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USMLE Step3 Cardiovascular

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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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
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
Holocystolic murmur loudest at lower left sternal border

2. When to treat sinus brady after acute MI
2.5-3.5
When it is symptomatic. asso with dec cardiac output resulting hypotension
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

3. 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.
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

4. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Without AF; INR 2-3; with AF: 2.5-3.5
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

5. when NSTEMI without comorbidiites should get PCI?
Persistent brady after MI which is refractory to atropine tx
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
Within 24 hours
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

6. When to increase warfarin dose?
Monitor EF after cardiotoxic chemo - bypass surgery
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
Amiodarone;

7. Indication of gemfibrozil?
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Reduce hypertriglyceridemia; in liver
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Coronary angio - identify blockage and tx with stent/bypass

8. When to start thrombolytic therapry in MI
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

9. When to use dobutamine?
Pt with cardiogenic shock
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

10. INR goal for bileaflet mechnial valve
Without AF; INR 2-3; with AF: 2.5-3.5
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Post wall MI - occlusion of right coronary artery. tx with atropine

11. When to use anticoag or aspiring in AF
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Monitor EF after cardiotoxic chemo - bypass surgery
Increases the risk of MI - thromboembolism - breast cancer - dementia

12. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Scoliosis and pes planus
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

13. How do you diagnose multifocal atrial tachy?
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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;
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.

14. torsade and unresponsive
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Defibrillation
Persistent brady after MI which is refractory to atropine tx

15. paroxysmal AF with structural HD
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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
Defibrillation

16. When rhythm control strategy is suprior than rate control in the Tx of AF
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Monitor EF after cardiotoxic chemo - bypass surgery
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

17. How to dx SVT? tx?
VSD; can be asymptomatic to large with significant L to R shunt
No p wave - narrow qrs; first line of tx-adenosine
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
CABG not angioplasty

18. what MI cause sinus brady?
Post wall MI - occlusion of right coronary artery. tx with atropine
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
PPAR gamma receptor agonist pioglitazone.PPAR
Increases the risk of MI - thromboembolism - breast cancer - dementia

19. should we give thrombolytic in ST depression?
No...except posterior or dorsal MI
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Amiodarone;
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

20. most effective non pharmacologic measure to decease blood pressure?
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Development of AF. after ETOH - develop AF---sudden cardia arrest
Weight loss
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

21. indication of radionuclide ventriculography
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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
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.

22. What is PEA? How do you treat?
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Amiodarone;

23. 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
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Weight loss

24. paroxysmal AF without structural HD
If there is evidence of heart failure
Flecainamide
Scoliosis and pes planus
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

25. ehlers danlos
Coronary angio - identify blockage and tx with stent/bypass
Scoliosis and pes planus
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.

26. When to use digoxin in AF
Increases the risk of MI - thromboembolism - breast cancer - dementia
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
If there is evidence of heart failure
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

27. bradycardia with type 2 heart block
Transvenous pacemaker
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Increases the risk of MI - thromboembolism - breast cancer - dementia
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

28. bradycardia after MI with hypotension. what would you do?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
The dose should be adjusted such that TS H below 0.35
Increases the risk of MI - thromboembolism - breast cancer - dementia

29. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
Within 24 hours
Defibrillation
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

30. What is kussmaul sign
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Amiodarone;
If there is evidence of heart failure
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

31. patient with new onset CHF - What is next best step?
Persistent brady after MI which is refractory to atropine tx
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Reduce hypertriglyceridemia; in liver

32. how amiodarone affects on warfarin
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
No...except posterior or dorsal MI
Lidcaine drip
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

33. sinus bradycardia after inf wall MI
Defibrillation
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
Weight loss

34. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Lidcaine drip
Streptokinase
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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.

35. stable angina with heart failure
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
Go for coronary angio. high likelyhood of severe coronary artery disease
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

36. What is paroxysmal AF? How do you treat?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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 -
The dose should be adjusted such that TS H below 0.35
Pt with cardiogenic shock

37. drugs increases the effect of warfarin
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Coronary angio - identify blockage and tx with stent/bypass
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Lidcaine drip

38. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
When it is symptomatic. asso with dec cardiac output resulting hypotension
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

39. s/s carotid dissection
When it is symptomatic. asso with dec cardiac output resulting hypotension
No p wave - narrow qrs; first line of tx-adenosine
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

40. How to treat a a patient with tCA overdose
Lidcaine drip
Pt with cardiogenic shock
If patient is started on rifampin or phenobarbital; they increases its metabolism
Monitor EF after cardiotoxic chemo - bypass surgery

41. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
PPAR gamma receptor agonist pioglitazone.PPAR
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Coronary angio - identify blockage and tx with stent/bypass
No p wave - narrow qrs; first line of tx-adenosine

42. what medication cause pulmonary edema?
VSD; can be asymptomatic to large with significant L to R shunt
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
PPAR gamma receptor agonist pioglitazone.PPAR
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;

43. patient with secondary htn - What is next step
Defibrillation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

44. How long it takes for digoxin to have significant effect on rate control
Development of AF. after ETOH - develop AF---sudden cardia arrest
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

45. sudden onset of HTN. How do you manage
R/o IHD which is the most common causes of CHF. stress test if indicated or 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
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. the dose levothyroxine in thyroid cancer remission
Flecainamide
The dose should be adjusted such that TS H below 0.35
Persistent brady after MI which is refractory to atropine tx
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. when 24 hour holter monitoring and admission recommended?
VSD; can be asymptomatic to large with significant L to R shunt
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Go for coronary angio. high likelyhood of severe coronary artery disease

48. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Post wall MI - occlusion of right coronary artery. tx with atropine
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
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 -

49. What is mech of TCA overdose
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
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 symptomatic (hypotension - hx of syncope) place transvenous pacemaker
PPAR gamma receptor agonist pioglitazone.PPAR

50. Why nitroprusside cannot be used alone in aortic dissection
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Coronary angio - identify blockage and tx with stent/bypass
Pt with cardiogenic shock
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