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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. Difference between cardioversion and defibrillation
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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
Go for coronary angio. high likelyhood of severe coronary artery disease

2. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement 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
Weight loss
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

3. How do you diagnose multifocal atrial tachy?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Holocystolic murmur loudest at lower left sternal border
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.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

4. spontaneous papillary muscle rupture
Elderly people with MI
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.
2.5-3.5
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

5. Why nitroprusside cannot be used alone in aortic dissection
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
When it is symptomatic. asso with dec cardiac output resulting hypotension
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

6. patient pw with new onset of heart failure and AF
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Transvenous pacemaker
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Scoliosis and pes planus

7. how amiodarone affects on warfarin
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
VSD; can be asymptomatic to large with significant L to R shunt
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

8. When to replace aortic valve
Within 24 hours
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
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

9. sinus bradycardia after inf wall MI
Development of AF. after ETOH - develop AF---sudden cardia arrest
Go for coronary angio. high likelyhood of severe coronary artery disease
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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.

10. should we give thrombolytic in ST depression?
Elderly people with MI
No...except posterior or dorsal MI
Increases the risk of MI - thromboembolism - breast cancer - dementia
Streptokinase

11. What is PEA? How do you treat?
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
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

12. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

13. When to treat sinus brady after acute 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
When it is symptomatic. asso with dec cardiac output resulting hypotension
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If patient is started on rifampin or phenobarbital; they increases its metabolism

14. What drugs precipitate digoxin toxicity?
Reduce hypertriglyceridemia; in liver
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Development of AF. after ETOH - develop AF---sudden cardia arrest

15. patient with secondary htn - What is next step
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
When it is symptomatic. asso with dec cardiac output resulting hypotension
Monitor EF after cardiotoxic chemo - bypass surgery
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

16. When to use anticoag or aspiring in AF
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
Weight loss
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

17. wpw syndrome
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Without AF; INR 2-3; with AF: 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
Defibrillation

18. s/s carotid dissection
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

19. paroxysmal AF without structural HD
No...except posterior or dorsal MI
Flecainamide
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Transvenous pacemaker

20. drugs increases the effect of warfarin
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Lidcaine drip
When it is symptomatic. asso with dec cardiac output resulting hypotension

21. who should get coronary intervention after MI
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.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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

22. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Defibrillation
If patient is started on rifampin or phenobarbital; they increases its metabolism

23. complication of HRT
Development of AF. after ETOH - develop AF---sudden cardia arrest
Pt with cardiogenic shock
Increases the risk of MI - thromboembolism - breast cancer - dementia
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

24. bradycardia with type 2 heart block
No p wave - narrow qrs; first line of tx-adenosine
Increases the risk of MI - thromboembolism - breast cancer - dementia
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Transvenous pacemaker

25. 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 -
Without AF; INR 2-3; with AF: 2.5-3.5
Reduce hypertriglyceridemia; in liver
Development of AF. after ETOH - develop AF---sudden cardia arrest

26. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 2.5-3.5
Lidcaine drip
VSD; can be asymptomatic to large with significant L to R shunt
Development of AF. after ETOH - develop AF---sudden cardia arrest

27. How to treat a a patient with tCA overdose
If patient is started on rifampin or phenobarbital; they increases its metabolism
Lidcaine 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
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.

28. What is the most effective way to treat multivessel coronary artery blockade?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
CABG not angioplasty
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Post wall MI - occlusion of right coronary artery. tx with atropine

29. ehlers danlos
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
CABG not angioplasty
If there is evidence of heart failure
Scoliosis and pes planus

30. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Flecainamide
Reduce hypertriglyceridemia; in liver
Coronary angio - identify blockage and tx with stent/bypass
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

31. indication of radionuclide ventriculography
The dose should be adjusted such that TS H below 0.35
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Monitor EF after cardiotoxic chemo - bypass surgery
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

32. baloon valvulotomy for AS
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Pt with cardiogenic shock
Transvenous pacemaker
If there is evidence of heart failure

33. When to use digoxin in AF
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Coronary angio - identify blockage and tx with stent/bypass
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If there is evidence of heart failure

34. When rhythm control strategy is suprior than rate control in the Tx of AF
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Flecainamide
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

35. stable angina with heart failure
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Go for coronary angio. high likelyhood of severe coronary artery disease
PPAR gamma receptor agonist pioglitazone.PPAR
Coronary angio - identify blockage and tx with stent/bypass

36. How long it takes for digoxin to have significant effect on rate control
Without AF; INR 2-3; with AF: 2.5-3.5
CABG not angioplasty
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

37. common complications of ca antagonists?
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
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
The dose should be adjusted such that TS H below 0.35

38. what medication cause pulmonary edema?
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Holocystolic murmur loudest at lower left sternal border
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
PPAR gamma receptor agonist pioglitazone.PPAR

39. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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
The dose should be adjusted such that TS H below 0.35
Defibrillation

40. new onset LBBB - What is the next step
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
High suspicion of MI. LAD occlusion leading to LBBB - next step 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

41. What is beck's triad?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Coronary angio - identify blockage and tx with stent/bypass

42. 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)
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Within 24 hours
Amiodarone;

43. What is most congenital heart malformation?
VSD; can be asymptomatic to large with significant L to R shunt
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Coronary angio - identify blockage and tx with stent/bypass
Unexplained synocope - dizziness - near syncope - recurrent palpitation

44. patient with new onset CHF - What is next best step?
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Increases the risk of MI - thromboembolism - breast cancer - dementia
No p wave - narrow qrs; first line of tx-adenosine
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

45. What is paroxysmal AF? How do you treat?
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
If there is evidence of heart failure
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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 -

46. Indication of gemfibrozil?
No p wave - narrow qrs; first line of tx-adenosine
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
Reduce hypertriglyceridemia; in liver

47. bradycardia after MI with hypotension. what would you do?
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
When it is symptomatic. asso with dec cardiac output resulting hypotension
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Holocystolic murmur loudest at lower left sternal border

48. what MI cause sinus brady?
No...except posterior or dorsal MI
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Post wall MI - occlusion of right coronary artery. tx with atropine
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

49. primordial prevention vs primary/secondary/tertiary prevention
If patient is started on rifampin or phenobarbital; they increases its metabolism
Without AF; INR 2-3; with AF: 2.5-3.5
VSD; can be asymptomatic to large with significant L to R shunt
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.

50. 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
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.
Persistent brady after MI which is refractory to atropine tx
Coronary angio - identify blockage and tx with stent/bypass