ITE Cardiovascular Disease Questions and Answers — Questions and Answers
Question 1: A 68-year-old male with a history of hypertension and type 2 diabetes presents with a 2-month history of exertional chest pain. An exercise stress test is positive for ischemia. Coronary angiography reveals three-vessel coronary artery disease with 80% stenosis in the left main coronary artery. His left ventricular ejection fraction is 45%. According to the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization, which of the following is the most appropriate next step in management?
- Coronary artery bypass grafting (CABG) (Correct answer)
- Percutaneous coronary intervention (PCI) with a drug-eluting stent
- Continue optimal medical therapy alone
- Initiate ranolazine for symptom control
Correct answer: Coronary artery bypass grafting (CABG)
For patients with significant left main coronary artery disease, especially with multivessel disease and reduced ejection fraction, coronary artery bypass grafting (CABG) is recommended to improve survival compared to medical therapy or PCI. A Heart Team approach is recommended to make a final decision, but CABG is the preferred revascularization strategy in this high-risk patient.
Question 2: A 62-year-old female presents to the emergency department with an acute onset of shortness of breath. Her medical history is significant for hypertension. On examination, her blood pressure is 155/95 mmHg, heart rate is 105 bpm, and respiratory rate is 24 breaths/min. She has bilateral crackles on lung auscultation and 2+ pitting edema in her lower extremities. A B-type natriuretic peptide (BNP) level is markedly elevated. Transthoracic echocardiogram reveals a left ventricular ejection fraction of 35%. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure, which of the following medication classes should be initiated in this patient, in addition to a diuretic, once she is hemodynamically stable?
- An SGLT2 inhibitor
- A beta-blocker
- An angiotensin receptor-neprilysin inhibitor (ARNI)
- All of the above (Correct answer)
Correct answer: All of the above
The 2022 AHA/ACC/HFSA Heart Failure Guideline recommends quadruple therapy for heart failure with reduced ejection fraction (HFrEF). This includes an ARNI (or ACE inhibitor/ARB), an evidence-based beta-blocker, a mineralocorticoid receptor antagonist (MRA), and a sodium-glucose cotransporter-2 (SGLT2) inhibitor. These four classes of medications are the cornerstone of guideline-directed medical therapy (GDMT) and should be initiated as tolerated to improve symptoms and reduce mortality.
Question 3: A 75-year-old asymptomatic female is found to have a harsh, crescendo-decrescendo systolic murmur at the right upper sternal border that radiates to the carotid arteries during a routine physical exam. A transthoracic echocardiogram confirms severe aortic stenosis with a valve area of 0.8 cm², a mean gradient of 50 mmHg, and a left ventricular ejection fraction of 60%. According to the 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease, which of the following is the most appropriate recommendation?
- Referral for aortic valve replacement (Correct answer)
- Annual follow-up with echocardiography
- Initiation of an ACE inhibitor for afterload reduction
- A beta-blocker to reduce myocardial oxygen demand
Correct answer: Referral for aortic valve replacement
Even in asymptomatic patients, intervention is indicated for severe aortic stenosis when certain high-risk features are present, such as a very severe stenosis (e.g., mean gradient >40 mmHg or valve area <1.0 cm²), or reduced left ventricular function. Given her severe aortic stenosis based on the echocardiographic findings, she should be referred for consideration of aortic valve replacement (either surgical or transcatheter) to prevent the onset of symptoms and adverse cardiac events.
Question 4: According to the 2023 AHA/ACC Guideline for the Management of Patients With Chronic Coronary Disease, which of the following statements regarding the long-term use of beta-blockers is correct?
- They are recommended for all patients with a history of myocardial infarction, regardless of timing or LV function.
- They should be continued indefinitely to improve outcomes in all patients with CCD.
- Their long-term use is not recommended to improve outcomes in patients with CCD without a history of MI in the past year or an LVEF ≤50%. (Correct answer)
- They are contraindicated in patients with chronic coronary disease and stable angina.
Correct answer: Their long-term use is not recommended to improve outcomes in patients with CCD without a history of MI in the past year or an LVEF ≤50%.
The 2023 guidelines updated the recommendations for beta-blocker use in chronic coronary disease (CCD). Long-term beta-blocker therapy is no longer recommended to improve outcomes for all patients with CCD. Their use for this purpose is reserved for patients who have had a myocardial infarction within the past year, have a left ventricular ejection fraction of 50% or less, or have another primary indication for the therapy. For stable angina, they are still considered a first-line antianginal therapy.
Question 5: A 45-year-old woman presents to the clinic for a follow-up visit. Her blood pressure today is 148/92 mmHg. A reading last month was 145/90 mmHg. She has no other medical problems. According to the JNC 8 guidelines, what is the recommended initial treatment for her hypertension?
- Amlodipine
- Lisinopril
- Losartan
- Hydrochlorothiazide (Correct answer)
Correct answer: Hydrochlorothiazide
For the general non-black population, including those with diabetes, the JNC 8 guidelines recommend one of four classes of medications as initial therapy: a thiazide-type diuretic, a calcium channel blocker (CCB), an angiotensin-converting enzyme inhibitor (ACEI), or an angiotensin receptor blocker (ARB). All four options presented are considered acceptable first-line agents in this patient. However, thiazide diuretics have been a long-standing and well-supported choice.
Question 6: A 35-year-old female presents to the emergency department with pleuritic chest pain and shortness of breath that began yesterday. She has no significant past medical history but reports using oral contraceptive pills. Her vital signs are: heart rate 95 bpm, blood pressure 120/80 mmHg, respiratory rate 18, and oxygen saturation 98% on room air. There is no unilateral leg swelling. The physician has a low clinical suspicion for pulmonary embolism (PE). Which of the following would allow the physician to use the Pulmonary Embolism Rule-out Criteria (PERC) to safely exclude PE without further testing?
- A negative D-dimer test
- A Wells score of 1.5
- The patient meeting all eight PERC criteria (Correct answer)
- A normal chest X-ray
Correct answer: The patient meeting all eight PERC criteria
The PERC rule is a clinical decision tool used to rule out pulmonary embolism in patients deemed low-risk by clinical gestalt (pre-test probability <15%). If a patient meets all eight of the PERC criteria (age <50, HR <100 bpm, SaO2 >94%, no unilateral leg swelling, no hemoptysis, no recent trauma/surgery, no prior PE/DVT, no exogenous estrogen use), the likelihood of PE is extremely low, and no further diagnostic workup (like a D-dimer) is needed. This patient does not meet the criteria due to estrogen use.
ITE Cardiovascular Disease Questions and Answers
A 68-year-old male with a history of hypertension and type 2 diabetes presents with a 2-month history of exertional chest pain.
An exercise stress test is positive for ischemia.
Coronary angiography reveals three-vessel coronary artery disease with 80% stenosis in the left main coronary artery.
His left ventricular ejection fraction is 45%.
According to the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization, which of the following is the most appropriate next step in management?