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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.
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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. should we give thrombolytic in ST depression?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
No...except posterior or dorsal MI
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
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

2. s/s carotid dissection
High suspicion of MI. LAD occlusion leading to LBBB - next step 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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

3. What is mech of TCA overdose
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
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

4. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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 -
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

5. paroxysmal AF without structural HD
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
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Flecainamide

6. What is most congenital heart malformation?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
PPAR gamma receptor agonist pioglitazone.PPAR
VSD; can be asymptomatic to large with significant L to R shunt
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

7. How to treat a a patient with tCA overdose
Lidcaine drip
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
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

8. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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.
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 -

9. most effective non pharmacologic measure to decease blood pressure?
No...except posterior or dorsal MI
Elderly people with MI
Weight loss
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

10. What drugs precipitate digoxin toxicity?
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Pt with cardiogenic shock
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

11. primordial prevention vs primary/secondary/tertiary prevention
Go for coronary angio. high likelyhood of severe coronary artery disease
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.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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. What is beck's triad?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
When it is symptomatic. asso with dec cardiac output resulting hypotension
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

13. When to use digoxin in AF
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Weight loss
If there is evidence of heart failure

14. bradycardia with type 2 heart block
Amiodarone;
Transvenous pacemaker
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

15. How long it takes for digoxin to have significant effect on rate control
CABG not angioplasty
Amiodarone;
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

16. How to dx SVT? tx?
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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
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.

17. torsade and unresponsive
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Defibrillation
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Coronary angio - identify blockage and tx with stent/bypass

18. what MI cause sinus brady?
No p wave - narrow qrs; first line of tx-adenosine
Flecainamide
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

19. When to start thrombolytic therapry in MI
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Amiodarone;
Development of AF. after ETOH - develop AF---sudden cardia arrest
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

20. How do you diagnose multifocal atrial tachy?
Coronary angio - identify blockage and tx with stent/bypass
Increases the risk of MI - thromboembolism - breast cancer - dementia
CABG not angioplasty
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.

21. When rhythm control strategy is suprior than rate control in the Tx of AF
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

22. when we say QT prolonged?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Within 24 hours
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

23. new onset LBBB - What is the next step
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
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
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

24. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
The dose should be adjusted such that TS H below 0.35
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Flecainamide

25. baloon valvulotomy for AS
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
No...except posterior or dorsal MI
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

26. problem of WPW?
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 -
Monitor EF after cardiotoxic chemo - bypass surgery
Development of AF. after ETOH - develop AF---sudden cardia arrest
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

27. What is poor R wave progression?
Holocystolic murmur loudest at lower left sternal border
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.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

28. What is the most effective way to treat multivessel coronary artery blockade?
Holocystolic murmur loudest at lower left sternal border
CABG not angioplasty
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 -
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

29. paroxysmal AF with structural HD
Weight loss
Transvenous pacemaker
CABG not angioplasty
Amiodarone;

30. sinus bradycardia after inf wall MI
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
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Without AF; INR 2-3; with AF: 2.5-3.5

31. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Increases the risk of MI - thromboembolism - breast cancer - dementia

32. 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
Reduce hypertriglyceridemia; in liver
CABG not angioplasty
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

33. stable angina with heart failure
Streptokinase
Go for coronary angio. high likelyhood of severe coronary artery disease
CABG not angioplasty
VSD; can be asymptomatic to large with significant L to R shunt

34. common complications of ca antagonists?
Coronary angio - identify blockage and tx with stent/bypass
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Transvenous pacemaker
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

35. Indication of gemfibrozil?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
If patient is started on rifampin or phenobarbital; they increases its metabolism
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 -
Reduce hypertriglyceridemia; in liver

36. Difference between cardioversion and defibrillation
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 patient is started on rifampin or phenobarbital; they increases its metabolism
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
Development of AF. after ETOH - develop AF---sudden cardia arrest

37. location of VSD/MR mumur
2.5-3.5
Pt with cardiogenic shock
Holocystolic murmur loudest at lower left sternal border
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

38. when 24 hour holter monitoring and admission recommended?
2.5-3.5
When it is symptomatic. asso with dec cardiac output resulting hypotension
Reduce hypertriglyceridemia; in liver
Unexplained synocope - dizziness - near syncope - recurrent palpitation

39. indication of radionuclide ventriculography
Persistent brady after MI which is refractory to atropine tx
Monitor EF after cardiotoxic chemo - bypass surgery
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Defibrillation

40. EKG shows ST elevation and suggest occlusion of major coronary artery.
Lidcaine drip
Monitor EF after cardiotoxic chemo - bypass surgery
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

41. 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
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
If patient is started on rifampin or phenobarbital; they increases its metabolism

42. the dose levothyroxine in thyroid cancer remission
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
The dose should be adjusted such that TS H below 0.35
CABG not angioplasty
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

43. When to replace aortic valve
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Within 24 hours
Defibrillation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

44. bradycardia after MI with hypotension. what would you do?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Go for coronary angio. high likelyhood of severe coronary artery disease
PPAR gamma receptor agonist pioglitazone.PPAR
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

45. 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.
2.5-3.5
Defibrillation
If patient is started on rifampin or phenobarbital; they increases its metabolism

46. INR goal for bileaflet mechnial valve
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Without AF; INR 2-3; with AF: 2.5-3.5

47. 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
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

48. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Go for coronary angio. high likelyhood of severe coronary artery disease
Lidcaine drip
Streptokinase
2.5-3.5

49. Why nitroprusside cannot be used alone in aortic dissection
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

50. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
PPAR gamma receptor agonist pioglitazone.PPAR
If there is evidence of heart failure
7 days. coz aspirin cause platelet dysfunction that can last more than a week.