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Q1: Definition and classification of ventricular tachyarrhythmias (2 min)
Define VT, VF, sustained vs non-sustained VT, monomorphic vs polymorphic VT, torsades de pointes, and bidirectional VT. Outline the three classification axes: duration (NSVT under 30 s, sustained over 30 s), morphology (mono-, poly-, bidirectional), and haemodynamic consequence (pulseless VT/VF vs VT with pulse). Explain why each axis matters for management.
Q2: Pathophysiology (3 min)
Take the examiner through the four mechanisms of VT — scar-related re-entry (post-MI, ~80%), enhanced automaticity (RVOT, digoxin), triggered activity from DADs (digoxin-toxic bidirectional VT, CPVT, RVOT) and triggered activity from EADs (torsades — IKr block, prolonged APD, L-type-Ca-channel reactivation). Then describe the multiple-wavelet re-entry of VF, the molecular basis of the channelopathies (long QT — KCNQ1/KCNH2/SCN5A; Brugada — SCN5A loss-of-function; CPVT — RyR2/CASQ2 Ca-leak), and why AV dissociation, fusion beats, and capture beats exist and are pathognomonic for VT.
Q3: Acute management (3 min)
Walk through the ALS shockable-rhythm algorithm verbatim: confirm arrest, CPR 30:2, attach pads, deliver one unsynchronised shock (150 to 200 J biphasic), 2 min CPR, reassess rhythm; from the second shock give adrenaline 1 mg IV every 3 to 5 min, amiodarone 300 mg after the 3rd shock then 150 mg after the 5th, and continue cycles until ROSC, non-shockable rhythm, or termination. Recall the 4 Hs and 4 Ts. Then the sustained-VT-with-pulse branch: unstable → synchronised DC cardioversion 100 J biphasic escalating; stable → IV amiodarone 300 mg over 20 to 60 min then 900 mg over 24 h. Then torsades: stop QT drug, IV Mg 2 g, correct K, raise HR with isoprenaline/overdrive pacing.
Q4: Long-term prevention of sudden cardiac death (2 min)
Define ICD secondary prevention (survivors of VT/VF, spontaneous sustained VT, syncope with inducible VT) and primary prevention (EF under 35%, NYHA II to III, more than 40 days post-MI, more than 3 months post-revascularisation, more than 3 months on optimal medical therapy — MADIT-II, SCD-HeFT). Recite the 5 ICD contraindications (within 40 days of MI per DINAMIT; within 3 months of CABG/PCI; within 3 months of starting OMT in non-ischaemic DCM; NYHA IV unless CRT-D; life-expectancy under 1 year). Recite the landmark trials: MADIT-I, MUSTT, MADIT-II, DEFINITE, DINAMIT, SCD-HeFT, CAMIAT, EMIAT, ALIVE, ROC-ALPS.
Q5: Pitfalls and examiner favourites (2 min)
Recite from memory: broad-complex = VT until proven otherwise; never give verapamil/adenosine to an undifferentiated broad-complex tachycardia; bidirectional VT + digoxin = toxicity → Digibind; electrical storm = 3 or more in 24 h → amiodarone + beta-blocker + deep sedation + ablation; Vereckei aVR: initial R = VT; Brugada step 1: no RS in any precordial lead = VT; CPVT = exercise-induced, structurally normal heart, normal resting ECG → nadolol; Brugada syndrome precipitated by fever → cool aggressively; sotalol contraindicated in severe HF (pro-arrhythmic); amiodarone toxicity: pulmonary, thyroid, hepatic, corneal, photosensitivity, neuropathy.