1
BON SECOURS MERCY HEALTH
BSMH ADVANCED ARRHYTHMIA COURSE
COMPREHENSIVE EXAMINATION — 2026
GRADED A+ ● 85 Questions ● Advanced Difficulty ● With Full Explanations
OFFICIAL EXAMINATION STUDY GUIDE | Electrophysiology & Device Therapy | Arrhythmia
Management
EXAMINATION DOMAIN OVERVIEW
This examination covers the following clinical domains: ECG Interpretation (16Q) · Electrophysiology
(12Q) · Pharmacology (14Q) · Arrhythmia Mechanisms (11Q) · Device Therapy (14Q) · Ablation
Techniques (10Q) · Clinical Management (8Q)
▶ ECG INTERPRETATION ◀
QUESTION 1 | Category: ECG Interpretation
A 58-year-old patient presents with a wide complex tachycardia (WCT) at a rate of 178 bpm. The QRS
duration is 160 ms. Lead aVR shows an initial R-wave > 40 ms. Which of the following criteria is MOST
consistent with ventricular tachycardia (VT)?
A. AV dissociation with fusion and capture beats
B. RBBB morphology with normal axis
C. Onset of tachycardia triggered by a PAC
D. Termination with adenosine 6 mg IV
✓ CORRECT ANSWER: A
Explanation: AV dissociation with fusion beats (Dressler beats) and capture beats are pathognomonic
for VT. These findings confirm that the ventricles are firing independently of the atria — the hallmark of
VT. The Brugada, Vereckei (aVR), and Josephson criteria all use morphological features, but AV
dissociation is the most definitive single criterion. RBBB with normal axis may suggest SVT with
aberrancy. Adenosine terminates most SVTs and AVNRT, not VT.
▶ ELECTROPHYSIOLOGY ◀
QUESTION 2 | Category: Electrophysiology
During an EP study, a patient demonstrates the following: VA interval 70 ms, concentric retrograde
atrial activation, and tachycardia termination with a His-refractory PVC. What is the MOST likely
diagnosis?
A. Atrial tachycardia originating near the CS os
B. AVNRT (typical slow-fast)
C. Orthodromic AVRT via a concealed left-sided accessory pathway
D. Junctional tachycardia
✓ CORRECT ANSWER: C
Explanation: Tachycardia termination by a His-refractory PVC (without affecting the next atrial beat via
the normal conduction system) proves the ventricle is part of the tachycardia circuit — definitively ruling
Bon Secours Mercy Health ● Advanced Arrhythmia ● 85 Questions with Solutions | Page 1
,2
out AT and junctional tachycardia and confirming AVRT. Concentric retrograde activation with a VA
interval >70 ms favors a left lateral AP over AVNRT (which typically has VA <70 ms). A His-refractory
PVC that resets or terminates tachycardia is diagnostic of AVRT.
▶ PHARMACOLOGY ◀
QUESTION 3 | Category: Pharmacology
A 67-year-old with hypertensive heart disease and new-onset atrial fibrillation with RVR (HR 138) is
hemodynamically stable. His BP is 108/72. Which antiarrhythmic agent should be AVOIDED for acute
rate control in this patient?
A. Digoxin
B. Diltiazem IV
C. Amiodarone IV
D. Metoprolol IV
✓ CORRECT ANSWER: B
Explanation: IV diltiazem (a non-dihydropyridine calcium channel blocker) is relatively contraindicated
in patients with reduced ejection fraction or decompensated heart failure because of its negative
inotropic effects. With a BP of 108/72, evidence of hemodynamic compromise, and likely underlying
structural heart disease (hypertensive), diltiazem may precipitate decompensation. IV amiodarone is
preferred for rate control in heart failure with AF. Digoxin is acceptable in the acute setting. Metoprolol
IV is generally acceptable but must be used cautiously; amiodarone remains the preferred agent here.
▶ ECG INTERPRETATION ◀
QUESTION 4 | Category: ECG Interpretation
A 45-year-old presents with palpitations. ECG shows: delta waves in leads I, aVL, V5-V6; negative
delta in V1; and a short PR interval. What accessory pathway location does this pattern BEST suggest?
A. Right anteroseptal
B. Left lateral
C. Right posterior
D. Posteroseptal
✓ CORRECT ANSWER: B
Explanation: Positive delta waves in leads I, aVL, and V5-V6, combined with a negative delta in V1, are
characteristic of a LEFT LATERAL accessory pathway (Type B WPW). Left lateral APs produce pre-
excitation that generates a positive vector toward the left arm and left precordial leads. A right
anteroseptal AP would produce dominant R in V1. Posteroseptal AP typically shows negative delta in
inferior leads. Right posterior AP shows negative delta in II, III, aVF.
▶ DEVICE THERAPY ◀
QUESTION 5 | Category: Device Therapy
A patient with a dual-chamber ICD presents for follow-up. Stored EGMs show an episode with rapid
atrial activity at 280 bpm with far-field R-wave oversensing in the atrial channel leading to mode switch.
The device delivered a 35J shock. The patient was asymptomatic during the event. This scenario BEST
describes:
A. Appropriate shock for fast VT
B. Inappropriate shock due to T-wave oversensing
C. Inappropriate shock due to SVT with AF and far-field sensing
D. Appropriate therapy for atrial flutter with 2:1 conduction
Bon Secours Mercy Health ● Advanced Arrhythmia ● 85 Questions with Solutions | Page 2
,3
✓ CORRECT ANSWER: C
Explanation: This scenario describes an INAPPROPRIATE ICD shock caused by AF with far-field R-
wave oversensing in the atrial channel. The rapid atrial rate (280 bpm is consistent with AF) with mode
switch, far-field R-wave oversensing, and patient asymptomatic during the event all support
inappropriate detection/therapy. The device misclassified the rapid, irregularly-sensed signals as VF due
to the double-counting from far-field R-waves. This is a well-known cause of inappropriate ICD shocks in
AF patients.
▶ ABLATION TECHNIQUES ◀
QUESTION 6 | Category: Ablation Techniques
During PVI (pulmonary vein isolation) for paroxysmal AF, you achieve entrance block in the LSPV. To
confirm complete isolation, what is the NEXT most important step?
A. Confirm exit block by pacing from within the vein
B. Repeat PV angiography
C. Apply additional RF lesions at the carina
D. Perform CS pacing to re-evaluate PV conduction
✓ CORRECT ANSWER: A
Explanation: Demonstration of BOTH entrance AND exit block is required for complete PVI. Entrance
block means signals from outside cannot enter the vein; exit block means pacing from within the vein
does not capture surrounding atrial tissue. Exit block is confirmed by pacing at high output from within
the isolated vein and demonstrating failure to capture the surrounding left atrium. Without exit block
confirmation, apparent entrance block may be incomplete, and reconnection rates are higher. This is the
HPSD standard for durable PVI.
▶ ARRHYTHMIA MECHANISMS ◀
QUESTION 7 | Category: Arrhythmia Mechanisms
Which of the following is the PRIMARY electrophysiologic mechanism responsible for torsades de
pointes (TdP) in acquired long QT syndrome?
A. Re-entry within the Purkinje fiber network
B. Abnormal automaticity from M-cells
C. Early afterdepolarizations (EADs) triggering re-entry in the setting of increased transmural dispersion
of repolarization
D. Delayed afterdepolarizations (DADs) due to intracellular calcium overload
✓ CORRECT ANSWER: C
Explanation: TdP in acquired LQTS is caused by EADs that act as triggering events, combined with
increased transmural dispersion of repolarization (TDR) that creates the substrate for re-entrant
excitation. EADs occur in the late plateau or phase 3 of the action potential, most commonly in M-cells
(midmyocardial cells), which have the longest APD. The increased TDR (difference in APD between
endocardium, M-cells, and epicardium) creates a vulnerable window for re-entry. DADs are responsible
for digitalis toxicity and catecholaminergic VT, not TdP.
▶ CLINICAL MANAGEMENT ◀
QUESTION 8 | Category: Clinical Management
A 72-year-old woman with persistent AF and a CHA₂DS₂-VASc score of 5 is on warfarin (INR 2.4). She
requires elective hip replacement. What is the RECOMMENDED perioperative anticoagulation
strategy?
Bon Secours Mercy Health ● Advanced Arrhythmia ● 85 Questions with Solutions | Page 3
, 4
A. Stop warfarin 5 days before; no bridging required
B. Stop warfarin 5 days before; bridge with LMWH
C. Switch to DOAC 3 days before procedure
D. Continue warfarin without interruption
✓ CORRECT ANSWER: A
Explanation: According to BRIDGE trial data and current ACC/AHA guidelines, bridging anticoagulation
with LMWH does NOT reduce thromboembolic events but DOES significantly increase major bleeding in
most AF patients — even those with high CHA₂DS₂-VASc scores. Major hip/joint surgery is considered
HIGH bleeding risk surgery. Bridging is generally reserved for patients with mechanical heart valves or
very high-risk situations (recent stroke/TIA <3 months). For most AF patients on warfarin, stopping 5
days before surgery without bridging is now standard of care per the BRIDGE trial.
▶ ECG INTERPRETATION ◀
QUESTION 9 | Category: ECG Interpretation
An ECG shows a regular tachycardia at 150 bpm with narrow QRS. P-waves are visible as a notch in
the terminal portion of the QRS (pseudo-r' in V1, pseudo-S in II). The RP interval is <70 ms. What is the
MOST likely diagnosis?
A. Atrial flutter with 2:1 block
B. Typical AVNRT (slow-fast)
C. Atypical AVNRT (fast-slow)
D. Sinus tachycardia
✓ CORRECT ANSWER: B
Explanation: Typical (slow-fast) AVNRT is the most common regular narrow-complex tachycardia at
150 bpm. It produces a very short RP interval (<70 ms, often <50 ms) because retrograde atrial
activation occurs nearly simultaneously with ventricular activation via the slow pathway, causing P-
waves to be buried in or immediately after the QRS complex. The pseudo-r' in V1 and pseudo-S in
II/III/aVF are the ECG hallmarks of retrograde P-waves in typical AVNRT. Atypical AVNRT (fast-slow)
would have a LONG RP interval (>half the RR interval).
▶ PHARMACOLOGY ◀
QUESTION 10 | Category: Pharmacology
Which of the following antiarrhythmic drugs works PRIMARILY by blocking the rapid component of the
delayed rectifier potassium current (IKr)?
A. Flecainide
B. Amiodarone
C. Dofetilide
D. Mexiletine
✓ CORRECT ANSWER: C
Explanation: Dofetilide is a pure Class III antiarrhythmic that selectively blocks IKr (the rapid
component of the delayed rectifier K+ current, encoded by HERG/KCNH2). This prolongs the action
potential duration and QT interval without affecting conduction velocity. Flecainide is a Class IC agent
(Na+ channel blocker). Amiodarone is a Class III agent but has multiple additional mechanisms (also
blocks IKs, ICa, INa, and has alpha/beta-blocking properties). Mexiletine is a Class IB sodium channel
blocker used for LQT3.
▶ DEVICE THERAPY ◀
Bon Secours Mercy Health ● Advanced Arrhythmia ● 85 Questions with Solutions | Page 4
BON SECOURS MERCY HEALTH
BSMH ADVANCED ARRHYTHMIA COURSE
COMPREHENSIVE EXAMINATION — 2026
GRADED A+ ● 85 Questions ● Advanced Difficulty ● With Full Explanations
OFFICIAL EXAMINATION STUDY GUIDE | Electrophysiology & Device Therapy | Arrhythmia
Management
EXAMINATION DOMAIN OVERVIEW
This examination covers the following clinical domains: ECG Interpretation (16Q) · Electrophysiology
(12Q) · Pharmacology (14Q) · Arrhythmia Mechanisms (11Q) · Device Therapy (14Q) · Ablation
Techniques (10Q) · Clinical Management (8Q)
▶ ECG INTERPRETATION ◀
QUESTION 1 | Category: ECG Interpretation
A 58-year-old patient presents with a wide complex tachycardia (WCT) at a rate of 178 bpm. The QRS
duration is 160 ms. Lead aVR shows an initial R-wave > 40 ms. Which of the following criteria is MOST
consistent with ventricular tachycardia (VT)?
A. AV dissociation with fusion and capture beats
B. RBBB morphology with normal axis
C. Onset of tachycardia triggered by a PAC
D. Termination with adenosine 6 mg IV
✓ CORRECT ANSWER: A
Explanation: AV dissociation with fusion beats (Dressler beats) and capture beats are pathognomonic
for VT. These findings confirm that the ventricles are firing independently of the atria — the hallmark of
VT. The Brugada, Vereckei (aVR), and Josephson criteria all use morphological features, but AV
dissociation is the most definitive single criterion. RBBB with normal axis may suggest SVT with
aberrancy. Adenosine terminates most SVTs and AVNRT, not VT.
▶ ELECTROPHYSIOLOGY ◀
QUESTION 2 | Category: Electrophysiology
During an EP study, a patient demonstrates the following: VA interval 70 ms, concentric retrograde
atrial activation, and tachycardia termination with a His-refractory PVC. What is the MOST likely
diagnosis?
