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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 is the most effective way to treat multivessel coronary artery blockade?
If there is evidence of heart failure
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
CABG not angioplasty
When it is symptomatic. asso with dec cardiac output resulting hypotension

2. indication of radionuclide ventriculography
2.5-3.5
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Monitor EF after cardiotoxic chemo - bypass surgery
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

3. s/s carotid dissection
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

4. EKG shows ST elevation and suggest occlusion of major coronary artery.
Flecainamide
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

5. When to replace aortic valve
No p wave - narrow qrs; first line of tx-adenosine
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Holocystolic murmur loudest at lower left sternal border

6. 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
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Holocystolic murmur loudest at lower left sternal border

7. What is PEA? How do you treat?
The dose should be adjusted such that TS H below 0.35
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Increases the risk of MI - thromboembolism - breast cancer - dementia
Reduce hypertriglyceridemia; in liver

8. What is poor R wave progression?
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.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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

9. paroxysmal AF without structural HD
Flecainamide
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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

10. drugs increases the effect of warfarin
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
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.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

11. when 24 hour holter monitoring and admission recommended?
Defibrillation
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Post wall MI - occlusion of right coronary artery. tx with atropine
Unexplained synocope - dizziness - near syncope - recurrent palpitation

12. wpw syndrome
Post wall MI - occlusion of right coronary artery. tx with atropine
The dose should be adjusted such that TS H below 0.35
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

13. patient with new onset CHF - What is next best step?
PPAR gamma receptor agonist pioglitazone.PPAR
Go for coronary angio. high likelyhood of severe coronary artery disease
Persistent brady after MI which is refractory to atropine tx
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

14. primordial prevention vs primary/secondary/tertiary prevention
Go for coronary angio. high likelyhood of severe coronary artery disease
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.
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

15. torsade and unresponsive
Defibrillation
Post wall MI - occlusion of right coronary artery. tx with atropine
Without AF; INR 2-3; with AF: 2.5-3.5
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

16. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Coronary angio - identify blockage and tx with stent/bypass
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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

17. baloon valvulotomy for AS
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
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Transvenous pacemaker
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

18. INR for mechanical prosthetic valve
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
2.5-3.5
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.
Within 24 hours

19. when NSTEMI without comorbidiites should get PCI?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Amiodarone;
Within 24 hours

20. what MI cause sinus brady?
Post wall MI - occlusion of right coronary artery. tx with atropine
If there is evidence of heart failure
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

21. bradycardia after MI with hypotension. what would you do?
Without AF; INR 2-3; with AF: 2.5-3.5
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

22. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

23. paroxysmal AF with structural HD
Amiodarone;
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
No...except posterior or dorsal 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.

24. When to use anticoag or aspiring in AF
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Post wall MI - occlusion of right coronary artery. tx with atropine
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

25. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
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.
Scoliosis and pes planus

26. sinus bradycardia after inf wall MI
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
If there is evidence of heart failure
No p wave - narrow qrs; first line of tx-adenosine
Weight loss

27. INR goal for bileaflet mechnial valve
Holocystolic murmur loudest at lower left sternal border
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Without AF; INR 2-3; with AF: 2.5-3.5

28. who should get coronary intervention after MI
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
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
VSD; can be asymptomatic to large with significant L to R shunt

29. How do you diagnose multifocal atrial tachy?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Transvenous pacemaker
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
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.

30. When to increase warfarin dose?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Lidcaine drip
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

31. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
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
Monitor EF after cardiotoxic chemo - bypass surgery

32. When to use dobutamine?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
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
Pt with cardiogenic shock

33. What is mech of TCA overdose
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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
Transvenous pacemaker

34. what medication cause pulmonary edema?
PPAR gamma receptor agonist pioglitazone.PPAR
Weight loss
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
The dose should be adjusted such that TS H below 0.35

35. spontaneous papillary muscle rupture
Elderly people with MI
Coronary angio - identify blockage and tx with stent/bypass
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
No p wave - narrow qrs; first line of tx-adenosine

36. when we say QT prolonged?
Persistent brady after MI which is refractory to atropine tx
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
2.5-3.5
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

37. Indication of gemfibrozil?
VSD; can be asymptomatic to large with significant L to R shunt
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
The dose should be adjusted such that TS H below 0.35
Reduce hypertriglyceridemia; in liver

38. What drugs precipitate digoxin toxicity?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

39. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
Post wall MI - occlusion of right coronary artery. tx with atropine
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 -
Unexplained synocope - dizziness - near syncope - recurrent palpitation

40. How to dx SVT? tx?
Coronary angio - identify blockage and tx with stent/bypass
No p wave - narrow qrs; first line of tx-adenosine
VSD; can be asymptomatic to large with significant L to R shunt
Scoliosis and pes planus

41. When rhythm control strategy is suprior than rate control in the Tx of AF
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Holocystolic murmur loudest at lower left sternal border
Reduce hypertriglyceridemia; in liver
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

42. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Reduce hypertriglyceridemia; in liver
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

43. How to treat a a patient with tCA overdose
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.
Lidcaine drip
Pt with cardiogenic shock

44. patient pw with new onset of heart failure and AF
No...except posterior or dorsal MI
2.5-3.5
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

45. Why nitroprusside cannot be used alone in aortic dissection
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%
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

46. most effective non pharmacologic measure to decease blood pressure?
VSD; can be asymptomatic to large with significant L to R shunt
The dose should be adjusted such that TS H below 0.35
Weight loss
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

47. When to use 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.
If patient is started on rifampin or phenobarbital; they increases its metabolism
The dose should be adjusted such that TS H below 0.35
Persistent brady after MI which is refractory to atropine tx

48. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
The dose should be adjusted such that TS H below 0.35
Within 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

49. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
Reduce hypertriglyceridemia; in liver
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Without AF; INR 2-3; with AF: 2.5-3.5

50. What is most congenital heart malformation?
VSD; can be asymptomatic to large with significant L to R shunt
Scoliosis and pes planus
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Holocystolic murmur loudest at lower left sternal border