Test your basic knowledge |

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. What is most congenital heart malformation?
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
Coronary angio - identify blockage and tx with stent/bypass
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

2. indication of radionuclide ventriculography
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Monitor EF after cardiotoxic chemo - bypass surgery
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

3. patient with secondary htn - What is next step
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
No...except posterior or dorsal MI
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

4. What is the most effective way to treat multivessel coronary artery blockade?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
CABG not angioplasty
Within 24 hours
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

5. how amiodarone affects on warfarin
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Defibrillation
Increases the risk of MI - thromboembolism - breast cancer - dementia

6. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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

7. When to treat sinus brady after acute MI
Amiodarone;
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
When it is symptomatic. asso with dec cardiac output resulting hypotension

8. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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 -
Scoliosis and pes planus
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

9. primordial prevention vs primary/secondary/tertiary prevention
Lidcaine drip
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.
Scoliosis and pes planus

10. bradycardia with type 2 heart block
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Transvenous pacemaker
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

11. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Pt with cardiogenic shock
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 symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Weight loss

12. wpw syndrome
Without AF; INR 2-3; with AF: 2.5-3.5
Amiodarone;
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

13. EKG shows ST elevation and suggest occlusion of major coronary artery.
CABG not angioplasty
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

14. How to treat a a patient with tCA overdose
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Lidcaine drip
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

15. When rhythm control strategy is suprior than rate control in the Tx of AF
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Reduce hypertriglyceridemia; in liver
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
2.5-3.5

16. spontaneous papillary muscle rupture
If there is evidence of heart failure
Elderly people with MI
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

17. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Weight loss
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Streptokinase
Without AF; INR 2-3; with AF: 2.5-3.5

18. INR goal for bileaflet mechnial valve
If patient is started on rifampin or phenobarbital; they increases its metabolism
Without AF; INR 2-3; with AF: 2.5-3.5
Weight loss
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

19. When to use transvenous pacing?
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.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Persistent brady after MI which is refractory to atropine tx
If patient is started on rifampin or phenobarbital; they increases its metabolism

20. paroxysmal AF with structural HD
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Amiodarone;
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
No p wave - narrow qrs; first line of tx-adenosine

21. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
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
Coronary angio - identify blockage and tx with stent/bypass
CABG not angioplasty
When it is symptomatic. asso with dec cardiac output resulting hypotension

22. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
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.
Amiodarone;
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

23. 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
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Weight loss
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

24. when should you stop aspirin before procedure that has bleeding risk?
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
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.
Within 24 hours

25. new onset LBBB - What is the next step
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Defibrillation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

26. When to use dobutamine?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Pt with cardiogenic shock
Lidcaine drip
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

27. what medication cause pulmonary edema?
Scoliosis and pes planus
PPAR gamma receptor agonist pioglitazone.PPAR
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

28. When to start thrombolytic therapry in MI
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
CABG not angioplasty
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

29. problem of WPW?
Elderly people with MI
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Pt with cardiogenic shock
Development of AF. after ETOH - develop AF---sudden cardia arrest

30. INR for mechanical prosthetic valve
2.5-3.5
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

31. What drugs precipitate digoxin toxicity?
No p wave - narrow qrs; first line of tx-adenosine
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
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

32. who should get coronary intervention after MI
Reduce hypertriglyceridemia; in liver
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.
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

33. what MI cause sinus brady?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Post wall MI - occlusion of right coronary artery. tx with atropine
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

34. when NSTEMI without comorbidiites should get PCI?
Holocystolic murmur loudest at lower left sternal border
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Within 24 hours
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

35. When to use anticoag or aspiring in AF
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
No...except posterior or dorsal MI
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

36. What is kussmaul sign
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 patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Within 24 hours

37. complication of HRT
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Increases the risk of MI - thromboembolism - breast cancer - dementia

38. the dose levothyroxine in thyroid cancer remission
When it is symptomatic. asso with dec cardiac output resulting hypotension
Development of AF. after ETOH - develop AF---sudden cardia arrest
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

39. when we say QT prolonged?
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
No p wave - narrow qrs; first line of tx-adenosine
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
If patient is started on rifampin or phenobarbital; they increases its metabolism

40. What is beck's triad?
2.5-3.5
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
No...except posterior or dorsal MI
When it is symptomatic. asso with dec cardiac output resulting hypotension

41. What is mech of TCA overdose
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.
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
2.5-3.5
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

42. How long it takes for digoxin to have significant effect on rate control
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
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Lidcaine drip

43. patient pw with new onset of heart failure and AF
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
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 it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

44. s/s carotid dissection
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
If there is evidence of heart failure
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

45. Why nitroprusside cannot be used alone in aortic dissection
Transvenous pacemaker
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Streptokinase
Amiodarone;

46. common complications of ca antagonists?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Flecainamide
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Amiodarone;

47. Most important predictor for future cardiovascular events
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Post wall MI - occlusion of right coronary artery. tx with atropine

48. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Scoliosis and pes planus
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

49. location of VSD/MR mumur
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Holocystolic murmur loudest at lower left sternal border
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
VSD; can be asymptomatic to large with significant L to R shunt

50. torsade and unresponsive
PPAR gamma receptor agonist pioglitazone.PPAR
Defibrillation
Amiodarone;
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