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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. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
2.5-3.5
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Scoliosis and pes planus

2. Indication of gemfibrozil?
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Reduce hypertriglyceridemia; in liver
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Go for coronary angio. high likelyhood of severe coronary artery disease

3. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Amiodarone;
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

4. indication of radionuclide ventriculography
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Monitor EF after cardiotoxic chemo - bypass surgery
Within 24 hours
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 -

5. When to use digoxin in AF
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.
Pt with cardiogenic shock
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
If there is evidence of heart failure

6. who should get coronary intervention after MI
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.
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Transvenous pacemaker

7. INR goal for bileaflet mechnial valve
Go for coronary angio. high likelyhood of severe coronary artery disease
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Without AF; INR 2-3; with AF: 2.5-3.5
Streptokinase

8. Most important predictor for future cardiovascular events
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
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 p wave - narrow qrs; first line of tx-adenosine

9. when should you stop aspirin before procedure that has bleeding risk?
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.
CABG not angioplasty
Streptokinase

10. sudden onset of HTN. How do you manage
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
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

11. when 24 hour holter monitoring and admission recommended?
Holocystolic murmur loudest at lower left sternal border
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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

12. When to start thrombolytic therapry in MI
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Without AF; INR 2-3; with AF: 2.5-3.5
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

13. patient with new onset CHF - What is next best step?
Scoliosis and pes planus
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
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

14. the dose levothyroxine in thyroid cancer remission
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Transvenous pacemaker
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
The dose should be adjusted such that TS H below 0.35

15. 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
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Holocystolic murmur loudest at lower left sternal border
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

16. problem of WPW?
Weight loss
Scoliosis and pes planus
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Development of AF. after ETOH - develop AF---sudden cardia arrest

17. what medication cause pulmonary edema?
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.
PPAR gamma receptor agonist pioglitazone.PPAR
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
When it is symptomatic. asso with dec cardiac output resulting hypotension

18. When to treat sinus brady after acute MI
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
When it is symptomatic. asso with dec cardiac output resulting hypotension
Coronary angio - identify blockage and tx with stent/bypass

19. 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)
Weight loss
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.
Flecainamide

20. complication of HRT
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Development of AF. after ETOH - develop AF---sudden cardia arrest
Increases the risk of MI - thromboembolism - breast cancer - dementia
No p wave - narrow qrs; first line of tx-adenosine

21. paroxysmal AF with structural HD
Amiodarone;
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Persistent brady after MI which is refractory to atropine tx
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

22. What drugs precipitate digoxin toxicity?
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
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

23. How do you diagnose multifocal atrial tachy?
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.
Amiodarone;
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

24. When to increase warfarin dose?
When it is symptomatic. asso with dec cardiac output resulting hypotension
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.
If patient is started on rifampin or phenobarbital; they increases its metabolism

25. most effective non pharmacologic measure to decease blood pressure?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Weight loss
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Pt with cardiogenic shock

26. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Flecainamide
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

27. 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
VSD; can be asymptomatic to large with significant L to R shunt
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

28. drugs increases the effect of warfarin
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Transvenous pacemaker
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

29. bradycardia after MI with hypotension. what would you do?
Within 24 hours
Monitor EF after cardiotoxic chemo - bypass surgery
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

30. When rhythm control strategy is suprior than rate control in the Tx of AF
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.
CABG not angioplasty
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

31. What is mech of TCA overdose
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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 patient is started on rifampin or phenobarbital; they increases its metabolism

32. bradycardia with type 2 heart block
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Flecainamide
Transvenous pacemaker
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

33. What is paroxysmal AF? How do you treat?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
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 -
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

34. When to use transvenous pacing?
Amiodarone;
Persistent brady after MI which is refractory to atropine 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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

35. When to use dobutamine?
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Pt with cardiogenic shock
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

36. sinus bradycardia after inf wall MI
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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

37. When to use anticoag or aspiring in AF
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Within 24 hours
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
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

38. How long it takes for digoxin to have significant effect on rate control
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Defibrillation
Streptokinase
VSD; can be asymptomatic to large with significant L to R shunt

39. stable angina with heart failure
Post wall MI - occlusion of right coronary artery. tx with atropine
Go for coronary angio. high likelyhood of severe coronary artery disease
Elderly people with MI
The dose should be adjusted such that TS H below 0.35

40. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Within 24 hours
If patient is started on rifampin or phenobarbital; they increases its metabolism
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

41. What is most congenital heart malformation?
Holocystolic murmur loudest at lower left sternal border
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
VSD; can be asymptomatic to large with significant L to R shunt

42. location of VSD/MR mumur
Persistent brady after MI which is refractory to atropine tx
Holocystolic murmur loudest at lower left sternal border
Scoliosis and pes planus
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

43. s/s carotid dissection
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Transvenous pacemaker
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Development of AF. after ETOH - develop AF---sudden cardia arrest

44. baloon valvulotomy for AS
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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
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. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Within 24 hours
If patient is started on rifampin or phenobarbital; they increases its metabolism
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Coronary angio - identify blockage and tx with stent/bypass

46. How to dx SVT? tx?
Streptokinase
When it is symptomatic. asso with dec cardiac output resulting hypotension
No p wave - narrow qrs; first line of tx-adenosine
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

47. when NSTEMI without comorbidiites should get PCI?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Within 24 hours
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

48. what MI cause sinus brady?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Within 24 hours
Post wall MI - occlusion of right coronary artery. tx with atropine
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.

49. wpw syndrome
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
VSD; can be asymptomatic to large with significant L to R shunt
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

50. spontaneous papillary muscle rupture
Elderly people with MI
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
2.5-3.5