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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. bradycardia with type 2 heart block
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Transvenous pacemaker
Coronary angio - identify blockage and tx with stent/bypass
VSD; can be asymptomatic to large with significant L to R shunt

2. complication of HRT
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Amiodarone;
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Increases the risk of MI - thromboembolism - breast cancer - dementia

3. When to increase warfarin dose?
When it is symptomatic. asso with dec cardiac output resulting hypotension
If patient is started on rifampin or phenobarbital; they increases its metabolism
PPAR gamma receptor agonist pioglitazone.PPAR
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

4. Most important predictor for future cardiovascular events
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Pt with cardiogenic shock
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Coronary angio - identify blockage and tx with stent/bypass

5. When to use digoxin in AF
If there is evidence of heart failure
Holocystolic murmur loudest at lower left sternal border
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
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

6. bradycardia after MI with hypotension. what would you do?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
When it is symptomatic. asso with dec cardiac output resulting hypotension
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Persistent brady after MI which is refractory to atropine tx

7. What is poor R wave progression?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
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
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.

8. when NSTEMI without comorbidiites should get PCI?
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 -
Within 24 hours
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Reduce hypertriglyceridemia; in liver

9. When to replace aortic valve
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Streptokinase

10. When to use anticoag or aspiring in AF
Monitor EF after cardiotoxic chemo - bypass surgery
Scoliosis and pes planus
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
CABG not angioplasty

11. stable angina with heart failure
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Go for coronary angio. high likelyhood of severe coronary artery disease
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

12. when 24 hour holter monitoring and admission recommended?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Flecainamide

13. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
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)
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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

14. What is most congenital heart malformation?
The dose should be adjusted such that TS H below 0.35
VSD; can be asymptomatic to large with significant L to R shunt
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.
Pt with cardiogenic shock

15. the dose levothyroxine in thyroid cancer remission
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Weight loss
The dose should be adjusted such that TS H below 0.35

16. When to use dobutamine?
Pt with cardiogenic shock
Reduce hypertriglyceridemia; in liver
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

17. EKG shows ST elevation and suggest occlusion of major coronary artery.
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Lidcaine drip
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 -

18. paroxysmal AF with structural HD
Amiodarone;
Pt with cardiogenic shock
If patient is started on rifampin or phenobarbital; they increases its metabolism
Development of AF. after ETOH - develop AF---sudden cardia arrest

19. when we say QT prolonged?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Persistent brady after MI which is refractory to atropine tx
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

20. common complications of ca antagonists?
Holocystolic murmur loudest at lower left sternal border
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Monitor EF after cardiotoxic chemo - bypass surgery

21. When to start thrombolytic therapry in MI
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
VSD; can be asymptomatic to large with significant L to R shunt
Scoliosis and pes planus

22. Why nitroprusside cannot be used alone in aortic dissection
Weight loss
If patient is started on rifampin or phenobarbital; they increases its metabolism
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

23. patient with secondary htn - What is next step
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
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

24. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
PPAR gamma receptor agonist pioglitazone.PPAR
Coronary angio - identify blockage and tx with stent/bypass
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

25. location of VSD/MR mumur
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Holocystolic murmur loudest at lower left sternal border
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

26. who should get coronary intervention after MI
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Coronary angio - identify blockage and tx with stent/bypass
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
VSD; can be asymptomatic to large with significant L to R shunt

27. INR goal for bileaflet mechnial valve
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
No...except posterior or dorsal MI
The dose should be adjusted such that TS H below 0.35

28. When rhythm control strategy is suprior than rate control in the Tx of AF
When it is symptomatic. asso with dec cardiac output resulting hypotension
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Monitor EF after cardiotoxic chemo - bypass surgery
No...except posterior or dorsal MI

29. INR for mechanical prosthetic valve
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
2.5-3.5
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

30. What drugs precipitate digoxin toxicity?
Lidcaine drip
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
CABG not angioplasty
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

31. spontaneous papillary muscle rupture
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Weight loss
If patient is started on rifampin or phenobarbital; they increases its metabolism
Elderly people with MI

32. What is kussmaul sign
Reduce hypertriglyceridemia; in liver
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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Transvenous pacemaker

33. What is PEA? How do you treat?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
No p wave - narrow qrs; first line of tx-adenosine

34. torsade and unresponsive
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
No p wave - narrow qrs; first line of tx-adenosine
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Defibrillation

35. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Scoliosis and pes planus
No p wave - narrow qrs; first line of tx-adenosine
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 symptomatic (hypotension - hx of syncope) place transvenous pacemaker

36. What is beck's triad?
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

37. new onset LBBB - What is the next step
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
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.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

38. Indication of gemfibrozil?
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.
Development of AF. after ETOH - develop AF---sudden cardia arrest
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Reduce hypertriglyceridemia; in liver

39. What is mech of TCA overdose
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
If patient is started on rifampin or phenobarbital; they increases its metabolism
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

40. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

41. 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
Amiodarone;
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

42. what medication cause pulmonary edema?
PPAR gamma receptor agonist pioglitazone.PPAR
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
No p wave - narrow qrs; first line of tx-adenosine
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.

43. baloon valvulotomy for AS
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
CABG not angioplasty
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
2.5-3.5

44. most effective non pharmacologic measure to decease blood pressure?
Flecainamide
Within 24 hours
Weight loss
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

45. What is the most effective way to treat multivessel coronary artery blockade?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
CABG not angioplasty
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.
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

46. 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
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Weight loss
Lidcaine drip

47. sudden onset of HTN. How do you manage
CABG not angioplasty
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Post wall MI - occlusion of right coronary artery. tx with atropine

48. how amiodarone affects on warfarin
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
No p wave - narrow qrs; first line of tx-adenosine
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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. indication of radionuclide ventriculography
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
Lidcaine drip
Monitor EF after cardiotoxic chemo - bypass surgery

50. problem of WPW?
Weight loss
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Development of AF. after ETOH - develop AF---sudden cardia arrest
Flecainamide