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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.
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. Indication of gemfibrozil?
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
Reduce hypertriglyceridemia; in liver
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

2. 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)
Transvenous pacemaker
Holocystolic murmur loudest at lower left sternal border
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.

3. INR for mechanical prosthetic valve
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.
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 -
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
2.5-3.5

4. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Coronary angio - identify blockage and tx with stent/bypass
Flecainamide
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

5. What is the most effective way to treat multivessel coronary artery blockade?
The dose should be adjusted such that TS H below 0.35
Elderly people with MI
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
CABG not angioplasty

6. how amiodarone affects on warfarin
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Monitor EF after cardiotoxic chemo - bypass surgery
VSD; can be asymptomatic to large with significant L to R shunt
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

7. sudden onset of HTN. How do you manage
Defibrillation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

8. drugs increases the effect of warfarin
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Development of AF. after ETOH - develop AF---sudden cardia arrest
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

9. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Transvenous pacemaker
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 -

10. when should you stop aspirin before procedure that has bleeding risk?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
If there is evidence of heart failure
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

11. spontaneous papillary muscle rupture
Within 24 hours
When it is symptomatic. asso with dec cardiac output resulting hypotension
Elderly people with MI
Weight loss

12. When to use transvenous pacing?
When it is symptomatic. asso with dec cardiac output resulting hypotension
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Persistent brady after MI which is refractory to atropine tx
Scoliosis and pes planus

13. who should get coronary intervention after MI
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Without AF; INR 2-3; with AF: 2.5-3.5
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 procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

14. new onset LBBB - What is the next step
Coronary angio - identify blockage and tx with stent/bypass
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
PPAR gamma receptor agonist pioglitazone.PPAR

15. common complications of ca antagonists?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Within 24 hours
Transvenous pacemaker

16. what medication cause pulmonary edema?
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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
PPAR gamma receptor agonist pioglitazone.PPAR

17. when 24 hour holter monitoring and admission recommended?
Flecainamide
Lidcaine drip
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Transvenous pacemaker

18. In cocaine induced vasospasm - if angio shows any thrombus - next step?
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
Reduce hypertriglyceridemia; in liver
Streptokinase
VSD; can be asymptomatic to large with significant L to R shunt

19. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

20. When to use dobutamine?
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Pt with cardiogenic shock

21. torsade and unresponsive
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Defibrillation
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 -
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

22. Why nitroprusside cannot be used alone in aortic dissection
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Persistent brady after MI which is refractory to atropine tx
Development of AF. after ETOH - develop AF---sudden cardia arrest
Elderly people with MI

23. bradycardia after MI with hypotension. what would you do?
2.5-3.5
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
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

24. when NSTEMI without comorbidiites should get PCI?
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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

25. When rhythm control strategy is suprior than rate control in the Tx of AF
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Development of AF. after ETOH - develop AF---sudden cardia arrest
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

26. ehlers danlos
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Scoliosis and pes planus
PPAR gamma receptor agonist pioglitazone.PPAR
VSD; can be asymptomatic to large with significant L to R shunt

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

28. baloon valvulotomy for AS
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

29. What is paroxysmal AF? How do you treat?
VSD; can be asymptomatic to large with significant L to R shunt
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Coronary angio - identify blockage and tx with stent/bypass
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 -

30. indication of radionuclide ventriculography
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Monitor EF after cardiotoxic chemo - bypass surgery
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.

31. What is most congenital heart malformation?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
VSD; can be asymptomatic to large with significant L to R shunt
2.5-3.5

32. What is PEA? How do you treat?
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
2.5-3.5

33. what MI cause sinus brady?
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
Lidcaine drip
Reduce hypertriglyceridemia; in liver

34. paroxysmal AF with structural HD
When it is symptomatic. asso with dec cardiac output resulting hypotension
Amiodarone;
No...except posterior or dorsal MI
Coronary angio - identify blockage and tx with stent/bypass

35. sinus bradycardia after inf wall MI
If patient is started on rifampin or phenobarbital; they increases its metabolism
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Transvenous pacemaker

36. When to start thrombolytic therapry in MI
Post wall MI - occlusion of right coronary artery. tx with atropine
Go for coronary angio. high likelyhood of severe coronary artery disease
Elderly people with MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

37. stable angina with heart failure
No p wave - narrow qrs; first line of tx-adenosine
Development of AF. after ETOH - develop AF---sudden cardia arrest
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Go for coronary angio. high likelyhood of severe coronary artery disease

38. How to dx SVT? tx?
No p wave - narrow qrs; first line of tx-adenosine
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
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

39. 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
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Elderly people with MI
Without AF; INR 2-3; with AF: 2.5-3.5

40. primordial prevention vs primary/secondary/tertiary prevention
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
High suspicion of MI. LAD occlusion leading to LBBB - next step 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.

41. What is poor R wave progression?
Reduce hypertriglyceridemia; in liver
Scoliosis and pes planus
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Unexplained synocope - dizziness - near syncope - recurrent palpitation

42. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Post wall MI - occlusion of right coronary artery. tx with atropine
Development of AF. after ETOH - develop AF---sudden cardia arrest

43. complication of HRT
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Increases the risk of MI - thromboembolism - breast cancer - dementia
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.

44. When to use digoxin in AF
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with 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
If there is evidence of heart failure
Coronary angio - identify blockage and tx with stent/bypass

45. When to treat sinus brady after acute MI
PPAR gamma receptor agonist pioglitazone.PPAR
Holocystolic murmur loudest at lower left sternal border
Scoliosis and pes planus
When it is symptomatic. asso with dec cardiac output resulting hypotension

46. should we give thrombolytic in ST depression?
Persistent brady after MI which is refractory to atropine tx
Reduce hypertriglyceridemia; in liver
Without AF; INR 2-3; with AF: 2.5-3.5
No...except posterior or dorsal MI

47. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

48. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Elderly people with 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
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 symptomatic (hypotension - hx of syncope) place transvenous pacemaker

49. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
If patient is started on rifampin or phenobarbital; they increases its metabolism
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

50. What is mech of TCA overdose
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
If patient is started on rifampin or phenobarbital; they increases its metabolism
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker