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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. What is PEA? How do you treat?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
No p wave - narrow qrs; first line of tx-adenosine
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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. s/s carotid dissection
Defibrillation
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
2.5-3.5
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

3. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If there is evidence of heart failure

4. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Scoliosis and pes planus

5. What is beck's triad?
Go for coronary angio. high likelyhood of severe coronary artery disease
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If patient is started on rifampin or phenobarbital; they increases its metabolism
PPAR gamma receptor agonist pioglitazone.PPAR

6. When to use transvenous pacing?
No...except posterior or dorsal MI
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
The dose should be adjusted such that TS H below 0.35
Persistent brady after MI which is refractory to atropine tx

7. How to treat a a patient with tCA overdose
Development of AF. after ETOH - develop AF---sudden cardia arrest
Lidcaine drip
2.5-3.5
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

8. When to start thrombolytic therapry in MI
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
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If there is evidence of heart failure

9. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
If patient is started on rifampin or phenobarbital; they increases its metabolism
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

10. INR for mechanical prosthetic valve
2.5-3.5
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Without AF; INR 2-3; with AF: 2.5-3.5
If there is evidence of heart failure

11. How do you diagnose multifocal atrial tachy?
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Lidcaine drip
No p wave - narrow qrs; first line of tx-adenosine
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.

12. when should you stop aspirin before procedure that has bleeding risk?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Go for coronary angio. high likelyhood of severe coronary artery disease

13. EKG shows ST elevation and suggest occlusion of major coronary artery.
If patient is started on rifampin or phenobarbital; they increases its metabolism
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

14. What is poor R wave progression?
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Go for coronary angio. high likelyhood of severe coronary artery disease
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
If patient is started on rifampin or phenobarbital; they increases its metabolism

15. Why nitroprusside cannot be used alone in aortic dissection
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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.
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

16. When to treat sinus brady after acute MI
Transvenous pacemaker
Within 24 hours
When it is symptomatic. asso with dec cardiac output resulting hypotension
Reduce hypertriglyceridemia; in liver

17. How to dx SVT? tx?
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
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

18. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 2.5-3.5
Go for coronary angio. high likelyhood of severe coronary artery disease
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Elderly people with MI

19. when we say QT prolonged?
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If there is evidence of heart failure
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

20. 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
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Unexplained synocope - dizziness - near syncope - recurrent palpitation

21. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Scoliosis and pes planus
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

22. new onset LBBB - What is the next step
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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
Defibrillation

23. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
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.
Weight loss
Coronary angio - identify blockage and tx with stent/bypass
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 -

24. stable angina with 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
Increases the risk of MI - thromboembolism - breast cancer - dementia
Go for coronary angio. high likelyhood of severe coronary artery disease
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

25. what medication cause pulmonary edema?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
PPAR gamma receptor agonist pioglitazone.PPAR
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

26. torsade and unresponsive
CABG not angioplasty
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Defibrillation

27. when NSTEMI without comorbidiites should get PCI?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Within 24 hours
Holocystolic murmur loudest at lower left sternal border
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.

28. ehlers danlos
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
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

29. what MI cause sinus brady?
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Post wall MI - occlusion of right coronary artery. tx with atropine
Reduce hypertriglyceridemia; in liver
When it is symptomatic. asso with dec cardiac output resulting hypotension

30. common complications of ca antagonists?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
2.5-3.5
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

31. What is paroxysmal AF? How do you treat?
Post wall MI - occlusion of right coronary artery. tx with atropine
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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 -

32. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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

33. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Holocystolic murmur loudest at lower left sternal border
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Monitor EF after cardiotoxic chemo - bypass surgery
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

34. the dose levothyroxine in thyroid cancer remission
Elderly people with MI
The dose should be adjusted such that TS H below 0.35
Holocystolic murmur loudest at lower left sternal border
Scoliosis and pes planus

35. baloon valvulotomy for AS
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Post wall MI - occlusion of right coronary artery. tx with atropine
Coronary angio - identify blockage and tx with stent/bypass
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

36. 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
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

37. 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
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
CABG not angioplasty
Development of AF. after ETOH - develop AF---sudden cardia arrest

38. sudden onset of HTN. How do you manage
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
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.

39. In cocaine induced vasospasm - if angio shows any thrombus - next step?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Streptokinase
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

40. Most important predictor for future cardiovascular events
Go for coronary angio. high likelyhood of severe coronary artery disease
Within 24 hours
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

41. Indication of gemfibrozil?
Lidcaine drip
Reduce hypertriglyceridemia; in liver
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
VSD; can be asymptomatic to large with significant L to R shunt

42. When to increase warfarin dose?
Weight loss
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
If patient is started on rifampin or phenobarbital; they increases its metabolism

43. What is kussmaul sign
The dose should be adjusted such that TS H below 0.35
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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
Monitor EF after cardiotoxic chemo - bypass surgery

44. bradycardia with type 2 heart block
The dose should be adjusted such that TS H below 0.35
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Transvenous pacemaker
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

45. When to use digoxin in AF
If there is evidence of heart failure
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
Amiodarone;

46. When rhythm control strategy is suprior than rate control in the Tx of AF
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Duplex doppleer us if renal function impaired. if normal renal function - MR 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

47. primordial prevention vs primary/secondary/tertiary prevention
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
No...except posterior or dorsal MI
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.

48. paroxysmal AF with structural HD
Holocystolic murmur loudest at lower left sternal border
Scoliosis and pes planus
Amiodarone;
No p wave - narrow qrs; first line of tx-adenosine

49. patient with new onset CHF - What is next best step?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
VSD; can be asymptomatic to large with significant L to R shunt
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

50. When to use dobutamine?
Pt with cardiogenic shock
Coronary angio - identify blockage and tx with stent/bypass
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.