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USMLE Step 2 CK High-Yield Cardiovascular Topics
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Cardiovascular
High Yield USMLE Step 2 CK Notes
Welcome to the Cardiovascular High-Yield Notes for Step 2 CK.
These are the most commonly tested topics on the exam—ideal for quick review in your last 2 weeks before the exam, when you’re short on time, or when you’re just starting out and want to focus on what is high yield. Created and peer-reviewed by physicians who scored 260+ on Step 2 CK in a Q&A style to reinforce active learning.
How to use this file
- Read the question ➔ cover the answer ➔ self-quiz before revealing.
- Review the NOTES ➔ they include high-yield details you don’t want to miss.
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- Don’t forget to watch the video lessons that go with this file. Learn more here.
Table of Contents
Hypertension
1. A 40-year-old man wants to be evaluated for hypertension. What is the first step to diagnose hypertension?
➔ BP measurement by automatic oscillometer
- Note: Hypertension diagnostic criteria → Elevated BP readings (>120/80) on 2 separate occasions
- First, take two readings with an automated oscillometer → If the readings are high, then go for measurement by auscultation → If the readings are still high, go for ambulatory BP monitoring or home BP monitoring → You can only diagnose hypertension once you get elevated BP inside as well as outside the office
2. A 45-year-old man is newly diagnosed with hypertension. He smokes, drinks alcohol, and has a BMI of 31. What is the most effective lifestyle intervention to reduce his blood pressure?
➔ Weight loss
- Note: Lifestyle intervention for BP reduction
○ HTN & obesity = Wt loss
○ HTN & normal BMI= DASH diet
3. A 34-year-old man with hypertension presents with muscle cramps and leg weakness. What is the next step in evaluating his blood pressure?
➔ Serum aldosterone-to-renin ratio
- Note: To evaluate for primary hyperaldosteronism (Conn syndrome). If the ratio is high (equal to or more than 20), then the next step is to do CT adrenals to confirm and localize the mass.
- HTN + Hypokalemia (muscle weakness) = Hyperaldosteronism
- D/D with pheochromocytoma that presents with paroxysmal HTN + headache, palpitations, and sweating (classic triad).
4. A 28-year-old woman presents with severe hypertension. On exam, a systolic-diastolic bruit is heard in the upper abdomen. What is the next step in management?
➔ Renal artery Doppler
- HTN + young female + abdominal/carotid bruit = Fibromuscular dysplasia
- HTN + old age + abdominal bruit + Hx of CVD (MI, stroke, DM, HTN) = Renal artery stenosis due to atherosclerosis.
5. A young woman with fibromuscular dysplasia is started on antihypertensive therapy. Her serum creatinine rises from 1.4 to 2.1 mg/dL. Which medication is responsible?
➔ ACE inhibitor/ARBs
- Note: Bilateral RAS → ↓ Renal perfusion → ACEi/ARB → ↓ Efferent arteriolar constriction → ↓ GFR → ↑ Creatinine
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6. A 12-week pregnant woman is found to have a blood pressure of 142/92 mmHg. What is the drug of choice for managing her hypertension?
➔ Nifedipine (CCBs >> methyldopa & hydralazine)
- Note: Anti-hypertensives and pregnancy
- Safe: CCBs, hydralazine, methyldopa, and (labetalol for hypertensive emergency)
- Avoid: ACE inhibitors and ARBs are absolutely C.I due to fetal renal agenesis risk.
7. A 40-year-old man with a history of diabetes and hypertension presents for routine follow-up. Which antihypertensive is preferred?
➔ ACE inhibitors/ARBs for renal protection in diabetes
Choice of Anti-hypertensives in different comorbid conditions
- HTN + Heart Failure / Post-MI/ LVH → ACEi or ARB
- HTN + Diabetes Mellitus (DM)/ CKD → ACEi or ARB
- HTN + Proteinuria → ACEi or ARB
- HTN + AFib / Anxiety (GAD)/ hyperthyroidism/ angina → Beta-blocker
- HTN + Osteoporosis / Elderly Female → Thiazide
8. A 50-year-old man is newly diagnosed with hypertension during a routine visit. Which laboratory tests should be included in his initial workup?
➔ Blood glucose, lipid profile, serum electrolytes, creatinine, and urinalysis
- Note: Initial lab workup in hypertension helps assess:
1. End-organ damage
2. Secondary causes
3. Cardiovascular risk factors
CAD
9. A 45-year-old woman reports exertional, pressure-like chest pain that is relieved by rest. ECG is normal. What is the next best step in evaluation?
➔ Exercise stress test
- Note: Use pharmacologic stress tests, “adenosine, dipyridamole, and dobutamine” if unable to exercise:
○ Severe Asthma & COPD
○ Arthritis
○ Limb amputation
○ Morbid obesity
10. A 48-year-old woman presents with sharp, localized chest pain that worsens with movement. Tenderness is noted over the 4th costochondral junction. What is the next step in management?
➔ Costochondritis → NSAIDs + reassure
- Note: Cardiac pain (e.g., angina) is usually pressure-like, diffuse, and not reproducible with palpation.
- Point tenderness over the chest wall virtually rules out myocardial ischemia. It may indicate costochondritis.
Common D/D of acute chest pain
- Angina/MI – Pressure-like, radiates to arm/jaw, associated with diaphoresis & nausea.
- Pericarditis – Sharp, pleuritic, better when sitting up, ± pericardial friction rub.
- Pulmonary embolism (PE) – Sudden pleuritic pain, dyspnea, tachycardia, ± hemoptysis.
- Pneumothorax – Sudden sharp pain with dyspnea, ↓ breath sounds on the affected side.
11. A 68-year-old man with stable angina is on metoprolol and nitrates but continues to have exertional chest pain and dyspnea. His ejection fraction is 60%. What is the next best medication to add?
➔ Ranolazine
- Note: Drug of choice for refractory chronic stable angina when symptoms persist despite beta-blockers, nitrates and calcium channel blockers.
- Ranolazine improves myocardial oxygen efficiency by inhibiting the late sodium current.
Drugs for angina
- Acute pain → Sublingual nitroglycerin
- Chronic stable angina
○ Beta-blockers/Calcium channel blockers
○ Long-acting nitrates
○ Ranolazine if Sx persists
○ Manage HTN, DM, and dyslipidemia
12. A 60-year-old man presents with 45 minutes of severe substernal chest pain radiating to the left arm. He is diaphoretic. ECG shows ST elevation in leads V1–V4. What is the initial management?
➔ Initial drugs to be given after MI (MONA-BASH)
- Note: Morphine (for pain relief if pain is severe and not relieved by nitro)
- Oxygen (if SpO₂ <90%)\
- Nitroglycerin (unless hypotensive or RVMI)
- Aspirin
- Beta-blocker
- Antiplatelet (Aspirin + clopidogrel/ticagrelor)
- Statin
- Heparin (anticoagulation with UFH or LMWH)
13. A 58-year-old man presents to a rural ED with 1 hour of chest pain. ECG shows ST elevation in leads II, III, and aVF. The nearest PCI-capable facility is 3 hours away. What is the next step?
➔ Administer fibrinolytic therapy (alteplase, reteplase, tenecteplase)
- Note: PCI: Preferred if available within 90–120 minutes of first medical contact.
- Fibrinolysis: If PCI is not available within 120 minutes, administer within 30 minutes of arrival.
- Fibrinolysis adverse effect: Risk of major bleeding, especially intracranial hemorrhage.
- Contraindications: Any active bleeding, prior intracranial hemorrhage, ischemic stroke within 3 months, uncontrolled hypertension (>180/110), or aortic dissection.
14. A 29-year-old woman with a history of smoking presents with sudden, crushing chest pain and ST elevations on ECG. The symptoms resolve on their own and are not related to exertional activity. What test confirms the diagnosis?
➔ Coronary angiography
- Note: Vasospastic angina → Clear coronaries on angiogram. It has the same pathophysiology as Raynaud’s syndrome.
- CCB (diltiazem) for prophylaxis, nitrates for acute.
- Smoking = key risk factor.
15. A 66-year-old man presents with chest pain, hypotension, and ST elevation in leads II, III, aVF, and V4R. Lung exam is clear. What is the drug of choice for treating his hypotension?
➔ IV Normal saline
- Note: RVMI is preload dependent.
○ Nitrates, diuretics, opioids → decrease preload and are contraindicated in RVMI
○ Inotropes used for anterior/lateral MI hypotension.
16. A 63-year-old man develops shortness of breath and orthopnea 24 hours after an anterior STEMI. The exam shows JVD, crackles, and BP 160/90 mmHg. He does not improve with oxygen and furosemide. What is the best next step?
➔ IV nitroprusside
- Note: Nitrates reduce cardiac preload.
- CHF management = O₂ + furosemide + IV nitrates.
17. A 64-year-old man presents on day 4 after an inferior MI with sudden dyspnea, hypotension, elevated JVP, and a new soft pansystolic murmur at the apex. What is the diagnosis?
➔ Acute MR
- Note: Acute MR – from papillary muscle rupture post-inferior MI, causing sudden LA overload and pulmonary edema.
- MR = soft, blowing apex murmur.
- VSD = harsh murmur along the left sternal border with thrill.
- Free wall rupture leads to cardiac tamponade.
18. A 62-year-old man has persistent shortness of breath after an anterior STEMI. ECG shows ST elevations and Q waves in V1–V4. Echocardiogram reveals a left ventricular wall bulge. Which medication helps prevent this complication?
➔ ACEi / ARBs
- Note: Persistent ST elevation + Q waves in the same leads months later → LV aneurysm → ↑ embolic stroke risk
- Start ACEi/ARBs early to prevent cardiac remodeling.
19. A 58-year-old man presents with chest pain and ST elevations in leads II, III, and aVF. He had an inferior MI with stent placement 5 months ago but has been noncompliant with medications. Which drugs could have prevented this reinfarction?
➔ Dual antiplatelet therapy- DAPT (Aspirin + clopidogrel x12 months post-stent)
- Note: DAPT is recommended for at least 12 months after stent placement to prevent stent thrombosis and recurrent MI “STEMI in previous leads”.
20. A 58-year-old man presents with 2 hours of chest pain and diaphoresis. He received nitrates, aspirin, and clopidogrel. ECG shows T-wave inversions in the inferior leads. Initial troponin is normal. What is the next best step?
➔ Repeat troponin in 3-6 hours
- Note: In chest pain with no ST-elevation and normal initial troponin, NSTEMI or unstable angina is still possible, as troponin levels typically rise within 3–6 hours.
21. A 60-year-old man presents with chest pain at rest. ECG shows T-wave inversions and ST depressions in the lateral leads. Troponin is negative. What is the diagnosis?
➔ Unstable angina
- Note: Unstable angina – presents with rest angina and ischemic ECG changes without troponin elevation, indicating subendocardial ischemia without myocardial necrosis.
- If troponin were positive, it would indicate NSTEMI instead.
22. A 28-year-old man presents with chest pain after cocaine use. ECG shows ST elevations, and troponins are elevated. What is the next best step in pain management?
➔ IV benzodiazepines
- Note: Cocaine induced MI
○ 1st line → Benzodiazepines ↓ sympathetic surge and pain
○ 2nd line → Nitrates and CCBs
○ Avoid beta-blockers (unopposed alpha vasoconstriction).
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Heart Failure
23. A 58-year-old man with HFrEF on lisinopril, bisoprolol, furosemide, and spironolactone presents with bilateral breast enlargement. Which medication is responsible?
➔ Spironolactone
- Note: Spironolactone causes gynecomastia due to its antiandrogenic effects, including androgen receptor blockade and inhibition of testosterone synthesis.
- Switch to eplerenone (no gynecomastia).
24. A 62-year-old man with HFrEF is taking enalapril, carvedilol, eplerenone, and digoxin. Which of these medications does not reduce mortality?
➔ Digoxin
Drugs that improve mortality in HF
- ACE inhibitors / ARBs
- Beta-blockers
- Aldosterone antagonists
- Sacubitril/valsartan
- SGLT2 inhibitors
25. A 58-year-old woman with hypertension presents with shortness of breath, fever, cough, and pitting edema. CXR shows bilateral infiltrates. What test helps distinguish heart failure from atypical pneumonia?
➔ BNP (sensitive but not specific for HF, as it can also rise in pulmonary problems that lead to right ventricular hypertension)
- Note: It is released by the ventricles in response to increased wall stress from fluid overload. Elevated BNP strongly suggests heart failure,
- BNP is the best to rule out heart failure.
26. A 58-year-old woman with systemic sclerosis presents with exertional dyspnea and leg swelling. Exam reveals JVD, loud P2, clear lungs, and hepatomegaly. What is the most likely diagnosis?
➔ Right-sided heart failure due to pulmonary hypertension
- Note: Clear lungs are a key finding that helps differentiate right-sided heart failure (RHF) from left-sided heart failure (LHF).
- LHF typically presents with pulmonary congestion (crackles, orthopnea, PND) and a PCWP >18
- RHF shows systemic venous signs (JVD, hepatomegaly, edema) without lung findings.
Common Causes of Cor Pulmonale (Isolated RHF)
- Chronic obstructive pulmonary disease (COPD)
- Interstitial lung diseases (e.g., idiopathic pulmonary fibrosis)
- Obstructive sleep apnea (OSA)
- Chronic thromboembolic pulmonary hypertension (CTEPH)
27. A 66-year-old man presents several days after an anterior MI with dyspnea, orthopnea, an S3, and a soft holosystolic murmur at the apex that improves after IV furosemide. What is the most likely cause of the murmur?
➔ Functional MR due to LV dilation
- Note: Functional MR due to LV dilation improves with furosemide
- Papillary muscle rupture: Functional MR murmur, new-onset holosystolic murmur at the cardiac apex. It does not and requires surgery.
- Contrast with → Interventricular septal rupture, where the murmur is also a new-onset holosystolic murmur, but it is heard at the left lower sternal border
Cardiomyopathies
28. A 28-year-old man presents with shortness of breath, orthopnea, and an S3 after a recent flu-like illness. Echocardiogram shows biventricular dilation and an ejection fraction of 35%. What is the most likely diagnosis?
➔ Myocarditis → leading to dilated cardiomyopathy
- Note: Viral infection (e.g., coxsackievirus) is the most common cause.
- S3 + global dilation = systolic dysfunction.
- Viral pericarditis presents with pleuritic chest pain and a friction rub that is not seen in myocarditis
29. A 55-year-old woman with HER2-positive breast cancer on trastuzumab presents with new-onset shortness of breath and orthopnea. What is the auscultatory finding?
➔ S3 gallop
- Note: Trastuzumab → reversible dilated cardiomyopathy
- Anthracyclines (Doxorubicin) → Irreversible (you can prevent it by giving dexrazoxane)
30. A 28-year-old woman, 3 months postpartum, presents with shortness of breath, orthopnea, and bilateral crackles. Echocardiogram shows an ejection fraction of 30%. What is the best initial treatment?
➔ IV Furosemide
- Note: Peripartum CMP is a form of dilated CMP treated similarly to systolic heart failure.
31. A 58-year-old man with Hodgkin lymphoma undergoing radiotherapy presents with shortness of breath, orthopnea, preserved EF (65%), and low-voltage QRS complexes on ECG. What is the diagnosis?
➔ Restrictive CMP
- Note: Restrictive cardiomyopathy caused by radiation-induced myocardial fibrosis leads to diastolic dysfunction with preserved EF and low voltage on ECG.
- HF with Normal EF + Hx of radiotherapy + low voltage QRS = Restrictive CMP
32. A 25-year-old man is found to have a systolic murmur that increases with Valsalva during a routine exam. What is the next step in evaluation?
➔ Echocardiography
| Aortic Stenosis | Hypertrophic Cardiomyopathy |
|---|---|
| Systolic ejection murmur at the right upper sternal border | Systolic ejection murmur at the left upper sternal border |
| Delayed carotid upstroke | Brisk carotid upstroke |
| Decreases with Valsalva maneuver and standing (decreased preload limits the blood flow through the stenosed valve, decreasing the murmur intensity) | Increases with Valsalva maneuver and standing (decreased preload allows us to hear the murmur more clearly) |
Usually presents in older adults, and the primary complaint is exertional syncope. It can also present in younger individuals with a bicuspid aortic valve, which tends to calcify early | The classic scenario is always in a young athlete who has a syncopal episode and requires evaluation for that |
33. Echocardiography confirms hypertrophic obstructive cardiomyopathy (HOCM) in an asymptomatic patient. What is the next step in management?
➔ Advice to avoid high-intensity exercise
- Note: In asymptomatic HOCM, no drugs are indicated.
- The most common cause of death in HOCM is due to ventricular fibrillation
34. A young man with known hypertrophic obstructive cardiomyopathy reports occasional dyspnea and fatigue. What is the best initial management?
➔ Beta blockers
- Note: Symptomatic HOCM, beta blockers are first line or switch to non-dihydropyridine CCB like verapamil if Beta blockers are C.I (e.g, asthma).
35. An 18-year-old male with hypertrophic obstructive cardiomyopathy remains dyspneic despite maximum-dose metoprolol. What is the next step in management?
➔ Surgical myectomy or septal ablation
- Note: HOCM + symptoms despite beta blockers → consider surgical myectomy / septal ablation → ↓ LVOT obstruction
36. A 22-year-old man presents with chest discomfort and dyspnea. His father died suddenly at age 35. Echocardiogram shows asymmetric septal hypertrophy and left ventricular outflow tract (LVOT) obstruction. He is currently on beta blockers. What is the next best step?
➔ Implantable Cardioverter-Defibrillator (ICD)
- Note: Symptomatic HOCM + family history of sudden cardiac death = high-risk → ICD indicated for primary prevention of sudden cardiac death.
HOCM Management
- Asymptomatic: Monitor + Avoid high intensity athletics
- Symptomatic: BB/verapamil
- Severe Sx refractory to Drugs: Septal myectomy or alcohol ablation.
- ICD: If syncope, VT, or family history of SCD.
Heart sounds
37. A 32-week pregnant woman presents with fatigue and mild dyspnea. Cardiac exam reveals a low-pitched early diastolic sound at the apex. What is the most likely finding, and what is the best next step?
➔ S3, Reassurance
Cause of physiological/benign S3
- Children
- Young adults
- Pregnant women (especially in the third trimester)
- Well-trained athletes
S-3, other than these, is always pathological and needs evaluation
38. A 68-year-old man with prior anterior MI has a low-pitched, late diastolic sound before S1, best heard at the apex in the left lateral decubitus position. What is this sound?
➔ S-4 gallop
- Note: S-4 is a low-pitched sound heard just before S1 (late diastole).
- It is caused by forceful atrial contraction against a stiff, noncompliant left ventricle.
- Seen in:
○ Left ventricular hypertrophy (LVH)
○ Myocardial ischemia
○ Old myocardial infarction (MI)
○ It can be heard normally in elderly individuals due to age-related ventricular stiffness.
39. A 25-year-old woman has a grade 2/6 systolic murmur at the left sternal border that decreases with standing. She is asymptomatic. What is the next step?
➔ Reassurance, Benign murmur, so no need to do echo
Benign vs pathologic murmur
- Benign murmur: Soft (grade 1-2), systolic, normal S1 & S2, dec with standing, no symptoms → Only reassurance
- Pathological murmur: Loud (grade 3+), holosystolic/diastolic, increases with standing, associated with symptoms → Need Echo
Pericardial conditions
40. A 60-year-old man who recently immigrated from Africa presents with shortness of breath. The exam shows elevated JVP, pericardial knock, and ascites. CXR reveals a calcified heart. What is the diagnosis?
➔ Constrictive pericarditis
- Note: In TB endemic areas, MC cause is TB
- In the USA, MC is viral pericarditis followed by radiation.
41. A 58-year-old man from India presents with fatigue, ascites, edema, and the echo shows biatrial enlargement, calcifications around the heart on CT, and low voltage QRS. What is the definitive management?
➔ Pericardiectomy
- Note: Diuretics are only for symptomatic treatment of constrictive pericarditis
42. A 32-year-old man presents with sharp, pleuritic chest pain. Exam reveals a scratchy, high-pitched sound. What is the diagnosis?
➔ Acute pericarditis
- Note: (Scratchy/squeaking/grating sound + pleuritic chest pain = Acute pericarditis)
- Pericarditis can also present as a complication of MI. There are mainly two types, fibrinous pericarditis (presents days after an MI) and autoimmune pericarditis (Dressler syndrome- presents weeks to months after an MI)
43. A 30-year-old man presents with sharp, pleuritic chest pain. ECG shows diffuse ST elevations and PR depressions. What is the most common cause of this condition?
➔ Viral infection (coxsackie) → MC cause of acute pericarditis (other causes include SLE, Uremia, etc)
44. A 48-year-old man with metastatic lung cancer presents with dizziness. BP drops from 94/60 to 80/55 mmHg on inspiration. The exam shows JVD, muffled heart sounds, and clear lungs. What is the diagnosis?
➔ Cardiac tamponade (elevated JVP + hypotension + muffled heart sounds- classic Beck’s triad)
- Note: Pulsus paradoxus (>10 mmHg drop) + clear lungs points to tamponade.
45. A 45-year-old man presents with hypotension, JVD, muffled heart sounds, and clear lungs. What is the next best step?
➔ Urgent pericardiocentesis
- Note: Clinical signs point to tamponade → pericardiocentesis is life-saving. Echo will delay the treatment.
- Important clinical cue to differentiate tamponade from CHF
○ Tamponade: Muffled heart sounds, clear lungs.
○ LVF/CHF: S3 and bilateral lung crackles.
46. A 60-year-old man presents with pleuritic chest pain. ECG is normal. Labs show urea 132 mg/dL and creatinine 3.4 mg/dL. What is the next step in management?
➔ Hemodialysis
- Note: In Uremic pericarditis, typical ECG findings of Diffuse ST-elevation/PR-depression are not seen.
Management of Pericarditis
- Viral/idiopathic pericarditis → NSAIDs/colchicine are 1st line. Steroids are 2nd line
- Uremic pericarditis → Dialysis is 1st line
- Pericarditis in the immediate post-MI period → High dose aspirin (NSAIDs and steroids are avoided in early post-MI, as they impair healing)
Arrhythmias
47. A young woman presents with weight loss, palpitations, and a irregularly irregular pulse. ECG shows atrial fibrillation. What is the next step in diagnosis?
➔ Thyroid function tests
- Note: Beta Blockers treat both conditions.
- New-onset AFib → check TSH first; if normal, do echocardiography to rule out structural causes like mitral stenosis.
48. A 40-year-old male with atrial fibrillation and a heart rate of 154/min is a known asthmatic. Drug of choice?
➔ Verapamil
- Note: Rate control in AF with asthma, non-dihydropyridine CCBs like verapamil are preferred over beta-blockers to avoid bronchospasm.
49. A 60-year-old man with hypertension and ischemic heart disease presents with dizziness. BP is 70/40 mmHg, HR 167/min. ECG shows atrial fibrillation with rapid ventricular response. What is the best next step?
➔ Synchronized cardioversion
Management of A-Fib with rapid ventricular rate
- Hemodynamically Stable: Rate control with β-blocker or non-DHP CCB
- Unstable (e.g., hypotension, chest pain): Immediate synchronized cardioversion
50. A 67-year-old woman with atrial fibrillation, hypertension, and diabetes has a well-controlled heart rate on bisoprolol. What is the next step in management?
➔ Start oral anticoagulation (Warfarin/rivaroxaban)
- Note: CHA₂DS₂-VASc score ≥2 warrants anticoagulation to reduce stroke risk.
51. A 50-year-old man with hypertension has a first-degree AV block. What is the next step?
➔ Reassurance
- Note: 1st degree heart block + normal QRS complex= Monitor/reassure
- 2nd degree type 1 heart block = Monitor/Reassurance
- 2nd degree type 2 heart block = Intracardiac pacemaker
52. A 68-year-old man with chest pain and dizziness is diagnosed with inferior wall MI. ECG shows complete AV dissociation. What is the next step in management?
➔ Temporary pacemaker
- Note: AV- dissociation (atria and ventricles beat independently) on ECG = Complete heart block → always treat with a pacemaker
53. A 23-year-old woman presents with palpitations. ECG shows regular, narrow QRS complexes at 180 bpm with no visible P waves. What is the drug of choice?
➔ Adenosine
- Note: SVT is characterized by a regular, rapid rhythm with absent P waves; the first line is vagal maneuvers. If refractory to them, go for I/V adenosine for termination of rhythm
- Synchronised cardioversion if hemodynamically unstable.
- Non-pharmacological measures to terminate SVT include:
○ Valsalva maneuver
○ Carotid sinus massage
○ Cold water face immersion
54. A 65-year-old man presents for a routine check-up. ECG shows occasional premature ventricular complexes (PVCs). What is the next step in management?
➔ Reassure
- Note: Occasional PVCs in an asymptomatic patient → Reassure
- PVCs with symptoms (palpitations) → beta blockers
55. A 58-year-old man with a history of ischemic heart disease presents with ventricular tachycardia and is hemodynamically stable. What is the next best step?
➔ Amiodarone or lidocaine
VT management in different presentations
- In stable VT, antiarrhythmic drugs like amiodarone or lidocaine are used for rhythm control.
- Hemodynamically unstable VT: VT with hypotension or signs of shock → synchronized cardioversion.
- Pulseless VT: VT with no pulse → Start with chest compressions, and then move to immediate defibrillation.
56. A 68-year-old man with ischemic heart disease and HFrEF has a brief syncopal episode while watching TV. No prodrome; he quickly regained consciousness and is vitally stable. What is the cause of syncope?
➔ Ventricular arrhythmia (likely VT secondary to structural heart disease)
- Note: Syncope at rest without a postictal state in the background of IHD makes cardiogenic syncope more likely.
57. A 63-year-old man with ischemic heart disease has recurrent episodes of ventricular tachycardia despite medical therapy. What is the next step?
➔ Check electrolytes → Recurrent monomorphic VT caused by elevated K⁺ & low calcium. If polymorphic VT (torsades pointes), then hypomagnesemia can be a likely cause
58. A 50-year-old man with Wolff-Parkinson-White (WPW) syndrome and a history of atrial fibrillation asks about long-term management. What is the most effective treatment?
➔ Catheter ablation
- Note: In WPW, catheter ablation of the accessory pathway is the definitive treatment.
- In WPW, the most useful drug is procainamide (remember that it can lead to drug-induced lupus; antihistone antibodies)
- Avoid drugs like adenosine, beta blockers, digoxin, and non-DHP-CCBs they can promote conduction via accessory pathway and inc the risk of Afib to VFib.
59. A 62-year-old man with acute MI suddenly collapses and dies shortly after presentation. What is the most likely cause of death?
➔ Ventricular fibrillation (VFib), the most common cause of death (<24 hrs) after MI
60. A 28-year-old woman is brought to the ER after a syncopal episode. ECG shows polymorphic ventricular tachycardia with prolonged QT. She recently started erythromycin for a respiratory infection. What is the most likely diagnosis?
➔ Torsades de Pointes
- Note: Common Risk Factors for Torsades de Pointes:
1. ↓ Potassium (K⁺), ↓ Magnesium (Mg²⁺), ↓ Calcium (Ca²⁺)
2. Drugs: Antiarrhythmics (e.g., quinidine, sotalol), macrolides, fluoroquinolones, antipsychotics (e.g., haloperidol), TCAs, methadone
3. Congenital long QT syndrome
61. A 42-year-old woman presents with palpitations. ECG shows torsades de pointes. She is hemodynamically stable and has normal serum magnesium. What is the next step in management?
