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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. most effective non pharmacologic measure to decease blood pressure?
Monitor EF after cardiotoxic chemo - bypass surgery
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 -
Weight loss
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

2. problem of WPW?
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Development of AF. after ETOH - develop AF---sudden cardia arrest
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

3. What drugs precipitate digoxin toxicity?
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Pt with cardiogenic shock
Go for coronary angio. high likelyhood of severe coronary artery disease

4. Most important predictor for future cardiovascular events
Within 24 hours
Without AF; INR 2-3; with AF: 2.5-3.5
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
If patient is started on rifampin or phenobarbital; they increases its metabolism

5. patient pw with new onset of heart failure and AF
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
2.5-3.5
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

6. bradycardia after MI with hypotension. what would you do?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Transvenous pacemaker
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

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

8. wpw syndrome
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Persistent brady after MI which is refractory to atropine tx
Go for coronary angio. high likelyhood of severe coronary artery disease

9. EKG shows ST elevation and suggest occlusion of major coronary artery.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Without AF; INR 2-3; with AF: 2.5-3.5
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

10. INR goal for bileaflet mechnial valve
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Without AF; INR 2-3; with AF: 2.5-3.5
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Amiodarone;

11. what MI cause sinus brady?
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Persistent brady after MI which is refractory to atropine tx
Post wall MI - occlusion of right coronary artery. tx with atropine

12. ehlers danlos
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
PPAR gamma receptor agonist pioglitazone.PPAR
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Scoliosis and pes planus

13. What is poor R wave progression?
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
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

14. common complications of ca antagonists?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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
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.

15. new onset LBBB - What is the next step
No p wave - narrow qrs; first line of tx-adenosine
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
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

16. paroxysmal AF with structural HD
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Go for coronary angio. high likelyhood of severe coronary artery disease
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Amiodarone;

17. 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.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Flecainamide
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

18. s/s carotid dissection
Persistent brady after MI which is refractory to atropine tx
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

19. How to treat a a patient with 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
Coronary angio - identify blockage and tx with stent/bypass
Within 24 hours
Lidcaine drip

20. What is kussmaul sign
Post wall MI - occlusion of right coronary artery. tx with atropine
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
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

21. when we say QT prolonged?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Elderly people with MI
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

22. When to use transvenous pacing?
Reduce hypertriglyceridemia; in liver
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Development of AF. after ETOH - develop AF---sudden cardia arrest
Persistent brady after MI which is refractory to atropine tx

23. What is beck's triad?
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
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

24. when NSTEMI without comorbidiites should get PCI?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Within 24 hours

25. torsade and unresponsive
Streptokinase
Defibrillation
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
No...except posterior or dorsal MI

26. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Coronary angio - identify blockage and tx with stent/bypass
Holocystolic murmur loudest at lower left sternal border
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

27. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Reduce hypertriglyceridemia; in liver

28. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Transvenous pacemaker
No...except posterior or dorsal MI
Increases the risk of MI - thromboembolism - breast cancer - dementia
Coronary angio - identify blockage and tx with stent/bypass

29. Indication of gemfibrozil?
Persistent brady after MI which is refractory to atropine tx
Reduce hypertriglyceridemia; in liver
No p wave - narrow qrs; first line of tx-adenosine
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

30. patient with secondary htn - What is next step
If there is evidence of heart failure
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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

31. What is paroxysmal AF? How do you treat?
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 -
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Go for coronary angio. high likelyhood of severe coronary artery disease
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

32. how amiodarone affects on warfarin
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
Holocystolic murmur loudest at lower left sternal border
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

33. What is mech of TCA overdose
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
Development of AF. after ETOH - develop AF---sudden cardia arrest
Persistent brady after MI which is refractory to atropine tx

34. indication of radionuclide ventriculography
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Monitor EF after cardiotoxic chemo - bypass surgery
2.5-3.5
Defibrillation

35. when should you stop aspirin before procedure that has bleeding risk?
2.5-3.5
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
The dose should be adjusted such that TS H below 0.35

36. Difference between cardioversion and defibrillation
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
CABG not angioplasty
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
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

37. When to use dobutamine?
Without AF; INR 2-3; with AF: 2.5-3.5
Streptokinase
Flecainamide
Pt with cardiogenic shock

38. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
No p wave - narrow qrs; first line of tx-adenosine
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
If patient is started on rifampin or phenobarbital; they increases its metabolism

39. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Scoliosis and pes planus
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
If patient is started on rifampin or phenobarbital; they increases its metabolism

40. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
Holocystolic murmur loudest at lower left sternal border
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

41. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

42. What is most congenital heart malformation?
VSD; can be asymptomatic to large with significant L to R shunt
Streptokinase
Increases the risk of MI - thromboembolism - breast cancer - dementia
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. bradycardia with type 2 heart block
Holocystolic murmur loudest at lower left sternal border
Transvenous pacemaker
PPAR gamma receptor agonist pioglitazone.PPAR
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

44. sinus bradycardia after inf wall MI
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Amiodarone;
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Post wall MI - occlusion of right coronary artery. tx with atropine

45. When to use anticoag or aspiring in AF
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
No...except posterior or dorsal MI
Amiodarone;

46. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Persistent brady after MI which is refractory to atropine tx
Without AF; INR 2-3; with AF: 2.5-3.5

47. When to use digoxin in AF
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.
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
If there is evidence of heart failure

48. When to treat sinus brady after acute MI
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
When it is symptomatic. asso with dec cardiac output resulting hypotension
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

49. paroxysmal AF without structural HD
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
No p wave - narrow qrs; first line of tx-adenosine
Weight loss
Flecainamide

50. When to replace aortic valve
Flecainamide
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Go for coronary angio. high likelyhood of severe coronary artery disease