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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. wpw syndrome
Defibrillation
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Pt with cardiogenic shock

2. s/s carotid dissection
Development of AF. after ETOH - develop AF---sudden cardia arrest
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
CABG not angioplasty

3. patient with new onset CHF - What is next best step?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
CABG not angioplasty
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

4. how amiodarone affects on warfarin
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Without AF; INR 2-3; with AF: 2.5-3.5
PPAR gamma receptor agonist pioglitazone.PPAR
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

5. most effective non pharmacologic measure to decease blood pressure?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Weight loss
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

6. When to use anticoag or aspiring in AF
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

7. When to use dobutamine?
Monitor EF after cardiotoxic chemo - bypass surgery
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Pt with cardiogenic shock
The dose should be adjusted such that TS H below 0.35

8. stable angina with heart failure
Increases the risk of MI - thromboembolism - breast cancer - dementia
Holocystolic murmur loudest at lower left sternal border
Coronary angio - identify blockage and tx with stent/bypass
Go for coronary angio. high likelyhood of severe coronary artery disease

9. Difference between cardioversion and defibrillation
Persistent brady after MI which is refractory to atropine tx
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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

10. should we give thrombolytic in ST depression?
No...except posterior or dorsal MI
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
PPAR gamma receptor agonist pioglitazone.PPAR

11. who should get coronary intervention after MI
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
Persistent brady after MI which is refractory to atropine tx
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

12. Most important predictor for future cardiovascular events
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Lidcaine drip

13. paroxysmal AF without structural HD
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 -
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Flecainamide

14. indication of radionuclide ventriculography
Monitor EF after cardiotoxic chemo - bypass surgery
Lidcaine drip
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
If patient is started on rifampin or phenobarbital; they increases its metabolism

15. 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 there is evidence of heart failure
PPAR gamma receptor agonist pioglitazone.PPAR
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

16. How long it takes for digoxin to have significant effect on rate control
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
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

17. bradycardia with type 2 heart block
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
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Transvenous pacemaker

18. sinus bradycardia after inf wall MI
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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

19. location of VSD/MR mumur
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Coronary angio - identify blockage and tx with stent/bypass
The dose should be adjusted such that TS H below 0.35
Holocystolic murmur loudest at lower left sternal border

20. what medication cause pulmonary edema?
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
Within 24 hours
Scoliosis and pes planus

21. when NSTEMI without comorbidiites should get PCI?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
No p wave - narrow qrs; first line of tx-adenosine
Within 24 hours

22. What is beck's triad?
Weight loss
Coronary angio - identify blockage and tx with stent/bypass
Monitor EF after cardiotoxic chemo - bypass surgery
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

23. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
When it is symptomatic. asso with dec cardiac output resulting hypotension
Defibrillation
Scoliosis and pes planus
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

24. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Monitor EF after cardiotoxic chemo - bypass surgery
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

25. patient pw with new onset of heart failure and AF
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Holocystolic murmur loudest at lower left sternal border
If there is evidence of heart failure

26. when should you stop aspirin before procedure that has bleeding risk?
VSD; can be asymptomatic to large with significant L to R shunt
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

27. drugs increases the effect of warfarin
Streptokinase
Coronary angio - identify blockage and tx with stent/bypass
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

28. INR for mechanical prosthetic valve
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.
2.5-3.5
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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

29. 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 -
2.5-3.5
Weight loss
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. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If patient is started on rifampin or phenobarbital; they increases its metabolism
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

31. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
PPAR gamma receptor agonist pioglitazone.PPAR
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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

32. What is poor R wave progression?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Monitor EF after cardiotoxic chemo - bypass surgery
VSD; can be asymptomatic to large with significant L to R shunt

33. How to treat a a patient with tCA overdose
Go for coronary angio. high likelyhood of severe coronary artery disease
Lidcaine drip
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Transvenous pacemaker

34. Why nitroprusside cannot be used alone in aortic dissection
Scoliosis and pes planus
Monitor EF after cardiotoxic chemo - bypass surgery
Streptokinase
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

35. What is most congenital heart malformation?
Streptokinase
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
VSD; can be asymptomatic to large with significant L to R shunt
Unexplained synocope - dizziness - near syncope - recurrent palpitation

36. What drugs precipitate digoxin toxicity?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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
Monitor EF after cardiotoxic chemo - bypass surgery

37. What is mech of TCA overdose
If patient is started on rifampin or phenobarbital; they increases its metabolism
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
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

38. In cocaine induced vasospasm - if angio shows any thrombus - next step?
VSD; can be asymptomatic to large with significant L to R shunt
Streptokinase
Monitor EF after cardiotoxic chemo - bypass surgery
Unexplained synocope - dizziness - near syncope - recurrent palpitation

39. when we say QT prolonged?
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
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 it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

40. EKG shows ST elevation and suggest occlusion of major coronary artery.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Coronary angio - identify blockage and tx with stent/bypass
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

41. When to replace aortic valve
Persistent brady after MI which is refractory to atropine tx
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Flecainamide

42. When to start thrombolytic therapry in MI
VSD; can be asymptomatic to large with significant L to R shunt
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Within 24 hours

43. When to treat sinus brady after acute MI
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
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Unexplained synocope - dizziness - near syncope - recurrent palpitation

44. when 24 hour holter monitoring and admission recommended?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
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

45. INR goal for bileaflet mechnial valve
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Without AF; INR 2-3; with AF: 2.5-3.5

46. When rhythm control strategy is suprior than rate control in the Tx of AF
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
No p wave - narrow qrs; first line of tx-adenosine

47. paroxysmal AF with structural HD
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 -
Amiodarone;
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
No...except posterior or dorsal MI

48. How to dx SVT? tx?
No p wave - narrow qrs; first line of tx-adenosine
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Defibrillation

49. spontaneous papillary muscle rupture
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
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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

50. What is PEA? How do you treat?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
If patient is started on rifampin or phenobarbital; they increases its metabolism
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.