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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. wpw syndrome
The dose should be adjusted such that TS H below 0.35
CABG not angioplasty
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

2. Why nitroprusside cannot be used alone in aortic dissection
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

3. What drugs precipitate digoxin toxicity?
If patient is started on rifampin or phenobarbital; they increases its metabolism
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Streptokinase
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

4. ehlers danlos
Development of AF. after ETOH - develop AF---sudden cardia arrest
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
The dose should be adjusted such that TS H below 0.35
Scoliosis and pes planus

5. problem of WPW?
Amiodarone;
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
Development of AF. after ETOH - develop AF---sudden cardia arrest
Weight loss

6. baloon valvulotomy for AS
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Without AF; INR 2-3; with AF: 2.5-3.5
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

7. most effective non pharmacologic measure to decease blood pressure?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Weight loss
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

8. When to use transvenous pacing?
Persistent brady after MI which is refractory to atropine tx
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
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

9. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
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
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
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

10. stable angina with heart failure
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Transvenous pacemaker
Go for coronary angio. high likelyhood of severe coronary artery disease

11. INR for mechanical prosthetic valve
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.
PPAR gamma receptor agonist pioglitazone.PPAR
2.5-3.5

12. 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
No...except posterior or dorsal MI
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Coronary angio - identify blockage and tx with stent/bypass

13. How do you diagnose multifocal atrial tachy?
If there is evidence of heart failure
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
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.

14. when 24 hour holter monitoring and admission recommended?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Pt with cardiogenic shock
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

15. how amiodarone affects on warfarin
Streptokinase
Weight loss
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
CABG not angioplasty

16. location of VSD/MR mumur
Amiodarone;
Holocystolic murmur loudest at lower left sternal border
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

17. bradycardia after MI with hypotension. what would you do?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Flecainamide
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

18. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
If patient is started on rifampin or phenobarbital; they increases its metabolism
VSD; can be asymptomatic to large with significant L to R shunt

19. What is mech of TCA overdose
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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
Post wall MI - occlusion of right coronary artery. tx with atropine
Weight loss

20. patient with new onset CHF - What is next best step?
Streptokinase
VSD; can be asymptomatic to large with significant L to R shunt
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.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

21. When to replace aortic valve
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
The dose should be adjusted such that TS H below 0.35

22. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 2.5-3.5
2.5-3.5
Post wall MI - occlusion of right coronary artery. tx with atropine
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

23. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
The dose should be adjusted such that TS H below 0.35
Holocystolic murmur loudest at lower left sternal border
VSD; can be asymptomatic to large with significant L to R shunt
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

24. what MI cause sinus brady?
2.5-3.5
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Post wall MI - occlusion of right coronary artery. tx with atropine

25. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

26. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
Within 24 hours
Pt with cardiogenic shock
Weight loss

27. How to dx SVT? tx?
2.5-3.5
Pt with cardiogenic shock
When it is symptomatic. asso with dec cardiac output resulting hypotension
No p wave - narrow qrs; first line of tx-adenosine

28. Most important predictor for future cardiovascular events
Amiodarone;
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
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.

29. Indication of gemfibrozil?
Transvenous pacemaker
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
Reduce hypertriglyceridemia; in liver
Without AF; INR 2-3; with AF: 2.5-3.5

30. When to increase warfarin dose?
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
If patient is started on rifampin or phenobarbital; they increases its metabolism
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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 -

31. torsade and unresponsive
Post wall MI - occlusion of right coronary artery. tx with atropine
2.5-3.5
Defibrillation
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

32. drugs increases the effect of warfarin
If there is evidence of heart failure
Holocystolic murmur loudest at lower left sternal border
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

33. who should get coronary intervention after MI
Unexplained synocope - dizziness - near syncope - recurrent palpitation
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

34. cocaine induced vasospasm leading to myocardial ischemia - initial 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
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
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.

35. Difference between cardioversion and defibrillation
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
Weight loss
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

36. patient pw with new onset of heart failure and AF
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
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
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

37. How to treat a a patient with tCA overdose
Within 24 hours
Lidcaine drip
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

38. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Weight loss
Coronary angio - identify blockage and tx with stent/bypass

39. What is beck's triad?
If patient is started on rifampin or phenobarbital; they increases its metabolism
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

40. 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.
Development of AF. after ETOH - develop AF---sudden cardia arrest
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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

41. when we say QT prolonged?
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
Flecainamide
Go for coronary angio. high likelyhood of severe coronary artery disease

42. EKG shows ST elevation and suggest occlusion of major coronary artery.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Scoliosis and pes planus
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

43. primordial prevention vs primary/secondary/tertiary prevention
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
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
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.

44. When to use dobutamine?
Pt with cardiogenic shock
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Weight loss

45. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

46. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
Within 24 hours
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Persistent brady after MI which is refractory to atropine tx

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 -
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
CABG not angioplasty

48. s/s carotid dissection
Streptokinase
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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

49. what medication cause pulmonary edema?
Post wall MI - occlusion of right coronary artery. tx with atropine
PPAR gamma receptor agonist pioglitazone.PPAR
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
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

50. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
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
CABG not angioplasty
R/o IHD which is the most common causes of CHF. stress test if indicated or angio