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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. INR for mechanical prosthetic valve
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
2.5-3.5
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

2. new onset LBBB - What is the next step
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
Increases the risk of MI - thromboembolism - breast cancer - dementia
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

3. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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
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
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. who should get coronary intervention after MI
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.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Scoliosis and pes planus

5. torsade and unresponsive
Post wall MI - occlusion of right coronary artery. tx with atropine
Defibrillation
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 -

6. most effective non pharmacologic measure to decease blood pressure?
Weight loss
If patient is started on rifampin or phenobarbital; they increases its metabolism
2.5-3.5
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

7. when NSTEMI without comorbidiites should get PCI?
R/o IHD which is the most common causes of CHF. stress test if indicated or 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
Within 24 hours
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

8. wpw syndrome
No p wave - narrow qrs; first line of tx-adenosine
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

9. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
The dose should be adjusted such that TS H below 0.35
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

10. when we say QT prolonged?
Go for coronary angio. high likelyhood of severe coronary artery disease
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
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

11. ehlers danlos
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Scoliosis and pes planus
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

12. stable angina with heart failure
Go for coronary angio. high likelyhood of severe coronary artery disease
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
If there is evidence of heart failure
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

13. s/s carotid dissection
Amiodarone;
Weight loss
VSD; can be asymptomatic to large with significant L to R shunt
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

14. What drugs precipitate digoxin toxicity?
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.
Persistent brady after MI which is refractory to atropine tx
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

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

16. 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.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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

17. patient pw with new onset of heart failure and AF
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;
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

18. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Defibrillation
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

19. when 24 hour holter monitoring and admission recommended?
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
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
Unexplained synocope - dizziness - near syncope - recurrent palpitation

20. Indication of gemfibrozil?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Reduce hypertriglyceridemia; in liver
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

21. the dose levothyroxine in thyroid cancer remission
Go for coronary angio. high likelyhood of severe coronary artery disease
The dose should be adjusted such that TS H below 0.35
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

22. how amiodarone affects on warfarin
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
No...except posterior or dorsal MI
2.5-3.5

23. What is poor R wave progression?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Post wall MI - occlusion of right coronary artery. tx with atropine
CABG not angioplasty
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

24. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
R/o IHD which is the most common causes of CHF. stress test if indicated or 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
Development of AF. after ETOH - develop AF---sudden cardia arrest

25. When to use digoxin in AF
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If there is evidence of heart failure

26. what medication cause pulmonary edema?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
PPAR gamma receptor agonist pioglitazone.PPAR
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Coronary angio - identify blockage and tx with stent/bypass

27. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Increases the risk of MI - thromboembolism - breast cancer - dementia
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Development of AF. after ETOH - develop AF---sudden cardia arrest

28. When to replace aortic valve
Reduce hypertriglyceridemia; in liver
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
When it is symptomatic. asso with dec cardiac output resulting hypotension

29. paroxysmal AF with 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
Amiodarone;
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.
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

30. How long it takes for digoxin to have significant effect on rate control
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Transvenous pacemaker
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

31. When to use transvenous pacing?
Lidcaine drip
Persistent brady after MI which is refractory to atropine tx
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

32. should we give thrombolytic in ST depression?
Reduce hypertriglyceridemia; in liver
No...except posterior or dorsal MI
Scoliosis and pes planus
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.

33. problem of WPW?
Increases the risk of MI - thromboembolism - breast cancer - dementia
Pt with cardiogenic shock
Amiodarone;
Development of AF. after ETOH - develop AF---sudden cardia arrest

34. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
2.5-3.5
Streptokinase

35. What is paroxysmal AF? How do you treat?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Within 24 hours
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
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 -

36. indication of radionuclide ventriculography
Monitor EF after cardiotoxic chemo - bypass surgery
Reduce hypertriglyceridemia; in liver
PPAR gamma receptor agonist pioglitazone.PPAR
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

37. common complications of ca antagonists?
Holocystolic murmur loudest at lower left sternal border
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
If there is evidence of heart failure
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

38. patient with secondary htn - What is next step
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Post wall MI - occlusion of right coronary artery. tx with atropine
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Unexplained synocope - dizziness - near syncope - recurrent palpitation

39. patient with new onset CHF - What is next best step?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Development of AF. after ETOH - develop AF---sudden cardia arrest
2.5-3.5
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

40. What is kussmaul sign
If patient is started on rifampin or phenobarbital; they increases its metabolism
VSD; can be asymptomatic to large with significant L to R shunt
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
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

41. Most important predictor for future cardiovascular events
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
PPAR gamma receptor agonist pioglitazone.PPAR
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. spontaneous papillary muscle rupture
Go for coronary angio. high likelyhood of severe coronary artery disease
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Elderly people with MI
Transvenous pacemaker

43. when should you stop aspirin before procedure that has bleeding risk?
Streptokinase
Transvenous pacemaker
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
When it is symptomatic. asso with dec cardiac output resulting hypotension

44. What is the most effective way to treat multivessel coronary artery blockade?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
CABG not angioplasty
Monitor EF after cardiotoxic chemo - bypass surgery
Flecainamide

45. When rhythm control strategy is suprior than rate control in the Tx of AF
Go for coronary angio. high likelyhood of severe coronary artery disease
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

46. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
No p wave - narrow qrs; first line of tx-adenosine
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
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

47. Difference between cardioversion and defibrillation
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
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
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

48. What is beck's triad?
No...except posterior or dorsal MI
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Persistent brady after MI which is refractory to atropine tx

49. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Monitor EF after cardiotoxic chemo - bypass surgery
Coronary angio - identify blockage and tx with stent/bypass

50. 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
Scoliosis and pes planus
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Post wall MI - occlusion of right coronary artery. tx with atropine