Ventricular arrhythmias: Pathology review

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Ventricular arrhythmias: Pathology review

Cardiovascular system

Cardiovascular system

Cardiovascular system

Cardiovascular system


Ventricular arrhythmias: Pathology review

USMLE® Step 1 questions

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USMLE® Step 1 style questions USMLE

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A 67-year-old male presents to the emergency department after a confirmed cardiac arrest in the field. Per EMS, the patient was found down by several bystanders without a pulse, and CPR was initiated immediately. The patient has no past medical history and is not on any medications. He is currently without a pulse, and CPR is ongoing. His 12 lead electrocardiogram is demonstrated below:  

Image reproduced from Wikimedia Commons   

The patient is shocked multiple times and dies despite resuscitation efforts. Post-mortem analysis is most likely to demonstrate which of the following as the etiology of this patient’s clinical presentation?  


Clint is a 19 year old male that’s brought to the emergency department for acute chest pain. Upon examination, you notice that his heart rate is really fast, about 170 beats per minute. He has a history of depression, and is currently being treated with TCAs. He is otherwise healthy. A few minutes after arriving, Clint loses consciousness. His ECG shows this.

All right, so based on his presentation and ECG, Clint has some form of arrhythmia. The best way to approach arrhythmias is to one: know what a normal ECG looks like, and two: have a good classification system to narrow down the diagnosis. To help identify an irregular rhythm, you can look at the morphology of the waveform and make sure that there is a P wave before every QRS complex, and a QRS complex after every P wave.

Now let’s take a look at the heart rate. The resting heart beats at a rate between 60 to 100 times per minute, and each of those beats starts off with depolarization of the sinoatrial node, and so we call it a normal sinus rhythm. It's also important to know that there is typically a delay in the conduction at the AV node and the Bundle of His, which gives some time for ventricular filling before the ventricle contracts. On the ECG, this is represented by the PR interval, which should be less than 5 small boxes, or 200 milliseconds.

Now, any disturbance in the rate, rhythm, site of origin, or conduction of the cardiac electrical activity is called an arrhythmia. Arrhythmias could be completely asymptomatic, and be picked up incidentally on an ECG. Arrhythmias can also present with palpitations, which is a sensation of your heart beating too hard or fast, fluttering, or skipping a beat. Additionally, they may alter cardiac output, causing individuals to present with signs of hypotension and decreased brain perfusion, like dizziness, altered mental status, or syncope.

If an arrhythmia is really fast, the heart muscles now demand more oxygen, and if oxygen supply is not met, then the myocardium suffers from ischemia, which presents as angina. In people with underlying heart disease, the sudden onset of an arrhythmia can precipitate acute heart failure. Finally, some arrhythmias may also cause sudden cardiac death.


An arrhythmia is any disturbance in the rate, rhythm, site of origin, or conduction of the cardiac electrical impulse. Ventricular arrhythmias are those that originate within the ventricles and have a wide QRS complex on ECG. These two types of ventricular arrhythmias are ventricular tachycardia and ventricular fibrillation.

Ventricular tachycardia can be monomorphic meaning that all the QRS complexes look the same, or polymorphic meaning the QRS complexes are different in each beat. A specific and very dangerous type of polymorphic ventricular tachycardia is Torsades de Pointes, which presents a twisting pattern of QRS complexes. This can rapidly progress to ventricular fibrillation, in which the whole PQRST ECG pattern breaks down completely, leaving just some random undulating waves. This is the most common cause of sudden cardiac death.


  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Monomorphic ventricular tachycardia as the primary presentation of an anterior STEMI" Clinical Case Reports (2019)
  3. "Drug induced QT prolongation and torsades de pointes" Heart (2003)
  4. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  5. "Pathophysiology of Heart Disease" Wolters Kluwer Health (2015)
  6. "Brugada syndrome: A general cardiologist's perspective" European Journal of Internal Medicine (2017)

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