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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. what medication cause pulmonary edema?
PPAR gamma receptor agonist pioglitazone.PPAR
Weight loss
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Without AF; INR 2-3; with AF: 2.5-3.5

2. bradycardia after MI with hypotension. what would you do?
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

3. Why nitroprusside cannot be used alone in aortic dissection
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Flecainamide
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

4. the dose levothyroxine in thyroid cancer remission
Within 24 hours
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
The dose should be adjusted such that TS H below 0.35
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

5. What is mech of TCA overdose
No...except posterior or dorsal MI
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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

6. How to treat a a patient with tCA overdose
VSD; can be asymptomatic to large with significant L to R shunt
Coronary angio - identify blockage and tx with stent/bypass
Amiodarone;
Lidcaine drip

7. What is beck's triad?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

8. When to use digoxin in AF
If patient is started on rifampin or phenobarbital; they increases its metabolism
CABG not angioplasty
Increases the risk of MI - thromboembolism - breast cancer - dementia
If there is evidence of heart failure

9. INR for mechanical prosthetic valve
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
2.5-3.5

10. When to increase warfarin dose?
Pt with cardiogenic shock
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
If patient is started on rifampin or phenobarbital; they increases its metabolism
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.

11. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

12. sinus bradycardia after inf wall MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

13. When to replace aortic valve
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
If there is evidence of heart failure
Post wall MI - occlusion of right coronary artery. tx with atropine
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

14. paroxysmal AF without structural HD
No p wave - narrow qrs; first line of tx-adenosine
If there is evidence of heart failure
When it is symptomatic. asso with dec cardiac output resulting hypotension
Flecainamide

15. 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.
Reduce hypertriglyceridemia; in liver
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with 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

16. When rhythm control strategy is suprior than rate control in the Tx of AF
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

17. wpw syndrome
Coronary angio - identify blockage and tx with stent/bypass
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Without AF; INR 2-3; with AF: 2.5-3.5

18. When to start thrombolytic therapry in MI
CABG not angioplasty
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
No p wave - narrow qrs; first line of tx-adenosine
Transvenous pacemaker

19. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Without AF; INR 2-3; with AF: 2.5-3.5
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

20. most effective non pharmacologic measure to decease blood pressure?
Holocystolic murmur loudest at lower left sternal border
Weight loss
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

21. should we give thrombolytic in ST depression?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
No...except posterior or dorsal MI
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Development of AF. after ETOH - develop AF---sudden cardia arrest

22. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
The dose should be adjusted such that TS H below 0.35
Unexplained synocope - dizziness - near syncope - recurrent palpitation

23. patient with new onset CHF - What is next best step?
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.
Elderly people with MI
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

24. 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.
The dose should be adjusted such that TS H below 0.35
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Flecainamide

25. When to use transvenous pacing?
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
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
If patient is started on rifampin or phenobarbital; they increases its metabolism
Persistent brady after MI which is refractory to atropine tx

26. when NSTEMI without comorbidiites should get PCI?
Holocystolic murmur loudest at lower left sternal border
Within 24 hours
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Transvenous pacemaker

27. what MI cause sinus brady?
Weight loss
Development of AF. after ETOH - develop AF---sudden cardia arrest
Post wall MI - occlusion of right coronary artery. tx with atropine
Within 24 hours

28. common complications of ca antagonists?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

29. Indication of gemfibrozil?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Lidcaine drip
If patient is started on rifampin or phenobarbital; they increases its metabolism
Reduce hypertriglyceridemia; in liver

30. Difference between cardioversion and defibrillation
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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

31. how amiodarone affects on warfarin
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
CABG not angioplasty
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

32. torsade and unresponsive
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.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Pt with cardiogenic shock
Defibrillation

33. 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
Amiodarone;
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

34. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

35. bradycardia with type 2 heart block
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
2.5-3.5
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Transvenous pacemaker

36. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Scoliosis and pes planus
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

37. patient pw with new onset of heart failure and AF
No p wave - narrow qrs; first line of tx-adenosine
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

38. primordial prevention vs primary/secondary/tertiary prevention
Unexplained synocope - dizziness - near syncope - recurrent palpitation
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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.
Transvenous pacemaker

39. How to dx SVT? tx?
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
No p wave - narrow qrs; first line of tx-adenosine
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

40. baloon valvulotomy for AS
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 -
If there is evidence of heart failure
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

41. INR goal for bileaflet mechnial valve
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Without AF; INR 2-3; with AF: 2.5-3.5
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
No p wave - narrow qrs; first line of tx-adenosine

42. What is most congenital heart malformation?
VSD; can be asymptomatic to large with significant L to R shunt
Pt with cardiogenic shock
When it is symptomatic. asso with dec cardiac output resulting hypotension
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

43. ehlers danlos
Scoliosis and pes planus
VSD; can be asymptomatic to large with significant L to R shunt
Without AF; INR 2-3; with AF: 2.5-3.5
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

44. location of VSD/MR mumur
Without AF; INR 2-3; with AF: 2.5-3.5
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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

45. What is paroxysmal AF? How do you treat?
Pt with cardiogenic shock
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 -
VSD; can be asymptomatic to large with significant L to R shunt
The dose should be adjusted such that TS H below 0.35

46. paroxysmal AF with structural HD
CABG not angioplasty
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Amiodarone;
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

47. complication of HRT
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
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

48. 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.
Pt with cardiogenic shock
Amiodarone;
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

49. drugs increases the effect of warfarin
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
Development of AF. after ETOH - develop AF---sudden cardia arrest
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

50. when 24 hour holter monitoring and admission recommended?
CABG not angioplasty
If there is evidence of heart failure
If patient is started on rifampin or phenobarbital; they increases its metabolism
Unexplained synocope - dizziness - near syncope - recurrent palpitation