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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. patient with secondary htn - What is next step
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Elderly people with MI
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

2. indication of radionuclide ventriculography
Without AF; INR 2-3; with AF: 2.5-3.5
Monitor EF after cardiotoxic chemo - bypass surgery
Flecainamide
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.

3. paroxysmal AF without structural HD
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
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.
Defibrillation
Flecainamide

4. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Streptokinase
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

5. Difference between cardioversion and defibrillation
VSD; can be asymptomatic to large with significant L to R shunt
Defibrillation
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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

6. What is beck's triad?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Development of AF. after ETOH - develop AF---sudden cardia arrest
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

7. patient pw with new onset of heart failure and AF
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Coronary angio - identify blockage and tx with stent/bypass
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.

8. How to treat a a patient with tCA overdose
Lidcaine drip
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.
Development of AF. after ETOH - develop AF---sudden cardia arrest

9. What is mech of TCA overdose
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
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Pt with cardiogenic shock

10. 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.
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Reduce hypertriglyceridemia; in liver
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

11. sinus bradycardia after inf wall MI
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

12. what medication cause pulmonary edema?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
When it is symptomatic. asso with dec cardiac output resulting hypotension
PPAR gamma receptor agonist pioglitazone.PPAR
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

13. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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

14. drugs increases the effect of warfarin
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

15. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
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.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

16. What is the most effective way to treat multivessel coronary artery blockade?
If patient is started on rifampin or phenobarbital; they increases its metabolism
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Reduce hypertriglyceridemia; in liver
CABG not angioplasty

17. When to use anticoag or aspiring in AF
Post wall MI - occlusion of right coronary artery. tx with atropine
Weight loss
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

18. spontaneous papillary muscle rupture
Elderly people with MI
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Within 24 hours
No p wave - narrow qrs; first line of tx-adenosine

19. s/s carotid dissection
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.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

20. 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
Lidcaine drip
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

21. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Streptokinase
VSD; can be asymptomatic to large with significant L to R shunt
If there is evidence of heart failure

22. When rhythm control strategy is suprior than rate control in the Tx of AF
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
If there is evidence of heart failure
Increases the risk of MI - thromboembolism - breast cancer - dementia
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

23. ehlers danlos
VSD; can be asymptomatic to large with significant L to R shunt
Scoliosis and pes planus
If patient is started on rifampin or phenobarbital; they increases its metabolism
Without AF; INR 2-3; with AF: 2.5-3.5

24. primordial prevention vs primary/secondary/tertiary prevention
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Streptokinase
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.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

25. location of VSD/MR mumur
Streptokinase
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Holocystolic murmur loudest at lower left sternal border
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

26. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

27. When to replace aortic valve
Without AF; INR 2-3; with AF: 2.5-3.5
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
Persistent brady after MI which is refractory to atropine tx
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

28. What is most congenital heart malformation?
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Scoliosis and pes planus
Streptokinase
VSD; can be asymptomatic to large with significant L to R shunt

29. sudden onset of HTN. How do you manage
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Development of AF. after ETOH - develop AF---sudden cardia arrest
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

30. When to treat sinus brady after acute MI
PPAR gamma receptor agonist pioglitazone.PPAR
When it is symptomatic. asso with dec cardiac output resulting hypotension
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

31. when we say QT prolonged?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Persistent brady after MI which is refractory to atropine tx
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Pt with cardiogenic shock

32. who should get coronary intervention after MI
VSD; can be asymptomatic to large with significant L to R shunt
Flecainamide
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
2.5-3.5

33. INR for mechanical prosthetic valve
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
No...except posterior or dorsal MI
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
2.5-3.5

34. problem of WPW?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Development of AF. after ETOH - develop AF---sudden cardia arrest
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

35. Why nitroprusside cannot be used alone in aortic dissection
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

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

37. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Unexplained synocope - dizziness - near syncope - recurrent palpitation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

38. common complications of ca antagonists?
Holocystolic murmur loudest at lower left sternal border
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Monitor EF after cardiotoxic chemo - bypass surgery
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

39. how amiodarone affects on warfarin
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Flecainamide
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

40. most effective non pharmacologic measure to decease blood pressure?
Elderly people with MI
Weight loss
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Reduce hypertriglyceridemia; in liver

41. bradycardia after MI with hypotension. what would you do?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Weight loss
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

42. complication of HRT
Scoliosis and pes planus
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Increases the risk of MI - thromboembolism - breast cancer - dementia

43. 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
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Go for coronary angio. high likelyhood of severe coronary artery disease
PPAR gamma receptor agonist pioglitazone.PPAR

44. new onset LBBB - What is the next step
No p wave - narrow qrs; first line of tx-adenosine
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

45. When to increase warfarin dose?
The dose should be adjusted such that TS H below 0.35
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
If patient is started on rifampin or phenobarbital; they increases its metabolism

46. EKG shows ST elevation and suggest occlusion of major coronary artery.
2.5-3.5
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 -
No...except posterior or dorsal MI
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

47. What is paroxysmal AF? How do you treat?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
2.5-3.5
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 -
Lidcaine drip

48. How do you diagnose multifocal atrial tachy?
Persistent brady after MI which is refractory to atropine tx
Coronary angio - identify blockage and tx with stent/bypass
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
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.

49. What is kussmaul sign
Transvenous pacemaker
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
PPAR gamma receptor agonist pioglitazone.PPAR
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

50. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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 -