Cardiac arrhythmias, or abnormal heart rhythms, encompass a wide range of conditions that can significantly impact a patient’s quality of life and cardiovascular health, ranging from benign palpitations to life-threatening emergencies. The management of arrhythmias is multifaceted, involving accurate diagnosis, identification of underlying causes, and a tailored therapeutic approach that may include pharmacological agents, electrical therapies, or invasive procedures. For PharmD students, a comprehensive understanding of the strategies used to manage various arrhythmias—including goals of therapy (rate vs. rhythm control), selection of appropriate antiarrhythmic drugs, non-pharmacological interventions, and ongoing monitoring—is crucial for effective participation in patient care and ensuring optimal outcomes. This MCQ quiz will test your knowledge on the principles and practices in the management of cardiac arrhythmias.
1. The two primary strategic goals in the management of atrial fibrillation (AFib) are:
- A. Lowering blood pressure and reducing cholesterol
- B. Ventricular rate control and rhythm control (conversion/maintenance of sinus rhythm), along with stroke prevention
- C. Only symptom relief with no focus on long-term outcomes
- D. Immediate defibrillation for all patients
Answer: B. Ventricular rate control and rhythm control (conversion/maintenance of sinus rhythm), along with stroke prevention
2. For acute termination of hemodynamically stable paroxysmal supraventricular tachycardia (PSVT) involving the AV node (e.g., AVNRT, AVRT), which intervention is often tried first?
- A. Intravenous amiodarone
- B. Vagal maneuvers (e.g., Valsalva maneuver, carotid sinus massage)
- C. Oral digoxin
- D. Electrical cardioversion
Answer: B. Vagal maneuvers (e.g., Valsalva maneuver, carotid sinus massage)
3. If vagal maneuvers fail to terminate acute stable PSVT, which intravenous medication with a very short half-life is commonly administered?
- A. Lidocaine
- B. Adenosine
- C. Sotalol
- D. Flecainide
Answer: B. Adenosine
4. In patients with atrial fibrillation and rapid ventricular response, which class of drugs is commonly used for initial ventricular rate control, provided there are no contraindications (e.g., acute decompensated HF)?
- A. Class Ic antiarrhythmics (e.g., flecainide)
- B. Beta-blockers or non-dihydropyridine calcium channel blockers (verapamil, diltiazem)
- C. Class III antiarrhythmics (e.g., dofetilide)
- D. Vasopressors
Answer: B. Beta-blockers or non-dihydropyridine calcium channel blockers (verapamil, diltiazem)
5. Digoxin can be used for ventricular rate control in atrial fibrillation, particularly in patients with concomitant:
- A. Severe bradycardia
- B. Heart failure (HFrEF), or if other rate control agents are ineffective or contraindicated
- C. Wolff-Parkinson-White syndrome
- D. Hypertension as the sole comorbidity
Answer: B. Heart failure (HFrEF), or if other rate control agents are ineffective or contraindicated
6. “Pill-in-the-pocket” therapy for selected patients with infrequent, symptomatic paroxysmal atrial fibrillation typically involves self-administration of a single oral dose of which type of antiarrhythmic upon arrhythmia onset?
- A. Amiodarone
- B. Sotalol
- C. Flecainide or Propafenone (Class Ic agents)
- D. Digoxin
Answer: C. Flecainide or Propafenone (Class Ic agents)
7. What is the primary goal of electrical cardioversion in a patient with persistent atrial fibrillation?
- A. To control the ventricular rate
- B. To restore normal sinus rhythm
- C. To prevent stroke
- D. To diagnose the type of atrial fibrillation
Answer: B. To restore normal sinus rhythm
8. For patients with atrial fibrillation undergoing elective electrical cardioversion who have been in AFib for >48 hours or unknown duration, what is crucial regarding anticoagulation?
- A. No anticoagulation is needed.
- B. Anticoagulation for at least 3 weeks before and at least 4 weeks after cardioversion.
- C. Anticoagulation only on the day of cardioversion.
- D. Only aspirin is required.
Answer: B. Anticoagulation for at least 3 weeks before and at least 4 weeks after cardioversion.
9. Which Class III antiarrhythmic drug is known for its broad spectrum of activity but also its extensive list of potential long-term toxicities (e.g., pulmonary, thyroid, liver)?
- A. Sotalol
- B. Dofetilide
- C. Amiodarone
- D. Ibutilide
Answer: C. Amiodarone
10. Catheter ablation is an invasive procedure that can be curative for which of the following arrhythmias by destroying the abnormal electrical pathway or focus?
- A. Sinus bradycardia
- B. Atrioventricular Nodal Reentrant Tachycardia (AVNRT) and Atrioventricular Reentrant Tachycardia (AVRT) involving an accessory pathway
- C. Third-degree AV block
- D. All types of ventricular fibrillation
Answer: B. Atrioventricular Nodal Reentrant Tachycardia (AVNRT) and Atrioventricular Reentrant Tachycardia (AVRT) involving an accessory pathway
11. The immediate management of a patient presenting with pulseless Ventricular Tachycardia (VT) or Ventricular Fibrillation (VF) is:
- A. Administration of oral amiodarone
- B. Immediate defibrillation (unsynchronized shock for VF/pulseless VT) and CPR according to ACLS guidelines
- C. Intravenous adenosine
- D. Initiation of a beta-blocker infusion
Answer: B. Immediate defibrillation (unsynchronized shock for VF/pulseless VT) and CPR according to ACLS guidelines
12. For hemodynamically stable monomorphic Ventricular Tachycardia (VT), acute pharmacological management may include intravenous administration of:
- A. Digoxin
- B. Adenosine
- C. Amiodarone, procainamide, or sotalol
- D. Verapamil
Answer: C. Amiodarone, procainamide, or sotalol
13. An Implantable Cardioverter-Defibrillator (ICD) is indicated for secondary prevention in patients who have survived:
- A. An episode of paroxysmal supraventricular tachycardia.
- B. A life-threatening ventricular arrhythmia (e.g., VF or hemodynamically unstable VT) not due to a reversible cause.
- C. Symptomatic sinus bradycardia.
- D. First-degree AV block.
Answer: B. A life-threatening ventricular arrhythmia (e.g., VF or hemodynamically unstable VT) not due to a reversible cause.
14. Torsades de Pointes (TdP) is a polymorphic ventricular tachycardia specifically associated with QT prolongation. The acute management includes:
- A. Administering a Class Ia antiarrhythmic
- B. Discontinuing any offending agents, correcting electrolyte imbalances (especially hypokalemia/hypomagnesemia), and administering intravenous magnesium sulfate
- C. Increasing the heart rate with isoproterenol
- D. Administering amiodarone as first-line therapy
Answer: B. Discontinuing any offending agents, correcting electrolyte imbalances (especially hypokalemia/hypomagnesemia), and administering intravenous magnesium sulfate
15. Which of the following medications has a significant risk of causing Torsades de Pointes due to QT prolongation?
- A. Aspirin
- B. Metoprolol
- C. Sotalol or Dofetilide (Class III antiarrhythmics)
- D. Lisinopril
Answer: C. Sotalol or Dofetilide (Class III antiarrhythmics)
16. In Wolff-Parkinson-White (WPW) syndrome with atrial fibrillation and a rapid ventricular response conducted via the accessory pathway, which drugs should generally be AVOIDED as they can paradoxically increase ventricular rate and precipitate VF?
- A. Beta-blockers
- B. Amiodarone
- C. AV nodal blocking agents like digoxin, verapamil, or diltiazem (if used alone without blocking accessory pathway)
- D. Procainamide
Answer: C. AV nodal blocking agents like digoxin, verapamil, or diltiazem (if used alone without blocking accessory pathway)
17. The primary long-term management strategy for asymptomatic, low-risk Premature Ventricular Complexes (PVCs) in a patient with no structural heart disease is typically:
- A. Initiation of amiodarone
- B. Catheter ablation
- C. Reassurance and management of underlying causes/triggers if any; often no specific antiarrhythmic therapy is needed
- D. Implantation of an ICD
Answer: C. Reassurance and management of underlying causes/triggers if any; often no specific antiarrhythmic therapy is needed
18. A permanent pacemaker is the treatment of choice for which symptomatic bradyarrhythmia?
- A. Sinus tachycardia
- B. Paroxysmal supraventricular tachycardia
- C. Symptomatic third-degree (complete) AV block or symptomatic Mobitz type II second-degree AV block
- D. Atrial fibrillation with rapid ventricular response
Answer: C. Symptomatic third-degree (complete) AV block or symptomatic Mobitz type II second-degree AV block
19. When managing arrhythmias, it is crucial to first identify and treat:
- A. The patient’s insurance status
- B. Reversible causes or exacerbating factors (e.g., electrolyte imbalances, ischemia, hypoxia, drug toxicity, thyroid dysfunction)
- C. The oldest available antiarrhythmic drug
- D. Only the most life-threatening arrhythmias, ignoring minor ones
Answer: B. Reversible causes or exacerbating factors (e.g., electrolyte imbalances, ischemia, hypoxia, drug toxicity, thyroid dysfunction)
20. The choice between a rate-control strategy and a rhythm-control strategy in atrial fibrillation is complex and depends on:
- A. Patient age only.
