IBHRE Quizzes

BRADY PACING TEST - #1
Voltage is:
a.
b.
c.
d.
If the Pacemaker output voltage is 5v and the measured lead resistance is 330 ohms,
then the current that flows out of the pacemaker into the heart is:
a.
b.
c.
d.
If a unipolar lead wire has an insulation break one would expect the resistance to:
a.
b.
c.
d.
For a wire fracture the resistance:

a.
b.
c.
d.
If the output voltage of the pacemaker is programmed from 5 volts to 2.5 volts, the
energy delivered to the heart is:
w
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____5.
Increases
Decreases
Increases then decreases
Has no change
.p
____4.
Stay the same

Rise
Decrease
None of the above
ac
er
____3.
1.65 mA
15.15 mA
66 mA
10 mA
ic
d.
____2.
The electromotive force pushing on electrons

Moving electrons
The opposition to current flow
Current divided by resistance
co
m
____1.
a.
b.
c.
d.
____6.
a.
b.
c.
d.
Doubled
Halved
Quartered
Quadrupled
Which of the following affect the longevity of the pacemaker?

Output voltage
Resistance of lead
% pacing
All of the above
Which patients pacemaker will last the longest?

a.
b.
c.
d.
The strength duration curve is dependent on the

a.
b.
c.
d.
A pacemaker patient on Flecainide should:
____10.
a.
b.
c.
d.
The acute threshold peaking is due to:
Trauma and inflammation

Fibrosis tissue capsule
Changes in the patients electrolyte balance
Appropriate pulse duration setting
An advantage of bipolar leads is:
w
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____11.
Have their pulse width reduced

Have their threshold checked
Have their base rate lowered
Have no change made to their parameters
ac
er
a.
b.
c.
d.
.p
____9.
Cells membrane capacitance, intracellular and extracellular resistance and threshold

voltage
Size of the cell
Nerve intervention
Mitochondria
ic
d.
____8.
Patient #1 - AMP = 5v, L.R. = 90 BPM, Resistance - 500 , PW = .5ms, 100% pacing
Patient #2 - AMP = 5v, L.R. = 60 BPM, Resistance - 500 , PS = .5ms, 100% pacing
Patient #3 - AMP = 2.5v, L.R. = 60 BPM, Resistance - 330 , PW = .5ms, 100%
pacing
Patient #4 - AMP = 2.5v, L.R. = 60 BPM, Resistance - 500 , PW = .5ms, 50% pacing
co
m
____7.
a.
b.
c.
d.
____12.
a.
b.
c.
d.
They are less susceptible to EMI

They cause muscle stimulation
Smaller IPG cases
Diameter of lead is smaller
The two parameters that are important for ventricular sensing and should be measured
are:
Level detection and amplitude
Reversion and R-wave
R-wave amplitude and slew rate
Acute threshold and amplitude
Brady Pacing Test - #1
Page 2
____15.
a.
b.
c.
d.
____16.
a.
b.
c.
d.
____17.
Less than 5mV

Greater than 20mV
2.5mV to 5mV
7 - 15mV
Typical acceptable P-wave amplitude values for an acute atrial lead is:
Greater than 2mV
Less than 1.5mV
Greater than 7mV
4mV to 10mV
The slew rate is:
Not important to measure because they are dependent on the patients heart
Change in voltage divided by time or the slope of the EGM
Acceptable in the ventricle for <.75v/sec
Acceptable in the atrium for <.5v/sec
Typical lead resistance range measured in ohms is:
300 2000
Less than 300
Greater than 3000
Is not important
w
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a.
b.
c.
d.
co
m
a.
b.
c.
d.
Typical acceptable R-wave amplitude values for an acute ventricular lead is:
ic
d.
____14.
Decrease the sensing to 7mV

Increase the sensing to 10mV
Increase sensing by lowering sensitivity # to 2.5mV
Move the sensitivity control to asynchronous
ac
er
a.
b.
c.
d.
If an external pacemaker is set to a sensitivity setting of 5mV and some R-waves go

unsensed, then you should do the following:
.p
____13.
____18.
a.
b.
c.
d.
At the time of implant we want a threshold
Taken at 1.0ms less than1 volt

At .5ms to be less than 1 volt for ventricle
Greater than 3 volts
Greater than 1.0v for the atrium
Page 3
____21.
a.
b.
c.
d.
____22.
a.
b.
c.
d.
Hysteresis is:
A lower rate for activity pacemakers

The interval the pacemaker waits after a sensed beat before pacing
The interval (rate) after a paced beat
Not useful for saving energy
A SSI pacemaker is one that:
Senses and paces in either the atrium or ventricle and inhibits

Senses the atrium and paces the ventricle
Should not be used for atrial application
Is contraindicated in the presence of atrial fibrillation
You should always check which of the following when programming a unipolar
pacemaker to bipolar configuration.
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____23.
(Time period in ms/60,000)

P.W. X AMP
(60,000 ms/min)/(Time period in ms)
Base rate/upper rate
co
m
a.
b.
c.
d.
The formula for calculating rate is:
ic
d.
____20.
Tighten both set screws

Place the pacemaker in the pocket to check pacing
Always implant so the lead comes off counterclockwise
Verify pacing before placing pacemaker in the pocket
ac
er
a.
b.
c.
d.
When connecting a unipolar pacemaker to the lead in the patient,
.p
____19.
a.
b.
c.
d.
____24.
a.
b.
c.
d.
Stimulation thresholds are adequate

Slew rate is normal
Real time telemetry
Bipolar lead is implanted
Which of the following is likely to happen during the lead maturation process?
Electrode surface deterioration
Encapsulation of electrode with fibrin tissue
Decrease in threshold to a level below that at the time of implantation
Insulation breakage
Page 4
____27.
a.
b.
c.
d.
____28.
Voltage
Current
Energy
All of the above
Which of the following combinations of variables interact to determine stimulation

threshold?
Voltage and pulse width
Rate and sensitivity
Amplitude and rate
Energy and rate
A pacemaker that paces and senses only in the ventricle and is inhibited by
spontaneous ventricular activity is designated:
VAT
VVT
VVI
VDD
w
w
a.
b.
c.
d.
co
m
a.
b.
c.
d.
Cardiac stimulation thresholds are expressed in terms of:
ic
d.
____26.
Output voltage
Lead resistance
Pulse duration
Blanking
ac
er
a.
b.
c.
d.
Which of the following is/are NOT factor(s) which influence pacemaker longevity?
.p
____25.
____29.
a.
b.
c.
d.
____30.
a.
b.
c.
d.
As pulse duration is shortened below 0.3 msec., stimulation threshold increases as

described by all of the following, except:
Energy
Charge
Volts
Current
Current pacemakers employ which of the following chemical batteries?

Lithium-iodide
Mercury-zinc
Nickel-cadmium
Nickel-cobalt
Page 5
____33.
a.
b.
c.
d.
____34.
a.
b.
c.
d.
1.50V
2.50V
2.78V
5.0V
Which of the following is not an advantage of DDD pacemakers?

AV synchrony is maintained
Two leads are required
There is a physiologic increase in heart rate
Minimum programmed heart rate is maintained
For a voltage of 5V, resistance of 500 ohms and pulse width of .5ms, calculate the
energy delivered:
25 joules
.25 joules
25 microjoules
None of the above
Which of the following factors does not contribute to development of the pacemaker
syndrome with ventricular pacing?
w
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____35.
co
m
a.
b.
c.
d.
What is the initial voltage of a lithium battery?
ic
d.
____32.
AV interval duration
Sensitivity
Refractory
Output
ac
er
a.
b.
c.
d.
All of the following functions are programmable in both VVI and DDD pacemakers,
except:
.p
____31.
a.
b.
c.
d.
Loss of AV synchrony
Hysteresis
Constant VA conduction
Inappropriate circulatory reflexes
Page 6
____38.
a.
b.
c.
d.
____39.
They provide the capability of a heart rate increase despite sinus node dysfunction
They are potentially useful in patients with atrial arrhythmias
Retrograde conduction is a potential problem with this pacing mode
They maintain constant AV synchrony
Characteristic findings in patients with the pacemaker syndrome include any of the
following except:
Pacing-induced hypotension
Symptoms of congestive heart failure
Febrile signs of pacemaker infection
Neurological symptoms
For a patient with evidence of sinus node dysfunction and intermittent heart block,
which of the following pacemakers would be inappropriate?
DDDR
AAI
VVI
VVIR
w
w
a.
b.
c.
d.
co
m
a.
b.
c.
d.
Which of the following statements is not true of rate-responsive ventricular

pacemakers that use a sensor other than the atrium?
ic
d.
____37.
Modifying pacemaker function in response to changing patient status

Diagnosing pacemaker ECGs
Prolongation of battery life
All of the above
ac
er
a.
b.
c.
d.
Pacemaker programmability allows which of the following?
.p
____36.
____40.
a.
b.
c.
d.
Which parameter provides the greatest safety when operating on the rheobase of the
strength duration curve?
PW
Sensitivity
Refractory
Voltage
Page 7
a.
b.
c.
d.
____43.
Setting a low pacing rate on a demand ventricular pacemaker may have all of the
following benefits except:
Allowing a patient with sinus rhythm to maintain AV synchrony for a significant
amount of time
Prolonging the life of the pulse generator
Preventing angina in patients with coronary artery disease
Allowing a lower output setting
In a bipolar pacing ventricular pacemaker:
The cathode is in the heart and the anode is in a remote location

The anode is in the heart and the cathode is in a remote location
Both the anode and the cathode are in the heart
Neither the anode nor the cathode is in the heart
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.p
a.
b.
c.
d.
co
m
____42.
Threshold
Intrinsic deflection
Pulse width
Slew rate
ic
d.
a.
b.
c.
d.
The specific intracardiac event sensed by pacemakers is termed:
ac
er
____41.
Page 8

CIRCLE THE LETTER OF THE CORRECT ANSWER:
Which of the following programmable variables would not be useful in preventing
pacemaker-mediated tachycardia?
2.
Automatic atrial refractory extension after PVCs

Atrial refractory period
Blanking period
Auto PVARP
co
m
a.
b.
c.
d.
Extending the post-ventricular atrial refractory period results in which of the following?
a.
b.
c.
d.
A narrowing of the Wenckebach window if upper rate limit is kept constant

A lower upper rate tracking limit in devices with 2:1 block upper rate behavior
Prevention of PMT if the new post-ventricular atrial refractory period is longer
than the ventriculo-atrial (VA) conduction time
All of the above
ic
d.
1.
ANSWER TRUE OR FALSE TO QUESTIONS 3 AND 4:
Some DDD pulse generators treat the first and last halves of the AV delay period
differently. (Ventricular Safety Pacing VSP, Ventricular Safety Standby, Nonphysiologic AV delay) With respect to this feature, mark the following true or false.
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er
3.
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a. The purpose of this function is prevention of crosstalk.

b. Ventricular sense events occurring during the last half of the AV delay
period are regarded as not resulting from normal conduction of the
preceding atrial stimulus.
c. This function may be invoked by crosstalk.
d. This function may be invoked by PVCs occurring in the first half of the
AV delay period.
e. When this function is invoked, pacing is characterized by a long AV
delay.
The ventricular channel of a DDD pacemaker has two refractory periods. Which of the
following are characteristic of the first ventricular refractory period or the blanking
period?
4.
5.
a.
b.
c.
d.
e.
It is present in every pacemaker cycle.

