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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. how amiodarone affects on warfarin
Defibrillation
No...except posterior or dorsal MI
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Post wall MI - occlusion of right coronary artery. tx with atropine

2. paroxysmal AF without structural HD
Post wall MI - occlusion of right coronary artery. tx with atropine
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.
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Flecainamide

3. What is kussmaul sign
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Increases the risk of MI - thromboembolism - breast cancer - dementia
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...except posterior or dorsal MI

4. Difference between cardioversion and defibrillation
If patient is started on rifampin or phenobarbital; they increases its metabolism
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
Within 24 hours

5. s/s carotid dissection
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Elderly people with MI
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

6. drugs increases the effect of warfarin
CABG not angioplasty
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

7. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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
VSD; can be asymptomatic to large with significant L to R shunt

8. primordial prevention vs primary/secondary/tertiary prevention
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
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.
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Persistent brady after MI which is refractory to atropine tx

9. When to increase warfarin dose?
Persistent brady after MI which is refractory to atropine tx
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
The dose should be adjusted such that TS H below 0.35
If patient is started on rifampin or phenobarbital; they increases its metabolism

10. Most important predictor for future cardiovascular events
Monitor EF after cardiotoxic chemo - bypass surgery
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Weight loss
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

11. INR goal for bileaflet mechnial valve
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.
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.
Reduce hypertriglyceridemia; in liver

12. spontaneous papillary muscle rupture
Without AF; INR 2-3; with AF: 2.5-3.5
CABG not angioplasty
Lidcaine drip
Elderly people with MI

13. patient with new onset CHF - What is next best step?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
CABG not angioplasty
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

14. sudden onset of HTN. How do you manage
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
CABG not angioplasty
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
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.

15. bradycardia with type 2 heart block
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
VSD; can be asymptomatic to large with significant L to R shunt
Elderly people with MI
Transvenous pacemaker

16. When to use transvenous pacing?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Weight loss
Persistent brady after MI which is refractory to atropine tx
PPAR gamma receptor agonist pioglitazone.PPAR

17. When to use digoxin in AF
If there is evidence of heart failure
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Elderly people with 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.

18. paroxysmal AF with structural HD
Amiodarone;
CABG not angioplasty
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
When it is symptomatic. asso with dec cardiac output resulting hypotension

19. Indication of gemfibrozil?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Reduce hypertriglyceridemia; in liver
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

20. How to treat a a patient with tCA overdose
Increases the risk of MI - thromboembolism - breast cancer - dementia
Lidcaine drip
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

21. baloon valvulotomy for AS
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with 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.
Post wall MI - occlusion of right coronary artery. tx with atropine
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

22. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

23. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Go for coronary angio. high likelyhood of severe coronary artery disease
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Flecainamide

24. who should get coronary intervention after MI
Holocystolic murmur loudest at lower left sternal border
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

25. What is most congenital heart malformation?
VSD; can be asymptomatic to large with significant L to R shunt
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.
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

26. INR for mechanical prosthetic valve
Elderly people with MI
Monitor EF after cardiotoxic chemo - bypass surgery
2.5-3.5
Lidcaine drip

27. what medication cause pulmonary edema?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Lidcaine drip
PPAR gamma receptor agonist pioglitazone.PPAR
Persistent brady after MI which is refractory to atropine tx

28. common complications of ca antagonists?
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

29. What is beck's triad?
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

30. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Scoliosis and pes planus
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
No p wave - narrow qrs; first line of tx-adenosine
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

31. when should you stop aspirin before procedure that has bleeding risk?
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
When it is symptomatic. asso with dec cardiac output resulting hypotension
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

32. How long it takes for digoxin to have significant effect on rate control
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Scoliosis and pes planus

33. bradycardia after MI with hypotension. what would you do?
Increases the risk of MI - thromboembolism - breast cancer - dementia
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
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

34. When to use dobutamine?
Defibrillation
Streptokinase
Pt with cardiogenic shock
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

35. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Pt with cardiogenic shock

36. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Weight loss
Streptokinase
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

37. Why nitroprusside cannot be used alone in aortic dissection
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
No p wave - narrow qrs; first line of tx-adenosine
2.5-3.5
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

38. When rhythm control strategy is suprior than rate control in the Tx of AF
Streptokinase
Amiodarone;
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

39. What is the most effective way to treat multivessel coronary artery blockade?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
If there is evidence of heart failure
CABG not angioplasty

40. When to replace aortic valve
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
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 -
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

41. When to treat sinus brady after acute MI
When it is symptomatic. asso with dec cardiac output resulting hypotension
Without AF; INR 2-3; with AF: 2.5-3.5
PPAR gamma receptor agonist pioglitazone.PPAR
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

42. What is paroxysmal AF? How do you treat?
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 -
Within 24 hours
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
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

43. torsade and unresponsive
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Post wall MI - occlusion of right coronary artery. tx with atropine
Defibrillation
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

44. most effective non pharmacologic measure to decease blood pressure?
Defibrillation
If there is evidence of heart failure
Flecainamide
Weight loss

45. What drugs precipitate digoxin toxicity?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Flecainamide
Persistent brady after MI which is refractory to atropine tx
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

46. 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)
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Go for coronary angio. high likelyhood of severe coronary artery disease

47. 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
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Within 24 hours

48. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Weight loss
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Coronary angio - identify blockage and tx with stent/bypass

49. indication of radionuclide ventriculography
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Monitor EF after cardiotoxic chemo - bypass surgery
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

50. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours