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Cardiology USMLE Step 3 > Section 1: Ischemic Heart Disease > Flashcards

Section 1: Ischemic Heart Disease Flashcards

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1
Q

When is family history considered significant as a risk factor of CAD?

A

For family history to be significant, the family member must be young:

  • Female relatives < 65
  • Male relatives < 55

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1496-1497). . Kindle Edition.

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1
Q

Types or features of chest pain not likely to be CAD. Give example(s) of each type.

A

Pleuritic Pain (changes with respiration)

  • Pulmonary embolism
  • Pneumonia
  • Pleuritis
  • Pericarditis
  • Pneumothorax

Positional (changes with bodily position)

  • Pericarditis

Tender (pain on palpation)

  • Costochondritis

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1505-1515). . Kindle Edition.

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2
Q

A patient comes to the emergency department with chest pain. There is right-upper quadrant tenderness and mild fever. What do you recommend?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1522-1523). . Kindle Edition.

A

Order an abdominal sonogram for gallstones.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1527). . Kindle Edition.

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3
Q

What is the single worst or most dangerous factor for CAD?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1502). . Kindle Edition.

A

Diabetes mellitus

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5
Q

Besides chest pain, what are the other clues to ischemic disease as the cause of chest pain?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1528-1534). . Kindle Edition.

A
  • Dull pain
  • Lasts 15– 30 minutes
  • Occurs on exertion
  • Substernal location
  • Radiates to the jaw or left arm

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1528-1534). . Kindle Edition.

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6
Q

What is the most common cause of chest pain that is not cardiac in etiology?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1516-1517). . Kindle Edition.

A

Gastroesophageal reflux disease (GERD)

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7
Q

A patient comes to the emergency department with chest pain. The pain also occurs in the epigastric area and is associated with a sore throat, a bad metallic taste in the mouth, and a cough. What do you recommend?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1518-1519). . Kindle Edition.

A

Give a proton pump inhibitor

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8
Q

An alcoholic patient comes to the emergency department with chest pain. There is nausea and vomiting and epigastric tenderness. What do you recommend?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1520-1521). . Kindle Edition.

A

Check amylase and lipase levels.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1526). . Kindle Edition.

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9
Q

List the risk factors of coronary artery disease (CAD)

A
  • Diabetes mellitus
  • Hypertension
  • Tobacco use
  • Hyperlipidemia
  • Peripheral arterial disease (PAD)
  • Obesity
  • Inactivity
  • Family history

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1488-1495). . Kindle Edition.

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10
Q

What are the likely abnormal findings in ischemic heart disease on examination of the cardiovascular system?

A
  1. S3 gallop: Dilated left ventricle
  2. S4 gallop: Left ventricular hypertrophy
  3. Jugulovenous distention
  4. Holosystolic murmur of mitral regurgitation

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1546-1549). . Kindle Edition.

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11
Q

What are the likely abnormal finding(s) in ischemic heart disease on examination of the chest?

A

Rales suggestive of congestive heart failure

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1551). . Kindle Edition.

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12
Q

What are the likely abnormal finding(s) in ischemic heart disease on general examination?

A

Distressed patient, short of breath, clutching chest

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1553-1554). . Kindle Edition.

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13
Q

What are the likely abnormal finding(s) in ischemic heart disease on examination of the extremities?

A

Edema

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1556). . Kindle Edition.

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14
Q

What is the best initial test for an ischemic-type pain?

A

An EKG is always the best initial diagnostic test for ischemic-type pain.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1562). . Kindle Edition.

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15
Q

If the case presented to you is very clearly a case of ischemic pain and the examiners ask you to choose between an EKG and aspirin, nitrates, oxygen, and morphine, what will you choose first?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1564-1565). . Kindle Edition.

A

Aspirin

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16
Q

How long does it take for CK-MB and troponin to rise after the start of chest pain

A

3 – 6 hours

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1575-1576). . Kindle Edition.

17
Q

What is the main difference between CK-MB and troponin?

A

The main difference between CK-MB and troponin is that CK-MB only stays elevated 1– 2 days while troponin stays elevated for 1– 2 weeks.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1576-1577). . Kindle Edition.

18
Q

What is the best test to check for re-infarction a few days after an initail infarction?

A

CK-MB

19
Q

True or False

LDH level or LDH isoenzymes is always the wrong answer

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1580). . Kindle Edition.

A

True

20
Q

How long does it take for myoglobin to rise after the start of chest pain in ACS?

A

Myoglobin elevates as early as 1– 4 hours after the start of chest pain.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1581-1582). . Kindle Edition.