It is usually 75 - 100 ms long.
It occurs coincident with an atrial stimulus.
It is used to prevent pacemaker-mediated tachycardia.
If it is too long, it may prevent the sensing of PVCs occurring in the AV
interval.
f. If it is too short it may allow crosstalk.
Two years after implant, the sensing characteristics of the QRS complex can be
accurately determined by analysis of:
a.
b.
c.
d.
The stimulation threshold is a fixed value independent of :
a.
b.
c.
d.
e.
8.
ic
d.
What is the optimal mode of pacing for sinus node dysfunction with paroxysmal atrial
arrhythmias, compromised AV conduction and when the patient is on medication to
control the tachyarrhythmias?
AAIR
VVIR
DDDR with Mode Switching
DDIR
VDD
ac
er
7.
Pulse width
Electrode surface area
Electrode lead impedance
Voltage
Cardiac enlargement
co
m
a.
b.
c.
d.
e.
What is the optimal mode of pacing for sinus node dysfunction with paroxysmal atrial
arrhythmias, intact AV conduction and anticipate starting on antiarrhythmic drugs?
AAIR
VVIR
DDDR with Mode Switching
DDIR
VDD
w
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a.
b.
c.
d.
e.
.p
6.
The surface ECG

The amplitude of the R wave measured during implant
The characteristics of the intracardiac electrogram
The spontaneous cardiac rate
9.
What is the best mode of pacing for a 9 year old with congenital complete heart block,
sinus rate 92 bpm?
a.
b.
c.
d.
e.
AAIR
VVIR
DDD with Mode Switching
DDIR
VDD
The purpose of the ventricular blanking period is to:
d.
e.
Non-physiologic AV delay pacing (AV pacing with an AV delay shorter than

programmed) results from:
d.
12.
The rate of the pacemaker-mediated tachycardia is more likely to be equal to the upper
tracking rate if:
a.
b.
c.
d.
13.
Retrograde atrial conduction

Crosstalk (ventricular channel senses the atrial stimulus)
Cross stimulation (current passed down the ventricular electrode during atrial
stimulation)
Undersensing
ic
d.
a.
b.
c.
ac
er
11.
Prevent the ventricular sensing amplifier from sensing the far-field P wave
Limit the maximal atrial rate which the pacemaker can track 1:1
Prevent the ventricular sensing amplifier from sensing the far-field atrial pacing
stimulus
Prevent sensing of the T wave
Prevent the inappropriate inhibition of ventricular pacing by environmental
electrical noise (EMI)
co
m
a.
b.
c.
The pacemaker upper rate behavior is Wenckebach

It is initiated by pectoral muscle sensing rather than a PVC
The pacemakers upper rate behavior is 2:1 block
The retrograde conduction time is long
Which of the following have been proposed as a sensor for rate adaptive pacing?
Minute Ventilation
QT interval
Body activity
Central O2 saturation
All of the above
w
w
a.
b.
c.
d.
e.
.p
10.
In which of the following situations might non-synchronous rate responsive pacing be

preferred to DDD pacing?
14.
a.
b.
c.
d.
Chronic atrial fibrillation

Severe sinus bradycardia at rest and during exercise
Sinus node dysfunction with frequent paroxysmal atrial tachyarrhthmias
All of the above
The NBG code includes an indicator for the power source of the pacemaker.
a.
b.
The third position of the NBG code indicates the presence of hysteresis in the pacemaker
rate.
17.
Pacemaker mediated tachycardia often require therapeutic intervention with drugs and
other modalities.
a.
b.
18.
True
False
Dual chamber pacemakers should not be considered in patients with a history of

paroxysmal atrial fibrillation.
True
False
.p
a.
b.
All patients who require pacing except those with chronic atrial fibrillation, should have a
dual chamber system.
w
w
20.
True
False
Most reported dual chamber malfunctions are not due to mechanical or electronic
pacemaker problems, but rather to errors of interpretations on the part of the observer.
a.
b.
19.
True
False
co
m
a.
b.
ic
d.
16.
True
False
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er
15.
a.
b.
21.
True
False
All of the following are absolute contraindications to DDD pacing except:
a.
b.
c.
d.
Chronic atrial fib/flutter

Chronotropic incompetence
Retrograde atrial conduction
Rapid atrial rhythm
What is the first step to take in a patient with a DDD pacemaker experiencing a
pacemaker mediated tachycardia at the upper tracking limit?
All of the following are types of upper rate behaviors except:

a.
b.
c.
d.
e.
24.
Wenckebach
Fallback
Conditional ventricular tracking limit (CVTL)
Rate smoothing
2:1 block
ic
d.
23.
Apply a magnet
Turn on the PMT intervention feature
Increase the PVARP
Shorten the AV delay
Turn on the PVC response feature
co
m
a.
b.
c.
d.
e.
All of the following are strategies for eliminating crosstalk except:

Decrease atrial output
Decrease ventricular sensitivity
Enable ventricular safety pacing
Lengthen PVARP
Increase ventricular blanking period
w
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.p
a.
b.
c.
d.
e.
ac
er
22.

Answer questions 1-17 by circling the best answer. There is only one correct answer for
each question.
Retrograde VA conduction
All of the following are necessary for the development of a dual-chamber

pacemaker endless-loop tachycardia except
3.
All of the following terms are associated with DDD upper rate behavior except
a.
b.
c.
d.
4.
a short post-ventricular atrial refractory period.

an atrially sensing dual-chamber pacemaker
retrograde VA conduction
premature ventricular contraction
ic
d.
a.
b.
c.
d.
ac
er
2.
is important in the genesis of endless-loop pacemaker tachycardia

may contribute to the development of the pacemaker syndrome
may be present despite fixed antegrade AV block
all of above
co
m
a.
b.
c.
d.
AV block
safety pacing
rate smoothing
pseudo-Wenckebach response
Which of the following does not aid in the prevention of crosstalk?

a prolonged blanking period
high ventricular sensitivity (increasing sensitivity, lower number)
low atrial output
low ventricular sensitivity ( decreasing sensitivity, higher number)
w
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a.
b.
c.
d.
.p
1.
5.
Which of the following drugs lower pacing stimulation thresholds?
a.
b.
c.
d.
Epinephrine, amiodarone, flecainide

Flecainide, encainide, propanolol
Epinephrine, dexamethasone, atropine
Procainamide, lidocaine, sotolol
One advantage that bipolar has over unipolar is:
A pacemakers low rate is programmed to 60 bpm. The interval of time between

paced beats is 1000ms and the interval of time between a sensed beat followed by
a paced beat is 1200ms. This could be due to:
8.
All of the following describe normal hysteresis operation except:

a.
b.
c.
d.
9.
ventricular refractory period programmed to 400ms.

a rate modulated pacing mode.
a sensitivity value that is too high (lower number)
undersensing
a programmed hysteresis rate of 50
ic
d.
a.
b.
c.
d.
e.
allows the patient to be in an intrinsic rhythm below the pacing rate

an intentionally longer escape interval vs. pacing interval
typically only available in single chamber pacemakers
provides a lower pacing rate during sleep
ac
er
7.
increases crosstalk
is less susceptible to EMI
is more likely to cause pectoralis muscle stimulation
makes pacing artifacts easier to see on the ECG tracing
leads are smaller in diameter, and thus, easier to implant with a dual chamber
system
co
m
a.
b.
c.
d.
e.
All of the following describe normal hysteresis operation except:

to determine proper sensing of intrinsic events
to determine safety margin of programmed amplitude
to determine ERI status of a device
is a fast method to determine capture
w
w
a.
b.
c.
d.
.p
6.
10.
Calculation of the atrial escape interval is made by:
a.
b.
c.
d.
the AV interval minus the lower rate

60000 / time in ms
60000 / (AV + Ref)
the lower rate interval minus the AV interval
Safety pacing (non-physiologic AV delay)

a.
b.
c.
d.
e.
13.
The Wenckebach period can be calculated as

a.
b.
c.
d.
e.
14.
6000 / (A-V + PVARP)

the AV delay + PVARP
(PVARP + A-V delay) / Upper rate period
the upper tracking rate TARP
atrial escape interval the AV interval
The two-to-one blocking pacemaker rate is:

a.
b.
c.
d.
e.
caused by intrinsic AV conduction

AV interval and PVARP
is determined by the programmed upper rate limit
60,000 / TARP
lower rate - AV interval
The following statements are true of DDIR mode pacing except:
w
w
15.
lower rate pacing

atrial tracking
2:1 block
atrial pacing with normal AV conduction
triggered response atrial pacing
ic
d.
a.
b.
c.
d.
e.
co
m
Normal function of a DDD pacemaker can include all of the following except:
ac
er
12.
has an increased AV interval

protects the patient from the ill effects of crosstalk
prevents PMT from ever occurring
decreases the AV interval as the atrial rate rises
increases the PVARP to 400ms after a PVC occurs
.p
11.
a. some generators switch to this mode in the presence of an SVT

b. it is the preferred mode for the patient with SSS, intermittent SVTs, and
intact A-V conduction
c. it maintains AV synchrony in the presence of A-V block
d. it is therapeutic for chronotropic incompetence and sinus arrest
e. it is a better mode than AAIR for patients with tachy - brady syndrome
16.
The following statements are true of mode switching except:
17.
co
m
a. it results in VVIR pacing throughout the time the device has changed ( modes
in all generators which have mode switch as an option)
b. there is always some delay from the onset of the SVT until the actual mode
switch occurs
c. different manufacturers use different algorithms to achieve mode switching
d. it is programmable on or off for DDD, DDDR, and VDD modes (if it is a
parameter available in the generator)
All of the following are expected outcomes of mode switch except:
ac
er
ic
d.
a. decreases the frequency of necessary mode reprogramming due to intermittent

SVTs
b. decreases the symptoms associated with SVTs due to inappropriate rapid
ventricular pacing in DDD, DDDR, VDD modes
c. promotes AV conduction during the bradycardia period after the SVT has
ceased
d. ensures detection of a rapid atrial arrhythmia by incorporating refractory
sensing and short blanking periods.
e. results in a return to the programmed mode after the SVT has ceased
Below is a list of transducers used in rate responsive pacing. Select the letter of the
transducer that matches the type of pacemakers:
Thermistor
LEDS
Piezoelectric
Electrode and Current
Accelerometer
Pressure
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A.
B.
C.
D.
E.
F.
18.
Temperature
19.
Activity
20.
O2 Sat.
21.
Impedance
22.
DP/DT
Answer True or False:

23. A pacemaker mediated tachycardia may be initiated by:
Loss of atrial capture
A PVC
Loss of atrial sensing
Oversensing EMI
24. Magnet operation can NOT be used to:

Assess battery status
Terminate a retrograde cycle
Assess safety margin
Check for proper sensing
ic
d.
1.
2.
3.
4.
co
m
1.
2.
3.
4.
25. Ventricular safety pacing emits a pace in the ventricle at:

100ms.
400ms.
110ms.
150ms.
ac
er
1.
2.
3.
4.
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Continued on Next Page
Match the following terms with their definitions:

Asynchronous pacing
Oversensing
A-V interval
Physiologic pacing
Retrograde conduction
Lower rate
co
m
a.
b.
c.
d.
e.
f.
In a dual chamber pacemaker, the period of time between an atrial event (sensed
or paced) and a paced ventricular event.
27.
In atrial tracking dual chamber pacemakers, the programmed rate at which the
pacemaker will pace the heart in the absence of cardiac activity.
28.
The propagation of depolarization from the ventricles to the atria, i.e., V-A
Conduction.
29.
Inhibition of a pacemaker by events other than those, which the pacemaker was
designed to sense, i.e., myopotentials, EMI, crosstalk, etc.
30.
Artificial pacing, which maintains the hearts normal contraction sequence with
resulting hemodynamic benefits.
31.
Stimulation of the heart at a fixed, preset rate, independent of any electrical and/or
mechanical activity of the heart.
ac
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ic
d.
26.
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(Continued on Next Page)
Answer the following True or False:

In the presence of retrograde conduction, the PVARP should always be
programmed to the maximum value of 600 ms.
33.
In DDD pacing, the second position of the NBG code represents the
chamber (s) being sensed.
34.
Appropriate rate increase results in increased cardiac output for most

hearts.
35.
Without correct atrial sensing, rate increase is compromised and the

pacemaker paces sequentially at the upper rate.
36.
Crosstalk is a potential problem in virtually all VVI pacemakers.
37.
The Lower Rate, AV Interval, and the Upper Tracking Rate are all
parameters to be selected for the DDI mode.
38.
DDDR with mode switch is the therapy of choice for patients with SSS,
unreliable AV conduction or AV block, and intermittent SVTs.
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.p
ac
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ic
d.
co
m
32.

