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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. When to use anticoag or aspiring in AF
Without AF; INR 2-3; with AF: 2.5-3.5
Flecainamide
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

2. s/s carotid dissection
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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
Lidcaine drip

3. Indication of gemfibrozil?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Reduce hypertriglyceridemia; in liver
Weight loss
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

4. What is mech of TCA overdose
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
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
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Weight loss

5. new onset LBBB - What is the next step
CABG not angioplasty
VSD; can be asymptomatic to large with significant L to R shunt
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

6. EKG shows ST elevation and suggest occlusion of major coronary artery.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

7. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Pt with cardiogenic shock
Elderly people with MI

8. What is most congenital heart malformation?
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Holocystolic murmur loudest at lower left sternal border
VSD; can be asymptomatic to large with significant L to R shunt
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

9. How to treat a a patient with tCA overdose
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
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Lidcaine drip

10. when 24 hour holter monitoring and admission recommended?
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
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Unexplained synocope - dizziness - near syncope - recurrent palpitation

11. what MI cause sinus brady?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Post wall MI - occlusion of right coronary artery. tx with atropine
PPAR gamma receptor agonist pioglitazone.PPAR

12. Difference between cardioversion and defibrillation
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Post wall MI - occlusion of right coronary artery. tx with atropine
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
Persistent brady after MI which is refractory to atropine tx

13. How do you diagnose multifocal atrial tachy?
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
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.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

14. torsade and unresponsive
Defibrillation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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.

15. location of VSD/MR mumur
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Without AF; INR 2-3; with AF: 2.5-3.5
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Holocystolic murmur loudest at lower left sternal border

16. What is paroxysmal AF? How do you treat?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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 -
The dose should be adjusted such that TS H below 0.35
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

17. who should get coronary intervention after MI
Go for coronary angio. high likelyhood of severe coronary artery disease
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Elderly people with MI
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

18. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
If patient is started on rifampin or phenobarbital; they increases its metabolism
PPAR gamma receptor agonist pioglitazone.PPAR
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

19. when should you stop aspirin before procedure that has bleeding risk?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
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.

20. How long it takes for digoxin to have significant effect on rate control
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
VSD; can be asymptomatic to large with significant L to R shunt

21. How to dx SVT? tx?
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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
No p wave - narrow qrs; first line of tx-adenosine
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

22. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

23. most effective non pharmacologic measure to decease blood pressure?
Flecainamide
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Weight loss
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

24. 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
Persistent brady after MI which is refractory to atropine tx
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

25. What is the most effective way to treat multivessel coronary artery blockade?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
CABG not angioplasty
2.5-3.5
VSD; can be asymptomatic to large with significant L to R shunt

26. when we say QT prolonged?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Within 24 hours
Elderly people with MI
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

27. paroxysmal AF without structural HD
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Flecainamide
Lidcaine drip

28. baloon valvulotomy for AS
PPAR gamma receptor agonist pioglitazone.PPAR
2.5-3.5
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

29. stable angina with heart failure
Transvenous pacemaker
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Go for coronary angio. high likelyhood of severe coronary artery disease
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

30. When to use dobutamine?
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
Pt with cardiogenic shock
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

31. When to use transvenous pacing?
Persistent brady after MI which is refractory to atropine tx
Increases the risk of MI - thromboembolism - breast cancer - dementia
Lidcaine drip
The dose should be adjusted such that TS H below 0.35

32. Why nitroprusside cannot be used alone in aortic dissection
Go for coronary angio. high likelyhood of severe coronary artery disease
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
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

33. wpw syndrome
If there is evidence of heart failure
VSD; can be asymptomatic to large with significant L to R shunt
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Persistent brady after MI which is refractory to atropine tx

34. What is beck's triad?
Transvenous pacemaker
Persistent brady after MI which is refractory to atropine tx
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

35. when NSTEMI without comorbidiites should get PCI?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Within 24 hours
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 -
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

36. problem of WPW?
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
CABG not angioplasty
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Development of AF. after ETOH - develop AF---sudden cardia arrest

37. spontaneous papillary muscle rupture
Elderly people with MI
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

38. patient pw with new onset of heart failure and AF
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
The dose should be adjusted such that TS H below 0.35
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Weight loss

39. When to replace aortic valve
The dose should be adjusted such that TS H below 0.35
Unexplained synocope - dizziness - near syncope - recurrent palpitation
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Transvenous pacemaker

40. What is kussmaul sign
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 marked palpitaion - diszzines - dyspnoea - or 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
2.5-3.5

41. What is PEA? How do you treat?
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.
Lidcaine drip
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

42. When rhythm control strategy is suprior than rate control in the Tx of AF
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
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.
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

43. When to treat sinus brady after acute MI
When it is symptomatic. asso with dec cardiac output resulting hypotension
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
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

44. what medication cause pulmonary edema?
If patient is started on rifampin or phenobarbital; they increases its metabolism
PPAR gamma receptor agonist pioglitazone.PPAR
Post wall MI - occlusion of right coronary artery. tx with atropine
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

45. When to use digoxin in AF
If there is evidence of heart failure
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
CABG not angioplasty
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

46. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Lidcaine drip

47. how amiodarone affects on warfarin
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
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
PPAR gamma receptor agonist pioglitazone.PPAR

48. patient with secondary htn - What is next step
Within 24 hours
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

49. What drugs precipitate digoxin toxicity?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Within 24 hours
CABG not angioplasty
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

50. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 2.5-3.5
Increases the risk of MI - thromboembolism - breast cancer - dementia
Scoliosis and pes planus
R/o IHD which is the most common causes of CHF. stress test if indicated or angio