Internal Medicine Exam Cardiovascular Disease Management 2 — Questions and Answers
Question 1: A 58-year-old man with stable angina is found to have a left main coronary artery stenosis of 70% on angiography. What is the preferred management?
- Coronary artery bypass grafting (CABG) (Correct answer)
- Percutaneous coronary intervention (PCI) with drug-eluting stent
- Optimal medical therapy alone
- Enhanced external counterpulsation (EECP)
Correct answer: Coronary artery bypass grafting (CABG)
Left main coronary artery stenosis ≥50% with suitable anatomy is a Class I indication for CABG due to superior long-term survival outcomes compared to PCI.
Question 2: A 65-year-old woman with HFrEF (EF 30%) is already on maximally tolerated ACE inhibitor and beta-blocker. Her NT-proBNP remains elevated. Which medication should be added next?
- Sacubitril/valsartan replacing the ACE inhibitor (Correct answer)
- Spironolactone
- Digoxin
- Hydralazine
Correct answer: Sacubitril/valsartan replacing the ACE inhibitor
Sacubitril/valsartan (ARNI) reduces mortality and hospitalization in HFrEF and should replace ACE inhibitor therapy in eligible patients with persistently symptomatic disease.
Question 3: A 72-year-old man presents with a blood pressure of 185/110 mmHg and acute pulmonary edema. What is the immediate pharmacologic priority?
- IV nitrates and IV furosemide (Correct answer)
- Oral amlodipine
- IV labetalol alone
- IV hydralazine alone
Correct answer: IV nitrates and IV furosemide
Hypertensive emergency with pulmonary edema requires rapid BP reduction with IV nitrates (venodilators) and diuresis with IV furosemide to reduce preload and congestion.
Question 4: A 50-year-old woman with atrial fibrillation has a CHA₂DS₂-VASc score of 3. She has no contraindications to anticoagulation. Which therapy is most appropriate?
- Direct oral anticoagulant (DOAC) (Correct answer)
- Aspirin alone
- Aspirin plus clopidogrel
- No antithrombotic therapy
Correct answer: Direct oral anticoagulant (DOAC)
A CHA₂DS₂-VASc score ≥2 in women (≥3 in this case) is a Class I indication for oral anticoagulation; DOACs are preferred over warfarin due to superior safety profile.
Question 5: Which finding on echocardiography is most consistent with cardiac tamponade?
- Diastolic collapse of the right ventricle (Correct answer)
- Left ventricular hypertrophy with diastolic dysfunction
- Mitral valve prolapse with regurgitation
- Dilated cardiomyopathy with global hypokinesis
Correct answer: Diastolic collapse of the right ventricle
Diastolic RV collapse due to external pericardial pressure is the hallmark echocardiographic finding of cardiac tamponade.
Question 6: A patient with chronic stable heart failure (EF 25%) develops a 3-second pause on Holter monitoring and near-syncope. What is the most appropriate next step?
- Implantable cardioverter-defibrillator (ICD) evaluation (Correct answer)
- Permanent pacemaker implantation only
- Oral amiodarone
- Observation and repeat Holter in 3 months
Correct answer: Implantable cardioverter-defibrillator (ICD) evaluation
Patients with HFrEF (EF ≤35%) and symptomatic arrhythmia should be evaluated for ICD, which treats both bradycardia (if combined with pacing) and sudden cardiac death risk.
Question 7: A 60-year-old man with hypertension, diabetes, and dyslipidemia has an LDL of 130 mg/dL despite lifestyle changes. His 10-year ASCVD risk is 22%. What is the LDL goal?
- <70 mg/dL with high-intensity statin (Correct answer)
- <100 mg/dL with moderate-intensity statin
- <130 mg/dL with low-intensity statin
- No pharmacologic therapy needed
Correct answer: <70 mg/dL with high-intensity statin
A 10-year ASCVD risk ≥20% is considered high risk, warranting high-intensity statin therapy with an LDL goal of <70 mg/dL.
Internal Medicine Exam Cardiovascular Disease Management 2
A 58-year-old man with stable angina is found to have a left main coronary artery stenosis of 70% on angiography.
What is the preferred management?