1. Match the following modes with the appropriate descriptions:
DDD, DDI, DDDR, VVIR, DOO
co
m
_______ For patients with intermittent atrial fibrillation

_______ For patients with complete heart block with normal sinus function
_______ For patients with chronic atrial fibrillation
_______ For patients undergoing shoulder surgery
_______ For patients with sick sinus syndrome
DDDR
VVIR
DDIR
AAIR
.p
A.
B.
C.
D.
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ic
d.
2. Before implant a patient presents with the following rhythm. Which pacing mode
would you recommend?
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3. Before implant a patient presents with the following rhythm. Which pacing mode
would you recommend?
A.
B.
C.
D.
DDDR
VVIR
DDIR
AAIR
ic
d.
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After performing a final interrogation to retrieve a final printout at implant, you see the
following. Identify the problem. (The EGM source shown is from the atrium.)
A.
B.
C.
D.
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4. What is the problem presented in the above ECG?
The atrial lead has fallen into the ventricle

It is programmed to the DOO mode
Leads are reversed
Loose ventricular set screw
Measure lead impedances in both leads

Temporarily program to VVI and AAI while observing the ECG
Take a portable PA & Lateral Chest X-Ray
Place a magnet over the device and observe the intracardiac EGM
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A.
B.
C.
D.
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5. A strategy to verify the correct diagnosis above is to:
6. After performing a final interrogation to retrieve a final printout at an acute pacemaker

implant, the Quick Look screen reveals the ventricular lead impedance is 2400 ohms.
During the implant, the analyzer measured the lead impedance to be 950 ohms. What is
the most likely cause of this?
A.
B.
C.
D.
The lead has dislodged

The lead was nicked by a scalpel during implant that caused an insulation
failure
The lead was damaged due to rough handling during the implant
Loose set screw at the ventricular port
You are presented with the following tracing from a patient in a pacemaker clinic for a
routine visit. The patient is not pacemaker dependent and is asymptomatic. The
information you are given is as follows:
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Mode: VVI
Lower Rate: 70 PPM
A.
B.
C.
D.
ic
d.
7. What is the best corrective action for the problem above?
Normal pacing function no action is required

Measure lead impedance and assess for lead problem
Do a threshold test and increase output
Remove the magnet to resume normal function
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You are presented with the following tracing from a patient in the pacemaker clinic for a
routine visit. The patient is rather stoic and initially denies any problems. With further
questioning she admits that she occasionally has a very light and very transient sensation
of light-headedness but had discounted the symptoms. The information you are given is
as follows:
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.p
Mode: DDDR
Lower Rate: 50 ppm
Upper Rate: 110 ppm
PVARP: 160ms
8. Identify the problem in the ECG above and choose the best answer:
A.
B.
C.
D.
Ventricular oversensing increase the post atrial ventricular blanking period

Measure ventricular lead impedance loose set set screw
Loss of ventricular capture increase output
Measure ventricular lead impedance insulation failure
You are presented with the following tracing from a patient in the pacemaker clinic for a
routine visit. The patient is asymptomatic. The information you are given is as follows:
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Mode: DDD
Lower Rate: 50ppm
Upper Rate: 110ppm
PVARP: 250ms
A.
B.
C.
D.
ic
d.
9. Is the pacemaker functioning normally? Choose the best answer.
Pacemaker Mediated Tachycardia Turn on PMT Termination

Normal sensing of a PVC with extended PVARP response
Normal synchronous pacing of atrial tachycardia
Ventricular tachycardia Turn on Ventricular High Rate Diagnostic
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You see the following strip at a one-week wound check appointment.
10. The ECG presents with the following. Choose the best description of the problem:
A.
B.
C.
D.
Leads are reversed

Ventricular Safety Pacing
Loss of atrial sensing
Atrial lead has fallen into the ventricle
CASE STUDIES
You will be presented with a case history with ECGs and/or programmer printouts
followed by a series of multiple choice questions regarding each case. Choose the BEST
answer.
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ic
d.
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CASE #1
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ic
d.
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CASE #1
11. The narrow complex Tachycardia observed in ECG Strip #2 may have been initiated
from the atrial lead positioning.
a. true
b. false
ic
d.
13. ECG Strip #4 demonstrates:

a. atrial capture
b. ventricular sensing
c. both A and B
d. neither A or B
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12. ECG Strip #3 confirms:

a. atrial sensing
b. ventricular capture
c. both A and B
d. neither A or B
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14. Magnet application in ECG Strip #5 confirms:

a. atrial capture
b. ventricular capture
c. atrial and ventricular leads are not reversed in the pacemaker header
d. all of the above
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.p
15. The PSA threshold results on these two implanted tined steroid eluting pacemaker
leads would be best described by the following:
a. average
b. unacceptable, need for repositioning of leads
c. average with exceptional P-waves
d. exceptional
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ic
d.
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CASE #2
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ic
d.
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.p
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CASE STUDY 2
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16. Based on the findings from the initial ECG Strip #1 and EGM Strip #1, what is the
cause of this patients accelerated rate?
a. sensor driven pacing
b. PMT
c. balanced endless-loop Tachycardia
d. tracking atrial tachyarrhythmia
17. What is the most valuable tool for assessing this patients problem?
a. atrial EGM
b. ventricular EGM
c. surface ECG
d. chest X-ray
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ic
d.
18. What programmed parameter could be changed to alleviate this problem?

a. sensed AV delay
b. atrial output
c. mode switching
d. rate smoothing
e. PMT termination algorithm
19. Which diagnostic functions could be utilized to evaluate frequency of these episodes?
a. rate response optimization episodes and high atrial rate histogram
b. high atrial rate histogram and mode switch episode
c. rate vs. time trend and percent total event summary
d. mode switch episode and AV conduction histogram
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20. If the patient develops this arrhythmia frequently, what mode could best be utilized?
a. VVIR
b. AAIR
c. DVIR
d. DDIR
10
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ic
d.
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Case #3
11
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ic
d.
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.p
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12
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ic
d.
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.p
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13
Case #3
22. What is consistently demonstrated in ECG Strip #1?

a. atrial sensing
b. atrial capture
c. ventricular sensing
d. ventricular capture
e. A and D only
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21. What timing period is not present in ECG Strip #1 that is present in ECG Strip #2?
a. PVARP (320ms)
b. ventricular blanking (24ms)
c. ventricular blanking (after V. pace 126ms)
d. atrial blanking (225ms)
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ic
d.
23. What is the recorded basis for atrial pacing above the programmed lower rate in ECG
strip #2?
a. atrial tracking
b. sensor drive
c. rate smoothing
d. all of the above
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24. The purpose of the shortest blanking period observed in ECG Strip #2 is to prevent:
a. PMT
b. AVDA
c. crosstalk
d. atrial oversensing
14
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ic
d.
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CASE #4
15
CASE #4
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25. The chest x-rays of this case study represent which of the following views?
a. AP and lateral
b. Left anterior oblique (LAO)
c. Right anterior oblique (RAO)
d. 2 lateral views
ic
d.
26. The atrial lead position appears:

a. normal
b. too open
c. too closed
d. posterior
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27. An atrial lead position with the electrode facing posterior as opposed to anterior
would make the patient more susceptible to?
a. pericarditis
b. exit block
c. diaphragmatic stimulation
d. over-sensing
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28. The standard view for assessing ventricular lead redundancy (slack) would be?
a. AP or PA
b. Lateral
c. RAO
d. LAO
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29. The ECG demonstrates?

a. normal DDD function
b. loss of atrial capture
c. loss of atrial sensing
d. loss of atrial capture and sensing
16
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d.
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CASE #5
17
CASE #5
30. Which of the following do we know from ECG Strip #1?
a. atrial capture and ventricular sensing
b. atrial and ventricular sensing
c. ventricular sensing
d. none of the above
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31. Which of the following do we know from ECG Strip #2?

a. atrial and ventricular capture
b. atrial sensing
c. ventricular capture
d. atrial sensing and ventricular capture
ic
d.
32. Which of the following would be programmed in ECG Strip #1 to confirm atrial
sensing?
a. decrease low rate
b. increase low rate
c. increase AV interval
d. decrease AV interval
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33. Which of the following would be programmed in to confirm ventricular sensing in

ECG Strip #2?
a. decrease low rate
b. increase low rate
c. increase AV interval
d. decrease AV interval
18
BRADY PACING TEST #1 -- ANSWERS
E=(V2/R)*t
Lowest Amp, higher
.p
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See Pg. 4 Hayes Text
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resistance, 50% pacing
39. b
40. d
41. b
42. d
43. c
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I=V/R=5v/.33 Kohm
20. c
21. b
22. a
23. d
24. b
25. d
26. d
27. a
28. c
29. b
30. a
31. a
32. c
33. b
34. c
35. b
36. d
37. d
38. c
ic
d.
1. a
2. b
3. c
4. a
5. c
6. d
7. d
8. a
9. b
10. a
11. a
12. c
13. c
14. d
15. a
16. b
17. a
18. b
19. b
See Pg. 5 Hayes Text

ANSWERS
.p
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E
C
B
A
E
D
B - False
B - False
B - False
A - True
B - False
B - True
C
A
C
D
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9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
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2.
3a.
3b.
3c.
3d.
3e.
4a.
4b.
4c.
4d.
4e.
4f.
5.
6.
7.
8.
C
D
False
False
True
True
False
False
False
True
False
True
True
C
E
C
D
ic
d.
1.

ANSWERS
25.
.p
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D
F
All True
# 1-3 False,
# 4 True
# 1&3 True,
# 2&4 False
C
F
E
B
D
A
False
True
True
False
False
False
True
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21.
22.
23.
24.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
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2
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
D
D
B
B
C
B
E
D
A
D
B
E
D
D
C
A
C
A
C, E
B
ic
d.
1.
BRADY PACING TEST #4

ANSWERS
1. Match the following modes with the appropriate descriptions:
DDD, DDI, DDDR, VVIR, DOO
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ic
d.
C
B
D
B
E
B
C
D
B
C
A
D
C
D
D
C
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18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
.p
2. B
3. A
4. C
5. B
6. D
7. C
8. A
9. B
10. D
11. A
12. C
13. C
14. D
15. C
16. D
17. A
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DDI For patients with intermittent atrial fibrillation

DDD For patients with complete heart block with normal sinus function
VVIR For patients with chronic atrial fibrillation
_DOO_ For patients undergoing shoulder surgery
DDDR For patients with sick sinus syndrome
CRT Quiz
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1. Stages of Heart Failure (Please label as A, B, C, D)

a. Patients with structural heart disease but without signs and symptoms of
heart failure. ______
b. Patients who have current or previous symptoms of heart failure
associated with underlying structural heart disease. _______
c. Patients with structural heart disease and marked symptoms of heart
failure at rest despite maximal medical therapy. ______
d. Patients at high risk (Hypertension, CAD, Diabetes, Strong family history
) _____
ic
d.
2. Fill in the table with the appropriate symptoms of NYHA

a. I
b. II
c. III
d. IV
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3. What 2 classes of drugs should be used with all heart failure patients?
a. ACE and BETA
b. BETA and Statins
c. BETA and Antiarrhythmic
d. BETA and Digoxin
.p
4. Epidemiological databases indicate that the mortality for patients who present
with heart failure is what at 2-3 years after diagnosis?
a. 15%
b. 35%
c. 50%
d. 70%
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5. What drug should be administered to all patients with symptomatic heart failure
when they become stable as well as patients with LV dysfunction after MI? Antihypertensive
a. Beta-Blocker
b. Anti-thrombolytic
c. Anti-arrhythmic
6. Match the following drugs to their appropriate classification:
Furosemide
Captopril
Carvedilol
Eplerenone
A. Beta-blocker
B. ACE-inhibitor
C. Aldosterone-antagonist
D. Diuretic
7. Do patients whose condition appear stable remain at risk for disease progression?
a. Yes
b. No
8. In clinical practice, what should be done first for heart failure treatment
a. ACE inhibitor
b. Beta-Blocker
c. Diuretics to rid excess volume
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9. Pacing for treatment of medically refractory dilated cardiomyopathy is designated

as what type of indication by the ACC/AHA guidelines?
a. I
b. II
c. IIB
d. III
ic
d.
10. QRS duration has been shown to correlate with mortality?

a. True
b. False
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11. What causes the abnormal motion of the ventricular septum in a patient with a
LBBB?
a. The early activation of the LV
b. The Interventricular dyssynchrony and abnormal pressure gradient
between the ventricles
c. Early opening of the Aortic valve leading to decreased ventricular filling
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12. Can CRT be used in patients with RBBB?

a. Yes
b. No
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13. Where is the place on the LV that shows the greatest improvement in dp/dt and
pulse pressure according to Path-CHF I?
a. Lateral
b. Posterior
c. Mid-Lateral
d. Apical
14. Is there evidence to support that a patient with a normal QRS and clinical heart
failure can have Interventricular dyssynchrony and can benefit from CRT?
a. Yes
b. No
15. What is a secondary effect of the decrease in MR and LV dimension from CRT?
a. Less VT
b. Less PVCs
c. Decrease in LA dimension
16. Identify the optimized AV delay for this patient. Explain your rationale.
AV 240
ic
d.
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AV 280
AV 180
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AV 200
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ic
d.
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17. Please identify what device operation is occurring within this strip from a patient
with an InSync III 8042?
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18. What are the indications for CRT-ICD? (Mark all that apply)
a. NYHA class 2, 3
b. EF 35%
c. QRS 150 ms
d. Stable medical therapy
e. ICD indication
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ic
d.
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19. This is a ventricular threshold test in the InSync 8040 device. What do you think
is going on and how do you fix it?
20. Does SDANN correlate with mortality?

a. Yes
b. No
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21. A positive R-wave in Lead I would suggest a signal coming from where?
a. Left ventricle to right
b. Right ventricle to left
22. What are the inferior leads?

a. II, III, aVF
b. I, aVL, V4
c. V4-V6
d. V1, aVR, III
23. Will a positive deflection in V1, aVR, and III show
a. Right to left
b. Left to right
24. Lead I if positive suggests
a. Septal pacing
b. Inferior
c. RV apex (Middle Cardiac Vein)
25. A positive R wave in aVF suggest

a. LV posterior
b. Anterior Interventricular
c. Basal
C
D
ic
d.
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26. Label the cardiac veins in the following venogram.
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27. Identify the veins in this venogram. What is the target lead placement site for the
LV lead in this venogram?
Balloon
D
Balloon
Catheter
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Ostium
ic
d.
Guide
Catheter
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.p
28. In the normal state, sinus impulses from the junction of the RA reach the LA
primarily through the
a. Atrial septum
b. SA node
c. Roof of the atrium (Bachmanns Bundle)
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29. Programming a short AV delay causes

a. Late closure of the Mitral valve
b. Early closure of the Mitral valve
30. Short AV delays cause

a. Long diastolic filling time
b. Short diastolic filling time
31. On echo, an A wave represents what?
a. Passive atrial filling
b. Passive ventricular filling
c. Active atrial filling
d. Active ventricular filling
32. When should Mitral valve closure occur?

a. After the E wave
b. At the very end of the A wave
c. Delayed a set time after the A wave
d. During the A wave
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33. What is a good method for evaluating V-V timing?

a. Mitral inflow
b. M-Mode
c. Ritter method
d. Color
34. Do electrical and mechanical synchrony always correlate?

a. Yes
b. No
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ic
d.
35. Septal to lateral wall delay by M-mode echo of more than what may be a good
predictor of CRT response?
a. 100ms
b. 130ms
c. 150ms
d. 180ms
36. ICD therapy for those at risk for having arrhythmias is
a. Primary prevention
b. Secondary prevention
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37. Sudden death can be reduced to what with ICDs?

a. 1%
b. 3%
c. 5%
d. 10%
38. Should meds be discontinued after a CRT implant?

a. Yes
b. No
39. Should QRS duration always be used as an indictor of CRT response?

a. Yes
b. No
40. The following studies demonstrate the benefit of CRT on heart failure patient
functional status (ie, Quality of Life, NYHA Class, etc) Circle ALL that apply:
a. HOPE
b. MIRACLE
c. Contak CD
d. SOLVD
e. MUSTIC
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ic
d.
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41. The following study demonstrated the benefit of CRT in improving patient risk
for heart failure hospitalization and mortality:
a. MADIT
b. CONSENSUS
c. COMPANION
d. COPERNICUS
e. AVID
CRT Quiz
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1. Stages of Heart Failure (Please label as A, B, C, D)

a. Patients with structural heart disease but without signs and symptoms of
heart failure. ___B___
b. Patients who have current or previous symptoms of heart failure
associated with underlying structural heart disease. ___C____
c. Patients with structural heart disease and marked symptoms of heart
failure at rest despite maximal medical therapy. ___D___
d. Patients at high risk (Hypertension, CAD, Diabetes, Strong family history
) __A___
ic
d.
2. Fill in the table with the appropriate symptoms of NYHA

a. I No Symptoms
b. II Symptoms with moderate activity
c. III Symptoms with minimal activity
d. IV Symptoms at rest
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3. What 2 classes of drugs should be used with all heart failure patients?
a. ACE and BETA
b. BETA and Statins
c. BETA and Antiarrhythmic
d. BETA and Digoxin
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w
.p
4. Epidemiological databases indicate that the mortality for patients who present
with heart failure is what at 2-3 years after diagnosis?
a. 15%
b. 35%
c. 50%
d. 70%
5. What drug should be administered to all patients with symptomatic heart failure
when they become stable as well as patients with LV dysfunction after MI?
a. Anti-hypertensive
b. Beta-Blocker
c. Anti-thrombolytic
d. Anti-arrhythmic
6. Match the following drugs to their appropriate classification:
Furosemide
Captopril
Carvedilol
Eplerenone
D
B
A
C
A. Beta-blocker
B. ACE-inhibitor
C. Aldosterone-antagonist
D. Diuretic
7.Do patients whose condition appear stable remain at risk for disease progression?
a. Yes
b. No
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8.In clinical practice, what should be done first for heart failure treatment
c. ACE inhibitor
d. Beta-Blocker
e. Diuretics to rid excess volume
ic
d.
9. Pacing for treatment of medically refractory dilated cardiomyopathy is designated

as what type of indication by the ACC/AHA guidelines?
a. I
b. II
c. IIB
d. III
10. QRS duration has been shown to correlate with mortality?
a. True
b. False
ac
er
11. What causes the abnormal motion of the ventricular septum in a patient with a
LBBB?
a. The early activation of the LV
b. The Interventricular dyssynchrony and abnormal pressure gradient
between the ventricles
c. Early opening of the Aortic valve leading to decreased ventricular filling
.p
12. Can CRT be used in patients with RBBB?

a. Yes
b. No
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13. Where is the place on the LV that shows the greatest improvement in dp/dt and
pulse pressure according to Path-CHF I?
a. Lateral
b. Posterior
c. Mid-Lateral
d. Apical
14. Is there evidence to support that a patient with a normal QRS and clinical heart
failure can have Interventricular dyssynchrony and can benefit from CRT?
a. Yes
b. No
15. What is a secondary effect of the decrease in MR and LV dimension from CRT?
a. Less VT
b. Less PVCs
c. Decrease in LA dimension
16. Identify the optimized AV delay for this patient. Explain your rationale.
AV 240
ac
er
AV 180
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AV 200
ic
d.
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AV 280
Full E & A wave without A wave truncation. Therefore we will pace the ventricles at
the end of active filling and not interfere with the atrial contribution.
17. Please identify what device operation is occurring within this strip from a patient
with an InSync III 8042?
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er
ic
d.
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VSR
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.p
18. What are the indications for CRT-ICD? (Mark all that apply)
a. NYHA class 2, 3
b. EF 35%
c. QRS 150 ms
d. Stable medical therapy
e. ICD indication
ac
er
ic
d.
co
m
19. This is a ventricular threshold test in the InSync 8040 device. What do you think
is going on and how do you fix it?
.p
This is a LV lead dislodgement. The V EGM shows a large deflection after the A
sense. The LV lead is sensing atrial activity demonstrated by the initial VS that
is associated with the P wave and not the QRS complex on the surface ECG.
Also note only 1 sense with the QRS. The RV is still sensing ventricular activity
but the LV lead has dislodged and is probably in the main CS, therefore sensing
Atrial activity.
Suggest a chest X-ray and will probably need a lead revision to regain LV
capture.
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20. Does SDANN correlate with mortality?

a. Yes
b. No
21. A positive R-wave in Lead I would suggest a signal coming from where?
a. Left ventricle to right
b. Right ventricle to left
22. What are the inferior leads?
a. II, III, aVF
b. I, aVL, V4
c. V4-V6
d. V1, aVR, III
23. Will a positive deflection in V1, aVR, and III show

a. Right to left
b. Left to right
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24. Lead I if positive suggests

a. Septal pacing
b. Inferior
c. RV apex (Middle Cardiac Vein)
25. A positive R wave in aVF suggest
a. LV posterior
b. Anterior Interventricular
c. Basal
ic
d.
26. Label the cardiac veins in the following venogram.

A. Posterior branch B. Coronary Sinus C. AIV
D. Lateral branch E. MCV
ac
er
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.p
27. Identify the veins in this venogram. What is the target lead placement site for the
LV lead in this venogram?
Balloon
Catheter
ic
d.
Ostium
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Guide
Catheter
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Balloon
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A. MCV B. Posterior Lateral
C. Main CS D. AIV
B is target
28. In the normal state, sinus impulses from the junction of the RA reach the LA
primarily through the
a. Atrial septum
b. SA node
c. Roof of the atrium (Bachmanns Bundle)
29. Programming a short AV delay causes
a. Late closure of the Mitral valve
b. Early closure of the Mitral valve
30. Short AV delays cause
a. Long diastolic filling time
b. Short diastolic filling time
32. When should Mitral valve closure occur?

a. After the E wave
b. At the very end of the A wave
c. Delayed a set time after the A wave
d. During the A wave
co
m
31. On echo, an A wave represents what?

a. Passive atrial filling
b. Passive ventricular filling
c. Active atrial filling
d. Active ventricular filling
ic
d.
33. What is a good method for evaluating V-V timing?

a. Mitral inflow
b. M-Mode
c. Ritter method
d. Color
ac
er
34. Do electrical and mechanical synchrony always correlate?

a. Yes
b. No
35. Septal to lateral wall delay by M-mode echo of more than what may be a good
predictor of CRT response?
a. 100ms
b. 130ms
c. 150ms
d. 180ms
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w
.p
36. ICD therapy for those at risk for having arrhythmias is

a. Primary prevention
b. Secondary prevention
37. Sudden death can be reduced to what with ICDs?

a. 1%
b. 3%
c. 5%
d. 10%
38. Should meds be discontinued after a CRT implant?
a. Yes
b. No
39. Should QRS duration always be used as an indictor of CRT response?
a. Yes
b. No
40. The following studies demonstrate the benefit of CRT on heart failure patient
functional status (ie, Quality of Life, NYHA Class, etc) Circle ALL that apply:
a. HOPE
b. MIRACLE
c. Contak CD
d. SOLVD
e. MUSTIC
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41. The following study demonstrated the benefit of CRT in improving patient risk
for heart failure hospitalization and mortality:
a. MADIT
b. CONSENSUS
c. COMPANION
d. COPERNICUS
e. AVID
Defib Questions.
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1. The premise of a proposed theory of defibrillation is that a shock need only

eliminate the fibrillatory wavelets in a percentage of myocardium to extinguish
the arrhythmia.
a. Upper limit of vulnerability
b. Critical mass
c. Progressive depolarization
d. Defbrillation threshold
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d.
2. Factors that can affect whether a shock will succeed include:

a. fibrillation duration
b. potassium accumulation
c. circulating pharmacologic agents
d. all of the above
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3. Biphasic waveforms have been shown to result in higher implantation success

rates due to:
a. smaller can/device size
b. lower DFTs
c. utilization of high output devices
d. none of the above.
4. Factors favoring use of a dual chamber ICD include but are not limited to;
a. chronic AF
b. need for heart rate variability diagnostics
c. standard indication for a dual chamber pacemaker
d. preservation of A-V synchrony
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5. If external defibrillation is necessary, the preferred position for external Defib pad
placement in a patient with an implanted ICD is:
a. anterior-posterior
b. anterior-anterior with pads placed right pectoral and left lateral
c. apex-posterior
Defib Questions Answer Key
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1. The premise of a proposed theory of defibrillation is that a shock need only

eliminate the fibrillatory wavelets in a percentage of myocardium to extinguish
the arrhythmia.
a. Upper limit of vulnerability
b. Critical mass
c. Progressive depolarization
d. Defbrillation threshold
ic
d.
2. Factors that can affect whether a shock will succeed include:

a. fibrillation duration
b. potassium accumulation
c. circulating pharmacologic agents
d. all of the above
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3. Biphasic waveforms have been shown to result in higher implantation success

rates due to:
a. smaller can/device size
b. lower DFTs
c. utilization of high output devices
4. Factors favoring use of a dual chamber ICD include but are not limited to;
a. chronic AF
b. need for heart rate variability diagnostics
c. standard indication for a dual chamber pacemaker
d. preservation of A-V synchrony
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5. If external defibrillation is necessary, the preferred position for external Defib pad
placement in a patient with an implanted ICD is:
a. anterior-posterior
b. anterior-anterior with pads placed right pectoral and left lateral
c. apex-posterior
Quiz
ICD Indications
Which of the following is not a class I indication for ICD implantation?
a. Cardiac arrest due to ventricular fibrillation (VF) or ventricular
tachycardia (VT) not due to a transient or reversible cause.
b. Syncope of undetermined origin with clinically relevant,
hemodynamically significant sustained VT or VF induced at EP study
when drug therapy is ineffective, not tolerated, or not preferred.
c. Patients with LV ejection fraction of less than or equal to 30%, at least one
month post myocardial infarction and three months post coronary artery
revascularization surgery.
d. Nonsustained VT with coronary disease, previous myocardial infarction,
left ventricular dysfunction, and inducible VF or sustained VT at EP tudy
that is not suppressible by a class I antiarrhythmic drug.
2.
This study showed a 54% reduction in mortality over conventional therapy in

post-MI patients with an LVEF of less that 35%, asymptomatic NSVT and
inducible VT on EP study.
a. MADIT II
b. SCD-HeFT
c. DEFINITE
d. MADIT
3.
This study showed a 34% reduction in mortality for patients with nonischemic
cardiomyopathy, NSVT and low EF who received ICD therapy vs. optimal
medical therapy.
a. MADIT II
b. SCD-HeFT
c. DEFINITE
d. CABG-PATCH
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The trial results in the previous question were shown to be statistically

significant.
a. True
b. False
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1.
5.
The only clinical trial which led to a class I indication for ICD implantation
for primary prevention of SCD was:
a. MADIT
b. MADIT II
c. SCD-HeFT
d. DEFINITE
Quiz
ICD Indications
Which of the following is not a class I indication for ICD implantation?
a. Cardiac arrest due to ventricular fibrillation (VF) or ventricular
tachycardia (VT) not due to a transient or reversible cause.
b. Syncope of undetermined origin with clinically relevant,
hemodynamically significant sustained VT or VF induced at EP study
when drug therapy is ineffective, not tolerated, or not preferred.
c. Patients with LV ejection fraction of less than or equal to 30%, at least
one month post myocardial infarction and three months post coronary
artery revascularization surgery.
d. Nonsustained VT with coronary disease, previous myocardial infarction,
left ventricular dysfunction, and inducible VF or sustained VT at EP tudy
that is not suppressible by a class I antiarrhythmic drug.
2.
This study showed a 54% reduction in mortality over conventional therapy in

post-MI patients with an LVEF of less that 35%, asymptomatic NSVT and
inducible VT on EP study.
a. MADIT II
b. SCD-HeFT
c. DEFINITE
d. MADIT
3.
This study showed a 34% reduction in mortality for patients with nonischemic
cardiomyopathy, NSVT and low EF who received ICD therapy vs. optimal
medical therapy.
a. MADIT II
b. SCD-HeFT
c. DEFINITE
d. CABG-PATCH
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The trial results in the previous question were shown to be statistically

significant.
a. True
b. False
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1.
5.
The only clinical trial which led to a class I indication for ICD implantation
for primary prevention of SCD was:
a. MADIT
b. MADIT II
c. SCD-HeFT
d. DEFINITE
Quiz
ICD Programming
This feature is designed to avoid delayed detection when an arrhythmia
straddles the VT and VF zones of an ICD:
a. FVT via VF
b. Auto-adjusting sensitivity
c. Combined count detection
d. Express TherapyTM
2.
Guidant ICDs use which method to maintain appropriate sensing of QRS

complexes and VF while avoiding oversensing T-waves?
a. Auto-adjusting sensitivity
b. Beat-to-beat adjustment of sensing
c. Automatic gain control
d. None - fixed sensing only
3.
This detection enhancement uses an abrupt change in rate to distinguish sinus

tachycardia from true VT.
a. Onset
b. Stability
c. BuzzFreeTM
d. EGM Width
4.
The Guidant Atrial View detection enhancements add which of the following
features to stability and onset (choose all that apply):
a. A Rate > V Rate
b. AV Dissociation
c. Lookback
d. A Fib Rate Threshold
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ELAs PARAD Detection enhancement utilizes each of the following to

distinguish VT from SVT except:
a. Chamber of onset
b. AV Association
c. EGM morphology
d. Interval stability
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1.
6.
What are the elements of PR logic?
7.
What are the therapy options delivered by Medtronics atrial defibrillators?
Quiz
ICD Programming
This feature is designed to avoid delayed detection when an arrhythmia
straddles the VT and VF zones of an ICD:
a. FVT via VF
b. Auto-adjusting sensitivity
c. Combined count detection
d. Express TherapyTM
2.
Guidant ICDs use which method to maintain appropriate sensing of QRS

complexes and VF while avoiding oversensing T-waves?
a. Auto-adjusting sensitivity
b. Beat-to-beat adjustment of sensing
c. Automatic gain control
d. None - fixed sensing only
3.
This detection enhancement uses an abrupt change in rate to distinguish sinus

tachycardia from true VT.
a. Onset
b. Stability
c. BuzzFreeTM
d. EGM Width
4.
The Guidant Atrial View detection enhancements add which of the following
features to stability and onset (choose all that apply):
a. A Rate > V Rate
b. AV Dissociation
c. Lookback
d. A Fib Rate Threshold
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d.
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ELAs PARAD Detection enhancement utilizes each of the following to

distinguish VT from SVT except:
a. Chamber of onset
b. AV Association
c. EGM morphology
d. Interval stability
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1.
6.
What are the elements of PR logic?

Rate, Pattern, Regularity, AV Dissociation, Far Field R Wave and AF
Evidence (according to Hayes)
7.
What are the prevention/termination therapy options delivered by Medtronics

atrial defibrillators?
Atrial rate stabilization, High-rate overdrive pacing, Atrial ATP, 50 Hz
burst, Atrial cardioversion
Quiz
ICD Troubleshooting
What are the benefits of storing a far-field electrogram for ICD episode
analysis?
2.
The following strip illustrates:
Lead fracture on the ventricular tip conductor

EMI
Lead fracture on the RV coil conductor
T wave oversensing
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a.
b.
c.
d.
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1.
3.
How can you tell whether the ventricular EGM is near-field or far-field?
4.
Is absence of symptoms prior to a shock always indicative of inappropriate

therapy? Why or why not?
5.
Are multiple therapies (more than two) in a single episode always indicative
that the therapies are inappropriate? What about shocks? Why or why not?
Quiz
ICD Troubleshooting
1.
What are the benefits of storing a far-field electrogram for ICD episode
analysis?
The following strip illustrates:
How can you tell whether the ventricular EGM is near-field or far-field?
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Lead fracture on the ventricular tip conductor

EMI
Lead fracture on the RV coil conductor
T wave oversensing
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a.
b.
c.
d.
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2.
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More closely resembles surface ECG, can sometimes distinguish P waves,

easier to distinguish between sinus and VT morphology
Look at all of the noise on the EGM, then notice that the marker channel is
showing normal ventricular sensing. If the tip or ring conductors were
involved over sensing on the V channel would have been noted
4.
Is absence of symptoms prior to a shock always indicative of inappropriate

therapy? Why or why not?
No. According to at least one study more than 60% of VT episodes were
asymptomatic. Remember to program PainFREE!
5.
Are multiple therapies (more than two) in a single episode always indicative
that the therapies are inappropriate? What about shocks? Why or why not?
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No, although it can be a strong indicator. Many factors can contribute to

multiple therapies, such as inappropriate programming of initial therapy or
changes in DFTs over time.
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NASPE PRE-TEST
History: A VVIR pacemaker was implanted three months earlier. The ECG
demonstrated loss of capture and intermittant loss of sensing.
1) Regarding the X-ray on the previous page. The ECG problems described
were most likely the result of:
A. inappropriate programming
B. twiddlers syndrome
C. lead fracture
D. right ventricular perforation
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2) Regarding the X-ray on the previous page. Based on the X-ray image, the
most probable indication for pacing in this patient was:
A. sarcoidosis induced AV block
B. hypertensive cardiomyopathy
C. congential AV block
D. sick sinus syndrome
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3) How would a lead conductor fracture affect battery longevity?

A. no effect
B. increase longevity
C. decrease longevity
D. it depends as to whether there is a break in the insulation as well
E. both B and C
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4) Which of the following drugs is known to decrease chronic defibrillation

thresholds and increase chronic pacing thresholds?
A. sotalol
B. encainide
C. flecainide
D. propafenone
5) Which of the following conditions would rule out ventricular tachycardia?

A. V rate > A rate
B. A rate > V rate
C. A rate = V rate
D. none of the above
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6) Which of the following assessments could one make from the tracing
above?
A. appropriate atrial and ventricular capture
B. appropriate atrial and ventricular sensing
C. appropriate rate response function
D. appropriate SVT discrimination
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7) The most likely pacing indication for this patient would be?
A. intermittent CHB
B. tachy-brady syndrome
C. hypertrophic obstructive cardiomyopathy
D. vasovagal syncope
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8) In the printout above, which of the following measured values would not
be considered normal?
A. cell impedance and battery current
B. battery voltage and cell impedance
C. atrial and ventricular lead impedance
D. atrial amplitude and ventricular lead impedance
E. both A and C
9) Based on the printout above, which of the following would be the most
likely ECG manifestation(s) of the abnormal telemetry readings?
A. change in magnet rate
B. intermittent failure to output on the atrial and ventricular channels
C. loss of atrial capture and ventricular oversensing
D. no ECG manifestations
E. premature battery depletion
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10) Dislodgement of the atrial lead is best assessed from which fluoroscopic
view?
A. anteroposterior
B. left anterior oblique
C. right anterior oblique
D. lateral
11) Of the ECG's above (A-D), which would be the most likely ECG follow up
presentation if the patient's indication for pacing was hypertrophic obstructive
cardiomyopathy?
A. A
B. B
C. C
D. D
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12) Hypertrophic obstructive cardiomyopathy is what type of indication?

A. Class I
B. Class IIa
C. Class IIb
D. Class III
E. Class IV
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13) During a standard dual chamber ICD implant, VF sensing should be

tested:
A. at the least sensitive setting
B. at the most sensitive setting
C. in the DDD mode
D. during magnet application
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14) To reduce biphasic DFT in a transvenous lead system, an additional lead

may be placed in any of the following, except:
A. coronary sinus
B. superior vena cava
C. subcutaneous axillary position
D. cardiac vein
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15) What is the most likely explanation for a new pacing system that fails to
pace in the bipolar configuration, but paces normally in the unipolar
configuration?
A. loose anodal setscrew
B. loose cathodal setscrew
C. unipolar lead
D. outer coil fracture
16) Which of the following detection enhancements improves specificity in
a patient with Ashman's phenomena?
A. onset
B. QRS morphology
C. stability
D. AV dissociation
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History: This 63 year old male with no known structural heart disease was
implanted with a defibrillator. The patient is also on antiarrhythmic drug
therapy for his tachyarrhythmias.
17) One would interpret the above interval plot as follows:

A. sinus rhythm to atrial flutter to sinus rhythm
B. sinus rhythm to VT back to sinus
C. atrial fibrillation to VT to sinus rhythm
D. sinus rhythm to VF back to sinus
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History: The following strip was saved during a mode switch episode. The
device is programmed to DDDR LR60, UTR140, USR140.
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18) The pacing rate increases following the mode switch due to:
A. device switched to a tracking mode
B. rate responsive pacing at time of mode switch
C. smoothing algorhythm associated with mode switch
D. atrial oversensing
E. noise reversion pacing
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19) The DDD pacemaker implanted in a 75 year old male with an old
anterior myocardial infarction is set to a lower rate of 60 ppm, a MTR of 100
ppm, an AVI of 200 ms, an ARP of 350 ms and a VRP of 300 ms. The
Wenckebach interval is:
A. 0 ms
B. 50 ms
C. 75 ms
D. 100 ms
20) The term virtual electrode desribes the:

A. porous surface
B. fibrous layer
C. excitable tissue
D. electrolyte concentration
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21) Given the above ECG, which of the following best describes the
pacemaker function: (Mode: DDD, LR 60 ppm, AVI 200ms, UTR 100 ppm)
A. atrial oversensing
B. atrial undersensing
C. pacemaker wenckebach
D. pacemaker mediated tachycardia
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22) Given the above ECG, which of the following best describes the
pacemaker function. (Mode: DVI, LR 70 ppm, AVI 200 ms)
A. normal DVI pacemaker function
B. atrial undersensing or atrial oversensing
C. ventricular undersensing or ventricular oversensing
D. atrial or ventricular loss of capture
23) The transmembrane potential of a typical purkinje fiber is approximately

how many mV at the threshold of depolarization?
A. -20mV to +20mV
B. -30mV to -50mV
C. -60mV to -70mV
D. -80mV to -90mV
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24) Given the above ECG/Marker Channel, which of the following is most
clearly demonstrated? (Mode DDD, LR 60ppm, AVI 200ms, UTR 125,
PVARP 225ms)
A. atrial sensing
B. atrial capture
C. ventricular sensing
D. ventricular capture
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25) Which of the following best approximates the point of minimum

threshold energy (microjoules) required for myocardial depolarization?
A. chronaxie
B. rheobase
C. stimulation threshold
D. intermittent threshold
E. DFT threshold
26) Which formula demonstrates that a pulse duration longer than the
chronaxie has relatively little effect on threshold voltage and stimulation
energy?
A. V = IR
B. E = V (squared) / R x T
C. E = I x V x T
D. CO = SV x HR
E. None of the above
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History: A 72 year old male was implanted with his third pulse generator
for sinus node disease. In addition, the patient has had two leads implanted
coinciding with the initial implant and the first generator change. The
current generator is attached to the original lead. The ventricular threshold
measures 3.0 V and .60 ms PW with R-waves measuring 7.0 mV.
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27) Regarding the X-ray image and history above. Considering the lead
system and current stimulation threshold, which of the following problems
did this patient most likely experience?
A. diaphragmatic stimulation
B. crosstalk
C. undersensing
D. oversensing
28) Regarding the X-ray image above. Event counters indicated 23%
ventricular pacing at a rate of 60 bpm in the VVI mode. The patient
complains of some palpitations and fatigue at rest. This patient would
probably best be served by programming his device to which of the
following settings?
A. VVI at 50 bpm
B. VVI at 70 bpm
C. VVIR at 50 bpm
D. VVIR at 70 bpm
E. DDD at 60 bpm
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29) What is the appropriate clinical response to a patient whose ICD reaches
the ERI after five years without a single shock?
A. conduct EP studies to determine if an ICD is needed
B. replace the ICD
C. reduce follow-up visits
D. explant the ICD and use drug therapy
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30) Which of the following settings are desirable when biventricular pacing
for heart failure in a 62 year old patient with no history of significant
arrhythmias?
A. mode switch on, UTR 120 ppm, ventricular sensitivity 1.4mV
B. mode switch off, UTR 120 ppm, ventricular sensitivity 2.8mV
C. mode switch on, UTR 150 ppm, ventricular sensitivity 1.4mV
D. mode switch off, UTR 150 ppm, ventricular sensitivity 2.8mV
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31) When defibrillating a pacemaker patient, the defibrillation paddles

should be placed:
A. in an anteroposterior position
B. parallel to the pacing system
C. over the pulse generator
D. pacemaker patients should not be externally defibrillated
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32) The VDI mode would be useful in evaluating:

A. endless loop tachycardia
B. crosstalk
C. retrograde conduction
D. upper rate behavior
33) Which of the following V-V intervals is considered optimal when the
LV lead is placed in a lateral or anterior-lateral cardiac vein?
A. LV + 0 ms
B. LV - 5 ms to - 30 ms
C. LV + 5 ms to + 30 ms
D. LV - 40 ms to - 80 ms
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History: A 62 year old male was implanted with a dual chamber

defibrillator.
34) The EGM and annotations featured above demonstrate:

A. atrial flutter with spontaneous conversion to sinus rhtyhm
B. atrial fibrillation with successful cardioversion
C. ventricular fibrillation with spontaneous cardioversion
D. ventricular fibrillation with successful defibrillation
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35) Which of the following approximates the mortality rate of persistent

infection when infective leads are not removed?
A. 5 - 10 %
B. 15 - 25 %
C. 30 - 45 %
D. 50 - 65 %
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36) The most common organism found in a chronic pacemaker pocket

infection is:
A. staphylococcus albus
B. escherichia coli
C. staphylococcus aureus
D. staphylococcus epidermidis
E. streptococcus pyogenes
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37) Each of the following is a requirement for a reentry tachycardia except:

A. two conducting pathways connected proximally and distally
B. differing refractory periods of two pathways
C. differing conduction velocities of two pathways
D. an area of ischemic tissue
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38) Which of the following statements is true regarding atrial defibrillation

thresholds?
A. they are typically lower than ventricular defibrillation thresholds
B. they are typically higher than ventricular defibrillation thresholds
C. they are equivalent to ventricular defibrillation thresholds
D. they vary significantly depending on catecholamine level and time
of day
39) Which of the following characteristics of atrial fibrillation is likely to

contribute to congestive heart failure?
A. loss of atrial kick
B. rate related cardiomyopathies
C. loss of AV synchrony
D. all of the above
E. none of the above, AF does not lead to heart failure
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History: This 64 year old female was implanted with a DDD pacemaker
following an open heart procedure. The nursing staff questioned the
pacemaker functioning and called in the pacemaker representative to
evaluate the system. Below is seen an ECG tracing with a mean arterial and
pulmonary artery pressure tracing of 76 mm Hg and 53/22 mm Hg,
respectively.
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40) A mean pulmonary pressure of 22 mm Hg would be considered:

A. low
B. normal
C. High
D. depends on the patient
E. pulmonary pressure is not measured in units of mm Hg
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41) What would be the most likely reason for the frequent rapid ventricular
pacing in this patient?
A. pacemaker mediated tachycardia
B. intermittent tracking of atrial fibrillation
C. inappropriate rate modulation
D. tracking of atrial flutter
42) Which of the following drugs is not known for increasing the likelihood
of Torsade de Pointes?
A. lidocaine
B. quinidine
C. procainamide
D. sotalol
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History: A 78 year old male was implanted 14 months earlier with a DDDR
pacemaker for high grade AV block. The patient has a history of COPD,
CHF, and myoplasty. At the time the ECG below was recorded the patient
was in respiratory arrest. The pacemaker is programmed to DDDR with a
lower rate of 70 ppm and max tracking rate of 120 ppm.
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43) Which of the following modes does the pacemaker in the ECG above
appear to be functioning?
A. DDD
B. VDI
C. DVI
D. VDD
44) Which of the following scenarios would be the MOST likely explanation
for this patient's intermittent loss of capture?
A. intrinsic refractoriness of hypoxic tissue
B. unstable lead position
C. intermittent conductor fracture
D. inappropriate programming of output
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History: A 58 year old male was implanted 3 months earlier with an ICD
following an EP study performed for unexplained syncope. He has been
admitted to the hospital for reevaluation of his arrhythmias and medical
therapy due to his frequent shocks. (17 in first 3 months)
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45) Based on the above ECG, which of the following would best describe
this patient's arrhythmia?
A. atrial fibrillation with aberrancy
B. monomorphic ventricular tachycardia
C. polymorphic ventricular tachycardia
D. ventricular fibrillation
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46) In light of the frequent shocks and the EGM featured above, which of
the following therapies would be most appropriate to consider?
A. shock only
B. antitachy pacing then shock
C. antitachy pacing, cardioversion, then shock
D. cardioversion of the atrial fibrillation
47) When should Mitral valve closure occur?
A. after the E wave
B. during the A wave
C. at the very end of the A wave
D. delayed a set time after the A wave
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History: This 91 year old female was implanted 3.5 years ago with a
Telectronics Model 1250 pulse generator with Medtronic 4058M and 4004M
leads in the atrium and ventricle respectively. The initial indication for
DDDR pacing was tachy-brady syndrome but the patient had since
developed chronic atrial fibrillation and was programmed to VVIR mode.
The following telemetries and ECGs were obtained during routine
asymptomatic follow-up. Telemetry strip #1 corresponds with ECG strip #1
and telemetry strip #2 corresponds with ECG strip #2.
Case continued on next page
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48) With regards to the case presented on the previous page and the ECG
above: Having only reviewed the ECGs and knowing the history of the
implanted hardware, one would be suspicious of the:
A. pacemaker
B. atrial lead
C. ventricular lead
D. both A and C
E. both B and C
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49) In light of the telemetry readings, the most likely explanation for the
ECG strips is:
A. a short circuit in the soft header connector block
B. an atrial lead fracture
C. a ventricular lead fracture
D. normal inhibition of the pulse generator
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50) X-ray "A" features which of the following angiograms?

A. coronary sinus
B. circumflex
C. left hepatic
D. left anterior descending
51) Which of the following represents a significant challenge to implantation

and acute follow-up the lead system represented in x-ray "B"?
A. assessing two atrial thresholds
B. assessing two ventricular thresholds
C. the long term stability of lead "2"
D. B and C
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52) A long term complication of epicardial defibrillation patches is:

A. patch crumpling
B. constrictive pericarditis
C. patch erosion
D. both A and C
E. all of the above
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53) Which of the following effects of antiarrhythmic drug use in ICD

patients is considered both a benefit and a risk?
A. decreased pacing thresholds
B. increased VT cycle length
C. increased DFT threshold
D. SVT prevention
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54) Doubling the distance from the radiation source reduces the level of
radiation exposure by:
A. 1/2
B. 1/3
C. 1/4
D. 1/8
E. It depends on whether the radiation is ionizing
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55) Which of the following detection enhancements discriminates between

AF and VT on the basis of cycle length?
A. stability
B. onset
C. EGM width
D. morphology
56) Rate hysteresis may be misinterpreted as:

A. loss of capture
B. oversensing
C. rate smoothing
D. undersensing
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History: A 79 year old male had a CPI Model 926 DDDC pacemaker
implanted for second degree Mobitz type II heart block. The patient's
chronic follow-up visits consistently demonstrated a reliable escape rhythm.
Thirty months following the implant, the patient called the clinic stating that
he did not feel well and thought his pacemaker should be checked. The
patient was instructed to come to the pacemaker clinic and the following
telemetry and ECG strips were obtained.
22
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57) The fact that the pacemaker was firing intermittently in the ventricle at
360 beats per minute represents a failure of the pacemaker's:
A. reed switch
B. runaway protection circuit
C. Zener diode
D. noise reversion response
E. rate response sensor
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58) If the programming change that was done resulting in the second ECG
on the previous page had not been successful, an appropriate step for the
physician would be to:
A. defibrillate the patient
B. underdrive pace
C. place a temporary lead if the patient is unstable
D. cut the lead wires
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59) Eligibility criteria for the MADIT and MUSTT studies of ICD therapy
included all of the following except:
A. dilated left ventricle
B. coronary artery disease
C. reduced ejection fraction
D. nonsustained ventricular tachycardia
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60) Which of the following is a Class II indication for ICD therapy?

A. spontaneous sustained VT
B. familial conditions with a high risk for life-threatening VT
C. incessant VT or VF
D. NYHA Class IV drug refractory CHF
61) Which of the following responses is possible with exposure of an

implanted pacemaker to an antitheft surveillance device?
A. temporary oversensing
B. inappropriate mode switching
C. reversion to back-up mode
D. circuit damage
E. inappropriate shock
23
History: A patient has a history of previous myocardial infarction and

congestive heart failure. Holter monitoring reveals no complex ventricular
ectopy, but does show a brief non-symptomatic episode of heart block
during the night. The patient's ejection fraction measure 28%. The patient
recently experienced an episode of dizziness and his ECG demonstrates a
left bundle branch block with a QRS width of 200 ms.
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62) Which of the following statements would be most appropriate in regard

to ICD capabilities in this patient?
A. desirable because dizziniess may have occurred due to VT
B. not necessary since the dizziness was most likely due to
intermittent CHB
C. desirable due to patient's history of CHF, MI and a low ejection
fraction
D. both A and C
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63) This patient's one year risk of experiencing sudden cardiac death is
about:
A. 5%
B. 10%
C. 30%
D. it depends on his/her age
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This ECG was taken from a patient implanted with a DDD pacemaker for sinus
node disease.
24
ic
d.
65) The ECG on the previous page demonstrates:

A. atrial undersensing
B. ventricular undersensing
C. atrial oversensing
D. ventricular oversensing
E. both C and D
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64) The patient's underlying atrial rate on ECG on the previous page is
approximately:
A. 47 bpm
B. 57 bpm
C. 67 bpm
D. too variable to assign one rate
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66) Regarding the ECG on the previous page: Intrinsic R-waves measured
14 mV and Intrinsic P-waves measured 1.8 mV in this patient. Repeated
isometric testing with appropriate programming of sensitivities in this
patient would most likely yield the following results:
A. atrial undersensing
B. ventricular oversensing
C. atrial oversensing
D. both A and B
E. both B and C
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67) What are the inferior leads?

A. II, III, aVF
B. I, aVL, V4
C. V4, V5, V6
D. V1, aVR, III
68) On echo, an A wave represents what?
A. passive atrial filling
B. passive ventricular filling
C. active atrial filling
D. active ventricular filling
25
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History: A 66-year old male was implanted with a dual chamber ICD due to
a monomorphic VT at a rate of 150 bpm. This patient also suffers from a
dilated cardiomyopathy with an EF of 23%. His bradycardia requires dual
chamber pacing approximately 75% of the time. On this occasion the
patient was seen in the clinic for routine evaluation.
26
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ic
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69) In the case above and on the preceding page, what detection
enhancements are programmed on for this patient?
A. V rate > A rate
B. Stability
C. Onset
D. None
27
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70) In the case on the two preceding pages, what kind of rhythm does the
atrial intracardiac electrogram show?
A. sinus tach
B. atrial flutter
C. atrial fib
D. ventricular fib
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71) In the case on the two preceding pages, what therapy is delivered during
this episode?
A. Ramp ATP
B. Burst ATP
C. Ramp/Scan ATP
D. Shock
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72) What detection enhancement should have been programmed on to

prevent this episode from occurring?
A. stability
B. onset
C. V rate > A rate
D. Sustained Rate Duration
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73) A patient's DDDR pacemaker is set to a lower rate limit of 60 ppm and
an upper tracking rate of 130 ppm. After a few minutes of converstion at
follow-up, the pacemaker is pacing at 110 ppm. Which of the following
programmed parameters should be adjusted?
A. sensitivity setting
B. sensor threshold
C. rate response slope
D. activities of daily living rate
E. upper sensor rate
74) The most common indication for permanent pacing is:
A. sick sinus syndrome
B. acquired AV block
C. chronic bifascicular block
D. carotid sinus syndrome
28
75) A pacemaker patient with lung cancer is scheduled for radiation therapy.
What precautions must be taken?
A. none, radiation does not affect the IPG
B. turn therapies off during treatment
C. avoid directing the radiation beam on the IPG
D. shield the IPG and limit the field of radiation
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76) Which of the following outputs are safest and most efficient for a
threshold measured at 2.0 V and .5 ms?
A. 4.0 V and .5 ms PW
B. 2.0 V and 1.5 ms PW
C. 4.0 V and 1.0 ms PW
D. 2.5 V and .6 ms PW
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77) What is the characteristic range of lead impedance for a high voltage
lead?
A. 800 to 1,000 ohms
B. 100 to 300 ohms
C. 20 to 70 ohms
D. 100 to 250 ohms
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78) The optimal tilt per phase for single capacitor biphasic waveforms is in
the range of:
A. 35% to 55%
B. 40% to 65%
C. 50% to 80%
D. 60% to 75%
79) Pulling back on a dedicated bipolar transvenous ICD lead can affect the
DFT by:
A. moving the distal coil closer to the ventricular apex
B. moving the distal coil closer to the proximal electrode
C. moving the distal coil away from the proximal electrode
D. moving the distal coil away from the ventricular apex
29
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History: The printout below was taken from a moderately active 78 year
old male implanted with a DDDR pacemaker.
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80) The event summary would seem to indicate that this patient is:
A. chronotopically competant
B. chronotopically incompetant
C. in need of mode switch turned on
D. in danger of sudden cardiac death
E. none of the above
81) The programmed rate adaptive settings in the above patient would most
likely correspond with which of the following:
A. initiate rate response with heavy activity and increase rate slowly
B. increase rate slowly and initiate rate response with light activity
C. initiate rate response with light activity and increase rate rapidly
D. increase rate rapidly with medium to heavy activity
30
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ic
d.
82) The above ECG demonstrates each of the following EXCEPT:

