Internal Medicine Exam Cardiovascular Disease 2 — Questions and Answers
Question 1: A 58-year-old man with hypertension and diabetes presents with exertional chest pain. Stress testing shows ST depression in leads V4-V6. What is the most appropriate next step?
- Start aspirin and observe
- Coronary angiography (Correct answer)
- Repeat stress test in 3 months
- Prescribe long-acting nitrates only
Correct answer: Coronary angiography
Significant ST depression on stress testing (≥2 mm) in a high-risk patient warrants coronary angiography to define anatomy and guide revascularization.
Question 2: Which finding on echocardiography is most consistent with cardiac tamponade?
- Left ventricular hypertrophy
- Right ventricular diastolic collapse (Correct answer)
- Mitral valve prolapse
- Aortic root dilation
Correct answer: Right ventricular diastolic collapse
Right ventricular diastolic collapse on echocardiography is the classic finding of cardiac tamponade due to elevated pericardial pressure compressing the low-pressure right heart.
Question 3: A 45-year-old woman is found to have a QTc of 520 ms on routine ECG. She is asymptomatic. Which medication should be avoided?
- Metoprolol
- Ondansetron (Correct answer)
- Lisinopril
- Amlodipine
Correct answer: Ondansetron
Ondansetron is a 5-HT3 antagonist that prolongs the QT interval and can precipitate torsades de pointes in patients with baseline QT prolongation.
Question 4: A patient with known heart failure with reduced ejection fraction (HFrEF) has a resting heart rate of 82 bpm despite maximum tolerated beta-blocker therapy. Which additional agent is indicated?
- Digoxin
- Ivabradine (Correct answer)
- Amiodarone
- Verapamil
Correct answer: Ivabradine
Ivabradine is indicated in HFrEF patients in sinus rhythm with heart rate ≥70 bpm on maximally tolerated beta-blocker to further reduce hospitalizations.
Question 5: A 70-year-old man with atrial fibrillation and CKD stage 3 (eGFR 40) needs anticoagulation. His CHA₂DS₂-VASc score is 4. Which anticoagulant is most appropriate?
- Warfarin
- Apixaban (Correct answer)
- Dabigatran at full dose
- Rivaroxaban standard dose
Correct answer: Apixaban
Apixaban is preferred in moderate CKD as it has the least renal clearance (~27%) among DOACs and requires minimal dose adjustment down to eGFR 25.
Question 6: Which hemodynamic pattern is most consistent with constrictive pericarditis on right heart catheterization?
- Elevated PCWP with low RVEDP
- Equalization of diastolic pressures (Correct answer)
- Low CVP with high cardiac output
- Elevated pulmonary artery pressure only
Correct answer: Equalization of diastolic pressures
Equalization of diastolic pressures (RVEDP = LVEDP = mean RA = mean PCWP within 5 mmHg) is the hallmark hemodynamic finding of constrictive pericarditis.
Question 7: A 55-year-old woman with hypertension presents with a blood pressure of 220/120 mmHg and new-onset confusion. Creatinine is 2.8 mg/dL (baseline 1.0). What is the target blood pressure reduction in the first hour?
- Normalize blood pressure immediately
- Reduce mean arterial pressure by no more than 25% (Correct answer)
- Reduce systolic to below 140 mmHg
- Reduce diastolic to below 80 mmHg immediately
Correct answer: Reduce mean arterial pressure by no more than 25%
In hypertensive emergency, the MAP should be reduced by no more than 25% in the first hour to avoid ischemia from loss of cerebral autoregulation.
Internal Medicine Exam Cardiovascular Disease 2
A 58-year-old man with hypertension and diabetes presents with exertional chest pain.
Stress testing shows ST depression in leads V4-V6.
What is the most appropriate next step?