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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. What is beck's triad?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Without AF; INR 2-3; with AF: 2.5-3.5

2. 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
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
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

3. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Defibrillation
Within 24 hours
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

4. indication of radionuclide ventriculography
Amiodarone;
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
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.

5. When to treat sinus brady after acute MI
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
No...except posterior or dorsal MI
When it is symptomatic. asso with dec cardiac output resulting hypotension

6. ehlers danlos
Scoliosis and pes planus
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
No p wave - narrow qrs; first line of tx-adenosine

7. How to dx SVT? tx?
Persistent brady after MI which is refractory to atropine tx
No p wave - narrow qrs; first line of tx-adenosine
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

8. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

9. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
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.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Scoliosis and pes planus

10. What is PEA? How do you treat?
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.
When it is symptomatic. asso with dec cardiac output resulting hypotension
The dose should be adjusted such that TS H below 0.35

11. When to start thrombolytic therapry in MI
2.5-3.5
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Streptokinase

12. patient pw with new onset of heart failure and AF
Weight loss
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Pt with cardiogenic shock
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

13. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Pt with cardiogenic shock
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Coronary angio - identify blockage and tx with stent/bypass

14. When to use dobutamine?
Increases the risk of MI - thromboembolism - breast cancer - dementia
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
CABG not angioplasty
Pt with cardiogenic shock

15. What is mech of TCA overdose
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
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
PPAR gamma receptor agonist pioglitazone.PPAR
Weight loss

16. Most important predictor for future cardiovascular events
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.
If patient is started on rifampin or phenobarbital; they increases its metabolism
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

17. when we say QT prolonged?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Reduce hypertriglyceridemia; in liver
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

18. patient with secondary htn - What is next step
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Streptokinase
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

19. 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.
Amiodarone;
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

20. How long it takes for digoxin to have significant effect on rate control
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
CABG not angioplasty
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

21. wpw syndrome
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 days. coz aspirin cause platelet dysfunction that can last more than a week.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
PPAR gamma receptor agonist pioglitazone.PPAR

22. bradycardia with type 2 heart block
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Transvenous pacemaker
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

23. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Streptokinase
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Coronary angio - identify blockage and tx with stent/bypass
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

24. should we give thrombolytic in ST depression?
No p wave - narrow qrs; first line of tx-adenosine
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Defibrillation
No...except posterior or dorsal MI

25. spontaneous papillary muscle rupture
Flecainamide
No p wave - narrow qrs; first line of tx-adenosine
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Elderly people with MI

26. 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
Flecainamide
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
No...except posterior or dorsal MI

27. paroxysmal AF with structural HD
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Amiodarone;
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

28. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
Coronary angio - identify blockage and tx with stent/bypass
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
No p wave - narrow qrs; first line of tx-adenosine

29. when NSTEMI without comorbidiites should get PCI?
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Within 24 hours
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Unexplained synocope - dizziness - near syncope - recurrent palpitation

30. when 24 hour holter monitoring and admission recommended?
Coronary angio - identify blockage and tx with stent/bypass
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
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

31. bradycardia after MI with hypotension. what would you do?
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
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

32. common complications of ca antagonists?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

33. 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%
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
PPAR gamma receptor agonist pioglitazone.PPAR

34. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Go for coronary angio. high likelyhood of severe coronary artery disease
No...except posterior or dorsal MI
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

35. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
R/o IHD which is the most common causes of CHF. stress test if indicated or 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
Pt with cardiogenic shock

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

37. When to use digoxin in AF
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
If there is evidence of heart failure
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

38. INR for mechanical prosthetic valve
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
2.5-3.5
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

39. new onset LBBB - What is the next step
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
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
Flecainamide

40. When rhythm control strategy is suprior than rate control in the Tx of AF
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
PPAR gamma receptor agonist pioglitazone.PPAR
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.

41. What is the most effective way to treat multivessel coronary artery blockade?
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
CABG not angioplasty
PPAR gamma receptor agonist pioglitazone.PPAR
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

42. 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
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 -
CABG not angioplasty
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

43. What is most congenital heart malformation?
VSD; can be asymptomatic to large with significant L to R shunt
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
No p wave - narrow qrs; first line of tx-adenosine
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

44. most effective non pharmacologic measure to decease blood pressure?
Development of AF. after ETOH - develop AF---sudden cardia arrest
VSD; can be asymptomatic to large with significant L to R shunt
Weight loss
If there is evidence of heart failure

45. torsade and unresponsive
Defibrillation
When it is symptomatic. asso with dec cardiac output resulting hypotension
2.5-3.5
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.

46. What drugs precipitate digoxin toxicity?
Monitor EF after cardiotoxic chemo - bypass surgery
Without AF; INR 2-3; with AF: 2.5-3.5
Amiodarone;
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

47. problem of WPW?
If there is evidence of heart failure
Development of AF. after ETOH - develop AF---sudden cardia arrest
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

48. what medication cause pulmonary edema?
Increases the risk of MI - thromboembolism - breast cancer - dementia
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
PPAR gamma receptor agonist pioglitazone.PPAR
Weight loss

49. Difference between cardioversion and defibrillation
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
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

50. When to use transvenous pacing?
Reduce hypertriglyceridemia; in liver
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Persistent brady after MI which is refractory to atropine tx
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.