21
Q

True or False

Stress testing is the answer when the case is not acute and the initial EKG and/ or enzyme tests do not establish the diagnosis.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1584-1585). . Kindle Edition.

A

True

22
Q

A 56-year-old man comes to the office a few days after an episode of chest pain. This was his first episode of pain, and he has no risk factors. In the emergency department, he had a normal EKG and normal CK-MB and was released the next day. Which of the following is most appropriate in his further management?

a. Repeat CK-MB
b. Statin
c. LDL level
d. Stress (exercise tolerance) testing
e. Angiography

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1586-1592). . Kindle Edition.

A

D. Stress test when the case is equivocal or uncertain for the presence of CAD. Do not do an angiography unless the stress test is abnormal. Exercise tolerance, or “stress,” testing detects coronary artery disease when the heart rate is raised and ST segment depression is detected. This case is asking you to know that a stress test is a way of increasing the sensitivity of detection of CAD beyond an EKG and enzymes.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1595-1597). . Kindle Edition.

23
Q

When do I answer dipyridamole or adenosine thallium stress test or dobutamine echo?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1601). . Kindle Edition.

A

Patients who cannot exercise to a target heart rate of > 85% of maximum:

  • COPD
  • Amputation
  • Deconditioning
  • Weakness/ previous stroke
  • Lower-extremity ulcer
  • Dementia
  • Obesity

The maximum heart rate by age is (220 - Age)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1604-1612). . Kindle Edition.

24
Q

List the indications for exercise thallium testing OR stress (exercise) echocardiography

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1602-1603). . Kindle Edition.

A
  1. Left bundle branch block (LBBB)
  2. Digoxin use
  3. Pacemaker in place
  4. Left venticular hypertrophy
  5. Any baseline abnormality of the ST segment of the EKG

When EKG is unreliable for ischemia

25
Q

A 63-year-old woman is in your office for evaluation of an abnormal stress test that shows an area of reversible ischemia. She has no risk factors for CAD. What is the most accurate diagnostic test, or what is the best next step in further management?

a. Troponin level
b. Angiography
c. Coronary bypass
d. Echocardiogram
e. Nuclear ventriculogram (MUGA scan)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1620-1627). . Kindle Edition.

A

B. Angiography is the next diagnostic test to evaluate an abnormal stress test that shows “reversible” ischemia. Reversible ischemia is the most dangerous thing that a stress test can show. If the stress test shows “fixed” defects— that is, a defect unchanged between exercise and rest— this is a scar from a previous infarction. Fixed defects do not need angiography.

Coronary bypass is the answer only if the angiogram has already been done.

Echocardiography is the best initial test to evaluate valve function or ventricular wall motion.

Nuclear ventriculogram is the most accurate method to evaluate ejection fraction.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1628-1634). . Kindle Edition.

26
Q
  1. Under what circumstances are Sestamibi nuclear stress testing used?
  2. Why?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1635). . Kindle Edition.

A
  1. Obese patients and those with large breasts
  2. Because of the greater ability of this radioisotope to penetrate tissue.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1636). . Kindle Edition.

27
Q

A patient admitted 5 days ago for a myocardial infarction has a new episode of chest pain. Which of the following is the most specific method of establishing the diagnosis of a new infarction?

a. CK-MB
b. Troponin
c. Echocardiogram
d. Stress testing
e. Angiography

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1638-1643). . Kindle Edition.

A

A. The CK-MB level should return to normal 2– 3 days after a myocardial infarction. If a reinfarction has occurred, the level will go back up again 5 days later, while the troponin level will still be up from the original infarction.

Angiography can detect obstructive, stenotic lesions but cannot detect myocardial necrosis.

Stress testing should never be performed if the patient is having current chest pain; chest pain is a reason to stop a stress test.

Echo will show decreased wall movement, but this could have been present from the previous cardiac injury.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1645-1649). . Kindle Edition.

28
Q
  1. Exercise Thalium Test = ?
  2. What is the general indication for an exercise thalium test?
  3. Dipyridamole thalium test = ?
  4. What is the general indication for dipyridamole thalium test?
  5. Adenosine thalium test = ?
  6. What is the general indication for adenosine thalium test?
A
  1. Exercise echocardiography (echo)
  2. EKG is unreadable for ischemia
  3. Dobutamine echo
  4. Patients cannot exercise to a target heart rate of > 85% of maximum
  5. Dobutamine echo
  6. Patients cannot exercise to a target heart rate of > 85% of maximum

Cardiology USMLE Step 3 (12 decks)

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