A. ventricular capture
B. ventricular sensing
C. atrial capture
D. atrial sensing
E. None of the above
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83) First line therapy for patients experiencing cardioneurogenic syncope

would be:
A. Beta Blockers
B. midodrine
C. pacemaker
D. patient education, diet, exercise
84) Loss or intermittent loss of atrial sensing may result in which of the
following:
A. falsely high PVC count
B. inappropriate rate drop response therapy
C. frequent safety pacing
D. Both A and B
E. All of the above
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85) At the implantation of a dual chamber pacing system, an active fixation

bipolar lead is implanted into the ventricle of a 72 year old female. The
bipolar threshold is measured at 2.5 volts and .5 milliseconds. When
connected unipolar, they are unable to capture at 10 volts. Bipolar
impedance is measured at 800 ohms, unipolar impedance is measured at 650
ohms. Which of the following is likely to be true?
A. Unipolar thresholds will improve when new test cables are utilized
B. On inspection, the active screw is damaged, preventing capture
C. The threshold measured from lead tip to pocket will be <10 Volts
D. The threshold measured from lead ring to pocket will be <10 Volts
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ic
d.
86) Which of the following detection enhancements discriminates between

ventricular tachycardia and sinus tachycardia?
A. stability
B. onset
C. EGM width
D. morphology
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87) During ICD troubleshooting for nonconversion of VT, the clinician

discovers a large increase in lead impedance. The most likely cause of
increased lead impedance is:
A. lead dislodgement
B. patch electrode crumpling
C. component failure
D. lead fracture
88) Which of the following conditions is associated with an increase in

stimulation threshold, a wide QRS, latency, or undersensing?
A. hypotension
B. hyperkalemia
C. hypercalcemia
D. hypothyroidism
32
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89) Which of the following studies compared the benefits of controlling rate
vs. maintaining the sinus rhythm in patients at high risk for atrial
fibrillation?
A. AFFIRM
B. MIRACLE
C. COMPANION
D. MUSTIC
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90) The defibrillation waveform generated by an ICD is a:

A. nontruncated full capacitor discharge
B. truncated curvilinear discharge
C. truncated bilinear discharge
D. turncated exponentially declining pulse
33
Pacer Questions: 46
1, 2, 3, 6, 7, 8, 9, 11, 12, 15, 18, 19, 20, 21
22, 24, 25, 27, 28, 31, 32, 37, 41, 43, 44, 48
49, 56, 57, 58, 61, 64, 65, 66, 73, 74, 75, 76
80, 81, 82, 83, 84, 85, 88, 89
CRT Questions: 7
30, 33, 39, 47, 50, 51, 68
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X-ray Questions: 8
1, 2, 10, 27, 28, 50, 51 75
ic
d.
ICD Questions: 28
4, 5, 13, 14, 16, 17, 29, 34, 37, 38, 45, 46, 52
53, 55, 59, 60, 62, 69, 70, 71, 72, 77, 78, 79
86, 87, 90
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HRS Pre-test - Breakdown by Topic
Drug Questions: 3
4, 42, 53
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Indications Questions: 7
2, 7, 11, 12, 60, 62, 74
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Basic Science / Epidemiology / Physiology Questions: 17

3, 20, 23, 25, 26, 35, 36, 39, 40, 47, 54, 63
67, 68, 77, 78, 90
ECG / Strip Identification / Troubleshooting Questions: 28

6, 8, 11, 17, 18, 21, 22, 24, 34, 41, 43, 44, 45
46, 48, 49, 57, 58, 64, 65, 66, 69, 70, 71, 72
80, 81, 82
Topics
X-Ray, Twiddler Syndrome
X-Ray, Pediatric Indications
Ohms law, longevity calculation
AntiArrythmic Medications
Tachy Concepts
Sensing/Capture, Rate Drop Response
Indications, Rate Drop Response
Lead Failure, lead impedance
Lead Failure, lead impedance
Fluro / X-ray views, lead dislodgement
Pacing in HOCM
Indications, HOCM
ICD implant protocol, VF testing
DFT's, Coil placement
Implant troubleshooting
ICD Detection Enhancements
Episode recognition / diagnostics
Mode Switching
Upper rate behavior
Lead maturation
Upper rate behavior
Ventricular Safety Pacing, DVI mode
Physiology of Depolarization
ECG troubleshooting
Energy, threshold concepts
Energy, threshold concepts
X-Ray, LV pacing issues, Complications
Pacemaker Syndrome
Indications, ERI
CRT Programming
Defibrialltion of Pacer Patients
Evaluation of retrograde conduction
CRT V-V timing
Tachy Diagostics, atrial cardioversion
Complications, Infection
Complications, Infection
Tachy theory, Re-entry pathology
Atrial Cardioversion for AF
AF leads to CHF
Pulmonary arterial pressure
ECG troubleshooting
Drugs, Torsade de Pointes
Mode Recognition
Cardiac Physiology
Rhythm Recognition, VT
Treatment of polymorphic VT
CRT - Echo AV optimization
Recall knowledge
Recall knowledge
X-ray / fluoro, Cardiac Anatomy
X-ray / fluoro, CRT follow up issues
Epicardial patch, complications
ic
d.
Twiddler Syndrome
Congential AV Block
Increase longevity
Sotalol
None of the above
Appropriate A & V sensing
vasovagal syncope
A & V lead impedance
loss of A capture, V oversensing
Lateral
C - As Vp with short AV
Class Iib
Least sensitive setting
Cardiac Vein
loose anodal setscrew
Stability
sinus-VT-sinus
smoothing algorhythm
50 ms
Fibrous Layer
Pacemaker Wenckebach
Normal DVI (with VSP)
minus 60 mv to minus 70 mv
Ventricular Sensing
Chronaxie
E = V(squared) / R x T
Diaphragmatic Stimuation
VVI at 50 ppm
replace the ICD
Msoff,UTR150,vsense2.8
AP position
retrograde conduction
LV-5msto30ms
AF with cardioversion
50-65%
Staph Epi
area of ischemic tissue
lower than Vent. Thresholds
All of the above
High
intermittent tracking of AF
lidocaine
VDI
refractory hypoxic tissue
polymorphic VT
shock only
at the very end of the A wave
both A and C
short circuit in pacer
Coronary Sinus
2 V thresholds, stability LV lead
All of the above
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B
C
B
A
D
B
D
C
C
D
C
C
A
D
A
C
B
C
B
B
C
A
C
C
A
B
A
A
B
D
A
C
C
B
D
D
D
A
D
C
B
A
B
A
C
A
C
D
A
A
D
E
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Answer Answer
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
.p
Question
90
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m
drug effects
Radiation Effects
Rate hysteresis
runaway pacemaker
runaway pacemaker
ICD Clinical Studies
ICD Indications
EMI, oversensing
ICD indications, CRT indications
Epidemiology / Heart Disease Stats
calipers / rate assessment
Troubleshooting, Noise
Troubleshooting, Noise, Sensing
ECG leads, basic ECG
Echo, CRT
Rhythm Recognition, Afib
ATP therapy, Rhythm Recognition
Rate Response
Epidemiology / Heart Disease Stats
Radiation Effects
Threshold Safety Margins
Tachy function / electrical impedance
Tachy function / tilt
Tachy function, lead placement
Rate Response
Rate Response
ECG troubleshooting
Rate Drop Response
Atrial Undersensing
Implant troubleshooting
ICD Troubleshooting, lead failure
Troubleshooting, electrolytes
Clincal Studies
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ic
d.
increased VT cycle length

04-Jan
stability
oversensing
runaway protection circuit
Cut the lead wires
dilated left ventricle
familial conditions
temporary oversensing
possible VT(a) Hx CHF,MI,EF
10% SCD risk
47 bpm
A & V oversensing
Atrial Oversensing
II, III, aVF
Active atrial filling
None of the above
Atrial Fib
Ramp ATP
Stability
sensor threshold
Sick Sinus Syndrom
shield device and limit field
4V and .5 ms
20 to 70 ohms
40 to 65%
moving coil away from apex
Chronotopically incompetant
light activity, quick increase
Ventricular Capture
Patient Ed, Diet, Exercise
All of the above
lead ring-pocket <10 V
Onset
Lead Fracture
Hyperkalemia
AFFIRM
truncated exponentially declining
pulse
.p
B
C
A
B
B
D
A
B
A
D
B
A
E
C
A
C
D
C
A
A
B
A
D
A
C
B
D
B
C
A
D
E
D
B
D
B
A
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53
54
55
56
57
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60
61
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63
64
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66
67
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71
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73
74
75
76
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80
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83
84
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87
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89
Tachy Concepts

IBHRE Quizzes

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IBHRE Quizzes

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BRADY PACING TEST - #1

For a wire fracture the resistance:

Stay the same

The electromotive force pushing on electrons

Which of the following affect the longevity of the pacemaker?

Which patients pacemaker will last the longest?

The strength duration curve is dependent on the

A pacemaker patient on Flecainide should:

The acute threshold peaking is due to:

Trauma and inflammation

Have their pulse width reduced

Cells membrane capacitance, intracellular and extracellular resistance and threshold

They are less susceptible to EMI

Brady Pacing Test - #1

Less than 5mV

Decrease the sensing to 7mV

If an external pacemaker is set to a sensitivity setting of 5mV and some R-waves go

At the time of implant we want a threshold

Taken at 1.0ms less than1 volt

Brady Pacing Test - #1

A lower rate for activity pacemakers

Senses and paces in either the atrium or ventricle and inhibits

(Time period in ms/60,000)

The formula for calculating rate is:

Tighten both set screws

When connecting a unipolar pacemaker to the lead in the patient,

Stimulation thresholds are adequate

Brady Pacing Test - #1

Which of the following combinations of variables interact to determine stimulation

Cardiac stimulation thresholds are expressed in terms of:

As pulse duration is shortened below 0.3 msec., stimulation threshold increases as

Current pacemakers employ which of the following chemical batteries?

Brady Pacing Test - #1

Which of the following is not an advantage of DDD pacemakers?

What is the initial voltage of a lithium battery?

Brady Pacing Test - #1

Which of the following statements is not true of rate-responsive ventricular

Modifying pacemaker function in response to changing patient status

Pacemaker programmability allows which of the following?

Brady Pacing Test - #1

The cathode is in the heart and the anode is in a remote location

The specific intracardiac event sensed by pacemakers is termed:

Brady Pacing Test - #1

BRADY PACING TEST - #2

Automatic atrial refractory extension after PVCs

A narrowing of the Wenckebach window if upper rate limit is kept constant

ANSWER TRUE OR FALSE TO QUESTIONS 3 AND 4:

a. The purpose of this function is prevention of crosstalk.

It is present in every pacemaker cycle.

Brady Pacing Test - #2

The stimulation threshold is a fixed value independent of :

The surface ECG

Brady Pacing Test - #2

The purpose of the ventricular blanking period is to:

Non-physiologic AV delay pacing (AV pacing with an AV delay shorter than

Retrograde atrial conduction

The pacemaker upper rate behavior is Wenckebach

In which of the following situations might non-synchronous rate responsive pacing be

Chronic atrial fibrillation

Brady Pacing Test - #2

Dual chamber pacemakers should not be considered in patients with a history of

All of the following are absolute contraindications to DDD pacing except:

Chronic atrial fib/flutter

Brady Pacing Test - #2