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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. sudden onset of HTN. How do you manage
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Lidcaine drip
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

2. What drugs precipitate digoxin toxicity?
2.5-3.5
Monitor EF after cardiotoxic chemo - bypass surgery
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

3. 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 -
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Within 24 hours
Scoliosis and pes planus

4. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Scoliosis and pes planus
CABG not angioplasty
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

5. How long it takes for digoxin to have significant effect on rate control
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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
Persistent brady after MI which is refractory to atropine tx

6. What is kussmaul sign
Post wall MI - occlusion of right coronary artery. tx with atropine
Holocystolic murmur loudest at lower left sternal border
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
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

7. When to start thrombolytic therapry in MI
Increases the risk of MI - thromboembolism - breast cancer - dementia
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

8. paroxysmal AF without structural HD
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Flecainamide
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

9. What is PEA? How do you treat?
Go for coronary angio. high likelyhood of severe coronary artery disease
Post wall MI - occlusion of right coronary artery. tx with atropine
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
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

10. spontaneous papillary muscle rupture
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Weight loss
Elderly people with MI
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

11. 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.
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
Development of AF. after ETOH - develop AF---sudden cardia arrest

12. what medication cause pulmonary edema?
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
PPAR gamma receptor agonist pioglitazone.PPAR
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

13. patient pw with new onset of heart failure and AF
Monitor EF after cardiotoxic chemo - bypass surgery
CABG not angioplasty
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

14. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
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
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Weight loss

15. How do you diagnose multifocal atrial tachy?
Post wall MI - occlusion of right coronary artery. tx with atropine
Without AF; INR 2-3; with AF: 2.5-3.5
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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.

16. Most important predictor for future cardiovascular events
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Go for coronary angio. high likelyhood of severe coronary artery disease
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Amiodarone;

17. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 2.5-3.5
If patient is started on rifampin or phenobarbital; they increases its metabolism
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Transvenous pacemaker

18. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
PPAR gamma receptor agonist pioglitazone.PPAR
Coronary angio - identify blockage and tx with stent/bypass

19. when we say QT prolonged?
Defibrillation
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
If patient is started on rifampin or phenobarbital; they increases its metabolism

20. new onset LBBB - What is the next step
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
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
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.

21. complication of HRT
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
Increases the risk of MI - thromboembolism - breast cancer - dementia
Weight loss

22. When to use transvenous pacing?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Weight loss
2.5-3.5
Persistent brady after MI which is refractory to atropine tx

23. what MI cause sinus brady?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Persistent brady after MI which is refractory to atropine tx
Post wall MI - occlusion of right coronary artery. tx with atropine
CABG not angioplasty

24. What is beck's triad?
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Development of AF. after ETOH - develop AF---sudden cardia arrest
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Lidcaine drip

25. paroxysmal AF with structural HD
Elderly people with MI
Amiodarone;
CABG not angioplasty
Streptokinase

26. Indication of gemfibrozil?
Reduce hypertriglyceridemia; in liver
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Pt with cardiogenic shock
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

27. s/s carotid dissection
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Within 24 hours
The dose should be adjusted such that TS H below 0.35
CABG not angioplasty

28. baloon valvulotomy for AS
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Without AF; INR 2-3; with AF: 2.5-3.5
Lidcaine drip
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

29. patient with secondary htn - What is next step
Within 24 hours
Holocystolic murmur loudest at lower left sternal border
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 -
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

30. How to treat a a patient with tCA overdose
Lidcaine drip
Development of AF. after ETOH - develop AF---sudden cardia arrest
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
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

31. ehlers danlos
Development of AF. after ETOH - develop AF---sudden cardia arrest
Flecainamide
When it is symptomatic. asso with dec cardiac output resulting hypotension
Scoliosis and pes planus

32. when should you stop aspirin before procedure that has bleeding risk?
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

33. problem of WPW?
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Development of AF. after ETOH - develop AF---sudden cardia arrest
VSD; can be asymptomatic to large with significant L to R shunt
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

34. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Weight loss
Transvenous pacemaker

35. indication of radionuclide ventriculography
Transvenous pacemaker
Monitor EF after cardiotoxic chemo - bypass surgery
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.

36. Difference between cardioversion and defibrillation
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
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.
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

37. how amiodarone affects on warfarin
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Holocystolic murmur loudest at lower left sternal border

38. When to use anticoag or aspiring in AF
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.
Streptokinase
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

39. bradycardia after MI with hypotension. what would you do?
Development of AF. after ETOH - develop AF---sudden cardia arrest
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

40. common complications of ca antagonists?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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.
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 R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

41. 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
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
Elderly people with MI
Flecainamide

42. stable angina with heart failure
Go for coronary angio. high likelyhood of severe coronary artery disease
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

43. When to replace aortic valve
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Elderly people with MI
The dose should be adjusted such that TS H below 0.35

44. the dose levothyroxine in thyroid cancer remission
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
The dose should be adjusted such that TS H below 0.35

45. drugs increases the effect of warfarin
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
2.5-3.5
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

46. 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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If patient is started on rifampin or phenobarbital; they increases its metabolism
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

47. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Development of AF. after ETOH - develop AF---sudden cardia arrest
Streptokinase

48. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Coronary angio - identify blockage and tx with stent/bypass
No p wave - narrow qrs; first line of tx-adenosine
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
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

49. INR for mechanical prosthetic valve
2.5-3.5
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
Holocystolic murmur loudest at lower left sternal border

50. bradycardia with type 2 heart block
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Weight loss
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Transvenous pacemaker