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USMLE Step3 Cardiovascular

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. s/s carotid dissection
Increases the risk of MI - thromboembolism - breast cancer - dementia
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
If there is evidence of heart failure

2. ehlers danlos
The dose should be adjusted such that TS H below 0.35
Without AF; INR 2-3; with AF: 2.5-3.5
Scoliosis and pes planus
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

3. patient with new onset CHF - What is next best step?
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If there is evidence of heart failure

4. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Look for predisposing condition: hypoxia - COPD - hypokalemia - hypomagnesemia - CAD - medications like theophyline - aminophylline - isoproterenol; look at EKG: p wave of 3 different morphologies - narrow qrs. tx underlying cause.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
When it is symptomatic. asso with dec cardiac output resulting hypotension

5. What is kussmaul sign
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Normally jvp falls with inspiration due to reduced pressure in the expanding thoracic cavity and expansion of right ventricle duing diastole. in pericardial tamponade - impaired filling of ventricle leads to backflow of blood into venous system leadi

6. What is beck's triad?
Primordial prevention is the prevention of risk factors; action undertaken before onset of disease- primary prevention; action halts progression of disease-secondary; disease advanced - action taken to limit impairment and disabilities.
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Streptokinase
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

7. when 24 hour holter monitoring and admission recommended?
Elderly people with MI
Amiodarone;
Coronary angio - identify blockage and tx with stent/bypass
Unexplained synocope - dizziness - near syncope - recurrent palpitation

8. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Amiodarone;
Lidcaine drip

9. when should you stop aspirin before procedure that has bleeding risk?
Transvenous pacemaker
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

10. complication of HRT
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Increases the risk of MI - thromboembolism - breast cancer - dementia
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

11. When rhythm control strategy is suprior than rate control in the Tx of AF
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

12. Difference between cardioversion and defibrillation
Increases the risk of MI - thromboembolism - breast cancer - dementia
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Cardioversion is a synchonized shock of an unorganized tachyarrythmia AF or PSVT. defibrillation is to stop heart momentarily so unorganized activity such as ventricular fibillation is stopped. there will be a brief period of asystole and then normal

13. EKG shows ST elevation and suggest occlusion of major coronary artery.
Defibrillation
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Go for coronary angio. high likelyhood of severe coronary artery disease
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

14. what medication cause pulmonary edema?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Normally jvp falls with inspiration due to reduced pressure in the expanding thoracic cavity and expansion of right ventricle duing diastole. in pericardial tamponade - impaired filling of ventricle leads to backflow of blood into venous system leadi
TCA inhibit fast Na channel in His-purkinje system- -slow av conduction---reentrant arrythmia---VT or VF. tx with sodium bicarb drip and lidocaine drip
PPAR gamma receptor agonist pioglitazone.PPAR

15. INR goal for bileaflet mechnial valve
TCA inhibit fast Na channel in His-purkinje system- -slow av conduction---reentrant arrythmia---VT or VF. tx with sodium bicarb drip and lidocaine drip
Monitor EF after cardiotoxic chemo - bypass surgery
Increases the risk of MI - thromboembolism - breast cancer - dementia
Without AF; INR 2-3; with AF: 2.5-3.5

16. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Flecainamide
When it is symptomatic. asso with dec cardiac output resulting hypotension
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

17. baloon valvulotomy for AS
Holocystolic murmur loudest at lower left sternal border
CABG not angioplasty
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Within 24 hours

18. How long it takes for digoxin to have significant effect on rate control
Amiodarone;
Persistent brady after MI which is refractory to atropine tx
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Increases the risk of MI - thromboembolism - breast cancer - dementia

19. When to increase warfarin dose?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Go for coronary angio. high likelyhood of severe coronary artery disease
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If patient is started on rifampin or phenobarbital; they increases its metabolism

20. who should get coronary intervention after MI
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
No...except posterior or dorsal MI
The dose should be adjusted such that TS H below 0.35
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

21. wpw syndrome
Pt with cardiogenic shock
Reduce hypertriglyceridemia; in liver
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

22. common complications of ca antagonists?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Coronary angio - identify blockage and tx with stent/bypass
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

23. primordial prevention vs primary/secondary/tertiary prevention
No...except posterior or dorsal MI
Primordial prevention is the prevention of risk factors; action undertaken before onset of disease- primary prevention; action halts progression of disease-secondary; disease advanced - action taken to limit impairment and disabilities.
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

24. stable angina with heart failure
The dose should be adjusted such that TS H below 0.35
Go for coronary angio. high likelyhood of severe coronary artery disease
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Holocystolic murmur loudest at lower left sternal border

25. What is poor R wave progression?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Persistent brady after MI which is refractory to atropine tx
If patient is started on rifampin or phenobarbital; they increases its metabolism

26. torsade and unresponsive
No...except posterior or dorsal MI
Defibrillation
The dose should be adjusted such that TS H below 0.35
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

27. Most important predictor for future cardiovascular events
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Look for predisposing condition: hypoxia - COPD - hypokalemia - hypomagnesemia - CAD - medications like theophyline - aminophylline - isoproterenol; look at EKG: p wave of 3 different morphologies - narrow qrs. tx underlying cause.
Defibrillation
Persistent brady after MI which is refractory to atropine tx

28. when we say QT prolonged?
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

29. what MI cause sinus brady?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Post wall MI - occlusion of right coronary artery. tx with atropine
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
The dose should be adjusted such that TS H below 0.35

30. What is mech of TCA overdose
Scoliosis and pes planus
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Lidcaine drip
TCA inhibit fast Na channel in His-purkinje system- -slow av conduction---reentrant arrythmia---VT or VF. tx with sodium bicarb drip and lidocaine drip

31. When to replace aortic valve
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Coronary angio - identify blockage and tx with stent/bypass
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
TCA inhibit fast Na channel in His-purkinje system- -slow av conduction---reentrant arrythmia---VT or VF. tx with sodium bicarb drip and lidocaine drip

32. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
Cardioversion is a synchonized shock of an unorganized tachyarrythmia AF or PSVT. defibrillation is to stop heart momentarily so unorganized activity such as ventricular fibillation is stopped. there will be a brief period of asystole and then normal
No...except posterior or dorsal MI
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

33. how amiodarone affects on warfarin
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Look for predisposing condition: hypoxia - COPD - hypokalemia - hypomagnesemia - CAD - medications like theophyline - aminophylline - isoproterenol; look at EKG: p wave of 3 different morphologies - narrow qrs. tx underlying cause.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

34. the dose levothyroxine in thyroid cancer remission
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Holocystolic murmur loudest at lower left sternal border
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
The dose should be adjusted such that TS H below 0.35

35. What is paroxysmal AF? How do you treat?
Reduce hypertriglyceridemia; in liver
AF episode-- relieved with Diltiazem. ..then patient is asymptomatic but pulse irregularly irregular. recurrent episode of AF. treat with amiodarone. this is also best drug if AF is due to structural HD. eg CAD - CCF due to cardiomyo - HTN with LVH -
TCA inhibit fast Na channel in His-purkinje system- -slow av conduction---reentrant arrythmia---VT or VF. tx with sodium bicarb drip and lidocaine drip
The dose should be adjusted such that TS H below 0.35

36. In cocaine induced vasospasm - if angio shows any thrombus - next step?
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Streptokinase
Weight loss
TCA inhibit fast Na channel in His-purkinje system- -slow av conduction---reentrant arrythmia---VT or VF. tx with sodium bicarb drip and lidocaine drip

37. new onset LBBB - What is the next step
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Scoliosis and pes planus
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

38. INR for mechanical prosthetic valve
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
2.5-3.5
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

39. bradycardia after MI with hypotension. what would you do?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
No p wave - narrow qrs; first line of tx-adenosine
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

40. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Go for coronary angio. high likelyhood of severe coronary artery disease
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Unexplained synocope - dizziness - near syncope - recurrent palpitation

41. sudden onset of HTN. How do you manage
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Monitor EF after cardiotoxic chemo - bypass surgery
When it is symptomatic. asso with dec cardiac output resulting hypotension
Scoliosis and pes planus

42. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Scoliosis and pes planus
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

43. drugs increases the effect of warfarin
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

44. when NSTEMI without comorbidiites should get PCI?
VSD; can be asymptomatic to large with significant L to R shunt
Persistent brady after MI which is refractory to atropine tx
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Within 24 hours

45. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Development of AF. after ETOH - develop AF---sudden cardia arrest
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

46. When to treat sinus brady after acute MI
When it is symptomatic. asso with dec cardiac output resulting hypotension
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
No...except posterior or dorsal MI
Normally jvp falls with inspiration due to reduced pressure in the expanding thoracic cavity and expansion of right ventricle duing diastole. in pericardial tamponade - impaired filling of ventricle leads to backflow of blood into venous system leadi

47. Why nitroprusside cannot be used alone in aortic dissection
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Weight loss
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

48. bradycardia with type 2 heart block
Transvenous pacemaker
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Weight loss
Primordial prevention is the prevention of risk factors; action undertaken before onset of disease- primary prevention; action halts progression of disease-secondary; disease advanced - action taken to limit impairment and disabilities.

49. What is most congenital heart malformation?
VSD; can be asymptomatic to large with significant L to R shunt
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Flecainamide

50. most effective non pharmacologic measure to decease blood pressure?
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Weight loss
Persistent brady after MI which is refractory to atropine tx
VSD; can be asymptomatic to large with significant L to R shunt