^ What gradation of B.Lown, M.Wolf classification this extrasystole is belong to?

а) 1 b) 2 c) 3 d) 4А e) 4B

Task №18

For a patient 66 years, suffering CHD, postinfarction cardiosclerosis, heart failure II B, IV FC is present chronic arrhythmia (fig.). He regulary takes ACE-inhibitor, cardiac glycoside,  – adrenoreceptor antagonists, diuretic и aldosterone receptor antagonist.

^ What preparation is it necessary to add to therapy of this patient?

а) cardio protector

b) anticoagulan

c) statin

d) calcium channel-blocking agent

e) antiaggregant

Task №19

The classic ECG-sings of atrial fibrillation are:

- absence of Р wave

- Isoline rippling


а) regularity of ventricular rate (equal RR intervals)

b) irregularity of ventricular rate (different RR intervals)

c) interval QT elongation

d) interval QT shortening

e) widening of complex QRS ≥0,11 sec

Task №20

The most frequent reasons of atrial fibrillation are:


- AH

- heart failure

  • thyrotoxicosis


а) mitral valvular disease

b) aortal valvular disease

c) pulmonary embolism

d) chronic cor pulmonale

e) cardiomyopathy


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