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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. most effective non pharmacologic measure to decease blood pressure?
2.5-3.5
Weight loss
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

2. What drugs precipitate digoxin toxicity?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Development of AF. after ETOH - develop AF---sudden cardia arrest
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

3. new onset LBBB - What is the next step
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Amiodarone;
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

4. What is beck's triad?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Go for coronary angio. high likelyhood of severe coronary artery disease
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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

5. When to use dobutamine?
CABG not angioplasty
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Pt with cardiogenic shock
Within 24 hours

6. spontaneous papillary muscle rupture
Scoliosis and pes planus
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Post wall MI - occlusion of right coronary artery. tx with atropine
Elderly people with MI

7. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
CABG not angioplasty
Reduce hypertriglyceridemia; in liver
No...except posterior or dorsal MI

8. What is mech of TCA overdose
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.
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
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

9. 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.
Post wall MI - occlusion of right coronary artery. tx with atropine
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

10. What is paroxysmal AF? How do you treat?
Defibrillation
Reduce hypertriglyceridemia; in liver
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 -
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

11. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Within 24 hours
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Coronary angio - identify blockage and tx with stent/bypass
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

12. When to use digoxin in AF
If there is evidence of heart failure
Increases the risk of MI - thromboembolism - breast cancer - dementia
Pt with cardiogenic shock
When it is symptomatic. asso with dec cardiac output resulting hypotension

13. Indication of gemfibrozil?
Reduce hypertriglyceridemia; in liver
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
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

14. bradycardia after MI with hypotension. what would you do?
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
Post wall MI - occlusion of right coronary artery. tx with atropine
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

15. When to replace aortic valve
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
2.5-3.5
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

16. INR goal for bileaflet mechnial valve
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Without AF; INR 2-3; with AF: 2.5-3.5

17. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Coronary angio - identify blockage and tx with stent/bypass
PPAR gamma receptor agonist pioglitazone.PPAR
When it is symptomatic. asso with dec cardiac output resulting hypotension

18. what medication cause pulmonary edema?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
PPAR gamma receptor agonist pioglitazone.PPAR

19. should we give thrombolytic in ST depression?
No...except posterior or dorsal MI
Weight loss
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.

20. when we say QT prolonged?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
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
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

21. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
Holocystolic murmur loudest at lower left sternal border
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Unexplained synocope - dizziness - near syncope - recurrent palpitation

22. Most important predictor for future cardiovascular events
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Flecainamide
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

23. When to use anticoag or aspiring in AF
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
VSD; can be asymptomatic to large with significant L to R shunt
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

24. indication of radionuclide ventriculography
Monitor EF after cardiotoxic chemo - bypass surgery
Elderly people with MI
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Defibrillation

25. What is most congenital heart malformation?
VSD; can be asymptomatic to large with significant L to R shunt
Elderly people with MI
Increases the risk of MI - thromboembolism - breast cancer - dementia
No p wave - narrow qrs; first line of tx-adenosine

26. who should get coronary intervention after MI
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
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

27. when should you stop aspirin before procedure that has bleeding risk?
Post wall MI - occlusion of right coronary artery. tx with atropine
2.5-3.5
PPAR gamma receptor agonist pioglitazone.PPAR
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

28. 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
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Go for coronary angio. high likelyhood of severe coronary artery disease
VSD; can be asymptomatic to large with significant L to R shunt

29. patient pw with new onset of heart failure and AF
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%
Persistent brady after MI which is refractory to atropine tx
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

30. INR for mechanical prosthetic valve
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
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Holocystolic murmur loudest at lower left sternal border
2.5-3.5

31. ehlers danlos
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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.
Scoliosis and pes planus
Weight loss

32. EKG shows ST elevation and suggest occlusion of major coronary artery.
The dose should be adjusted such that TS H below 0.35
Scoliosis and pes planus
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
2.5-3.5

33. baloon valvulotomy for AS
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
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
Transvenous pacemaker

34. stable angina with heart failure
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
Go for coronary angio. high likelyhood of severe coronary artery disease
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

35. s/s carotid dissection
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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

36. what MI cause sinus brady?
Elderly people with MI
Coronary angio - identify blockage and tx with stent/bypass
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Post wall MI - occlusion of right coronary artery. tx with atropine

37. How long it takes for digoxin to have significant effect on rate control
No p wave - narrow qrs; first line of tx-adenosine
When it is symptomatic. asso with dec cardiac output resulting hypotension
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

38. When rhythm control strategy is suprior than rate control in the Tx of AF
Coronary angio - identify blockage and tx with stent/bypass
Without AF; INR 2-3; with AF: 2.5-3.5
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

39. common complications of ca antagonists?
Post wall MI - occlusion of right coronary artery. tx with atropine
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
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Development of AF. after ETOH - develop AF---sudden cardia arrest

40. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
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)
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

41. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
No p wave - narrow qrs; first line of tx-adenosine

42. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

43. complication of HRT
Elderly people with MI
2.5-3.5
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Increases the risk of MI - thromboembolism - breast cancer - dementia

44. How to dx SVT? tx?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
No p wave - narrow qrs; first line of tx-adenosine
Defibrillation
If there is evidence of heart failure

45. how amiodarone affects on warfarin
Lidcaine drip
Pt with cardiogenic shock
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Within 24 hours

46. 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
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
No p wave - narrow qrs; first line of tx-adenosine
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

47. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
PPAR gamma receptor agonist pioglitazone.PPAR
Nitrate/ca channel blocker - aspirin - benzo; if no improvement 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
The dose should be adjusted such that TS H below 0.35

48. In cocaine induced vasospasm - if angio shows any thrombus - next step?
When it is symptomatic. asso with dec cardiac output resulting hypotension
VSD; can be asymptomatic to large with significant L to R shunt
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

49. 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
Pt with cardiogenic shock
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
No p wave - narrow qrs; first line of tx-adenosine

50. location of VSD/MR mumur
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
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
Transvenous pacemaker
Holocystolic murmur loudest at lower left sternal border