- B. Patient symptoms, preferences, duration of AFib, presence of heart failure, and other comorbidities, following a shared decision-making approach.
- C. The availability of a cardiologist.
- D. The most expensive treatment option.
Answer: B. Patient symptoms, preferences, duration of AFib, presence of heart failure, and other comorbidities, following a shared decision-making approach.
21. Which of the following is a primary goal when initiating beta-blocker therapy for rate control in atrial fibrillation?
- A. To achieve a resting heart rate of >100 bpm.
- B. To achieve a resting heart rate typically <80 bpm (lenient goals <110 bpm if asymptomatic and LV function preserved may be considered).
- C. To convert AFib to sinus rhythm.
- D. To eliminate the need for anticoagulation.
Answer: B. To achieve a resting heart rate typically <80 bpm (lenient goals <110 bpm if asymptomatic and LV function preserved may be considered).
22. Class Ic antiarrhythmics like flecainide and propafenone are generally contraindicated or used with extreme caution in patients with:
- A. Paroxysmal supraventricular tachycardia and a structurally normal heart.
- B. Structural heart disease (e.g., coronary artery disease, prior MI, significant LV dysfunction) due to increased risk of proarrhythmia.
- C. Hypertension.
- D. Asthma.
Answer: B. Structural heart disease (e.g., coronary artery disease, prior MI, significant LV dysfunction) due to increased risk of proarrhythmia.
23. What is the role of an electrophysiology study (EPS) in arrhythmia management?
- A. It is a non-invasive test to monitor heart rate.
- B. It is an invasive procedure used to diagnose the type and mechanism of arrhythmias, assess risk, and guide catheter ablation.
- C. It is used solely for pacemaker implantation.
- D. It measures cardiac enzyme levels.
Answer: B. It is an invasive procedure used to diagnose the type and mechanism of arrhythmias, assess risk, and guide catheter ablation.
24. Synchronized electrical cardioversion is used to treat hemodynamically unstable tachyarrhythmias (like VT with a pulse, AFib, AFlutter, SVT) by delivering a shock that is timed to avoid which part of the ECG cycle?
- A. The P wave
- B. The QRS complex
- C. The vulnerable period of the T wave (to avoid inducing VF)
- D. The U wave
Answer: C. The vulnerable period of the T wave (to avoid inducing VF)
25. For long-term suppression of ventricular tachycardia in a patient with an ICD and structural heart disease, which antiarrhythmic is often considered if beta-blockers are insufficient or contraindicated?
- A. Flecainide
- B. Adenosine
- C. Amiodarone or Sotalol (with caution for proarrhythmia)
- C. Diltiazem
Answer: C. Amiodarone or Sotalol (with caution for proarrhythmia)
26. What is a key consideration when managing atrial flutter regarding anticoagulation?
- A. Anticoagulation is generally not needed.
- B. The stroke risk and indications for anticoagulation are generally considered similar to atrial fibrillation.
- C. Only aspirin is required.
- D. Anticoagulation is only needed if the flutter rate is very high.
Answer: B. The stroke risk and indications for anticoagulation are generally considered similar to atrial fibrillation.
27. If a patient on dofetilide develops hypokalemia, this increases the risk of:
- A. Decreased dofetilide efficacy
- B. Dofetilide-induced Torsades de Pointes
- C. Bradycardia only
- D. Liver toxicity
Answer: B. Dofetilide-induced Torsades de Pointes
28. In the acute setting, if a patient with known Wolff-Parkinson-White syndrome develops atrial fibrillation with a very rapid ventricular response via the accessory pathway (wide QRS), which medication is strongly contraindicated?
- A. Procainamide
- B. Ibutilide
- C. AV nodal blocking agents like Verapamil, Diltiazem, Digoxin, or Adenosine
- D. Amiodarone
Answer: C. AV nodal blocking agents like Verapamil, Diltiazem, Digoxin, or Adenosine
29. What does the term “pharmacological cardioversion” refer to?
- A. Using electrical shocks to restore sinus rhythm.
- B. Using antiarrhythmic medications to convert an arrhythmia (like AFib) back to sinus rhythm.
- C. Slowing the ventricular rate with drugs.
- D. Implanting a pacemaker.
Answer: B. Using antiarrhythmic medications to convert an arrhythmia (like AFib) back to sinus rhythm.
30. Which antiarrhythmic agent is generally considered safe and effective for rhythm control in patients with atrial fibrillation and significant structural heart disease, including heart failure?
- A. Flecainide
- B. Propafenone
- C. Amiodarone or Dofetilide (with appropriate monitoring and patient selection)
- D. Sotalol
Answer: C. Amiodarone or Dofetilide (with appropriate monitoring and patient selection)
31. The primary goal of managing symptomatic sinus bradycardia or high-grade AV block is often:
- A. To increase the QRS duration.
- B. To increase the heart rate and improve symptoms, often with a permanent pacemaker if persistent and symptomatic.
- C. To administer long-term beta-blocker therapy.
- D. To initiate anticoagulation.
Answer: B. To increase the heart rate and improve symptoms, often with a permanent pacemaker if persistent and symptomatic.
32. What is a key aspect of monitoring for patients initiated on amiodarone for rhythm control?
- A. Only annual ECGs
- B. Baseline and periodic monitoring of thyroid function, liver function, pulmonary function, and ophthalmologic exams
- C. Daily serum amiodarone levels
- D. Weekly complete blood counts
Answer: B. Baseline and periodic monitoring of thyroid function, liver function, pulmonary function, and ophthalmologic exams
33. The decision to pursue a rhythm-control strategy over a rate-control strategy in atrial fibrillation is often favored in:
- A. All elderly asymptomatic patients.
- B. Younger patients, those with persistent symptoms despite adequate rate control, or if it’s the patient’s preference after discussing risks/benefits.
- C. Patients with permanent atrial fibrillation.
- D. Patients with severe contraindications to anticoagulation.
Answer: B. Younger patients, those with persistent symptoms despite adequate rate control, or if it’s the patient’s preference after discussing risks/benefits.
34. For a patient with recurrent, symptomatic paroxysmal supraventricular tachycardia (PSVT) that is not well managed by vagal maneuvers or acute drug therapy, what is often the definitive treatment?
- A. Long-term oral adenosine
- B. Lifelong beta-blocker therapy
- C. Catheter ablation of the reentrant pathway
- D. Implantation of an ICD
Answer: C. Catheter ablation of the reentrant pathway
35. Which class of antiarrhythmics is generally considered to have “use-dependent” sodium channel blockade, meaning their effect is more pronounced at faster heart rates?
- A. Class II (Beta-blockers)
- B. Class I (Sodium channel blockers), especially Class Ic and some Ia
- C. Class III (Potassium channel blockers)
- D. Class IV (Calcium channel blockers)
Answer: B. Class I (Sodium channel blockers), especially Class Ic and some Ia
36. If a patient is on amiodarone and warfarin, the warfarin dose typically needs to be:
- A. Increased
- B. Decreased (as amiodarone inhibits warfarin metabolism)
- C. Kept the same
- D. Discontinued
Answer: B. Decreased (as amiodarone inhibits warfarin metabolism)
37. The primary management strategy for asymptomatic premature atrial complexes (PACs) or premature ventricular complexes (PVCs) in an otherwise healthy individual is:
- A. Immediate catheter ablation
- B. Initiation of amiodarone
- C. Reassurance and addressing any identifiable triggers (e.g., caffeine, stress); often no specific drug therapy is needed
- D. Implantation of a pacemaker
Answer: C. Reassurance and addressing any identifiable triggers (e.g., caffeine, stress); often no specific drug therapy is needed
38. What is the primary advantage of using direct current (DC) cardioversion over pharmacological cardioversion for certain tachyarrhythmias?
- A. It is less painful for the patient.
- B. It has a higher immediate success rate for converting to sinus rhythm and is preferred in hemodynamically unstable patients.
- C. It carries no risk of proarrhythmia.
- D. It does not require sedation.
Answer: B. It has a higher immediate success rate for converting to sinus rhythm and is preferred in hemodynamically unstable patients.
39. In the management of drug-induced QT prolongation and Torsades de Pointes, what is the first and most crucial step?
- A. Administer a beta-blocker
- B. Discontinue the offending QT-prolonging agent(s)
- C. Initiate amiodarone therapy
- D. Perform electrical cardioversion immediately for all QT prolongation
Answer: B. Discontinue the offending QT-prolonging agent(s)
40. What does “atrial kick” refer to, and why is its loss significant in atrial fibrillation?
- A. The force of ventricular contraction; its loss weakens pulse.
