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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
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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 patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

2. what medication cause pulmonary edema?
Holocystolic murmur loudest at lower left sternal border
Lidcaine drip
PPAR gamma receptor agonist pioglitazone.PPAR
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

3. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
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
No...except posterior or dorsal MI

4. What is most congenital heart malformation?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
VSD; can be asymptomatic to large with significant L to R shunt
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

5. paroxysmal AF without structural HD
No...except posterior or dorsal MI
If patient is started on rifampin or phenobarbital; they increases its metabolism
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Flecainamide

6. When to use transvenous pacing?
Increases the risk of MI - thromboembolism - breast cancer - dementia
Persistent brady after MI which is refractory to atropine tx
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

7. How long it takes for digoxin to have significant effect on rate control
Post wall MI - occlusion of right coronary artery. tx with atropine
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Amiodarone;
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

8. What is poor R wave progression?
Go for coronary angio. high likelyhood of severe coronary artery disease
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
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

9. most effective non pharmacologic measure to decease blood pressure?
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.
No...except posterior or dorsal MI
Transvenous pacemaker
Weight loss

10. What is beck's triad?
No p wave - narrow qrs; first line of tx-adenosine
The dose should be adjusted such that TS H below 0.35
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

11. How do you diagnose multifocal atrial tachy?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

12. When to use anticoag or aspiring in AF
Scoliosis and pes planus
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Reduce hypertriglyceridemia; in liver
No...except posterior or dorsal MI

13. who should get coronary intervention after MI
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%
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

14. What drugs precipitate digoxin toxicity?
Without AF; INR 2-3; with AF: 2.5-3.5
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

15. INR for mechanical prosthetic valve
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
2.5-3.5

16. patient with new onset CHF - What is next best step?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
If patient is started on rifampin or phenobarbital; they increases its metabolism
Flecainamide

17. What is mech of TCA overdose
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
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
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

18. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
VSD; can be asymptomatic to large with significant L to R shunt
Streptokinase

19. Indication of gemfibrozil?
If there is evidence of heart failure
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Reduce hypertriglyceridemia; in liver

20. Most important predictor for future cardiovascular events
CABG not angioplasty
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Pt with cardiogenic shock

21. when we say QT prolonged?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Post wall MI - occlusion of right coronary artery. tx with atropine
Coronary angio - identify blockage and tx with stent/bypass
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

22. common complications of ca antagonists?
Post wall MI - occlusion of right coronary artery. tx with atropine
Flecainamide
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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

23. patient pw with new onset of heart failure and AF
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
CABG not angioplasty
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

24. How to dx SVT? tx?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
No p wave - narrow qrs; first line of tx-adenosine
Without AF; INR 2-3; with AF: 2.5-3.5
If there is evidence of heart failure

25. How to treat a a patient with tCA overdose
Lidcaine drip
Post wall MI - occlusion of right coronary artery. tx with atropine
Without AF; INR 2-3; with AF: 2.5-3.5
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

26. stable angina with heart failure
Amiodarone;
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
No...except posterior or dorsal MI
Go for coronary angio. high likelyhood of severe coronary artery disease

27. 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
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
No p wave - narrow qrs; first line of tx-adenosine
Without AF; INR 2-3; with AF: 2.5-3.5

28. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
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
Without AF; INR 2-3; with AF: 2.5-3.5
If patient is started on rifampin or phenobarbital; they increases its metabolism

29. sinus bradycardia after inf wall MI
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
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

30. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Streptokinase
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
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.

31. patient with secondary htn - What is next step
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Scoliosis and pes planus

32. 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 -
No...except posterior or dorsal MI
Development of AF. after ETOH - develop AF---sudden cardia arrest
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

33. baloon valvulotomy for AS
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
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

34. torsade and unresponsive
2.5-3.5
Defibrillation
Streptokinase
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 -

35. indication of radionuclide ventriculography
Monitor EF after cardiotoxic chemo - bypass surgery
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
VSD; can be asymptomatic to large with significant L to R shunt
When it is symptomatic. asso with dec cardiac output resulting hypotension

36. sudden onset of HTN. How do you manage
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
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

37. When to increase warfarin dose?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
If patient is started on rifampin or phenobarbital; they increases its metabolism
Monitor EF after cardiotoxic chemo - bypass surgery
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

38. bradycardia after MI with hypotension. what would you do?
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 -
Elderly people with MI
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
The dose should be adjusted such that TS H below 0.35

39. When rhythm control strategy is suprior than rate control in the Tx of AF
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
PPAR gamma receptor agonist pioglitazone.PPAR
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

40. When to replace aortic valve
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

41. What is kussmaul sign
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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Within 24 hours

42. s/s carotid dissection
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Reduce hypertriglyceridemia; in liver

43. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
The dose should be adjusted such that TS H below 0.35
Increases the risk of MI - thromboembolism - breast cancer - dementia

44. what MI cause sinus brady?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Transvenous pacemaker
Post wall MI - occlusion of right coronary artery. tx with atropine

45. new onset LBBB - What is the next step
Persistent brady after MI which is refractory to atropine tx
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.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

46. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
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
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

47. bradycardia with type 2 heart block
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
No...except posterior or dorsal MI
Development of AF. after ETOH - develop AF---sudden cardia arrest
Transvenous pacemaker

48. complication of HRT
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Increases the risk of MI - thromboembolism - breast cancer - dementia
VSD; can be asymptomatic to large with significant L to R shunt
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

49. When to use digoxin in AF
VSD; can be asymptomatic to large with significant L to R shunt
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
If there is evidence of heart failure

50. Difference between cardioversion and defibrillation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If patient is started on rifampin or phenobarbital; they increases its metabolism