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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. location of VSD/MR mumur
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
CABG not angioplasty
Holocystolic murmur loudest at lower left sternal border

2. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Persistent brady after MI which is refractory to atropine tx
No...except posterior or dorsal MI
Weight loss

3. How do you diagnose multifocal atrial tachy?
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
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.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

4. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

5. How to treat a a patient with tCA overdose
Defibrillation
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Lidcaine drip
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

6. 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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Persistent brady after MI which is refractory to atropine tx
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

7. s/s carotid dissection
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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.
Without AF; INR 2-3; with AF: 2.5-3.5

8. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 2.5-3.5
The dose should be adjusted such that TS H below 0.35
Defibrillation
Scoliosis and pes planus

9. indication of radionuclide ventriculography
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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
Scoliosis and pes planus

10. 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
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%
Go for coronary angio. high likelyhood of severe coronary artery disease

11. who should get coronary intervention after MI
Increases the risk of MI - thromboembolism - breast cancer - dementia
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

12. wpw syndrome
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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

13. Why nitroprusside cannot be used alone in aortic dissection
Streptokinase
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
If patient is started on rifampin or phenobarbital; they increases its metabolism
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

14. patient with secondary htn - What is next step
If there is evidence of heart failure
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

15. INR for mechanical prosthetic valve
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Transvenous pacemaker
2.5-3.5
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

16. paroxysmal AF without structural HD
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Flecainamide
No...except posterior or dorsal MI
CABG not angioplasty

17. 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.
Weight loss
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Pt with cardiogenic shock

18. when NSTEMI without comorbidiites should get PCI?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
CABG not angioplasty
Within 24 hours
Lidcaine drip

19. Difference between cardioversion and defibrillation
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
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

20. What is the most effective way to treat multivessel coronary artery blockade?
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
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
CABG not angioplasty

21. When to replace aortic valve
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Persistent brady after MI which is refractory to atropine tx
Development of AF. after ETOH - develop AF---sudden cardia arrest
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

22. Indication of gemfibrozil?
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
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.
Weight loss
Reduce hypertriglyceridemia; in liver

23. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
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
No...except posterior or dorsal MI

24. When to use transvenous pacing?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
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.
Persistent brady after MI which is refractory to atropine tx
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

25. In cocaine induced vasospasm - if angio shows any thrombus - next step?
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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Streptokinase

26. When to use anticoag or aspiring in AF
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Unexplained synocope - dizziness - near syncope - recurrent palpitation
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

27. What is mech of TCA overdose
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
Streptokinase
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

28. the dose levothyroxine in thyroid cancer remission
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
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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

29. What is most congenital heart malformation?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
If patient is started on rifampin or phenobarbital; they increases its metabolism
VSD; can be asymptomatic to large with significant L to R shunt
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

30. what medication cause pulmonary edema?
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
PPAR gamma receptor agonist pioglitazone.PPAR
If there is evidence of heart failure
If patient is started on rifampin or phenobarbital; they increases its metabolism

31. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
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
No p wave - narrow qrs; first line of tx-adenosine
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
VSD; can be asymptomatic to large with significant L to R shunt

32. When to use digoxin in AF
Lidcaine drip
If there is evidence of heart failure
Unexplained synocope - dizziness - near syncope - recurrent palpitation
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

33. torsade and unresponsive
Defibrillation
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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 -
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

34. When to use dobutamine?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Monitor EF after cardiotoxic chemo - bypass surgery
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Pt with cardiogenic shock

35. What is kussmaul sign
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
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
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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

36. 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
The dose should be adjusted such that TS H below 0.35
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.

37. spontaneous papillary muscle rupture
Amiodarone;
When it is symptomatic. asso with dec cardiac output resulting hypotension
Elderly people with MI
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

38. when 24 hour holter monitoring and admission recommended?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

39. bradycardia after MI with hypotension. what would you do?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
When it is symptomatic. asso with dec cardiac output resulting hypotension
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
PPAR gamma receptor agonist pioglitazone.PPAR

40. patient pw with new onset of heart failure and AF
Increases the risk of MI - thromboembolism - breast cancer - dementia
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
The dose should be adjusted such that TS H below 0.35
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

41. drugs increases the effect of warfarin
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

42. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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
Lidcaine drip

43. How long it takes for digoxin to have significant effect on rate control
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

44. ehlers danlos
Scoliosis and pes planus
Elderly people with MI
Increases the risk of MI - thromboembolism - breast cancer - dementia
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

45. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

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

47. 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 -
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Streptokinase

48. What is beck's triad?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
CABG not angioplasty
VSD; can be asymptomatic to large with significant L to R shunt

49. common complications of ca antagonists?
Within 24 hours
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Reduce hypertriglyceridemia; in liver
Increases the risk of MI - thromboembolism - breast cancer - dementia

50. Most important predictor for future cardiovascular events
The dose should be adjusted such that TS H below 0.35
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Streptokinase
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect