Free Internal Medicine Cardiovascular Disease Management Questions and Answers — Questions and Answers
Question 1: A 62-year-old male with a history of hypertension and dyslipidemia presents to the emergency department with severe, substernal chest pain that started 2 hours ago. An ECG shows ST-segment elevation in the anterior leads. He undergoes successful percutaneous coronary intervention (PCI) with the placement of a drug-eluting stent in his left anterior descending artery. According to the most recent ACC/AHA guidelines, what is the recommended minimum duration of dual antiplatelet therapy (DAPT) for this patient?
- 3 months
- 6 months
- 12 months (Correct answer)
- 24 months
Correct answer: 12 months
For patients who have undergone PCI with a drug-eluting stent after an ST-elevation myocardial infarction (STEMI), which is a form of acute coronary syndrome (ACS), the standard recommendation is at least 12 months of DAPT (aspirin plus a P2Y12 inhibitor). This duration is proven to reduce the risk of stent thrombosis and major adverse cardiovascular events. Shorter durations may be considered in patients with a very high bleeding risk, while longer durations might be considered in those with low bleeding risk and high ischemic risk.
Question 2: A 58-year-old female without known cardiovascular disease presents for a routine physical exam. She has a history of hypertension, is a former smoker (quit 10 years ago), and her father had a myocardial infarction at age 55. Her blood pressure is 135/85 mmHg, total cholesterol is 210 mg/dL, and HDL is 45 mg/dL. Her calculated 10-year ASCVD risk is 8.5%. According to 2019 ACC/AHA guidelines on primary prevention, what is the most appropriate next step in management?
- Initiate high-intensity statin therapy immediately.
- Recommend lifestyle modifications only.
- Initiate moderate-intensity statin therapy after a clinician-patient risk discussion. (Correct answer)
- Order a coronary artery calcium (CAC) score before deciding on statin therapy.
Correct answer: Initiate moderate-intensity statin therapy after a clinician-patient risk discussion.
The patient falls into the intermediate-risk category (ASCVD risk ≥7.5% to <20%). In this group, the guidelines recommend a clinician-patient risk discussion to review risk-enhancing factors and consider the potential benefits and harms of statin therapy. If a decision is made to treat, initiating a moderate-intensity statin is the recommended first-line approach. A CAC score is a reasonable option if risk-based decisions remain uncertain after this discussion.
Question 3: A 74-year-old woman with a history of hypertension and type 2 diabetes is diagnosed with heart failure with preserved ejection fraction (HFpEF), with an LVEF of 55%. She experiences dyspnea on exertion. Her current medications include lisinopril and metformin. Which of the following medication classes has been shown in major clinical trials to reduce the composite endpoint of cardiovascular death and heart failure hospitalizations in patients with HFpEF?
- Beta-blockers
- Angiotensin receptor-neprilysin inhibitors (ARNIs)
- Loop diuretics
- Sodium-glucose cotransporter-2 (SGLT2) inhibitors (Correct answer)
Correct answer: Sodium-glucose cotransporter-2 (SGLT2) inhibitors
Large randomized controlled trials, such as EMPEROR-Preserved and DELIVER, have demonstrated that SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin) significantly reduce the primary composite endpoint of cardiovascular death or hospitalization for heart failure in patients with HFpEF. While ARNIs and MRAs may have a role, particularly in patients with LVEF on the lower end of the preserved spectrum, SGLT2 inhibitors have a broader and stronger recommendation for this patient population. Loop diuretics manage symptoms of congestion but do not have a mortality benefit.
Question 4: A 67-year-old male presents with a 3-month history of predictable, substernal chest discomfort that occurs when he walks uphill and resolves within 5 minutes of rest. He has a normal resting ECG and no history of myocardial infarction. Which of the following is the most appropriate initial non-invasive test to evaluate for coronary artery disease?
- Coronary MRA (Magnetic Resonance Angiography)
- Exercise stress echocardiography (Correct answer)
- Resting 2D echocardiogram
- Coronary angiography
Correct answer: Exercise stress echocardiography
For a patient with an intermediate pre-test probability of stable coronary artery disease who is able to exercise and has a normal baseline ECG, an exercise stress test is the recommended initial diagnostic step. An exercise stress echocardiogram provides both functional (ECG changes, symptoms) and imaging (wall motion abnormalities) data, which increases its diagnostic accuracy compared to an exercise ECG alone. A resting echo is not sufficient to diagnose ischemia, and coronary angiography is an invasive test reserved for high-risk patients or when non-invasive testing is inconclusive.
Question 5: A 55-year-old African American male is diagnosed with Stage 1 Hypertension with an average blood pressure of 138/88 mmHg on multiple readings. He has no other comorbidities. His 10-year ASCVD risk score is calculated to be 12%. According to the 2025 ACC/AHA guidelines, what is the most appropriate initial monotherapy?
- Amlodipine (Correct answer)
- Lisinopril
- Metoprolol
- Spironolactone
Correct answer: Amlodipine
For African American adults with hypertension but without heart failure or chronic kidney disease, the ACC/AHA guidelines recommend either a thiazide-type diuretic or a calcium channel blocker (CCB) as first-line therapy. ACE inhibitors or ARBs are less effective as monotherapy in this population for blood pressure control, although they may be used in combination. Beta-blockers are not considered first-line agents for uncomplicated hypertension.
Question 6: A 70-year-old female with a history of heart failure and hypertension presents to the emergency department with acute-onset severe dyspnea, orthopnea, and a cough producing pink, frothy sputum. On examination, her blood pressure is 180/100 mmHg, heart rate is 110 bpm, and respiratory rate is 30/min. Auscultation reveals diffuse crackles throughout both lung fields. Oxygen saturation is 88% on room air. After applying oxygen, what is the most critical next step in management?
- Administer intravenous dobutamine
- Administer a high-dose intravenous loop diuretic
- Administer intravenous nitroglycerin (Correct answer)
- Obtain a B-type natriuretic peptide (BNP) level
Correct answer: Administer intravenous nitroglycerin
This patient is presenting with hypertensive acute decompensated heart failure, specifically flash pulmonary edema. The immediate priority is to reduce both preload and afterload. Intravenous vasodilators, such as nitroglycerin, are the key component of care in this scenario. They rapidly decrease afterload, leading to improved cardiac output and resolution of pulmonary congestion. While diuretics are important, their onset is slower, and afterload reduction is the most urgent priority in a hypertensive crisis. Dobutamine is an inotrope and is not indicated in a hypertensive patient. A BNP level can confirm the diagnosis but should not delay critical treatment.
Free Internal Medicine Cardiovascular Disease Management Questions and Answers
A 62-year-old male with a history of hypertension and dyslipidemia presents to the emergency department with severe, substernal chest pain that started 2 hours ago.
An ECG shows ST-segment elevation in the anterior leads.
He undergoes successful percutaneous coronary intervention (PCI) with the placement of a drug-eluting stent in his left anterior descending artery.
According to the most recent ACC/AHA guidelines, what is the recommended minimum duration of dual antiplatelet therapy (DAPT) for this patient?