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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. paroxysmal AF without structural HD
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.
Within 24 hours
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Flecainamide

2. 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
Post wall MI - occlusion of right coronary artery. tx with atropine
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

3. What is kussmaul sign
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
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
Without AF; INR 2-3; with AF: 2.5-3.5

4. drugs increases the effect of warfarin
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Coronary angio - identify blockage and tx with stent/bypass
Holocystolic murmur loudest at lower left sternal border

5. ehlers danlos
Post wall MI - occlusion of right coronary artery. tx with atropine
Scoliosis and pes planus
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Development of AF. after ETOH - develop AF---sudden cardia arrest

6. 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.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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.
If patient is started on rifampin or phenobarbital; they increases its metabolism

7. bradycardia with type 2 heart block
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Without AF; INR 2-3; with AF: 2.5-3.5
Transvenous pacemaker
No p wave - narrow qrs; first line of tx-adenosine

8. 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
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.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

9. what MI cause sinus brady?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Post wall MI - occlusion of right coronary artery. tx with atropine
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

10. most effective non pharmacologic measure to decease blood pressure?
Weight loss
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

11. when NSTEMI without comorbidiites should get PCI?
Transvenous pacemaker
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Within 24 hours
Defibrillation

12. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
If patient is started on rifampin or phenobarbital; they increases its metabolism
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Persistent brady after MI which is refractory to atropine tx

13. when 24 hour holter monitoring and admission recommended?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Without AF; INR 2-3; with AF: 2.5-3.5

14. common complications of ca antagonists?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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%
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. when should you stop aspirin before procedure that has bleeding risk?
Pt with cardiogenic shock
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
No...except posterior or dorsal MI

16. sinus bradycardia after inf wall MI
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Transvenous pacemaker
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

17. How long it takes for digoxin to have significant effect on rate control
Persistent brady after MI which is refractory to atropine tx
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
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

18. new onset LBBB - What is the next step
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
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

19. when we say QT prolonged?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

20. What is poor R wave progression?
Streptokinase
Within 24 hours
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 -
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

21. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
PPAR gamma receptor agonist pioglitazone.PPAR
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Unexplained synocope - dizziness - near syncope - recurrent palpitation

22. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
No...except posterior or dorsal MI
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Development of AF. after ETOH - develop AF---sudden cardia arrest
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

23. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Lidcaine drip
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

24. wpw syndrome
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Monitor EF after cardiotoxic chemo - bypass surgery
2.5-3.5
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

25. indication of radionuclide ventriculography
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Monitor EF after cardiotoxic chemo - bypass surgery
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

26. When to use transvenous pacing?
Without AF; INR 2-3; with AF: 2.5-3.5
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Persistent brady after MI which is refractory to atropine tx

27. 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
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
CABG not angioplasty

28. bradycardia after MI with hypotension. what would you do?
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 p wave - narrow qrs; first line of tx-adenosine
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

29. patient pw with new onset of heart failure and AF
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Post wall MI - occlusion of right coronary artery. tx with atropine
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

30. How do you diagnose multifocal atrial tachy?
Within 24 hours
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.
No p wave - narrow qrs; first line of tx-adenosine
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

31. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Scoliosis and pes planus
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give 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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

32. How to treat a a patient with tCA overdose
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

33. 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
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
No...except posterior or dorsal MI
Transvenous pacemaker

34. Why nitroprusside cannot be used alone in aortic dissection
Within 24 hours
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Increases the risk of MI - thromboembolism - breast cancer - dementia

35. 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.
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Flecainamide
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

36. When to use anticoag or aspiring in AF
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.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

37. patient with secondary htn - What is next step
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
CABG not angioplasty
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Streptokinase

38. who should get coronary intervention after MI
VSD; can be asymptomatic to large with significant L to R shunt
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
No p wave - narrow qrs; first line of tx-adenosine

39. Indication of gemfibrozil?
Elderly people with MI
Development of AF. after ETOH - develop AF---sudden cardia arrest
VSD; can be asymptomatic to large with significant L to R shunt
Reduce hypertriglyceridemia; in liver

40. When to treat sinus brady after acute MI
Post wall MI - occlusion of right coronary artery. tx with atropine
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
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

41. What is PEA? How do you treat?
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.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Persistent brady after MI which is refractory to atropine tx

42. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
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
Transvenous pacemaker
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

43. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
No...except posterior or dorsal 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.
When it is symptomatic. asso with dec cardiac output resulting hypotension
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

44. complication of HRT
Holocystolic murmur loudest at lower left sternal border
Increases the risk of MI - thromboembolism - breast cancer - dementia
Unexplained synocope - dizziness - near syncope - recurrent palpitation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

45. should we give thrombolytic in ST depression?
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Pt with cardiogenic shock
No...except posterior or dorsal MI

46. INR for mechanical prosthetic valve
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
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
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.

47. EKG shows ST elevation and suggest occlusion of major coronary artery.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
If patient is started on rifampin or phenobarbital; they increases its metabolism
Transvenous pacemaker
Flecainamide

48. What is beck's triad?
PPAR gamma receptor agonist pioglitazone.PPAR
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Development of AF. after ETOH - develop AF---sudden cardia arrest
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

49. When to start thrombolytic therapry in MI
Transvenous pacemaker
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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

50. When to use dobutamine?
If there is evidence of heart failure
Transvenous pacemaker
Pt with cardiogenic shock
7 days. coz aspirin cause platelet dysfunction that can last more than a week.