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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. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

2. torsade and unresponsive
Go for coronary angio. high likelyhood of severe coronary artery disease
Defibrillation
No...except posterior or dorsal MI
Amiodarone;

3. paroxysmal AF without structural HD
Flecainamide
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Persistent brady after MI which is refractory to atropine tx
Pt with cardiogenic shock

4. what MI cause sinus brady?
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
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
Post wall MI - occlusion of right coronary artery. tx with atropine

5. When to use digoxin in AF
If there is evidence of heart failure
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Elderly people with MI

6. When to treat sinus brady after acute MI
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Go for coronary angio. high likelyhood of severe coronary artery disease
When it is symptomatic. asso with dec cardiac output resulting hypotension

7. new onset LBBB - What is the next step
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Lidcaine drip

8. What is poor R wave progression?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Holocystolic murmur loudest at lower left sternal border
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

9. When to use dobutamine?
Without AF; INR 2-3; with AF: 2.5-3.5
Coronary angio - identify blockage and tx with stent/bypass
No p wave - narrow qrs; first line of tx-adenosine
Pt with cardiogenic shock

10. patient pw with new onset of heart failure and AF
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

11. When to replace aortic valve
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Without AF; INR 2-3; with AF: 2.5-3.5
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

12. spontaneous papillary muscle rupture
CABG not angioplasty
If patient is started on rifampin or phenobarbital; they increases its metabolism
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Elderly people with MI

13. What is most congenital heart malformation?
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Development of AF. after ETOH - develop AF---sudden cardia arrest
VSD; can be asymptomatic to large with significant L to R shunt
Persistent brady after MI which is refractory to atropine tx

14. Most important predictor for future cardiovascular events
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
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

15. 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
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
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

16. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Weight loss
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

17. Why nitroprusside cannot be used alone in aortic dissection
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Amiodarone;
When it is symptomatic. asso with dec cardiac output resulting hypotension
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 -

18. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
Monitor EF after cardiotoxic chemo - bypass surgery
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

19. common complications of ca antagonists?
Increases the risk of MI - thromboembolism - breast cancer - dementia
If patient is started on rifampin or phenobarbital; they increases its metabolism
Persistent brady after MI which is refractory to atropine tx
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

20. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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 -
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Increases the risk of MI - thromboembolism - breast cancer - dementia

21. What is PEA? How do you treat?
If there is evidence of heart failure
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
2.5-3.5

22. paroxysmal AF with structural HD
Amiodarone;
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Flecainamide
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

23. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
VSD; can be asymptomatic to large with significant L to R shunt
Unexplained synocope - dizziness - near syncope - recurrent palpitation
PPAR gamma receptor agonist pioglitazone.PPAR

24. stable angina with heart failure
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Go for coronary angio. high likelyhood of severe coronary artery disease
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

25. When to use anticoag or aspiring in AF
Go for coronary angio. high likelyhood of severe coronary artery disease
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

26. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
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.
Defibrillation

27. should we give thrombolytic in ST depression?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
No...except posterior or dorsal MI
Reduce hypertriglyceridemia; in liver

28. How to treat a a patient with tCA overdose
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Lidcaine drip
Defibrillation
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

29. When to use transvenous pacing?
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Persistent brady after MI which is refractory to atropine tx
If there is evidence of heart failure

30. complication of HRT
Without AF; INR 2-3; with AF: 2.5-3.5
VSD; can be asymptomatic to large with significant L to R shunt
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Increases the risk of MI - thromboembolism - breast cancer - dementia

31. who should get coronary intervention after MI
Without AF; INR 2-3; with AF: 2.5-3.5
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Go for coronary angio. high likelyhood of severe coronary artery disease
CABG not angioplasty

32. What is kussmaul sign
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
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Pt with cardiogenic shock

33. wpw syndrome
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Transvenous pacemaker
No...except posterior or dorsal MI

34. When rhythm control strategy is suprior than rate control in the Tx of AF
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

35. Indication of gemfibrozil?
If there is evidence of heart failure
Amiodarone;
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Reduce hypertriglyceridemia; in liver

36. most effective non pharmacologic measure to decease blood pressure?
Elderly people with MI
Weight loss
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

37. 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.
Elderly people with MI
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

38. EKG shows ST elevation and suggest occlusion of major coronary artery.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
PPAR gamma receptor agonist pioglitazone.PPAR

39. sudden onset of HTN. How do you manage
PPAR gamma receptor agonist pioglitazone.PPAR
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
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

40. INR goal for bileaflet mechnial valve
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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.
Without AF; INR 2-3; with AF: 2.5-3.5

41. What is mech of TCA overdose
Without AF; INR 2-3; with AF: 2.5-3.5
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.
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
Amiodarone;

42. problem of WPW?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Development of AF. after ETOH - develop AF---sudden cardia arrest
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.

43. patient with secondary htn - What is next step
Weight loss
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

44. s/s carotid dissection
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Scoliosis and pes planus
When it is symptomatic. asso with dec cardiac output resulting hypotension

45. bradycardia with type 2 heart block
Flecainamide
Transvenous pacemaker
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Weight loss

46. indication of radionuclide ventriculography
No p wave - narrow qrs; first line of tx-adenosine
Scoliosis and pes planus
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Monitor EF after cardiotoxic chemo - bypass surgery

47. sinus bradycardia after inf wall MI
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Flecainamide

48. when 24 hour holter monitoring and admission recommended?
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
When it is symptomatic. asso with dec cardiac output resulting hypotension
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Unexplained synocope - dizziness - near syncope - recurrent palpitation

49. ehlers danlos
Reduce hypertriglyceridemia; in liver
Coronary angio - identify blockage and tx with stent/bypass
Scoliosis and pes planus
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 -

50. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Coronary angio - identify blockage and tx with stent/bypass
No...except posterior or dorsal MI
Post wall MI - occlusion of right coronary artery. tx with atropine