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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. indication of radionuclide ventriculography
Monitor EF after cardiotoxic chemo - bypass surgery
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
The dose should be adjusted such that TS H below 0.35
Reduce hypertriglyceridemia; in liver

2. primordial prevention vs primary/secondary/tertiary prevention
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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.
Weight loss
2.5-3.5

3. When to use dobutamine?
2.5-3.5
PPAR gamma receptor agonist pioglitazone.PPAR
Pt with cardiogenic shock
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

4. wpw syndrome
Unexplained synocope - dizziness - near syncope - recurrent palpitation
When it is symptomatic. asso with dec cardiac output resulting hypotension
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%

5. stable angina with heart failure
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
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

6. When to use digoxin in AF
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.
If there is evidence of heart failure
CABG not angioplasty
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

7. when 24 hour holter monitoring and admission recommended?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
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

8. When to increase warfarin dose?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Lidcaine drip
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
If patient is started on rifampin or phenobarbital; they increases its metabolism

9. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
No p wave - narrow qrs; first line of tx-adenosine
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Within 24 hours
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

10. complication of HRT
Coronary angio - identify blockage and tx with stent/bypass
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Increases the risk of MI - thromboembolism - breast cancer - dementia

11. What is most congenital heart malformation?
When it is symptomatic. asso with dec cardiac output resulting hypotension
Unexplained synocope - dizziness - near syncope - recurrent palpitation
The dose should be adjusted such that TS H below 0.35
VSD; can be asymptomatic to large with significant L to R shunt

12. common complications of ca antagonists?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Monitor EF after cardiotoxic chemo - bypass surgery
Coronary angio - identify blockage and tx with stent/bypass

13. 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
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

14. the dose levothyroxine in thyroid cancer remission
No p wave - narrow qrs; first line of tx-adenosine
VSD; can be asymptomatic to large with significant L to R shunt
The dose should be adjusted such that TS H below 0.35
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

15. drugs increases the effect of warfarin
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
No...except posterior or dorsal MI
Unexplained synocope - dizziness - near syncope - recurrent palpitation

16. s/s carotid dissection
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If there is evidence of heart failure
When it is symptomatic. asso with dec cardiac output resulting hypotension
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

17. What is poor R wave progression?
Persistent brady after MI which is refractory to atropine tx
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Scoliosis and pes planus

18. How do you diagnose multifocal atrial tachy?
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Elderly people with MI
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.
Scoliosis and pes planus

19. when we say QT prolonged?
Post wall MI - occlusion of right coronary artery. tx with atropine
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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

20. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 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.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
The dose should be adjusted such that TS H below 0.35

21. what MI cause sinus brady?
Post wall MI - occlusion of right coronary artery. tx with atropine
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
Weight loss
No p wave - narrow qrs; first line of tx-adenosine

22. how amiodarone affects on warfarin
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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.
When it is symptomatic. asso with dec cardiac output resulting hypotension

23. should we give thrombolytic in ST depression?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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...except posterior or dorsal MI

24. EKG shows ST elevation and suggest occlusion of major coronary artery.
CABG not angioplasty
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Defibrillation
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

25. when should you stop aspirin before procedure that has bleeding risk?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
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.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

26. How to dx SVT? tx?
No p wave - narrow qrs; first line of tx-adenosine
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Scoliosis and pes planus
If there is evidence of heart failure

27. What is mech of TCA overdose
High suspicion of MI. LAD occlusion leading to LBBB - next step 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
Weight loss
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

28. What drugs precipitate digoxin toxicity?
Flecainamide
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
The dose should be adjusted such that TS H below 0.35
CABG not angioplasty

29. When to treat sinus brady after acute MI
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
When it is symptomatic. asso with dec cardiac output resulting hypotension
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

30. What is beck's triad?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Lidcaine drip
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
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

31. What is the most effective way to treat multivessel coronary artery blockade?
Development of AF. after ETOH - develop AF---sudden cardia arrest
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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

32. How long it takes for digoxin to have significant effect on rate control
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.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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

33. who should get coronary intervention after MI
Streptokinase
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Transvenous pacemaker
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 -

34. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
If patient is started on rifampin or phenobarbital; they increases its metabolism
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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

35. paroxysmal AF with structural HD
Amiodarone;
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Development of AF. after ETOH - develop AF---sudden cardia arrest
Flecainamide

36. When to use transvenous pacing?
No...except posterior or dorsal MI
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Persistent brady after MI which is refractory to atropine tx
2.5-3.5

37. When rhythm control strategy is suprior than rate control in the Tx of AF
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

38. spontaneous papillary muscle rupture
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.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Within 24 hours
Elderly people with MI

39. torsade and unresponsive
Scoliosis and pes planus
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Defibrillation
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

40. When to use anticoag or aspiring in AF
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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Defibrillation

41. what medication cause pulmonary edema?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Streptokinase
Elderly people with MI
PPAR gamma receptor agonist pioglitazone.PPAR

42. INR for mechanical prosthetic valve
If patient is started on rifampin or phenobarbital; they increases its metabolism
2.5-3.5
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Reduce hypertriglyceridemia; in liver

43. Why nitroprusside cannot be used alone in aortic dissection
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Lidcaine drip
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

44. What is paroxysmal AF? How do you treat?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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 -

45. bradycardia with type 2 heart block
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
Within 24 hours
Transvenous pacemaker

46. Difference between cardioversion and defibrillation
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
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Transvenous pacemaker
When it is symptomatic. asso with dec cardiac output resulting hypotension

47. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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
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
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

48. How to treat a a patient with tCA overdose
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
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Flecainamide
Lidcaine drip

49. 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
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Weight loss
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

50. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
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
Holocystolic murmur loudest at lower left sternal border
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used