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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. s/s carotid dissection
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Defibrillation
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

2. How long it takes for digoxin to have significant effect on rate control
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
No...except posterior or dorsal MI
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

3. paroxysmal AF with structural HD
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
No...except posterior or dorsal MI
Amiodarone;

4. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If patient is started on rifampin or phenobarbital; they increases its metabolism
No...except posterior or dorsal MI
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
No p wave - narrow qrs; first line of tx-adenosine

5. When rhythm control strategy is suprior than rate control in the Tx of AF
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Go for coronary angio. high likelyhood of severe coronary artery disease
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

6. Why nitroprusside cannot be used alone in aortic dissection
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
If there is evidence of heart failure
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

7. bradycardia with type 2 heart block
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 -
Transvenous pacemaker
Streptokinase
Holocystolic murmur loudest at lower left sternal border

8. How do you diagnose multifocal atrial tachy?
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.
VSD; can be asymptomatic to large with significant L to R shunt
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

9. 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)
Increases the risk of MI - thromboembolism - breast cancer - dementia
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Pt with cardiogenic shock

10. ehlers danlos
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Scoliosis and pes planus
Go for coronary angio. high likelyhood of severe coronary artery disease

11. How to dx SVT? tx?
Development of AF. after ETOH - develop AF---sudden cardia arrest
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
When it is symptomatic. asso with dec cardiac output resulting hypotension

12. stable angina with heart failure
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Go for coronary angio. high likelyhood of severe coronary artery disease

13. When to use transvenous pacing?
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Persistent brady after MI which is refractory to atropine tx
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
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.

14. baloon valvulotomy for AS
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Streptokinase
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Unexplained synocope - dizziness - near syncope - recurrent palpitation

15. Indication of gemfibrozil?
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Reduce hypertriglyceridemia; in liver
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Post wall MI - occlusion of right coronary artery. tx with atropine

16. sinus bradycardia after inf wall MI
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Increases the risk of MI - thromboembolism - breast cancer - dementia
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.

17. what medication cause pulmonary edema?
PPAR gamma receptor agonist pioglitazone.PPAR
Within 24 hours
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

18. 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.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Transvenous pacemaker

19. What is PEA? How do you treat?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
If there is evidence of heart failure
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

20. Difference between cardioversion and defibrillation
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
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
If patient is started on rifampin or phenobarbital; they increases its metabolism

21. new onset LBBB - What is the next step
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
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

22. how amiodarone affects on warfarin
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Pt with cardiogenic shock
No p wave - narrow qrs; first line of tx-adenosine

23. When to replace aortic valve
Elderly people with MI
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Nitrate/ca channel blocker - aspirin - benzo; if no improvement 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.

24. torsade and unresponsive
Defibrillation
Weight loss
Reduce hypertriglyceridemia; in liver
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

25. when NSTEMI without comorbidiites should get PCI?
CABG not angioplasty
Within 24 hours
Increases the risk of MI - thromboembolism - breast cancer - dementia
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

26. In cocaine induced vasospasm - if angio shows any thrombus - next step?
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.
Streptokinase
If there is evidence of heart failure
No...except posterior or dorsal MI

27. How to treat a a patient with tCA overdose
Within 24 hours
VSD; can be asymptomatic to large with significant L to R shunt
Lidcaine drip
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

28. problem of WPW?
CABG not angioplasty
If there is evidence of heart failure
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.

29. the dose levothyroxine in thyroid cancer remission
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
The dose should be adjusted such that TS H below 0.35
If there is evidence of heart failure
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

30. spontaneous papillary muscle rupture
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
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
Elderly people with MI
PPAR gamma receptor agonist pioglitazone.PPAR

31. most effective non pharmacologic measure to decease blood pressure?
Reduce hypertriglyceridemia; in liver
PPAR gamma receptor agonist pioglitazone.PPAR
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Weight loss

32. 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
Holocystolic murmur loudest at lower left sternal border
Reduce hypertriglyceridemia; in liver

33. 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.
Development of AF. after ETOH - develop AF---sudden cardia arrest
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
Reduce hypertriglyceridemia; in liver

34. common complications of ca antagonists?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
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 -
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
If patient is started on rifampin or phenobarbital; they increases its metabolism

35. INR goal for bileaflet mechnial valve
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
Lidcaine drip
Without AF; INR 2-3; with AF: 2.5-3.5
If there is evidence of heart failure

36. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Defibrillation
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

37. drugs increases the effect of warfarin
Scoliosis and pes planus
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
When it is symptomatic. asso with dec cardiac output resulting hypotension

38. What is most congenital heart malformation?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
The dose should be adjusted such that TS H below 0.35
Unexplained synocope - dizziness - near syncope - recurrent palpitation
VSD; can be asymptomatic to large with significant L to R shunt

39. wpw syndrome
No...except posterior or dorsal MI
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
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

40. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Monitor EF after cardiotoxic chemo - bypass surgery
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

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
Elderly people with MI
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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

42. when 24 hour holter monitoring and admission recommended?
Coronary angio - identify blockage and tx with stent/bypass
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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

43. patient with secondary htn - What is next step
Transvenous pacemaker
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Reduce hypertriglyceridemia; in liver

44. When to increase warfarin dose?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Go for coronary angio. high likelyhood of severe coronary artery disease
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
If patient is started on rifampin or phenobarbital; they increases its metabolism

45. What is poor R wave progression?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Development of AF. after ETOH - develop AF---sudden cardia arrest
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

46. paroxysmal AF without structural HD
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Flecainamide
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Pt with cardiogenic shock

47. What is paroxysmal AF? How do you treat?
Monitor EF after cardiotoxic chemo - bypass surgery
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---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 -
Defibrillation

48. should we give thrombolytic in ST depression?
Post wall MI - occlusion of right coronary artery. tx with atropine
No...except posterior or dorsal MI
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If patient is started on rifampin or phenobarbital; they increases its metabolism

49. What drugs precipitate digoxin toxicity?
Transvenous pacemaker
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Coronary angio - identify blockage and tx with stent/bypass

50. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Development of AF. after ETOH - develop AF---sudden cardia arrest
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Weight loss