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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. when we say QT prolonged?
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Development of AF. after ETOH - develop AF---sudden cardia arrest
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

2. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Transvenous pacemaker
The dose should be adjusted such that TS H below 0.35
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

3. who should get coronary intervention after MI
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Pt with cardiogenic shock

4. EKG shows ST elevation and suggest occlusion of major coronary artery.
Development of AF. after ETOH - develop AF---sudden cardia arrest
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
CABG not angioplasty

5. When to treat sinus brady after acute MI
Development of AF. after ETOH - develop AF---sudden cardia arrest
Pt with cardiogenic shock
When it is symptomatic. asso with dec cardiac output resulting hypotension
Within 24 hours

6. indication of radionuclide ventriculography
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Monitor EF after cardiotoxic chemo - bypass surgery
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

7. Why nitroprusside cannot be used alone in aortic dissection
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

8. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
PPAR gamma receptor agonist pioglitazone.PPAR
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If patient is started on rifampin or phenobarbital; they increases its metabolism

9. What is mech of TCA overdose
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
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Flecainamide

10. bradycardia after MI with hypotension. what would you do?
Coronary angio - identify blockage and tx with stent/bypass
Holocystolic murmur loudest at lower left sternal border
Lidcaine drip
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

11. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
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.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

12. s/s carotid dissection
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Go for coronary angio. high likelyhood of severe coronary artery disease
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
If patient is started on rifampin or phenobarbital; they increases its metabolism

13. torsade and unresponsive
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Within 24 hours
Defibrillation
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

14. What is kussmaul sign
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
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Streptokinase
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 -

15. ehlers danlos
Scoliosis and pes planus
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Transvenous pacemaker
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

16. sinus bradycardia after inf wall MI
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

17. baloon valvulotomy for AS
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Pt with cardiogenic shock
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

18. Difference between cardioversion and defibrillation
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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
Lidcaine drip

19. What is beck's triad?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
No p wave - narrow qrs; first line of tx-adenosine
Persistent brady after MI which is refractory to atropine tx
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

20. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Monitor EF after cardiotoxic chemo - bypass surgery
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

21. When to start thrombolytic therapry in MI
Coronary angio - identify blockage and tx with stent/bypass
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
When it is symptomatic. asso with dec cardiac output resulting hypotension
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

22. new onset LBBB - What is the next step
Persistent brady after MI which is refractory to atropine tx
2.5-3.5
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Flecainamide

23. how amiodarone affects on warfarin
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

24. What is paroxysmal AF? How do you treat?
If patient is started on rifampin or phenobarbital; they increases its metabolism
When it is symptomatic. asso with dec cardiac output resulting hypotension
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
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 -

25. How to treat a a patient with tCA overdose
Post wall MI - occlusion of right coronary artery. tx with atropine
Defibrillation
Scoliosis and pes planus
Lidcaine drip

26. What is most congenital heart malformation?
VSD; can be asymptomatic to large with significant L to R shunt
The dose should be adjusted such that TS H below 0.35
No p wave - narrow qrs; first line of tx-adenosine
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

27. most effective non pharmacologic measure to decease blood pressure?
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
2.5-3.5
Weight loss
Persistent brady after MI which is refractory to atropine tx

28. wpw syndrome
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
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

29. patient with new onset CHF - What is next best step?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

30. When to use transvenous pacing?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Persistent brady after MI which is refractory to atropine tx

31. bradycardia with type 2 heart block
Post wall MI - occlusion of right coronary artery. tx with atropine
Transvenous pacemaker
Amiodarone;
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

32. INR for mechanical prosthetic valve
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
2.5-3.5
Without AF; INR 2-3; with AF: 2.5-3.5
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

33. How long it takes for digoxin to have significant effect on rate control
CABG not angioplasty
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

34. paroxysmal AF without structural HD
Flecainamide
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Lidcaine drip
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

35. primordial prevention vs primary/secondary/tertiary prevention
Reduce hypertriglyceridemia; in liver
Weight loss
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
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.

36. when NSTEMI without comorbidiites should get PCI?
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Within 24 hours

37. What is the most effective way to treat multivessel coronary artery blockade?
2.5-3.5
Coronary angio - identify blockage and tx with stent/bypass
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
CABG not angioplasty

38. How do you diagnose multifocal atrial tachy?
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.
Go for coronary angio. high likelyhood of severe coronary artery disease
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Increases the risk of MI - thromboembolism - breast cancer - dementia

39. When to replace aortic valve
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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
Elderly people with MI
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

40. 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
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Go for coronary angio. high likelyhood of severe coronary artery disease
Monitor EF after cardiotoxic chemo - bypass surgery

41. patient with secondary htn - What is next step
Defibrillation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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 -
Holocystolic murmur loudest at lower left sternal border

42. When rhythm control strategy is suprior than rate control in the Tx of AF
Defibrillation
Go for coronary angio. high likelyhood of severe coronary artery disease
Weight loss
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

43. what medication cause pulmonary edema?
PPAR gamma receptor agonist pioglitazone.PPAR
If patient is started on rifampin or phenobarbital; they increases its metabolism
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

44. patient pw with new onset of heart failure and AF
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
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
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
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.

45. common complications of ca antagonists?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Lidcaine drip
PPAR gamma receptor agonist pioglitazone.PPAR
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

46. should we give thrombolytic in ST depression?
No p wave - narrow qrs; first line of tx-adenosine
Persistent brady after MI which is refractory to atropine tx
No...except posterior or dorsal MI
Coronary angio - identify blockage and tx with stent/bypass

47. Indication of gemfibrozil?
If there is evidence of heart failure
Reduce hypertriglyceridemia; in liver
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
The dose should be adjusted such that TS H below 0.35

48. When to use digoxin in AF
If there is evidence of heart failure
Within 24 hours
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

49. problem of WPW?
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Development of AF. after ETOH - develop AF---sudden cardia arrest
Holocystolic murmur loudest at lower left sternal border

50. when 24 hour holter monitoring and admission recommended?
Scoliosis and pes planus
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Development of AF. after ETOH - develop AF---sudden cardia arrest
If patient is started on rifampin or phenobarbital; they increases its metabolism