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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. the dose levothyroxine in thyroid cancer remission
Streptokinase
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
The dose should be adjusted such that TS H below 0.35
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. paroxysmal AF with structural HD
Without AF; INR 2-3; with AF: 2.5-3.5
Development of AF. after ETOH - develop AF---sudden cardia arrest
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Amiodarone;

3. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Go for coronary angio. high likelyhood of severe coronary artery disease
Pt with cardiogenic shock
Streptokinase
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

4. INR for mechanical prosthetic valve
Monitor EF after cardiotoxic chemo - bypass surgery
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
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
2.5-3.5

5. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Pt with cardiogenic shock
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
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

6. primordial prevention vs primary/secondary/tertiary prevention
Amiodarone;
Post wall MI - occlusion of right coronary artery. tx with atropine
Monitor EF after cardiotoxic chemo - bypass surgery
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.

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

8. When to use digoxin in AF
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
If there is evidence of heart failure
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
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 -

9. sudden onset of HTN. How do you manage
Within 24 hours
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Amiodarone;
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

10. When to replace aortic valve
The dose should be adjusted such that TS H below 0.35
No...except posterior or dorsal MI
When it is symptomatic. asso with dec cardiac output resulting hypotension
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

11. Most important predictor for future cardiovascular events
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

12. When to start thrombolytic therapry in MI
Defibrillation
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Holocystolic murmur loudest at lower left sternal border
Flecainamide

13. What is the most effective way to treat multivessel coronary artery blockade?
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
CABG not angioplasty
No...except posterior or dorsal MI

14. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

15. what medication cause pulmonary edema?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
PPAR gamma receptor agonist pioglitazone.PPAR
If patient is started on rifampin or phenobarbital; they increases its metabolism
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

16. drugs increases the effect of warfarin
Lidcaine drip
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;
The dose should be adjusted such that TS H below 0.35

17. when 24 hour holter monitoring and admission recommended?
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 symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Weight loss
Unexplained synocope - dizziness - near syncope - recurrent palpitation

18. How to treat a a patient with tCA overdose
Lidcaine drip
Pt with cardiogenic shock
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

19. How long it takes for digoxin to have significant effect on rate control
If patient is started on rifampin or phenobarbital; they increases its metabolism
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Development of AF. after ETOH - develop AF---sudden cardia arrest
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

20. ehlers danlos
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.
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
Scoliosis and pes planus

21. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Without AF; INR 2-3; with AF: 2.5-3.5
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.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

22. sinus bradycardia after inf wall MI
Increases the risk of MI - thromboembolism - breast cancer - dementia
Without AF; INR 2-3; with AF: 2.5-3.5
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Streptokinase

23. When to use dobutamine?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Weight loss
Pt with cardiogenic shock

24. when NSTEMI without comorbidiites should get PCI?
PPAR gamma receptor agonist pioglitazone.PPAR
Within 24 hours
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Increases the risk of MI - thromboembolism - breast cancer - dementia

25. s/s carotid dissection
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
The dose should be adjusted such that TS H below 0.35
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

26. bradycardia with type 2 heart block
Transvenous pacemaker
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Scoliosis and pes planus
If patient is started on rifampin or phenobarbital; they increases its metabolism

27. What is most congenital heart malformation?
Persistent brady after MI which is refractory to atropine tx
VSD; can be asymptomatic to large with significant L to R shunt
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Development of AF. after ETOH - develop AF---sudden cardia arrest

28. stable angina with heart failure
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Go for coronary angio. high likelyhood of severe coronary artery disease
Defibrillation
If there is evidence of heart failure

29. when we say QT prolonged?
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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 it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Reduce hypertriglyceridemia; in liver

30. location of VSD/MR mumur
When it is symptomatic. asso with dec cardiac output resulting hypotension
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Holocystolic murmur loudest at lower left sternal border

31. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
PPAR gamma receptor agonist pioglitazone.PPAR
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
2.5-3.5

32. complication of HRT
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.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Increases the risk of MI - thromboembolism - breast cancer - dementia
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

33. 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
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
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

34. spontaneous papillary muscle rupture
The dose should be adjusted such that TS H below 0.35
Go for coronary angio. high likelyhood of severe coronary artery disease
CABG not angioplasty
Elderly people with MI

35. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

36. how amiodarone affects on warfarin
PPAR gamma receptor agonist pioglitazone.PPAR
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Defibrillation

37. When to use transvenous pacing?
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
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Persistent brady after MI which is refractory to atropine tx

38. baloon valvulotomy for AS
Pt with cardiogenic shock
Monitor EF after cardiotoxic chemo - bypass surgery
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

39. Why nitroprusside cannot be used alone in aortic dissection
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Holocystolic murmur loudest at lower left sternal border

40. should we give thrombolytic in ST depression?
CABG not angioplasty
No...except posterior or dorsal MI
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

41. paroxysmal AF without structural HD
Flecainamide
Pt with cardiogenic shock
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.

42. what MI cause sinus brady?
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
VSD; can be asymptomatic to large with significant L to R shunt
Post wall MI - occlusion of right coronary artery. tx with atropine

43. when should you stop aspirin before procedure that has bleeding risk?
Streptokinase
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
PPAR gamma receptor agonist pioglitazone.PPAR

44. new onset LBBB - What is the next step
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Lidcaine drip
2.5-3.5
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

45. who should get coronary intervention after MI
Development of AF. after ETOH - develop AF---sudden cardia arrest
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
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%

46. problem of WPW?
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 -
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Transvenous pacemaker
Development of AF. after ETOH - develop AF---sudden cardia arrest

47. What is beck's triad?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
No p wave - narrow qrs; first line of tx-adenosine
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If there is evidence of heart failure

48. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 2.5-3.5
Streptokinase
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
If there is evidence of heart failure

49. wpw syndrome
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
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
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

50. most effective non pharmacologic measure to decease blood pressure?
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
Weight loss
VSD; can be asymptomatic to large with significant L to R shunt
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