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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 to increase warfarin dose?
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 -
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Defibrillation

2. 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
Weight loss
PPAR gamma receptor agonist pioglitazone.PPAR
When it is symptomatic. asso with dec cardiac output resulting hypotension

3. common complications of ca antagonists?
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.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Elderly people with MI
Coronary angio - identify blockage and tx with stent/bypass

4. most effective non pharmacologic measure to decease blood pressure?
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Weight loss
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

5. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
VSD; can be asymptomatic to large with significant L to R shunt
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
2.5-3.5

6. patient with new onset CHF - What is next best step?
If there is evidence of heart failure
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

7. when 24 hour holter monitoring and admission recommended?
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
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

8. How to dx SVT? tx?
Elderly people with MI
The dose should be adjusted such that TS H below 0.35
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
No p wave - narrow qrs; first line of tx-adenosine

9. when we say QT prolonged?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Development of AF. after ETOH - develop AF---sudden cardia arrest
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

10. complication of HRT
Flecainamide
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Increases the risk of MI - thromboembolism - breast cancer - dementia
PPAR gamma receptor agonist pioglitazone.PPAR

11. drugs increases the effect of warfarin
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
If patient is started on rifampin or phenobarbital; they increases its metabolism
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

12. When to use digoxin in AF
If there is evidence of heart failure
Pt with cardiogenic shock
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

13. How to treat a a patient with tCA overdose
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
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Lidcaine drip

14. 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.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
No...except posterior or dorsal MI
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

15. baloon valvulotomy for AS
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Amiodarone;

16. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Without AF; INR 2-3; with AF: 2.5-3.5

17. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
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.
Lidcaine drip

18. 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.
Streptokinase
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

19. ehlers danlos
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Scoliosis and pes planus
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

20. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
CABG not angioplasty
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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

21. torsade and unresponsive
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Reduce hypertriglyceridemia; in liver
Defibrillation
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

22. sinus bradycardia after inf wall MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Streptokinase
Within 24 hours
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

23. what medication cause pulmonary edema?
PPAR gamma receptor agonist pioglitazone.PPAR
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
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

24. When rhythm control strategy is suprior than rate control in the Tx of AF
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
2.5-3.5
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Lidcaine drip

25. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
VSD; can be asymptomatic to large with significant L to R shunt
Reduce hypertriglyceridemia; in liver
Coronary angio - identify blockage and tx with stent/bypass

26. What is mech of TCA overdose
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
CABG not angioplasty
Development of AF. after ETOH - develop AF---sudden cardia arrest
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

27. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

28. INR for mechanical prosthetic valve
2.5-3.5
Increases the risk of MI - thromboembolism - breast cancer - dementia
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

29. paroxysmal AF with structural HD
Go for coronary angio. high likelyhood of severe coronary artery disease
Amiodarone;
Pt with cardiogenic shock
The dose should be adjusted such that TS H below 0.35

30. EKG shows ST elevation and suggest occlusion of major coronary artery.
Increases the risk of MI - thromboembolism - breast cancer - dementia
Elderly people with MI
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.

31. What is paroxysmal AF? How do you treat?
Amiodarone;
Streptokinase
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 -
Persistent brady after MI which is refractory to atropine tx

32. sudden onset of HTN. How do you manage
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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 -
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

33. s/s carotid dissection
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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.
Persistent brady after MI which is refractory to atropine tx

34. bradycardia with type 2 heart block
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Transvenous pacemaker
CABG not angioplasty
Go for coronary angio. high likelyhood of severe coronary artery disease

35. When to replace aortic valve
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Flecainamide
If there is evidence of heart failure
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

36. Most important predictor for future cardiovascular events
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
CABG not angioplasty
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.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

37. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

38. paroxysmal AF without structural HD
No...except posterior or dorsal MI
Flecainamide
Duplex doppleer us if renal function impaired. if normal renal function - MR 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 -

39. patient pw with new onset of heart failure and AF
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
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
Increases the risk of MI - thromboembolism - breast cancer - dementia
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

40. new onset LBBB - What is the next step
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Amiodarone;
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
VSD; can be asymptomatic to large with significant L to R shunt

41. What is the most effective way to treat multivessel coronary artery blockade?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
CABG not angioplasty
Defibrillation

42. When to use anticoag or aspiring in AF
Elderly people with MI
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

43. should we give thrombolytic in ST depression?
If patient is started on rifampin or phenobarbital; they increases its metabolism
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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...except posterior or dorsal MI

44. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Amiodarone;
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Streptokinase
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

45. who should get coronary intervention after MI
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Reduce hypertriglyceridemia; in liver
PPAR gamma receptor agonist pioglitazone.PPAR

46. Indication of gemfibrozil?
Reduce hypertriglyceridemia; in liver
Streptokinase
Without AF; INR 2-3; with AF: 2.5-3.5
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

47. How long it takes for digoxin to have significant effect on rate control
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Flecainamide
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

48. When to treat sinus brady after acute MI
When it is symptomatic. asso with dec cardiac output resulting hypotension
No...except posterior or dorsal MI
Amiodarone;
Persistent brady after MI which is refractory to atropine tx

49. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
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
If patient is started on rifampin or phenobarbital; they increases its metabolism

50. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Post wall MI - occlusion of right coronary artery. tx with atropine
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