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USMLE Step3 Cardiovascular

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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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. Difference between cardioversion and defibrillation
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.
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
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

2. new onset LBBB - What is the next step
If patient is started on rifampin or phenobarbital; they increases its metabolism
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Go for coronary angio. high likelyhood of severe coronary artery disease
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

3. s/s carotid dissection
Persistent brady after MI which is refractory to atropine tx
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Defibrillation

4. paroxysmal AF without structural HD
Flecainamide
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
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

5. When to treat sinus brady after acute MI
When it is symptomatic. asso with dec cardiac output resulting hypotension
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

6. How to treat a a patient with tCA overdose
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Lidcaine drip
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

7. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Amiodarone;
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

8. How to dx SVT? tx?
No p wave - narrow qrs; first line of tx-adenosine
Reduce hypertriglyceridemia; in liver
2.5-3.5
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

9. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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 symptomatic (hypotension - hx of syncope) place transvenous pacemaker
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

10. When to use dobutamine?
Amiodarone;
Pt with cardiogenic shock
Coronary angio - identify blockage and tx with stent/bypass
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

11. torsade and unresponsive
No...except posterior or dorsal MI
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
Scoliosis and pes planus
Defibrillation

12. stable angina with heart failure
Increases the risk of MI - thromboembolism - breast cancer - dementia
Go for coronary angio. high likelyhood of severe coronary artery disease
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 -

13. who should get coronary intervention after MI
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
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
Go for coronary angio. high likelyhood of severe coronary artery disease
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

14. What is kussmaul sign
When it is symptomatic. asso with dec cardiac output resulting hypotension
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
Within 24 hours
Monitor EF after cardiotoxic chemo - bypass surgery

15. bradycardia after MI with hypotension. what would you do?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Amiodarone;

16. What is the most effective way to treat multivessel coronary artery blockade?
Defibrillation
CABG not angioplasty
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Streptokinase

17. baloon valvulotomy for AS
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with 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
Post wall MI - occlusion of right coronary artery. tx with atropine

18. patient pw with new onset of heart failure and AF
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
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Post wall MI - occlusion of right coronary artery. tx with atropine
Unexplained synocope - dizziness - near syncope - recurrent palpitation

19. when we say QT prolonged?
Elderly people with MI
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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

20. 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
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.
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

21. What is beck's triad?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

22. what medication cause pulmonary edema?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
PPAR gamma receptor agonist pioglitazone.PPAR
Holocystolic murmur loudest at lower left sternal border

23. EKG shows ST elevation and suggest occlusion of major coronary artery.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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.
Pt with cardiogenic shock

24. What is PEA? How do you treat?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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.

25. ehlers danlos
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Post wall MI - occlusion of right coronary artery. tx with atropine
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Scoliosis and pes planus

26. paroxysmal AF with structural HD
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
Amiodarone;
CABG not angioplasty
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

27. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Streptokinase
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

28. When to use transvenous pacing?
Holocystolic murmur loudest at lower left sternal border
Persistent brady after MI which is refractory to atropine tx
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

29. When rhythm control strategy is suprior than rate control in the Tx of AF
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
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
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Coronary angio - identify blockage and tx with stent/bypass

30. How do you diagnose multifocal atrial tachy?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Coronary angio - identify blockage and tx with stent/bypass
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.

31. When to replace aortic valve
VSD; can be asymptomatic to large with significant L to R shunt
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Post wall MI - occlusion of right coronary artery. tx with atropine
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.

32. problem of WPW?
Go for coronary angio. high likelyhood of severe coronary artery disease
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Development of AF. after ETOH - develop AF---sudden cardia arrest
Amiodarone;

33. INR for mechanical prosthetic valve
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Reduce hypertriglyceridemia; in liver
2.5-3.5
The dose should be adjusted such that TS H below 0.35

34. Indication of gemfibrozil?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Reduce hypertriglyceridemia; in liver
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

35. should we give thrombolytic in ST depression?
No...except posterior or dorsal MI
If there is evidence of heart failure
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Increases the risk of MI - thromboembolism - breast cancer - dementia

36. what MI cause sinus brady?
Monitor EF after cardiotoxic chemo - bypass surgery
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Post wall MI - occlusion of right coronary artery. tx with atropine

37. common complications of ca antagonists?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Pt with cardiogenic shock
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

38. primordial prevention vs primary/secondary/tertiary prevention
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.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Elderly people with MI

39. What is mech of TCA overdose
Pt with cardiogenic shock
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 symptomatic (hypotension - hx of syncope) place transvenous pacemaker
The dose should be adjusted such that TS H below 0.35

40. Why nitroprusside cannot be used alone in aortic dissection
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Post wall MI - occlusion of right coronary artery. tx with atropine
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

41. drugs increases the effect of warfarin
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Weight loss

42. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
Transvenous pacemaker
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Weight loss

43. 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
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
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 -
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

44. indication of radionuclide ventriculography
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
No...except posterior or dorsal MI
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Monitor EF after cardiotoxic chemo - bypass surgery

45. When to use anticoag or aspiring in AF
Weight loss
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 -
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Holocystolic murmur loudest at lower left sternal border

46. location of VSD/MR mumur
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
Holocystolic murmur loudest at lower left sternal border
Increases the risk of MI - thromboembolism - breast cancer - dementia
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

47. bradycardia with type 2 heart block
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
Coronary angio - identify blockage and tx with stent/bypass
Transvenous pacemaker

48. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
Monitor EF after cardiotoxic chemo - bypass surgery
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

49. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
2.5-3.5
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Flecainamide
Within 24 hours

50. when 24 hour holter monitoring and admission recommended?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Elderly people with MI