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USMLE Step3 Cardiovascular

Subjects : health-sciences, usmle-step-3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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. How long it takes for digoxin to have significant effect on rate control
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Streptokinase
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

2. patient with secondary htn - What is next step
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
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Lidcaine drip

3. common complications of ca antagonists?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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.
Scoliosis and pes planus

4. What is mech of TCA overdose
Within 24 hours
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
No...except posterior or dorsal MI

5. what medication cause pulmonary edema?
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
PPAR gamma receptor agonist pioglitazone.PPAR
High suspicion of MI. LAD occlusion leading to LBBB - next step 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.

6. who should get coronary intervention after MI
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
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
Transvenous pacemaker
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

7. 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.
2.5-3.5
Streptokinase
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

8. What is beck's triad?
Increases the risk of MI - thromboembolism - breast cancer - dementia
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Lidcaine drip

9. How to dx SVT? tx?
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.
Reduce hypertriglyceridemia; in liver
No p wave - narrow qrs; first line of tx-adenosine
Transvenous pacemaker

10. spontaneous papillary muscle rupture
Elderly people with MI
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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

11. What is poor R wave progression?
VSD; can be asymptomatic to large with significant L to R shunt
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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

12. What is kussmaul sign
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 -
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
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.
Lidcaine drip

13. stable angina with heart failure
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.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Go for coronary angio. high likelyhood of severe coronary artery disease

14. Most important predictor for future cardiovascular events
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
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.

15. What is PEA? How do you treat?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

16. 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
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Flecainamide
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

17. When to use dobutamine?
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Pt with cardiogenic shock
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

18. What drugs precipitate digoxin toxicity?
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
Post wall MI - occlusion of right coronary artery. tx with atropine
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

19. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Monitor EF after cardiotoxic chemo - bypass surgery
Reduce hypertriglyceridemia; in liver
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

20. new onset LBBB - What is the next step
CABG not angioplasty
Coronary angio - identify blockage and tx with stent/bypass
Go for coronary angio. high likelyhood of severe coronary artery disease
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

21. 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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
If there is evidence of heart failure

22. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Scoliosis and pes planus
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.

23. drugs increases the effect of warfarin
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Monitor EF after cardiotoxic chemo - bypass surgery
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

24. Indication of gemfibrozil?
Reduce hypertriglyceridemia; in liver
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
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.

25. EKG shows ST elevation and suggest occlusion of major coronary artery.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
PPAR gamma receptor agonist pioglitazone.PPAR
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

26. paroxysmal AF without structural HD
Flecainamide
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Unexplained synocope - dizziness - near syncope - recurrent palpitation
2.5-3.5

27. how amiodarone affects on warfarin
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
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 -
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

28. the dose levothyroxine in thyroid cancer remission
Go for coronary angio. high likelyhood of severe coronary artery disease
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
The dose should be adjusted such that TS H below 0.35

29. What is most congenital heart malformation?
If there is evidence of heart failure
VSD; can be asymptomatic to large with significant L to R shunt
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
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.

30. location of VSD/MR mumur
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
CABG not angioplasty
Holocystolic murmur loudest at lower left sternal border
Reduce hypertriglyceridemia; in liver

31. complication of HRT
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
Increases the risk of MI - thromboembolism - breast cancer - dementia
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

32. 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.
2.5-3.5
If patient is started on rifampin or phenobarbital; they increases its metabolism
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

33. When to use transvenous pacing?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Persistent brady after MI which is refractory to atropine tx
Monitor EF after cardiotoxic chemo - bypass surgery
Lidcaine drip

34. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Reduce hypertriglyceridemia; in liver
Development of AF. after ETOH - develop AF---sudden cardia arrest
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

35. paroxysmal AF with structural HD
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Amiodarone;
When it is symptomatic. asso with dec cardiac output resulting hypotension

36. Why nitroprusside cannot be used alone in aortic dissection
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Transvenous pacemaker

37. when 24 hour holter monitoring and admission recommended?
When it is symptomatic. asso with dec cardiac output resulting hypotension
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Lidcaine drip

38. When to replace aortic valve
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
VSD; can be asymptomatic to large with significant L to R shunt
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

39. When rhythm control strategy is suprior than rate control in the Tx of AF
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 -
Monitor EF after cardiotoxic chemo - bypass surgery
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

40. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
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
Persistent brady after MI which is refractory to atropine tx
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

41. INR for mechanical prosthetic valve
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 -
2.5-3.5
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

42. Difference between cardioversion and defibrillation
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
Lidcaine drip
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Without AF; INR 2-3; with AF: 2.5-3.5

43. indication of radionuclide ventriculography
Persistent brady after MI which is refractory to atropine tx
Elderly people with MI
Post wall MI - occlusion of right coronary artery. tx with atropine
Monitor EF after cardiotoxic chemo - bypass surgery

44. should we give thrombolytic in ST depression?
No...except posterior or dorsal MI
Go for coronary angio. high likelyhood of severe coronary artery disease
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
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.

45. INR goal for bileaflet mechnial valve
Coronary angio - identify blockage and tx with stent/bypass
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Weight loss
Without AF; INR 2-3; with AF: 2.5-3.5

46. most effective non pharmacologic measure to decease blood pressure?
Weight loss
The dose should be adjusted such that TS H below 0.35
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.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

47. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
CABG not angioplasty
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Scoliosis and pes planus

48. s/s carotid dissection
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
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

49. what MI cause sinus brady?
Pt with cardiogenic shock
Post wall MI - occlusion of right coronary artery. tx with atropine
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

50. When to treat sinus brady after acute MI
If patient is started on rifampin or phenobarbital; they increases its metabolism
Reduce hypertriglyceridemia; in liver
When it is symptomatic. asso with dec cardiac output resulting hypotension
Without AF; INR 2-3; with AF: 2.5-3.5

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USMLE Step3 Cardiovascular

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