- B. The contribution of atrial contraction to ventricular filling (about 15-30% of cardiac output); its loss in AFib can reduce cardiac output and exacerbate heart failure.
- C. The repolarization phase of the atria.
- D. The primary pacemaker activity of the atria.
Answer: B. The contribution of atrial contraction to ventricular filling (about 15-30% of cardiac output); its loss in AFib can reduce cardiac output and exacerbate heart failure.
41. Which antiarrhythmic is known to cause a metallic taste and can exacerbate asthma due to its beta-blocking properties?
- A. Digoxin
- B. Propafenone
- C. Adenosine
- D. Lidocaine
Answer: B. Propafenone
42. For long-term management of ventricular arrhythmias to prevent sudden cardiac death in high-risk patients (e.g., post-MI with low LVEF), which intervention has the most robust evidence for mortality reduction?
- A. Chronic therapy with Class Ic antiarrhythmics
- B. Implantation of an ICD
- C. High-dose beta-blocker monotherapy
- D. Lifelong oral lidocaine
Answer: B. Implantation of an ICD
43. The “Holiday Heart Syndrome” typically refers to an episode of atrial fibrillation occurring in individuals without structural heart disease after:
- A. A long vacation
- B. Acute excessive alcohol consumption
- C. A major cardiac surgery
- D. A viral illness
Answer: B. Acute excessive alcohol consumption
44. What is the primary consideration when choosing between a beta-1 selective beta-blocker (e.g., metoprolol) versus a non-selective beta-blocker (e.g., propranolol) for rate control in a patient with AFib and concomitant asthma?
- A. Cost of the medication
- B. Beta-1 selective agents are generally preferred to minimize the risk of bronchospasm.
- C. Non-selective agents have better rate control.
- D. Both are equally safe in asthma.
Answer: B. Beta-1 selective agents are generally preferred to minimize the risk of bronchospasm.
45. What is a common side effect of adenosine that limits its use for chronic arrhythmia management?
- A. Its extremely short half-life, making it suitable only for acute IV termination of SVTs.
- B. Severe hepatotoxicity.
- C. The development of tolerance.
- D. Its proarrhythmic effect causing atrial fibrillation.
Answer: A. Its extremely short half-life, making it suitable only for acute IV termination of SVTs.
46. When managing arrhythmias, “upstream therapy” refers to:
- A. Treating the arrhythmia with the most potent drug first.
- B. Managing underlying conditions and risk factors (e.g., hypertension, heart failure, ischemia, sleep apnea) that can promote or perpetuate arrhythmias.
- C. Using only Class III antiarrhythmics.
- D. Implanting a pacemaker before trying medications.
Answer: B. Managing underlying conditions and risk factors (e.g., hypertension, heart failure, ischemia, sleep apnea) that can promote or perpetuate arrhythmias.
47. Patients on long-term amiodarone therapy should be counseled about which potential skin-related side effect?
- A. Vitiligo
- B. Photosensitivity and a bluish-gray skin discoloration with prolonged use
- C. Severe acne
- D. Alopecia
Answer: B. Photosensitivity and a bluish-gray skin discoloration with prolonged use
48. Which of the following laboratory tests is essential to monitor in patients receiving dofetilide due to its risk of QT prolongation and renal excretion?
- A. Liver function tests
- B. Serum creatinine (to assess renal function for dosing) and serum potassium/magnesium
- C. Complete blood count
- D. Serum digoxin level
Answer: B. Serum creatinine (to assess renal function for dosing) and serum potassium/magnesium
49. The management of multifocal atrial tachycardia (MAT) primarily focuses on:
- A. Immediate electrical cardioversion.
- B. Treating the underlying precipitating illness (e.g., severe pulmonary disease, electrolyte imbalance).
- C. Administration of Class Ic antiarrhythmics.
- D. Long-term anticoagulation for all patients.
Answer: B. Treating the underlying precipitating illness (e.g., severe pulmonary disease, electrolyte imbalance).
50. What is the pharmacist’s role in the interprofessional team managing a patient with a complex arrhythmia?
- A. To perform the catheter ablation procedure.
- B. To optimize antiarrhythmic drug therapy, monitor for efficacy and adverse effects, manage drug interactions, and provide patient education.
- C. To make the sole decision on ICD implantation.
- D. To interpret all complex ECGs independently.
Answer: B. To optimize antiarrhythmic drug therapy, monitor for efficacy and adverse effects, manage drug interactions, and provide patient education.