➔ IV magnesium sulfate as a patient is stable hemodynamically
- Note: For torsades, even Mg levels are normal/unavailable, still DOC is Mg if stable
- If unstable Torsades de Pointes → Defibrillation
Defibrillation vs synchronized cardioversion
- Defibrillation → V-Fib and pulseless VT
- Synchronized cardioversion → Hemodynamically unstable atrial arrhythmias like afib, SVT, and VT with pulse.
62. A 65-year-old man collapses suddenly at home. Bystanders initiate CPR. EMS arrives and finds no detectable pulse with organized electrical activity on ECG. What is the next best step?
➔ Continue CPR and IV epinephrine every 3–5 minutes
- Note: Pulseless electrical activity (PEA) — a non-shockable rhythm.
- Defibrillation/cardioversion is not indicated.
- Identifying and treating reversible causes. These include:
| 5 Hs | 5 Ts |
|---|---|
| 1. Hypovolemia 2. Hypoxia 3. H⁺ (acidosis) 4. K⁺ (↓/↑) 5. Hypothermia | 1. Tension pneumothorax 2. Tamponade 3. Toxins 4. Thrombosis (PE) 5. Thrombosis (MI) |
63. A 55-year-old man presents with confusion, HR 38 bpm, and BP 80/50 mmHg after a beta-blocker overdose. ECG shows sinus bradycardia. What is the drug of choice?
➔ IV glucagon
- Note: Sinus Bradycardia Management
○ Asymptomatic sinus bradycardia → Usually no treatment needed
○ Symptomatic sinus bradycardia → Atropine IV & if atropine fails, then Transcutaneous pacing
○ Beta-blocker or calcium channel blocker overdose → IV glucagon (for beta-blocker) or IV calcium (for CCB overdose)
○ Digoxin toxicity → Digoxin-specific antibody fragments (Digoxin immune Fab)
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Aortic Diseases
64. A 70-year-old man presents with abdominal pain and a pulsatile abdominal mass. What is the single most important risk factor for this condition?
➔ Abdominal aortic aneurysm → Smoking
- Note: The most important R.F. for AAA formation is smoking
65. A 68-year-old man with a 40-pack-year smoking history presents for a routine check-up. He is asymptomatic. What is the next step in management?
➔ Abdominal ultrasound to screen for abdominal aortic aneurysm (AAA)
Male + age is between 65 to 75 + Smoking (even if they’ve quit) → Screen for AAA by one-time abdominal USG
66. A 67-year-old man, an ex-smoker, presents with a pulsatile abdominal mass. Ultrasound reveals a 6 cm abdominal aortic aneurysm. What is the next step in management?
➔ Surgical repair
- Note: AAA > 5.5cm or <5.5 cm but grown by 1 cm in the past year → Repair
- AAA <5.5 cm → Monitor
67. A 62-year-old man with hypertension and smoking history presents with sudden-onset tearing chest pain radiating to the back. BP is 160/100 in the right arm and 140/85 in the left. What test confirms the diagnosis?
➔ CT angio
- Note: Best initial test: CXR → Mediastinal widening
- Best test to confirm:
○ If stable, do CT angio to confirm.
○ If unstable, do a Transesophageal echo in OT to confirm.
- In aortic pathologies (i.e, aortic dissection, coarctation) always do TEE (Transesophageal echo) not the TTE.
- TTE (Transthoracic echo) has low sensitivity in detecting aortic pathologies.
68. A 60-year-old man presents with tearing chest pain and BP 180/105 mmHg. TEE confirms a descending aortic dissection. What is the next best step?
➔ IV labetalol
- Note: Ascending dissection → I/V beta blocker (esmolol is preferred due to its short-acting nature, but you can also use labetalol) + surgery
- Descending dissection → I/V labetalol
69. A 67-year-old man with diabetes, hypertension, and a history of smoking presents with chest pain and is diagnosed with aortic dissection. What is the single most important risk factor?
➔ Hypertension
- Note: Other risk factors for aortic dissection
1. Connective tissue disorders (e.g., Marfan syndrome, EDS)
2. Bicuspid aortic valve
3. Aortic aneurysm
4. Cocaine use
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Limb Ischemia
70. A 67-year-old man with diabetes and hypertension presents with calf pain during walking that is relieved by rest. What is the next best step? What is the best test to confirm the diagnosis?
➔ PAD → Next step Ankle-brachial index (ABI) & Confirm via Doppler USG if ABI is abnormal (≤ 0.9)
- Note: → If a patient has PAD → It indicates that they likely also have coronary artery disease → We should give statins + aspirin for prevention of ACS
PAD management
- Smoking cessation
- Structured exercise therapy
- Antiplatelet therapy (aspirin or clopidogrel)
- Statins for atherosclerosis
- Optimize glycemic and blood pressure control
- Cilostazol → inhibits PDE III → inhibition of platelet aggregation & vasodilation
- Revascularization for lifestyle-limiting symptoms or critical limb ischemia
71. A patient with atrial fibrillation presents with severe right leg pain and absent distal pulses. What is the best next step?
➔ Administer heparin
- Note: In acute limb ischemia, heparin is given first, followed by diagnostic evaluation (e.g., Doppler USG).
72. A 56-year-old man with a history of anterior wall MI presents with acute limb ischemia and undergoes stenting. ECG shows sinus rhythm. What is the best test to confirm the cause of the leg ischemia?
