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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. When to replace aortic valve
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Defibrillation
CABG not angioplasty
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

2. Most important predictor for future cardiovascular events
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Development of AF. after ETOH - develop AF---sudden cardia arrest
Persistent brady after MI which is refractory to atropine tx
If patient is started on rifampin or phenobarbital; they increases its metabolism

3. sudden onset of HTN. How do you manage
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

4. When to treat sinus brady after acute MI
When it is symptomatic. asso with dec cardiac output resulting hypotension
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

5. what MI cause sinus brady?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
The dose should be adjusted such that TS H below 0.35
Post wall MI - occlusion of right coronary artery. tx with atropine
Persistent brady after MI which is refractory to atropine tx

6. Difference between cardioversion and defibrillation
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
Pt with cardiogenic shock
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Increases the risk of MI - thromboembolism - breast cancer - dementia

7. What is paroxysmal AF? How do you treat?
Go for coronary angio. high likelyhood of severe coronary artery disease
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
Transvenous pacemaker

8. indication of radionuclide ventriculography
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Without AF; INR 2-3; with AF: 2.5-3.5
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Monitor EF after cardiotoxic chemo - bypass surgery

9. patient with new onset CHF - What is next best step?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
If patient is started on rifampin or phenobarbital; they increases its metabolism
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

10. Why nitroprusside cannot be used alone in aortic dissection
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
No p wave - narrow qrs; first line of tx-adenosine
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

11. when should you stop aspirin before procedure that has bleeding risk?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Monitor EF after cardiotoxic chemo - bypass surgery
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

12. torsade and unresponsive
Defibrillation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
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

13. When to use dobutamine?
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.
When it is symptomatic. asso with dec cardiac output resulting hypotension
Within 24 hours
Pt with cardiogenic shock

14. 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)
Lidcaine drip
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

15. patient with secondary htn - What is next step
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

16. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Reduce hypertriglyceridemia; in liver
The dose should be adjusted such that TS H below 0.35
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

17. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Pt with cardiogenic shock
Elderly people with MI
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

18. ehlers danlos
Persistent brady after MI which is refractory to atropine tx
Go for coronary angio. high likelyhood of severe coronary artery disease
Scoliosis and pes planus
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

19. What is PEA? How do you treat?
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.
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
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

20. sinus bradycardia after inf wall MI
Transvenous pacemaker
2.5-3.5
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Within 24 hours

21. Indication of gemfibrozil?
Weight loss
Reduce hypertriglyceridemia; in liver
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

22. wpw syndrome
If patient is started on rifampin or phenobarbital; they increases its metabolism
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

23. when we say QT prolonged?
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 -
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 it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
The dose should be adjusted such that TS H below 0.35

24. bradycardia with type 2 heart block
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
Defibrillation
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

25. drugs increases the effect of warfarin
PPAR gamma receptor agonist pioglitazone.PPAR
Holocystolic murmur loudest at lower left sternal border
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

26. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
The dose should be adjusted such that TS H below 0.35

27. who should get coronary intervention after MI
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Unexplained synocope - dizziness - near syncope - recurrent palpitation
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

28. primordial prevention vs primary/secondary/tertiary prevention
Elderly people with 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.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Within 24 hours

29. What is poor R wave progression?
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

30. should we give thrombolytic in ST depression?
Holocystolic murmur loudest at lower left sternal border
No...except posterior or dorsal MI
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Coronary angio - identify blockage and tx with stent/bypass

31. What is the most effective way to treat multivessel coronary artery blockade?
Pt with cardiogenic shock
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
CABG not angioplasty
No...except posterior or dorsal MI

32. location of VSD/MR mumur
Streptokinase
Holocystolic murmur loudest at lower left sternal border
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Within 24 hours

33. How to dx SVT? tx?
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.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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

34. When to use digoxin in AF
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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
If there is evidence of heart failure

35. 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
Holocystolic murmur loudest at lower left sternal border
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

36. EKG shows ST elevation and suggest occlusion of major coronary artery.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Flecainamide
2.5-3.5
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

37. When to use transvenous pacing?
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Persistent brady after MI which is refractory to atropine tx
Lidcaine drip

38. When to use anticoag or aspiring in AF
Weight loss
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Flecainamide
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

39. INR goal for bileaflet mechnial valve
Holocystolic murmur loudest at lower left sternal border
Weight loss
Without AF; INR 2-3; with AF: 2.5-3.5
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

40. When to start thrombolytic therapry in MI
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Defibrillation
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
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

41. s/s carotid dissection
Defibrillation
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
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

42. how amiodarone affects on warfarin
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

43. How to treat a a patient with tCA overdose
Flecainamide
Scoliosis and pes planus
Lidcaine drip
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

44. most effective non pharmacologic measure to decease blood pressure?
Pt with cardiogenic shock
If patient is started on rifampin or phenobarbital; they increases its metabolism
Weight loss
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

45. stable angina with heart failure
Go for coronary angio. high likelyhood of severe coronary artery disease
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.
No...except posterior or dorsal MI
No p wave - narrow qrs; first line of tx-adenosine

46. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Scoliosis and pes planus
Amiodarone;
Lidcaine drip
Streptokinase

47. INR for mechanical prosthetic valve
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
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
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

48. spontaneous papillary muscle rupture
When it is symptomatic. asso with dec cardiac output resulting hypotension
Increases the risk of MI - thromboembolism - breast cancer - dementia
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Elderly people with MI

49. paroxysmal AF without structural HD
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Post wall MI - occlusion of right coronary artery. tx with atropine
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Flecainamide

50. the dose levothyroxine in thyroid cancer remission
Without AF; INR 2-3; with AF: 2.5-3.5
The dose should be adjusted such that TS H below 0.35
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Pt with cardiogenic shock