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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. When to use dobutamine?
Persistent brady after MI which is refractory to atropine tx
Pt with cardiogenic shock
Transvenous pacemaker
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

2. location of VSD/MR mumur
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Holocystolic murmur loudest at lower left sternal border
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
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.

3. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
2.5-3.5

4. patient pw with new onset of heart failure and AF
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

5. common complications of ca antagonists?
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.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

6. what medication cause pulmonary edema?
If there is evidence of heart failure
Post wall MI - occlusion of right coronary artery. tx with atropine
PPAR gamma receptor agonist pioglitazone.PPAR
Amiodarone;

7. What is paroxysmal AF? How do you treat?
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
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 -
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

8. the dose levothyroxine in thyroid cancer remission
Defibrillation
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
The dose should be adjusted such that TS H below 0.35
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

9. s/s carotid dissection
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Without AF; INR 2-3; with AF: 2.5-3.5
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

10. bradycardia after MI with hypotension. what would you do?
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
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

11. who should get coronary intervention after MI
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
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
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

12. How to dx SVT? tx?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
CABG not angioplasty
No p wave - narrow qrs; first line of tx-adenosine
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

13. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
When it is symptomatic. asso with dec cardiac output resulting hypotension
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
Coronary angio - identify blockage and tx with stent/bypass
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.

14. patient with secondary htn - What is next step
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Persistent brady after MI which is refractory to atropine tx
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

15. indication of radionuclide ventriculography
Monitor EF after cardiotoxic chemo - bypass surgery
Defibrillation
Go for coronary angio. high likelyhood of severe coronary artery disease
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

16. paroxysmal AF without structural HD
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
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
Flecainamide

17. what MI cause sinus brady?
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
Post wall MI - occlusion of right coronary artery. tx with atropine
CABG not angioplasty

18. 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
Defibrillation
Lidcaine drip
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

19. What drugs precipitate digoxin toxicity?
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Monitor EF after cardiotoxic chemo - bypass surgery
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

20. Most important predictor for future cardiovascular events
Reduce hypertriglyceridemia; in liver
PPAR gamma receptor agonist pioglitazone.PPAR
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

21. most effective non pharmacologic measure to decease blood pressure?
If there is evidence of heart failure
Weight loss
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Development of AF. after ETOH - develop AF---sudden cardia arrest

22. paroxysmal AF with structural HD
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 there is evidence of heart failure
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Amiodarone;

23. How do you diagnose multifocal atrial tachy?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
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;
Flecainamide

24. When to use anticoag or aspiring in AF
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

25. What is most congenital heart malformation?
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
VSD; can be asymptomatic to large with significant L to R shunt
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

26. primordial prevention vs primary/secondary/tertiary prevention
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.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
If there is evidence of heart failure
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

27. stable angina with heart failure
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Without AF; INR 2-3; with AF: 2.5-3.5
Go for coronary angio. high likelyhood of severe coronary artery disease
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

28. spontaneous papillary muscle rupture
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Elderly people with MI
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

29. What is the most effective way to treat multivessel coronary artery blockade?
Weight loss
Flecainamide
CABG not angioplasty
Elderly people with MI

30. torsade and unresponsive
Coronary angio - identify blockage and tx with stent/bypass
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
PPAR gamma receptor agonist pioglitazone.PPAR
Defibrillation

31. when we say QT prolonged?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Within 24 hours
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

32. drugs increases the effect of warfarin
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Amiodarone;

33. INR for mechanical prosthetic valve
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
2.5-3.5
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

34. patient with new onset CHF - What is next best step?
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.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
If patient is started on rifampin or phenobarbital; they increases its metabolism

35. When to use transvenous pacing?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Transvenous pacemaker
Persistent brady after MI which is refractory to atropine tx
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

36. What is mech of TCA overdose
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If there is evidence of heart failure
Defibrillation
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

37. baloon valvulotomy for AS
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 -
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
No p wave - narrow qrs; first line of tx-adenosine

38. bradycardia with type 2 heart block
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Lidcaine drip
Transvenous pacemaker
Unexplained synocope - dizziness - near syncope - recurrent palpitation

39. 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.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Elderly people with MI

40. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Transvenous pacemaker
Persistent brady after MI which is refractory to atropine tx

41. When to use digoxin in AF
If there is evidence of heart failure
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
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

42. Why nitroprusside cannot be used alone in aortic dissection
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Streptokinase
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.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

43. 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.
Scoliosis and pes planus
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

44. when NSTEMI without comorbidiites should get PCI?
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
No p wave - narrow qrs; first line of tx-adenosine
Within 24 hours
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

45. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
If patient is started on rifampin or phenobarbital; they increases its metabolism
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 -
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.

46. new onset LBBB - What is the next step
Without AF; INR 2-3; with AF: 2.5-3.5
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
If there is evidence of heart failure
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

47. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Scoliosis and pes planus
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

48. What is beck's triad?
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Elderly people with MI
Monitor EF after cardiotoxic chemo - bypass surgery
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

49. sudden onset of HTN. How do you manage
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
The dose should be adjusted such that TS H below 0.35
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

50. when 24 hour holter monitoring and admission recommended?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady