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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. indication of radionuclide ventriculography
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Monitor EF after cardiotoxic chemo - bypass surgery
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
No p wave - narrow qrs; first line of tx-adenosine

2. ehlers danlos
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Scoliosis and pes planus
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

3. when 24 hour holter monitoring and admission recommended?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Elderly people with MI

4. when should you stop aspirin before procedure that has bleeding risk?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Streptokinase
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

5. 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 -
Without AF; INR 2-3; with AF: 2.5-3.5
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

6. bradycardia with type 2 heart block
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Transvenous pacemaker
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Without AF; INR 2-3; with AF: 2.5-3.5

7. When to replace aortic valve
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

8. when we say QT prolonged?
Go for coronary angio. high likelyhood of severe coronary artery disease
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Pt with cardiogenic shock
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

9. 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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Elderly people with MI

10. 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.
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
2.5-3.5
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

11. INR for mechanical prosthetic valve
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
2.5-3.5
Go for coronary angio. high likelyhood of severe coronary artery disease
Elderly people with MI

12. most effective non pharmacologic measure to decease blood pressure?
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Weight loss
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

13. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Post wall MI - occlusion of right coronary artery. tx with atropine
Reduce hypertriglyceridemia; in liver
If patient is started on rifampin or phenobarbital; they increases its metabolism

14. baloon valvulotomy for AS
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If there is evidence of heart failure
Holocystolic murmur loudest at lower left sternal border

15. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

16. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Scoliosis and pes planus
Development of AF. after ETOH - develop AF---sudden cardia arrest
Streptokinase
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

17. spontaneous papillary muscle rupture
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Elderly people with MI
Without AF; INR 2-3; with AF: 2.5-3.5
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

18. Most important predictor for future cardiovascular events
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

19. 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
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Streptokinase
Holocystolic murmur loudest at lower left sternal border

20. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
CABG not angioplasty
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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

21. How long it takes for digoxin to have significant effect on rate control
Defibrillation
If patient is started on rifampin or phenobarbital; they increases its metabolism
2.5-3.5
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

22. stable angina with heart failure
PPAR gamma receptor agonist pioglitazone.PPAR
Go for coronary angio. high likelyhood of severe coronary artery disease
Defibrillation
The dose should be adjusted such that TS H below 0.35

23. How to treat a a patient with tCA overdose
Defibrillation
Go for coronary angio. high likelyhood of severe coronary artery disease
Lidcaine drip
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

24. When to use anticoag or aspiring in AF
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

25. how amiodarone affects on warfarin
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
CABG not angioplasty
Increases the risk of MI - thromboembolism - breast cancer - dementia

26. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
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
PPAR gamma receptor agonist pioglitazone.PPAR
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

27. What is most congenital heart malformation?
Development of AF. after ETOH - develop AF---sudden cardia arrest
VSD; can be asymptomatic to large with significant L to R shunt
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Coronary angio - identify blockage and tx with stent/bypass

28. wpw syndrome
When it is symptomatic. asso with dec cardiac output resulting hypotension
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Development of AF. after ETOH - develop AF---sudden cardia arrest

29. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
CABG not angioplasty
Persistent brady after MI which is refractory to atropine tx

30. s/s carotid dissection
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

31. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
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
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.

32. primordial prevention vs primary/secondary/tertiary prevention
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
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.

33. paroxysmal AF with structural HD
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.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Amiodarone;
Monitor EF after cardiotoxic chemo - bypass surgery

34. problem of WPW?
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.
Development of AF. after ETOH - develop AF---sudden cardia arrest
Flecainamide
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

35. 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
Scoliosis and pes planus
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Post wall MI - occlusion of right coronary artery. tx with atropine

36. What is kussmaul sign
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
Go for coronary angio. high likelyhood of severe coronary artery disease
The dose should be adjusted such that TS H below 0.35

37. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 2.5-3.5
If patient is started on rifampin or phenobarbital; they increases its metabolism
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
No p wave - narrow qrs; first line of tx-adenosine

38. torsade and unresponsive
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Increases the risk of MI - thromboembolism - breast cancer - dementia
Defibrillation

39. When to start thrombolytic therapry in MI
VSD; can be asymptomatic to large with significant L to R shunt
Persistent brady after MI which is refractory to atropine tx
Streptokinase
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

40. When to increase warfarin dose?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If patient is started on rifampin or phenobarbital; they increases its metabolism
Flecainamide

41. What is beck's triad?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

42. drugs increases the effect of warfarin
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Flecainamide
Transvenous pacemaker

43. EKG shows ST elevation and suggest occlusion of major coronary artery.
Without AF; INR 2-3; with AF: 2.5-3.5
Monitor EF after cardiotoxic chemo - bypass surgery
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

44. When to treat sinus brady after acute MI
Coronary angio - identify blockage and tx with stent/bypass
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
When it is symptomatic. asso with dec cardiac output resulting hypotension
CABG not angioplasty

45. What drugs precipitate digoxin toxicity?
Lidcaine drip
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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.

46. paroxysmal AF without structural HD
Within 24 hours
Flecainamide
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

47. Indication of gemfibrozil?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
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.
Monitor EF after cardiotoxic chemo - bypass surgery
Reduce hypertriglyceridemia; in liver

48. When to use dobutamine?
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
When it is symptomatic. asso with dec cardiac output resulting hypotension
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Pt with cardiogenic shock

49. patient pw with new onset of heart failure and AF
PPAR gamma receptor agonist pioglitazone.PPAR
Pt with cardiogenic shock
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
CABG not angioplasty

50. bradycardia after MI with hypotension. what would you do?
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
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
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady