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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?
CABG not angioplasty
Pt with cardiogenic shock
Elderly people with MI
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

2. paroxysmal AF without structural HD
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
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
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Flecainamide

3. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
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
Defibrillation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

4. what MI cause sinus brady?
CABG not angioplasty
Post wall MI - occlusion of right coronary artery. tx with atropine
Streptokinase
Weight loss

5. bradycardia after MI with hypotension. what would you do?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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
Reduce hypertriglyceridemia; in liver
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

6. primordial prevention vs primary/secondary/tertiary prevention
CABG not angioplasty
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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.
VSD; can be asymptomatic to large with significant L to R shunt

7. bradycardia with type 2 heart block
Transvenous pacemaker
Scoliosis and pes planus
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

8. torsade and unresponsive
Holocystolic murmur loudest at lower left sternal border
Defibrillation
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
If patient is started on rifampin or phenobarbital; they increases its metabolism

9. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Development of AF. after ETOH - develop AF---sudden cardia arrest
2.5-3.5

10. What is most congenital heart malformation?
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
VSD; can be asymptomatic to large with significant L to R shunt
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
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

11. who should get coronary intervention after MI
PPAR gamma receptor agonist pioglitazone.PPAR
Transvenous pacemaker
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

12. How do you diagnose multifocal atrial tachy?
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 -
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.
The dose should be adjusted such that TS H below 0.35
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

13. 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
Holocystolic murmur loudest at lower left sternal border
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

14. how amiodarone affects on warfarin
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

15. patient pw with new onset of heart failure and AF
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Monitor EF after cardiotoxic chemo - bypass surgery
Defibrillation
Reduce hypertriglyceridemia; in liver

16. should we give thrombolytic in ST depression?
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.
No...except posterior or dorsal MI
Streptokinase
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

17. new onset LBBB - What is the next step
2.5-3.5
If patient is started on rifampin or phenobarbital; they increases its metabolism
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Amiodarone;

18. sudden onset of HTN. How do you manage
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Lidcaine drip
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

19. When to use anticoag or aspiring in AF
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
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
Reduce hypertriglyceridemia; in liver
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

20. When rhythm control strategy is suprior than rate control in the Tx of AF
Flecainamide
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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.
Go for coronary angio. high likelyhood of severe coronary artery disease

21. s/s carotid dissection
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Pt with cardiogenic shock

22. when should you stop aspirin before procedure that has bleeding risk?
Lidcaine drip
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If patient is started on rifampin or phenobarbital; they increases its metabolism
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

23. What is kussmaul sign
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
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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
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 -

24. Indication of gemfibrozil?
Reduce hypertriglyceridemia; in liver
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
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.

25. How to treat a a patient with tCA overdose
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Transvenous pacemaker
Lidcaine drip
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

26. When to use dobutamine?
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Pt with cardiogenic shock
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

27. common complications of ca antagonists?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Development of AF. after ETOH - develop AF---sudden cardia arrest
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Pt with cardiogenic shock

28. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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
Reduce hypertriglyceridemia; in liver

29. Difference between cardioversion and defibrillation
2.5-3.5
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
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Increases the risk of MI - thromboembolism - breast cancer - dementia

30. Most important predictor for future cardiovascular events
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Flecainamide
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

31. What is poor R wave progression?
Pt with cardiogenic shock
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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 R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

32. most effective non pharmacologic measure to decease blood pressure?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Weight loss
Pt with cardiogenic shock
Transvenous pacemaker

33. INR for mechanical prosthetic valve
2.5-3.5
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Monitor EF after cardiotoxic chemo - bypass surgery

34. When to use digoxin in AF
If there is evidence of heart failure
Pt with cardiogenic shock
Defibrillation
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

35. What is beck's triad?
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Coronary angio - identify blockage and tx with stent/bypass
Flecainamide
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

36. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
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
2.5-3.5
PPAR gamma receptor agonist pioglitazone.PPAR

37. INR goal for bileaflet mechnial valve
VSD; can be asymptomatic to large with significant L to R shunt
Without AF; INR 2-3; with AF: 2.5-3.5
Pt with cardiogenic shock
CABG not angioplasty

38. stable angina with heart failure
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Persistent brady after MI which is refractory to atropine tx
Go for coronary angio. high likelyhood of severe coronary artery disease
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

39. patient with secondary htn - What is next step
When it is symptomatic. asso with dec cardiac output resulting hypotension
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Scoliosis and pes planus

40. ehlers danlos
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Scoliosis and pes planus
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

41. paroxysmal AF with structural HD
Pt with cardiogenic shock
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
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
Amiodarone;

42. When to start thrombolytic therapry in MI
No p wave - narrow qrs; first line of tx-adenosine
Elderly people with MI
Weight loss
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

43. When to replace aortic valve
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Scoliosis and pes planus
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

44. What is mech of TCA overdose
VSD; can be asymptomatic to large with significant L to R shunt
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
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

45. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
2.5-3.5
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

46. sinus bradycardia after inf wall MI
Lidcaine drip
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

47. drugs increases the effect of warfarin
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

48. What is paroxysmal AF? How do you treat?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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 -

49. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

50. When to treat sinus brady after acute MI
2.5-3.5
When it is symptomatic. asso with dec cardiac output resulting hypotension
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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin