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USMLE Step3 Cardiovascular

Subjects : health-sciences, usmle-step-3

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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. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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

2. wpw syndrome
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
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
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

3. should we give thrombolytic in ST depression?
No...except posterior or dorsal MI
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
If patient is started on rifampin or phenobarbital; they increases its metabolism

4. when we say QT prolonged?
Within 24 hours
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If patient is started on rifampin or phenobarbital; they increases its metabolism
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

5. new onset LBBB - What is the next step
CABG not angioplasty
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

6. primordial prevention vs primary/secondary/tertiary prevention
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.
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
Flecainamide
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

7. What is poor R wave progression?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
VSD; can be asymptomatic to large with significant L to R shunt
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

8. stable angina with heart failure
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
Defibrillation
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

9. EKG shows ST elevation and suggest occlusion of major coronary artery.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

10. s/s carotid dissection
If patient is started on rifampin or phenobarbital; they increases its metabolism
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
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

11. How do you diagnose multifocal atrial tachy?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Defibrillation
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
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.

12. drugs increases the effect of warfarin
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
No p wave - narrow qrs; first line of tx-adenosine

13. When to treat sinus brady after acute MI
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
When it is symptomatic. asso with dec cardiac output resulting hypotension
Holocystolic murmur loudest at lower left sternal border

14. patient with secondary htn - What is next step
Streptokinase
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Development of AF. after ETOH - develop AF---sudden cardia arrest

15. torsade and unresponsive
No p wave - narrow qrs; first line of tx-adenosine
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Defibrillation
Go for coronary angio. high likelyhood of severe coronary artery disease

16. How long it takes for digoxin to have significant effect on rate control
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Within 24 hours

17. location of VSD/MR mumur
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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
Holocystolic murmur loudest at lower left sternal border
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

18. spontaneous papillary muscle rupture
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Elderly people with MI
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

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

20. How to treat a a patient with tCA overdose
Lidcaine drip
Weight loss
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.
Without AF; INR 2-3; with AF: 2.5-3.5

21. When to use dobutamine?
Pt with cardiogenic shock
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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.
Development of AF. after ETOH - develop AF---sudden cardia arrest

22. What is kussmaul sign
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
Transvenous pacemaker
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. When to increase warfarin dose?
VSD; can be asymptomatic to large with significant L to R shunt
Coronary angio - identify blockage and tx with stent/bypass
If patient is started on rifampin or phenobarbital; they increases its metabolism
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

24. baloon valvulotomy for AS
When it is symptomatic. asso with dec cardiac output resulting hypotension
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
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

25. How to dx SVT? tx?
No p wave - narrow qrs; first line of tx-adenosine
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Coronary angio - identify blockage and tx with stent/bypass
Persistent brady after MI which is refractory to atropine tx

26. bradycardia with type 2 heart block
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Holocystolic murmur loudest at lower left sternal border
Elderly people with MI
Transvenous pacemaker

27. when should you stop aspirin before procedure that has bleeding risk?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Increases the risk of MI - thromboembolism - breast cancer - dementia
Lidcaine drip
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

28. paroxysmal AF with structural HD
Flecainamide
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Amiodarone;
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

29. common complications of ca antagonists?
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
The dose should be adjusted such that TS H below 0.35
Go for coronary angio. high likelyhood of severe coronary artery disease
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

30. INR for mechanical prosthetic valve
Pt with cardiogenic shock
The dose should be adjusted such that TS H below 0.35
2.5-3.5
Monitor EF after cardiotoxic chemo - bypass surgery

31. ehlers danlos
No p wave - narrow qrs; first line of tx-adenosine
Coronary angio - identify blockage and tx with stent/bypass
Scoliosis and pes planus
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

32. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
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.

33. paroxysmal AF without structural HD
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
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.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Flecainamide

34. When to start thrombolytic therapry in MI
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

35. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Lidcaine drip
Reduce hypertriglyceridemia; in liver

36. sinus bradycardia after inf wall MI
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Defibrillation

37. When to replace aortic valve
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

38. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Increases the risk of MI - thromboembolism - breast cancer - dementia
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Without AF; INR 2-3; with AF: 2.5-3.5

39. When to use digoxin in AF
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If there is evidence of heart failure
Persistent brady after MI which is refractory to atropine tx
Increases the risk of MI - thromboembolism - breast cancer - dementia

40. In cocaine induced vasospasm - if angio shows any thrombus - next step?
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.
Reduce hypertriglyceridemia; in liver
Streptokinase
Pt with cardiogenic shock

41. What is the most effective way to treat multivessel coronary artery blockade?
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
CABG not angioplasty
Reduce hypertriglyceridemia; in liver
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

42. What is paroxysmal AF? How do you treat?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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 -
Increases the risk of MI - thromboembolism - breast cancer - dementia
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

43. Most important predictor for future cardiovascular events
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
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

44. bradycardia after MI with hypotension. what would you do?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Reduce hypertriglyceridemia; in liver
Development of AF. after ETOH - develop AF---sudden cardia arrest
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.

45. what MI cause sinus brady?
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
The dose should be adjusted such that TS H below 0.35
Post wall MI - occlusion of right coronary artery. tx with atropine
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

46. Indication of gemfibrozil?
Reduce hypertriglyceridemia; in liver
Without AF; INR 2-3; with AF: 2.5-3.5
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Go for coronary angio. high likelyhood of severe coronary artery disease

47. patient pw with new onset of heart failure and AF
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Defibrillation

48. When to use transvenous pacing?
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
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
Post wall MI - occlusion of right coronary artery. tx with atropine

49. What drugs precipitate digoxin toxicity?
VSD; can be asymptomatic to large with significant L to R shunt
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
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

50. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
Flecainamide
Go for coronary angio. high likelyhood of severe coronary artery disease
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

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USMLE Step3 Cardiovascular

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