A. Atrial tachycardia originating near the CS os
B. AVNRT (typical slow-fast)
C. Orthodromic AVRT via a concealed left-sided accessory pathway
D. Junctional tachycardia
✓ CORRECT ANSWER: C
Explanation: Tachycardia termination by a His-refractory PVC (without affecting the next atrial beat via
the normal conduction system) proves the ventricle is part of the tachycardia circuit — definitively ruling
Bon Secours Mercy Health ● Advanced Arrhythmia ● 85 Questions with Solutions | Page 1
,2
out AT and junctional tachycardia and confirming AVRT. Concentric retrograde activation with a VA
interval >70 ms favors a left lateral AP over AVNRT (which typically has VA <70 ms). A His-refractory
PVC that resets or terminates tachycardia is diagnostic of AVRT.
▶ PHARMACOLOGY ◀
QUESTION 3 | Category: Pharmacology
A 67-year-old with hypertensive heart disease and new-onset atrial fibrillation with RVR (HR 138) is
hemodynamically stable. His BP is 108/72. Which antiarrhythmic agent should be AVOIDED for acute
rate control in this patient?
A. Digoxin
B. Diltiazem IV
C. Amiodarone IV
D. Metoprolol IV
✓ CORRECT ANSWER: B
Explanation: IV diltiazem (a non-dihydropyridine calcium channel blocker) is relatively contraindicated
in patients with reduced ejection fraction or decompensated heart failure because of its negative
inotropic effects. With a BP of 108/72, evidence of hemodynamic compromise, and likely underlying
structural heart disease (hypertensive), diltiazem may precipitate decompensation. IV amiodarone is
preferred for rate control in heart failure with AF. Digoxin is acceptable in the acute setting. Metoprolol
IV is generally acceptable but must be used cautiously; amiodarone remains the preferred agent here.
▶ ECG INTERPRETATION ◀
QUESTION 4 | Category: ECG Interpretation
A 45-year-old presents with palpitations. ECG shows: delta waves in leads I, aVL, V5-V6; negative
delta in V1; and a short PR interval. What accessory pathway location does this pattern BEST suggest?
A. Right anteroseptal
B. Left lateral
C. Right posterior
D. Posteroseptal
✓ CORRECT ANSWER: B
Explanation: Positive delta waves in leads I, aVL, and V5-V6, combined with a negative delta in V1, are
characteristic of a LEFT LATERAL accessory pathway (Type B WPW). Left lateral APs produce pre-
excitation that generates a positive vector toward the left arm and left precordial leads. A right
anteroseptal AP would produce dominant R in V1. Posteroseptal AP typically shows negative delta in
inferior leads. Right posterior AP shows negative delta in II, III, aVF.
▶ DEVICE THERAPY ◀
QUESTION 5 | Category: Device Therapy
A patient with a dual-chamber ICD presents for follow-up. Stored EGMs show an episode with rapid
atrial activity at 280 bpm with far-field R-wave oversensing in the atrial channel leading to mode switch.
The device delivered a 35J shock. The patient was asymptomatic during the event. This scenario BEST
describes:
A. Appropriate shock for fast VT
B. Inappropriate shock due to T-wave oversensing
C. Inappropriate shock due to SVT with AF and far-field sensing
D. Appropriate therapy for atrial flutter with 2:1 conduction
Bon Secours Mercy Health ● Advanced Arrhythmia ● 85 Questions with Solutions | Page 2
,3
✓ CORRECT ANSWER: C
Explanation: This scenario describes an INAPPROPRIATE ICD shock caused by AF with far-field R-
wave oversensing in the atrial channel. The rapid atrial rate (280 bpm is consistent with AF) with mode
switch, far-field R-wave oversensing, and patient asymptomatic during the event all support
inappropriate detection/therapy. The device misclassified the rapid, irregularly-sensed signals as VF due
to the double-counting from far-field R-waves. This is a well-known cause of inappropriate ICD shocks in
AF patients.
▶ ABLATION TECHNIQUES ◀
QUESTION 6 | Category: Ablation Techniques
During PVI (pulmonary vein isolation) for paroxysmal AF, you achieve entrance block in the LSPV. To
confirm complete isolation, what is the NEXT most important step?
A. Confirm exit block by pacing from within the vein
B. Repeat PV angiography
C. Apply additional RF lesions at the carina
D. Perform CS pacing to re-evaluate PV conduction
✓ CORRECT ANSWER: A
Explanation: Demonstration of BOTH entrance AND exit block is required for complete PVI. Entrance
block means signals from outside cannot enter the vein; exit block means pacing from within the vein
does not capture surrounding atrial tissue. Exit block is confirmed by pacing at high output from within
the isolated vein and demonstrating failure to capture the surrounding left atrium. Without exit block
confirmation, apparent entrance block may be incomplete, and reconnection rates are higher. This is the
HPSD standard for durable PVI.
▶ ARRHYTHMIA MECHANISMS ◀
QUESTION 7 | Category: Arrhythmia Mechanisms
Which of the following is the PRIMARY electrophysiologic mechanism responsible for torsades de
pointes (TdP) in acquired long QT syndrome?
A. Re-entry within the Purkinje fiber network
B. Abnormal automaticity from M-cells
C. Early afterdepolarizations (EADs) triggering re-entry in the setting of increased transmural dispersion
of repolarization
D. Delayed afterdepolarizations (DADs) due to intracellular calcium overload
✓ CORRECT ANSWER: C
Explanation: TdP in acquired LQTS is caused by EADs that act as triggering events, combined with
increased transmural dispersion of repolarization (TDR) that creates the substrate for re-entrant
excitation. EADs occur in the late plateau or phase 3 of the action potential, most commonly in M-cells
(midmyocardial cells), which have the longest APD. The increased TDR (difference in APD between
endocardium, M-cells, and epicardium) creates a vulnerable window for re-entry. DADs are responsible
for digitalis toxicity and catecholaminergic VT, not TdP.
▶ CLINICAL MANAGEMENT ◀
QUESTION 8 | Category: Clinical Management
A 72-year-old woman with persistent AF and a CHA₂DS₂-VASc score of 5 is on warfarin (INR 2.4). She
requires elective hip replacement. What is the RECOMMENDED perioperative anticoagulation
strategy?
Bon Secours Mercy Health ● Advanced Arrhythmia ● 85 Questions with Solutions | Page 3
, 4
A. Stop warfarin 5 days before; no bridging required
B. Stop warfarin 5 days before; bridge with LMWH
C. Switch to DOAC 3 days before procedure
D. Continue warfarin without interruption
✓ CORRECT ANSWER: A
Explanation: According to BRIDGE trial data and current ACC/AHA guidelines, bridging anticoagulation
with LMWH does NOT reduce thromboembolic events but DOES significantly increase major bleeding in
most AF patients — even those with high CHA₂DS₂-VASc scores. Major hip/joint surgery is considered
HIGH bleeding risk surgery. Bridging is generally reserved for patients with mechanical heart valves or
very high-risk situations (recent stroke/TIA <3 months). For most AF patients on warfarin, stopping 5
days before surgery without bridging is now standard of care per the BRIDGE trial.
▶ ECG INTERPRETATION ◀
QUESTION 9 | Category: ECG Interpretation
An ECG shows a regular tachycardia at 150 bpm with narrow QRS. P-waves are visible as a notch in
the terminal portion of the QRS (pseudo-r' in V1, pseudo-S in II). The RP interval is <70 ms. What is the
MOST likely diagnosis?
A. Atrial flutter with 2:1 block
B. Typical AVNRT (slow-fast)
C. Atypical AVNRT (fast-slow)
D. Sinus tachycardia
✓ CORRECT ANSWER: B
Explanation: Typical (slow-fast) AVNRT is the most common regular narrow-complex tachycardia at
150 bpm. It produces a very short RP interval (<70 ms, often <50 ms) because retrograde atrial
activation occurs nearly simultaneously with ventricular activation via the slow pathway, causing P-
waves to be buried in or immediately after the QRS complex. The pseudo-r' in V1 and pseudo-S in
II/III/aVF are the ECG hallmarks of retrograde P-waves in typical AVNRT. Atypical AVNRT (fast-slow)
would have a LONG RP interval (>half the RR interval).
▶ PHARMACOLOGY ◀
QUESTION 10 | Category: Pharmacology
Which of the following antiarrhythmic drugs works PRIMARILY by blocking the rapid component of the
delayed rectifier potassium current (IKr)?
A. Flecainide
B. Amiodarone
C. Dofetilide
D. Mexiletine
✓ CORRECT ANSWER: C
Explanation: Dofetilide is a pure Class III antiarrhythmic that selectively blocks IKr (the rapid
component of the delayed rectifier K+ current, encoded by HERG/KCNH2). This prolongs the action
potential duration and QT interval without affecting conduction velocity. Flecainide is a Class IC agent
(Na+ channel blocker). Amiodarone is a Class III agent but has multiple additional mechanisms (also
blocks IKs, ICa, INa, and has alpha/beta-blocking properties). Mexiletine is a Class IB sodium channel
blocker used for LQT3.
▶ DEVICE THERAPY ◀
Bon Secours Mercy Health ● Advanced Arrhythmia ● 85 Questions with Solutions | Page 4
