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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. What drugs precipitate digoxin toxicity?
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
When it is symptomatic. asso with dec cardiac output resulting hypotension
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

2. When to use anticoag or aspiring in AF
PPAR gamma receptor agonist pioglitazone.PPAR
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

3. When to use dobutamine?
Defibrillation
Increases the risk of MI - thromboembolism - breast cancer - dementia
Pt with cardiogenic shock
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.

4. patient with new onset CHF - What is next best step?
Weight loss
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Transvenous pacemaker
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

5. What is beck's triad?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

6. s/s carotid dissection
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
When it is symptomatic. asso with dec cardiac output resulting hypotension
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

7. when 24 hour holter monitoring and admission recommended?
Go for coronary angio. high likelyhood of severe coronary artery disease
Weight loss
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Unexplained synocope - dizziness - near syncope - recurrent palpitation

8. How long it takes for digoxin to have significant effect on rate control
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

9. when we say QT prolonged?
If there is evidence of heart failure
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Persistent brady after MI which is refractory to atropine tx

10. When to use digoxin in AF
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
If there is evidence of heart failure
If patient is started on rifampin or phenobarbital; they increases its metabolism

11. paroxysmal AF without structural HD
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
CABG not angioplasty
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Flecainamide

12. location of VSD/MR mumur
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Holocystolic murmur loudest at lower left sternal border
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

13. EKG shows ST elevation and suggest occlusion of major coronary artery.
Defibrillation
No p wave - narrow qrs; first line of tx-adenosine
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

14. Most important predictor for future cardiovascular events
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

15. When to increase warfarin dose?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
If patient is started on rifampin or phenobarbital; they increases its metabolism
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Streptokinase

16. how amiodarone affects on warfarin
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
CABG not angioplasty
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

17. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Transvenous pacemaker
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

18. When rhythm control strategy is suprior than rate control in the Tx of AF
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Pt with marked palpitaion - diszzines - dyspnoea - or 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
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

19. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
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
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

20. new onset LBBB - What is the next step
Without AF; INR 2-3; with AF: 2.5-3.5
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
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
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

21. What is poor R wave progression?
Reduce hypertriglyceridemia; in liver
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
No...except posterior or dorsal MI
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

22. When to start thrombolytic therapry in MI
PPAR gamma receptor agonist pioglitazone.PPAR
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Coronary angio - identify blockage and tx with stent/bypass
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

23. when should you stop aspirin before procedure that has bleeding risk?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
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.
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

24. When to replace aortic valve
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Within 24 hours
Monitor EF after cardiotoxic chemo - bypass surgery
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

25. Indication of gemfibrozil?
Reduce hypertriglyceridemia; in liver
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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

26. What is the most effective way to treat multivessel coronary artery blockade?
Flecainamide
CABG not angioplasty
Reduce hypertriglyceridemia; in liver
Lidcaine drip

27. torsade and unresponsive
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Defibrillation
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

28. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
No p wave - narrow qrs; first line of tx-adenosine
Within 24 hours

29. what medication cause pulmonary edema?
Elderly people with MI
Pt with cardiogenic shock
Unexplained synocope - dizziness - near syncope - recurrent palpitation
PPAR gamma receptor agonist pioglitazone.PPAR

30. How to dx SVT? tx?
No p wave - narrow qrs; first line of tx-adenosine
Flecainamide
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

31. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
PPAR gamma receptor agonist pioglitazone.PPAR

32. How to treat a a patient with tCA overdose
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Lidcaine drip
PPAR gamma receptor agonist pioglitazone.PPAR
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

33. paroxysmal AF with structural HD
Amiodarone;
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

34. complication of HRT
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Increases the risk of MI - thromboembolism - breast cancer - dementia
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 -
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

35. Why nitroprusside cannot be used alone in aortic dissection
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
The dose should be adjusted such that TS H below 0.35
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

36. problem of WPW?
Coronary angio - identify blockage and tx with stent/bypass
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.
Development of AF. after ETOH - develop AF---sudden cardia arrest

37. what MI cause sinus brady?
No p wave - narrow qrs; first line of tx-adenosine
Defibrillation
Post wall MI - occlusion of right coronary artery. tx with atropine
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

38. patient pw with new onset of heart failure and AF
If patient is started on rifampin or phenobarbital; they increases its metabolism
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Elderly people with MI
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

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

40. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

41. the dose levothyroxine in thyroid cancer remission
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
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
The dose should be adjusted such that TS H below 0.35

42. spontaneous papillary muscle rupture
Elderly people with MI
Monitor EF after cardiotoxic chemo - bypass surgery
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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 -

43. What is kussmaul sign
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
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. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Go for coronary angio. high likelyhood of severe coronary artery disease
Flecainamide
Coronary angio - identify blockage and tx with stent/bypass

45. ehlers danlos
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Scoliosis and pes planus
No p wave - narrow qrs; first line of tx-adenosine
Weight loss

46. patient with secondary htn - What is next step
Weight loss
Holocystolic murmur loudest at lower left sternal border
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

47. When to use transvenous pacing?
Persistent brady after MI which is refractory to atropine tx
Go for coronary angio. high likelyhood of severe coronary artery disease
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

48. indication of radionuclide ventriculography
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Monitor EF after cardiotoxic chemo - bypass surgery
No p wave - narrow qrs; first line of tx-adenosine
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

49. bradycardia with type 2 heart block
Post wall MI - occlusion of right coronary artery. tx with atropine
Without AF; INR 2-3; with AF: 2.5-3.5
Transvenous pacemaker
Go for coronary angio. high likelyhood of severe coronary artery disease

50. primordial prevention vs primary/secondary/tertiary prevention
Amiodarone;
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 -
No...except posterior or dorsal 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.