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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. what medication cause pulmonary edema?
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
PPAR gamma receptor agonist pioglitazone.PPAR
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

2. spontaneous papillary muscle rupture
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
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.
Elderly people with MI
Coronary angio - identify blockage and tx with stent/bypass

3. s/s carotid dissection
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Increases the risk of MI - thromboembolism - breast cancer - dementia
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

4. sudden onset of HTN. How do you manage
Reduce hypertriglyceridemia; in liver
Holocystolic murmur loudest at lower left sternal border
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

5. Indication of gemfibrozil?
Weight loss
Reduce hypertriglyceridemia; in liver
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
2.5-3.5

6. When to use dobutamine?
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Pt with cardiogenic shock
Monitor EF after cardiotoxic chemo - bypass surgery
Flecainamide

7. most effective non pharmacologic measure to decease blood pressure?
Development of AF. after ETOH - develop AF---sudden cardia arrest
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Weight loss
Scoliosis and pes planus

8. When to start thrombolytic therapry in MI
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Transvenous pacemaker
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
No p wave - narrow qrs; first line of tx-adenosine

9. when NSTEMI without comorbidiites should get PCI?
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.
Lidcaine drip
Within 24 hours
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

10. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
No p wave - narrow qrs; first line of tx-adenosine
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

11. should we give thrombolytic in ST depression?
Pt with cardiogenic shock
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
Defibrillation
No...except posterior or dorsal MI

12. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Post wall MI - occlusion of right coronary artery. tx with atropine
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Reduce hypertriglyceridemia; in liver
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

13. wpw syndrome
If patient is started on rifampin or phenobarbital; they increases its metabolism
Persistent brady after MI which is refractory to atropine tx
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

14. What is PEA? How do you treat?
Elderly people with MI
Pt with cardiogenic shock
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Go for coronary angio. high likelyhood of severe coronary artery disease

15. when should you stop aspirin before procedure that has bleeding risk?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Go for coronary angio. high likelyhood of severe coronary artery disease
Amiodarone;
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

16. Most important predictor for future cardiovascular events
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 -
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Post wall MI - occlusion of right coronary artery. tx with atropine

17. What drugs precipitate digoxin toxicity?
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
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

18. When to use anticoag or aspiring in AF
When it is symptomatic. asso with dec cardiac output resulting hypotension
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Transvenous pacemaker

19. baloon valvulotomy for AS
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Holocystolic murmur loudest at lower left sternal border
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
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

20. EKG shows ST elevation and suggest occlusion of major coronary artery.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
If patient is started on rifampin or phenobarbital; they increases its metabolism
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Defibrillation

21. paroxysmal AF with structural HD
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Amiodarone;
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

22. drugs increases the effect of warfarin
Lidcaine drip
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

23. When to treat sinus brady after acute MI
When it is symptomatic. asso with dec cardiac output resulting hypotension
If patient is started on rifampin or phenobarbital; they increases its metabolism
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

24. how amiodarone affects on warfarin
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
CABG not angioplasty

25. patient pw with new onset of heart failure and AF
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Monitor EF after cardiotoxic chemo - bypass surgery
Defibrillation

26. bradycardia with type 2 heart block
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
No...except posterior or dorsal MI
Transvenous pacemaker

27. How to treat a a patient with tCA overdose
Persistent brady after MI which is refractory to atropine tx
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
PPAR gamma receptor agonist pioglitazone.PPAR
Lidcaine drip

28. INR goal for bileaflet mechnial valve
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Monitor EF after cardiotoxic chemo - bypass surgery
Pt with cardiogenic shock
Without AF; INR 2-3; with AF: 2.5-3.5

29. How long it takes for digoxin to have significant effect on rate control
VSD; can be asymptomatic to large with significant L to R shunt
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Within 24 hours

30. 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
Amiodarone;
Increases the risk of MI - thromboembolism - breast cancer - dementia
Weight loss

31. who should get coronary intervention after MI
Transvenous pacemaker
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Unexplained synocope - dizziness - near syncope - recurrent palpitation

32. When to increase warfarin dose?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Lidcaine drip
If patient is started on rifampin or phenobarbital; they increases its metabolism

33. How to dx SVT? tx?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
No p wave - narrow qrs; first line of tx-adenosine

34. INR for mechanical prosthetic valve
Flecainamide
2.5-3.5
Development of AF. after ETOH - develop AF---sudden cardia arrest
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

35. the dose levothyroxine in thyroid cancer remission
Monitor EF after cardiotoxic chemo - bypass surgery
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
The dose should be adjusted such that TS H below 0.35
If there is evidence of heart failure

36. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

37. bradycardia after MI with hypotension. what would you do?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Persistent brady after MI which is refractory to atropine tx

38. paroxysmal AF without structural HD
Flecainamide
Defibrillation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Pt with cardiogenic shock

39. common complications of ca antagonists?
PPAR gamma receptor agonist pioglitazone.PPAR
Flecainamide
Holocystolic murmur loudest at lower left sternal border
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

40. ehlers danlos
Scoliosis and pes planus
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Monitor EF after cardiotoxic chemo - bypass surgery
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

41. patient with new onset CHF - What is next best step?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Go for coronary angio. high likelyhood of severe coronary artery disease
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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

42. when we say QT prolonged?
Post wall MI - occlusion of right coronary artery. tx with atropine
Scoliosis and pes planus
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

43. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Coronary angio - identify blockage and tx with stent/bypass

44. How do you diagnose multifocal atrial tachy?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
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.
Lidcaine drip

45. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
When it is symptomatic. asso with dec cardiac output resulting hypotension
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Holocystolic murmur loudest at lower left sternal border
Coronary angio - identify blockage and tx with stent/bypass

46. What is poor R wave progression?
Holocystolic murmur loudest at lower left sternal border
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

47. What is paroxysmal AF? How do you treat?
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 -
If there is evidence of heart failure
Transvenous pacemaker
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

48. problem of WPW?
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Development of AF. after ETOH - develop AF---sudden cardia arrest
Elderly people with MI
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

49. new onset LBBB - What is the next step
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
No...except posterior or dorsal MI
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

50. What is beck's triad?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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