➔ Echocardiogram
- Note: The most common cause of acute leg ischemia is atrial fibrillation, followed by mural thrombus. Since this patient has sinus rhythm, the next step is an echocardiogram to rule out mural thrombus post-AWMI.
Valvular pathologies
73. A 52-year-old woman with chronic mitral regurgitation and an ejection fraction of 45% presents with fatigue and dyspnea. What is the best next step in management?
➔ Mitral valve repair (For Mitral valve, Repair >> Replacement)
Indications for Mitral Valve Repair in Chronic MR
- Symptomatic severe MR with EF 30–60%
- Asymptomatic severe MR with EF < 60%
74. A 38-year-old woman with a history of rheumatic fever presents with dyspnea and orthopnea. Exam reveals a loud S1, opening snap, and mid-diastolic murmur. Echo shows mitral stenosis with a valve area of 0.9 cm². What is the next best step?
➔ Mitral valve replacement
- Note: Indications for mitral valve intervention in severe MS:
- Symptomatic patients with severe MS (valve area ≤1.5 cm²)
- Asymptomatic patients with severe MS and:
○ Pulmonary hypertension (resting PASP >50 mmHg)
○ New-onset atrial fibrillation - For stenotic mitral valve with unfavourable anatomy: replacement > repair
- First-line for MS with favorable valve morphology and no other complications -> percutaneous balloon valvotomy
75. A 55-year-old man presents with exertional dyspnea and a systolic murmur at the right upper sternal border. Echo confirms aortic stenosis. What is the most likely cause of this valvular abnormality?
➔ Bicuspid aortic valve
- Note: Age >70 → Senile (age-related) calcific aortic stenosis
- Age <70 → Bicuspid aortic valve (early degeneration)
Aortic valve replacement indications in aortic stenosis
- Symptomatic severe AS → Dyspnea, angina, syncope
- Severe AS with LVEF < 50% → Even if asymptomatic
- Severe AS + other cardiac surgery → CABG or aortic surgery
76. A 58-year-old man with aortic stenosis has a BP of 100/84 mmHg and a late-peaking systolic murmur. What is the best next step in management?
➔ Valve replacement
- Note: Narrow pulse pressure (<25 mmHg) and late-peaking systolic murmur = Severe AS → Valve replacement
77. A tall, thin man with long limbs, scoliosis, high-arched palate, and joint hypermobility presents with chest pain. What cardiovascular finding is most likely associated with this condition?
➔ AR → Aortic root dilation (Marfan syndrome)
Indications for Aortic Valve Replacement (AVR) in AR
- Symptomatic severe AR → Symptoms of heart failure or angina
- Severe AR with LVEF ≤ 50% → LV systolic dysfunction
- Undergoing other cardiac surgery → CABG or aortic surgery
78. A 34-year-old IV drug user presents with fever, a new early diastolic murmur, and new-onset AV block on ECG. What is the most likely diagnosis? What is the next best step?
➔ Perivalvular abscess (The next step → Echo)
- Note: IV drug user + new onset AR + fever + AV-block = Perivalvular abscess
79. A 35-year-old IV drug user presents with fever, chills, a new systolic murmur, and splinter hemorrhages. What is the best next step in management?
➔ Obtain blood cultures
- Note: Fever + new onset murmur = IE (Blood culture >> before antibiotics)
- Other features include:
○ Janeway lesions (painless erythematous macules on palms and soles due to septic emboli)
○ Osler nodes (painful, tender subcutaneous nodules on fingers/toes)
○ Splinter hemorrhages (linear reddish-brown streaks under the nails)
80. A 27-year-old IV drug user presents with fever and a new murmur. Blood cultures are pending. What is the drug of choice for empiric treatment?
➔ IV Vancomycin (Covers MRSA and other common pathogens in suspected infective endocarditis)
Common causes of IE in different scenarios
1) Native valve: Streptococcus viridans (Dental procedures), Staphylococcus aureus
2) Prosthetic valve: Staphylococcus epidermidis
3) IV drug use: Staphylococcus aureus
4) Acute: Staphylococcus aureus
5) Subacute: Streptococcus viridans
6) Colon cancer: Streptococcus gallolyticus or Streptococcus bovis
81. A patient with a history of mitral valve prolapse plans to undergo a dental procedure. What is the antibiotic recommendation for him?
➔ No antibiotics are recommended
- Note: There are certain indications for antibiotic prophylaxis to prevent infective endocarditis in people who are at risk. The antibiotic prophylaxis recommendation is amoxicillin one hour before the procedure. Here are the people who should receive the antibiotic prophylaxis:
○ Prosthetic heart valves
○ Previous history of infective endocarditis
○ Unrepaired cyanotic congenital heart defect
○ Repaired congenital heart defects with shunts or regurgitation
○ Transplanted heart with a defective valve
Tip: Please note that no one besides patients with these conditions should receive any antibiotic prophylaxis for dental procedures
82. A 36-year-old man who recently immigrated from Uganda presents with exertional dyspnea and a pansystolic murmur best heard at the apex, radiating to the axilla. What is the most likely cause of this valvular abnormality?
➔ Rheumatic fever
- Note: MC cause of MR in underdeveloped countries → Rheumatic fever
- MC cause of MR in developed countries → Mitral valve prolapse (MVP)
83. A 15-year-old was diagnosed with rheumatic fever based on joint pain and elevated ASO titers. His echo is normal with no evidence of carditis. Prophylaxis recommendation?
➔ Benzathine penicillin every 4 weeks for 5 years or until age 21, whichever is longer
Duration of ABx prophylaxis:
- No carditis: 5 years or until age 21 (whichever is longer)
- Carditis, but no residual heart disease: 10 years or until age 21
- Carditis with persistent valvular disease (e.g., mitral stenosis): 10 years or until age 40
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CVS Pharmacology
84. A patient with HFrEF presents with nausea, vomiting, and yellowish vision with halos. What is the expected ECG finding
➔ Atrial tachycardia with AV block (classic finding in digoxin toxicity)
- Note: Common ECG findings in digoxin toxicity:
○ Atrial tachycardia with AV block (very classic)
○ ST-segment depression (scooped appearance)
○ PVCs.
85. A 56-year-old man with ischemic heart disease on aspirin, rosuvastatin, amlodipine, and spironolactone presents with tall T waves on ECG. What is the culprit drug?
➔ Spironolactone
- Note: K+ sparing diuretics (spironolactone, eplerenone & amiloride) cause hyperkalemia, which presents with tall, peaked T-waves on ECG.
86. A patient presents with palpitations, wide QRS complexes, and tall, peaked T waves on ECG. What is the next best step?
➔ IV calcium gluconate or IV calcium carbonate
Hyperkalemia Management
- IV calcium gluconate – stabilize the heart
- Insulin + glucose, albuterol – shift K⁺ into cells
- Diuretics, dialysis – remove K⁺ from the body
87. A patient with heart failure on digoxin recently started furosemide and now shows signs of digoxin toxicity. What test helps detect the cause of toxicity?
➔ Serum potassium
- Note: Other risk factors for digoxin toxicity:
1. Renal impairment
2. Amiodarone
3. Verapamil
88. A 58-year-old man with metabolic syndrome presents with dizziness and flushing after starting OTC supplements for hyperlipidemia. What is the best next step?
➔ Stop the supplement (likely containing niacin → release prostaglandins ) and start aspirin to alleviate symptoms
89. A 60-year-old man with coronary artery disease on nitrates takes a medication for erectile dysfunction and develops severe hypotension. What is the likely drug?
➔ Sildenafil (PDE-5 inhibitor)
- Note: Sildenafil with nitrates combined can cause severe hypotension due to enhanced vasodilation.
- Another key toxicity is cyanopsia (blue-tinted vision) from PDE-5 inhibition.
90. A 52-year-old man with ischemic heart disease, hypertension, and hyperlipidemia is on high-intensity atorvastatin, but LDL remains 160 mg/dL. What is the next drug to add?
➔ Ezetimibe
- Note: Ezetimibe is preferred for additional LDL lowering. Fibrates primarily target triglycerides and increase the risk of myopathy and rhabdomyolysis when combined with statins.
91. A 65-year-old man with HFrEF presents with dyspnea, dry cough, blue-gray skin discoloration, fatigue, constipation, and infiltrates on chest X-ray. What drug is responsible?
➔ Amiodarone
- Note: Amiodarone is the likely cause due to its known side effects of pulmonary toxicity (infiltrates), hypothyroidism, and blue-gray skin discoloration.
92. A 60-year-old man with ventricular arrhythmias is planned to start amiodarone therapy. Before initiating treatment, which baseline evaluations are essential?
➔ TFTs, PFTs, LFTs (to monitor for thyroid, lung, and liver toxicity)
93. A 50-year-old man with hypertension and diabetes has an LDL of 140 mg/dL and triglycerides of 360 mg/dL. What is the drug of choice for managing his dyslipidemia?
➔ Statins
- Note: Statins are first-line because they effectively lower LDL, reduce cardiovascular risk, and provide some triglyceride reduction.
- Fibrates are only the correct answer if TAGs are very high > 500 mg/dl, as this puts the patient at risk for acute pancreatitis.
Carotid dissection
94. A 32-year-old man presents with sudden right-sided neck pain, headache, ptosis, and miosis after minor neck trauma during soccer. No motor deficits. What is the diagnosis?
➔ Carotid artery dissection
95. A 35-year-old woman has left-sided neck pain, headache, and right arm numbness after neck hyperextension during yoga. Exam reveals left ptosis and miosis. What test confirms the diagnosis?
➔ CT/MR angiography of the head and neck
Carotid dissection
- Tear in carotid wall → hematoma → stroke risk.
- Seen in young adults after minor neck trauma/ yoga.
- Risk factors: neck injury, Ehlers-Danlos, Marfan, HTN.
- Presents with unilateral neck pain, headache, partial Horner (ptosis + miosis, no anhidrosis), and TIA/stroke signs.
- Best test: CT/MR angiography (CTA/MRA).
- Treatment: Aspirin or anticoagulation.
Blunt cardiac injuries
96. A trauma patient with chest wall bruising after a fall develops hypotension and elevated jugular venous pressure. ECG shows low-voltage QRS complexes. What is the diagnosis?
➔ Cardiac tamponade
- Note: Blunt chest trauma can cause cardiac tamponade presents with hypotension, elevated jugular venous pressure (JVP), and muffled heart sounds (Beck’s triad).
- ECG may be nonspecific or show low voltage.
- Dx: Clinical diagnosis (can supplement with echo)
- Rx: Pericardiocentesis
97. A patient presents after blunt chest trauma with chest pain. Chest exam, vitals, and ECG are normal, but troponins are elevated. What is the diagnosis?
➔ Myocardial contusion
Myocardial contusion
- Elevated troponin indicates myocardial injury despite normal ECG and vitals.
- Management includes cardiac monitoring (telemetry) for arrhythmias and instability.
- Repeat ECGs and troponins to monitor for progression.
🏁 Final Thoughts
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Disclaimer
Version 1.0 August 2025. No part of this document may be reproduced or distributed without written permission. For personal study only. Medical information herein is for educational purposes and does not constitute clinical advice. Always confirm with current guidelines and your institution’s policies.
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