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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. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
When it is symptomatic. asso with dec cardiac output resulting hypotension
Amiodarone;
Flecainamide

2. indication of radionuclide ventriculography
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Monitor EF after cardiotoxic chemo - bypass surgery
No p wave - narrow qrs; first line of tx-adenosine
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

3. s/s carotid dissection
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

4. 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 -
Go for coronary angio. high likelyhood of severe coronary artery disease
Flecainamide
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

5. 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
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Pt with cardiogenic shock

6. most effective non pharmacologic measure to decease blood pressure?
Weight loss
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Without AF; INR 2-3; with AF: 2.5-3.5
VSD; can be asymptomatic to large with significant L to R shunt

7. wpw syndrome
No p wave - narrow qrs; first line of tx-adenosine
Flecainamide
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

8. When to replace aortic valve
If patient is started on rifampin or phenobarbital; they increases its metabolism
The dose should be adjusted such that TS H below 0.35
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Elderly people with MI

9. ehlers danlos
Scoliosis and pes planus
No...except posterior or dorsal MI
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Without AF; INR 2-3; with AF: 2.5-3.5

10. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
If there is evidence of heart failure
Coronary angio - identify blockage and tx with stent/bypass
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

11. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Defibrillation
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

12. How do you diagnose multifocal atrial tachy?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
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.
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.

13. Difference between cardioversion and defibrillation
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
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
Without AF; INR 2-3; with AF: 2.5-3.5

14. What is mech of TCA overdose
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
Streptokinase
When it is symptomatic. asso with dec cardiac output resulting hypotension
Scoliosis and pes planus

15. new onset LBBB - What is the next step
Flecainamide
Lidcaine drip
Without AF; INR 2-3; with AF: 2.5-3.5
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

16. When to use anticoag or aspiring in AF
The dose should be adjusted such that TS H below 0.35
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
If there is evidence of heart failure
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

17. drugs increases the effect of warfarin
Monitor EF after cardiotoxic chemo - bypass surgery
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Increases the risk of MI - thromboembolism - breast cancer - dementia
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

18. Why nitroprusside cannot be used alone in aortic dissection
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
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

19. When to treat sinus brady after acute MI
Within 24 hours
When it is symptomatic. asso with dec cardiac output resulting hypotension
Development of AF. after ETOH - develop AF---sudden cardia arrest
Elderly people with MI

20. bradycardia with type 2 heart block
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Transvenous pacemaker
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

21. INR goal for bileaflet mechnial valve
CABG not angioplasty
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
Without AF; INR 2-3; with AF: 2.5-3.5

22. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
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
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

23. patient pw with new onset of heart failure and AF
Elderly people with MI
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

24. sinus bradycardia after inf wall MI
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.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

25. torsade and unresponsive
Pt with cardiogenic shock
Defibrillation
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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

26. location of VSD/MR mumur
Go for coronary angio. high likelyhood of severe coronary artery disease
The dose should be adjusted such that TS H below 0.35
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.
Holocystolic murmur loudest at lower left sternal border

27. baloon valvulotomy for AS
No p wave - narrow qrs; first line of tx-adenosine
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

28. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If patient is started on rifampin or phenobarbital; they increases its metabolism
Lidcaine drip

29. When to use dobutamine?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Pt with cardiogenic shock
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

30. What is the most effective way to treat multivessel coronary artery blockade?
Post wall MI - occlusion of right coronary artery. tx with atropine
CABG not angioplasty
VSD; can be asymptomatic to large with significant L to R shunt
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.

31. patient with new onset CHF - What is next best step?
Reduce hypertriglyceridemia; in liver
Transvenous pacemaker
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Defibrillation

32. What is most congenital heart malformation?
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Transvenous pacemaker
Coronary angio - identify blockage and tx with stent/bypass
VSD; can be asymptomatic to large with significant L to R shunt

33. What is poor R wave progression?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
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.
Streptokinase

34. 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 -
The dose should be adjusted such that TS H below 0.35
Coronary angio - identify blockage and tx with stent/bypass
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

35. When to use digoxin in AF
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Streptokinase
If there is evidence of heart failure
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

36. Indication of gemfibrozil?
Coronary angio - identify blockage and tx with stent/bypass
Reduce hypertriglyceridemia; in liver
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

37. What is beck's triad?
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
2.5-3.5
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

38. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Lidcaine drip
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
CABG not angioplasty
When it is symptomatic. asso with dec cardiac output resulting hypotension

39. how amiodarone affects on warfarin
Flecainamide
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Monitor EF after cardiotoxic chemo - bypass surgery
Coronary angio - identify blockage and tx with stent/bypass

40. 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
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Persistent brady after MI which is refractory to atropine tx
Lidcaine drip

41. bradycardia after MI with hypotension. what would you do?
Weight loss
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
When it is symptomatic. asso with dec cardiac output resulting hypotension

42. How to dx SVT? tx?
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.
Amiodarone;
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
No p wave - narrow qrs; first line of tx-adenosine

43. When to use transvenous pacing?
Persistent brady after MI which is refractory to atropine tx
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
Go for coronary angio. high likelyhood of severe coronary artery disease

44. should we give thrombolytic in ST depression?
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
No...except posterior or dorsal MI
If patient is started on rifampin or phenobarbital; they increases its metabolism
Holocystolic murmur loudest at lower left sternal border

45. sudden onset of HTN. How do you manage
Streptokinase
Weight loss
Go for coronary angio. high likelyhood of severe coronary artery disease
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

46. 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.
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
CABG not angioplasty

47. when we say QT prolonged?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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;

48. who should get coronary intervention after MI
Pt with cardiogenic shock
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
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

49. INR for mechanical prosthetic valve
2.5-3.5
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

50. How to treat a a patient with tCA overdose
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
Lidcaine drip
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used