Internal Medicine Cardiovascular Disease Questions and Answers — Questions and Answers
Question 1: A 68-year-old male with a history of stable ischemic heart disease underwent percutaneous coronary intervention (PCI) with a drug-eluting stent to the left anterior descending artery one year ago. He has been asymptomatic on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. He has a high bleeding risk (PRECISE-DAPT score of 30). According to the most recent ACC/AHA guidelines, what is the most appropriate recommendation for his antiplatelet therapy at this time?
- Continue DAPT for at least another 12 months.
- Discontinue clopidogrel and continue aspirin monotherapy. (Correct answer)
- Discontinue aspirin and continue clopidogrel monotherapy.
- Discontinue both aspirin and clopidogrel.
Correct answer: Discontinue clopidogrel and continue aspirin monotherapy.
For a patient with stable ischemic heart disease (SIHD) who is at high risk for bleeding and has completed 12 months of DAPT after receiving a drug-eluting stent, guidelines support transitioning to single antiplatelet therapy. In patients with SIHD treated with a drug-eluting stent, DAPT for 6 months is generally recommended. For patients with a high bleeding risk, this duration can be shortened to 3 months. Since this patient has completed 12 months, discontinuing the P2Y12 inhibitor (clopidogrel) and continuing aspirin monotherapy is the standard of care.
Question 2: A 76-year-old female with a history of hypertension and type 2 diabetes mellitus is diagnosed with non-valvular atrial fibrillation. Her CHA2DS2-VASc score is calculated to be 4. Which of the following is the most appropriate management for stroke prevention in this patient?
- No antithrombotic therapy is needed.
- Aspirin 81 mg daily.
- Aspirin 325 mg and clopidogrel 75 mg daily.
- Oral anticoagulation with a direct oral anticoagulant (DOAC) or warfarin. (Correct answer)
Correct answer: Oral anticoagulation with a direct oral anticoagulant (DOAC) or warfarin.
A CHA2DS2-VASc score of 2 or greater in males, or 3 or greater in females, indicates a high risk of stroke, and oral anticoagulation is recommended. This patient's score is 4 (1 for hypertension, 1 for age 65-74, 1 for diabetes, 1 for female sex), placing her at high risk for thromboembolic events. Therefore, oral anticoagulation is the indicated therapy. Aspirin alone or dual antiplatelet therapy is not considered sufficient for stroke prevention in this risk category.
Question 3: A 62-year-old male presents to the emergency department with 3 hours of substernal chest pressure. His ECG shows ST-segment depression in the lateral leads. Initial troponin levels are elevated. He is diagnosed with NSTE-ACS (Non-ST-Elevation Acute Coronary Syndrome). In addition to aspirin, nitrates, and a high-intensity statin, which of the following is a critical component of initial medical management?
- Immediate administration of a thrombolytic agent.
- Initiation of an ACE inhibitor within the first hour.
- Administration of a P2Y12 inhibitor and an anticoagulant. (Correct answer)
- Urgent cardioversion.
Correct answer: Administration of a P2Y12 inhibitor and an anticoagulant.
The initial management of NSTE-ACS involves a combination of anti-ischemic and antithrombotic therapies. Antithrombotic therapy is crucial and consists of both an antiplatelet agent (aspirin plus a P2Y12 inhibitor like clopidogrel or ticagrelor) and an anticoagulant (such as unfractionated heparin, enoxaparin, or fondaparinux). Thrombolytics are contraindicated in NSTEMI. While ACE inhibitors are important for long-term management, their immediate initiation is not as critical as antithrombotic therapy. Cardioversion is not indicated unless there is a life-threatening arrhythmia.
Question 4: Which of the following medication classes has been shown in recent large clinical trials to reduce the composite risk of cardiovascular death or hospitalization for heart failure in patients with Heart Failure with preserved Ejection Fraction (HFpEF)?
- Beta-blockers
- Angiotensin-converting enzyme (ACE) inhibitors
- Sodium-glucose cotransporter-2 (SGLT2) inhibitors (Correct answer)
- Loop diuretics
Correct answer: Sodium-glucose cotransporter-2 (SGLT2) inhibitors
Recent major clinical trials, such as EMPEROR-Preserved (empagliflozin) and DELIVER (dapagliflozin), have demonstrated that SGLT2 inhibitors significantly reduce the primary composite outcome of cardiovascular death or hospitalization for heart failure in patients with HFpEF. While beta-blockers, ACE inhibitors, and ARBs are mainstays in HFrEF, they have not shown a clear mortality or hospitalization benefit in HFpEF. Loop diuretics are used for symptom management of congestion but do not modify the disease course.
Question 5: A 55-year-old man is newly diagnosed with Stage 1 Hypertension with a blood pressure of 136/88 mmHg on multiple readings. He has no other medical problems, and his 10-year atherosclerotic cardiovascular disease (ASCVD) risk is calculated to be 6%. According to the 2025 ACC/AHA guidelines, what is the most appropriate initial management step?
- Initiate therapy with a thiazide diuretic.
- Start treatment with an ACE inhibitor.
- Recommend a 3- to 6-month trial of lifestyle modifications. (Correct answer)
- Initiate combination therapy with an ARB and a calcium channel blocker.
Correct answer: Recommend a 3- to 6-month trial of lifestyle modifications.
According to the 2025 ACC/AHA hypertension guidelines, for adults with Stage 1 hypertension (130-139/80-89 mmHg) and a low 10-year ASCVD risk (<7.5% using the PREVENT calculator), the initial recommendation is a trial of lifestyle modifications for 3 to 6 months. Pharmacologic therapy is recommended if blood pressure remains elevated after this trial. For those with Stage 1 hypertension and a high ASCVD risk (≥7.5%) or with clinical CVD, diabetes, or CKD, both lifestyle changes and antihypertensive medication are recommended from the start.
Question 6: A 79-year-old male with known coronary artery disease, prior myocardial infarction, and systolic heart failure (LVEF 30%) presents with recurrent episodes of syncope. A 12-lead ECG shows sinus rhythm with a left bundle branch block and a QRS duration of 160 ms. He is on optimal guideline-directed medical therapy. Which of the following interventions is most likely to improve his symptoms and reduce mortality?
- Ablation of the AV node and placement of a single-chamber pacemaker.
- Implantation of a subcutaneous implantable cardioverter-defibrillator (S-ICD).
- Implantation of a cardiac resynchronization therapy with defibrillator (CRT-D) device. (Correct answer)
- Coronary artery bypass grafting (CABG).
Correct answer: Implantation of a cardiac resynchronization therapy with defibrillator (CRT-D) device.
This patient has symptomatic systolic heart failure (LVEF ≤35%) on optimal medical therapy with evidence of ventricular dyssynchrony (LBBB with QRS ≥150 ms). In this setting, a Cardiac Resynchronization Therapy with Defibrillator (CRT-D) device is indicated. CRT improves synchrony of ventricular contraction, which can improve LVEF, reduce heart failure symptoms, and decrease mortality. The defibrillator component is indicated for primary prevention of sudden cardiac death in patients with ischemic cardiomyopathy and LVEF ≤35%.
Internal Medicine Cardiovascular Disease Questions and Answers
A 68-year-old male with a history of stable ischemic heart disease underwent percutaneous coronary intervention (PCI) with a drug-eluting stent to the left anterior descending artery one year ago.
He has been asymptomatic on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel.
He has a high bleeding risk (PRECISE-DAPT score of 30).
According to the most recent ACC/AHA guidelines, what is the most appropriate recommendation for his antiplatelet therapy at this time?