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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. baloon valvulotomy for AS
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Flecainamide
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

2. what MI cause sinus brady?
Post wall MI - occlusion of right coronary artery. tx with atropine
Unexplained synocope - dizziness - near syncope - recurrent palpitation
2.5-3.5
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

3. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Pt with cardiogenic shock
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Reduce hypertriglyceridemia; in liver
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

4. paroxysmal AF with structural HD
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Amiodarone;
Reduce hypertriglyceridemia; in liver
PPAR gamma receptor agonist pioglitazone.PPAR

5. In cocaine induced vasospasm - if angio shows any thrombus - next step?
PPAR gamma receptor agonist pioglitazone.PPAR
Coronary angio - identify blockage and tx with stent/bypass
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Streptokinase

6. what medication cause pulmonary edema?
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
PPAR gamma receptor agonist pioglitazone.PPAR
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Elderly people with MI

7. should we give thrombolytic in ST depression?
Lidcaine drip
Post wall MI - occlusion of right coronary artery. tx with atropine
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
No...except posterior or dorsal MI

8. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
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
Coronary angio - identify blockage and tx with stent/bypass
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

9. When to increase warfarin dose?
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Flecainamide
Coronary angio - identify blockage and tx with stent/bypass
If patient is started on rifampin or phenobarbital; they increases its metabolism

10. How do you diagnose multifocal atrial tachy?
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.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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

11. primordial prevention vs primary/secondary/tertiary prevention
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.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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.

12. What is poor R wave progression?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Post wall MI - occlusion of right coronary artery. tx with atropine
The dose should be adjusted such that TS H below 0.35

13. What is paroxysmal AF? How do you treat?
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Post wall MI - occlusion of right coronary artery. tx with atropine
When it is symptomatic. asso with dec cardiac output resulting hypotension
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 -

14. ehlers danlos
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Scoliosis and pes planus
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.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

15. new onset LBBB - What is the next step
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Go for coronary angio. high likelyhood of severe coronary artery disease
If there is evidence of heart failure

16. patient with new onset CHF - What is next best step?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Scoliosis and pes planus
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

17. the dose levothyroxine in thyroid cancer remission
Streptokinase
Go for coronary angio. high likelyhood of severe coronary artery disease
Coronary angio - identify blockage and tx with stent/bypass
The dose should be adjusted such that TS H below 0.35

18. problem of WPW?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Development of AF. after ETOH - develop AF---sudden cardia arrest
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
No...except posterior or dorsal MI

19. when we say QT prolonged?
CABG not angioplasty
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
VSD; can be asymptomatic to large with significant L to R shunt
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

20. when 24 hour holter monitoring and admission recommended?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Scoliosis and pes planus
PPAR gamma receptor agonist pioglitazone.PPAR
Unexplained synocope - dizziness - near syncope - recurrent palpitation

21. torsade and unresponsive
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
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
Defibrillation
Within 24 hours

22. common complications of ca antagonists?
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Flecainamide
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

23. Most important predictor for future cardiovascular events
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Flecainamide

24. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Unexplained synocope - dizziness - near syncope - recurrent palpitation

25. patient pw with new onset of heart failure and AF
Within 24 hours
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Lidcaine drip
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

26. When to use dobutamine?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Streptokinase
Pt with cardiogenic shock

27. indication of radionuclide ventriculography
Monitor EF after cardiotoxic chemo - bypass surgery
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
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

28. When to use digoxin in AF
If there is evidence of heart failure
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
Post wall MI - occlusion of right coronary artery. tx with atropine

29. 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.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

30. When to use anticoag or aspiring in AF
CABG not angioplasty
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
If patient is started on rifampin or phenobarbital; they increases its metabolism
Holocystolic murmur loudest at lower left sternal border

31. When to replace aortic valve
Persistent brady after MI which is refractory to atropine tx
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Streptokinase
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

32. What is PEA? How do you treat?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Weight loss

33. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Coronary angio - identify blockage and tx with stent/bypass
Elderly people with MI
2.5-3.5

34. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Persistent brady after MI which is refractory to atropine tx
2.5-3.5

35. INR for mechanical prosthetic valve
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
2.5-3.5

36. drugs increases the effect of warfarin
Amiodarone;
Holocystolic murmur loudest at lower left sternal border
Go for coronary angio. high likelyhood of severe coronary artery disease
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

37. spontaneous papillary muscle rupture
Pt with cardiogenic shock
If there is evidence of heart failure
Elderly people with MI
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 -

38. bradycardia with type 2 heart block
Flecainamide
PPAR gamma receptor agonist pioglitazone.PPAR
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Transvenous pacemaker

39. paroxysmal AF without structural HD
Flecainamide
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
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

40. 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
VSD; can be asymptomatic to large with significant L to R shunt
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.
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

41. sudden onset of HTN. How do you manage
Monitor EF after cardiotoxic chemo - bypass surgery
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Development of AF. after ETOH - develop AF---sudden cardia arrest

42. how amiodarone affects on warfarin
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

43. How to dx SVT? tx?
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
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)
CABG not angioplasty

44. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
No...except posterior or dorsal MI

45. How to treat a a patient with tCA overdose
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Lidcaine drip
Post wall MI - occlusion of right coronary artery. tx with atropine
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

46. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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)
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

47. wpw syndrome
Persistent brady after MI which is refractory to atropine tx
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
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

48. What drugs precipitate digoxin toxicity?
Pt with cardiogenic shock
Holocystolic murmur loudest at lower left sternal border
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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

49. INR goal for bileaflet mechnial valve
Within 24 hours
Without AF; INR 2-3; with AF: 2.5-3.5
Pt with cardiogenic shock
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

50. sinus bradycardia after inf wall MI
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Go for coronary angio. high likelyhood of severe coronary artery disease