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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. Why nitroprusside cannot be used alone in aortic dissection
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Flecainamide
If patient is started on rifampin or phenobarbital; they increases its metabolism
Scoliosis and pes planus

2. 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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Without AF; INR 2-3; with AF: 2.5-3.5
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

3. 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
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Elderly people with MI

4. what MI cause sinus brady?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Post wall MI - occlusion of right coronary artery. tx with atropine
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Coronary angio - identify blockage and tx with stent/bypass

5. What is poor R wave progression?
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;
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Monitor EF after cardiotoxic chemo - bypass surgery

6. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
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
Within 24 hours

7. How to treat a a patient with tCA overdose
Persistent brady after MI which is refractory to atropine tx
2.5-3.5
Lidcaine drip
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

8. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
No...except posterior or dorsal MI
If patient is started on rifampin or phenobarbital; they increases its metabolism
Flecainamide

9. drugs increases the effect of warfarin
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
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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

10. Most important predictor for future cardiovascular events
2.5-3.5
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Amiodarone;
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

11. When to use digoxin in AF
If there is evidence of heart failure
2.5-3.5
CABG not angioplasty
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

12. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If patient is started on rifampin or phenobarbital; they increases its metabolism
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 -

13. When to use dobutamine?
PPAR gamma receptor agonist pioglitazone.PPAR
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Pt with cardiogenic shock
Without AF; INR 2-3; with AF: 2.5-3.5

14. What is mech of TCA overdose
The dose should be adjusted such that TS H below 0.35
Without AF; INR 2-3; with AF: 2.5-3.5
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
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

15. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Coronary angio - identify blockage and tx with stent/bypass
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If there is evidence of heart failure

16. patient with new onset CHF - What is next best step?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Monitor EF after cardiotoxic chemo - bypass surgery
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

17. EKG shows ST elevation and suggest occlusion of major coronary artery.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
PPAR gamma receptor agonist pioglitazone.PPAR
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
When it is symptomatic. asso with dec cardiac output resulting hypotension

18. When to use anticoag or aspiring in AF
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
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

19. baloon valvulotomy for AS
Weight loss
2.5-3.5
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

20. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Streptokinase
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
No p wave - narrow qrs; first line of tx-adenosine

21. INR goal for bileaflet mechnial valve
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Without AF; INR 2-3; with AF: 2.5-3.5
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

22. most effective non pharmacologic measure to decease blood pressure?
Pt with cardiogenic shock
CABG not angioplasty
Weight loss
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

23. primordial prevention vs primary/secondary/tertiary prevention
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
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.
Holocystolic murmur loudest at lower left sternal border

24. INR for mechanical prosthetic valve
CABG not angioplasty
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
The dose should be adjusted such that TS H below 0.35
2.5-3.5

25. s/s carotid dissection
Reduce hypertriglyceridemia; in liver
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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

26. location of VSD/MR mumur
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Holocystolic murmur loudest at lower left sternal border
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

27. common complications of ca antagonists?
Pt with cardiogenic shock
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Weight loss
Lidcaine drip

28. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
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.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

29. paroxysmal AF with structural HD
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Amiodarone;
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

30. indication of radionuclide ventriculography
If patient is started on rifampin or phenobarbital; they increases its metabolism
Monitor EF after cardiotoxic chemo - bypass surgery
PPAR gamma receptor agonist pioglitazone.PPAR
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

31. What is PEA? How do you treat?
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
PPAR gamma receptor agonist pioglitazone.PPAR
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
VSD; can be asymptomatic to large with significant L to R shunt

32. When rhythm control strategy is suprior than rate control in the Tx of AF
Defibrillation
Reduce hypertriglyceridemia; in liver
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

33. Difference between cardioversion and defibrillation
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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
CABG not angioplasty
Amiodarone;

34. should we give thrombolytic in ST depression?
Lidcaine drip
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Defibrillation
No...except posterior or dorsal MI

35. ehlers danlos
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Scoliosis and pes planus
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

36. bradycardia after MI with hypotension. what would you do?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
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
Persistent brady after MI which is refractory to atropine tx

37. What is most congenital heart malformation?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
VSD; can be asymptomatic to large with significant L to R shunt
Holocystolic murmur loudest at lower left sternal border
Pt with cardiogenic shock

38. paroxysmal AF without structural HD
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Elderly people with MI
Flecainamide
No p wave - narrow qrs; first line of tx-adenosine

39. What is beck's triad?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

40. When to start thrombolytic therapry in MI
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
2.5-3.5
Lidcaine drip
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

41. new onset LBBB - What is the next step
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Pt with cardiogenic shock
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Elderly people with MI

42. What is the most effective way to treat multivessel coronary artery blockade?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
CABG not angioplasty
Amiodarone;
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

43. what medication cause pulmonary edema?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
PPAR gamma receptor agonist pioglitazone.PPAR
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

44. When to treat sinus brady after acute MI
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Coronary angio - identify blockage and tx with stent/bypass
When it is symptomatic. asso with dec cardiac output resulting hypotension
If there is evidence of heart failure

45. when NSTEMI without comorbidiites should get PCI?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Within 24 hours

46. When to replace aortic valve
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
2.5-3.5
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

47. 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 symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Defibrillation
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

48. when should you stop aspirin before procedure that has bleeding risk?
Pt with cardiogenic shock
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
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.
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

49. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
Holocystolic murmur loudest at lower left sternal border
Pt with cardiogenic shock
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

50. how amiodarone affects on warfarin
When it is symptomatic. asso with dec cardiac output resulting hypotension
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Increases the risk of MI - thromboembolism - breast cancer - dementia