CMC Risk Assessment & Management 4 — Questions and Answers
Question 1: A patient presenting with chest pain has a HEART score of 7. What is the recommended management course?
- Discharge with outpatient follow-up
- Serial troponins and early discharge if negative
- Admit and consider early invasive strategy (Correct answer)
- Perform immediate CT pulmonary angiography
Correct answer: Admit and consider early invasive strategy
A HEART score of 7–10 indicates high risk for MACE (>65% event rate), necessitating admission and consideration of early invasive evaluation.
Question 2: Which finding on a dobutamine stress echocardiogram is considered a high-risk marker predicting adverse cardiac outcomes?
- Normal wall motion at low dose only
- New wall motion abnormality in ≥ 3 segments at low dose dobutamine (Correct answer)
- Mild decrease in ejection fraction from rest to stress
- Isolated diastolic dysfunction at peak stress
Correct answer: New wall motion abnormality in ≥ 3 segments at low dose dobutamine
Inducible wall motion abnormalities in ≥ 3 segments at low dobutamine doses indicate extensive ischemia and are a high-risk marker associated with adverse outcomes.
Question 3: In chronic kidney disease (CKD) stage 3b, how does the estimated GFR impact cardiovascular risk stratification?
- CKD stage 3b is not a cardiovascular risk factor
- CKD stage 3b (eGFR 30–44) is a risk-enhancing factor that raises ASCVD risk (Correct answer)
- CKD only affects risk when dialysis-dependent
- CKD reduces statin efficacy and contraindicates its use
Correct answer: CKD stage 3b (eGFR 30–44) is a risk-enhancing factor that raises ASCVD risk
CKD stage 3b (eGFR 30–44 mL/min/1.73m²) is a recognized risk-enhancing factor in 2018 ACC/AHA guidelines, increasing baseline ASCVD risk estimate.
Question 4: A 58-year-old man with known CAD and recent PCI is prescribed dual antiplatelet therapy (DAPT). Which DAPT score component indicates a patient who benefits more from prolonged DAPT beyond 12 months?
- Age ≥ 75 years
- Prior MI or prior PCI (Correct answer)
- BMI > 30 kg/m²
- Female sex
Correct answer: Prior MI or prior PCI
Prior MI or prior PCI is a positive scoring component in the DAPT Score, indicating patients who may benefit from prolonged dual antiplatelet therapy beyond 12 months post-PCI.
Question 5: In the management of hypertensive emergency with acute aortic dissection, what is the primary blood pressure target and preferred agent class?
- SBP < 160 mmHg using IV loop diuretics
- SBP < 120 mmHg and HR < 60 bpm using IV beta-blockers first (Correct answer)
- MAP < 70 mmHg using IV vasodilators only
- SBP < 140 mmHg using oral ACE inhibitors
Correct answer: SBP < 120 mmHg and HR < 60 bpm using IV beta-blockers first
For aortic dissection, IV beta-blockers (e.g., esmolol) are first-line to reduce HR < 60 bpm and SBP to 100–120 mmHg to minimize aortic wall shear stress.
Question 6: A 65-year-old woman with HFrEF (EF 30%) and LBBB has a QRS duration of 158 ms despite optimal medical therapy. What device therapy is indicated for risk reduction?
- Implantable loop recorder
- Cardiac resynchronization therapy with defibrillator (CRT-D) (Correct answer)
- Subcutaneous ICD without pacing function
- Wearable cardioverter-defibrillator only
Correct answer: Cardiac resynchronization therapy with defibrillator (CRT-D)
CRT-D is indicated for HFrEF with LBBB and QRS ≥ 150 ms on optimal medical therapy to reduce mortality, hospitalization, and reverse remodel the LV.
Question 7: When stratifying risk in patients with hypertrophic cardiomyopathy (HCM) for sudden cardiac death (SCD), which factor independently increases 5-year SCD risk?
- LV outflow tract gradient < 30 mmHg
- Non-sustained ventricular tachycardia on Holter monitoring (Correct answer)
- LVEF > 65%
- Absence of family history of HCM
Correct answer: Non-sustained ventricular tachycardia on Holter monitoring
Non-sustained VT on ambulatory monitoring is one of five major SCD risk factors in HCM used by the AHA/ESC HCM risk models to guide ICD implantation decisions.
CMC Risk Assessment & Management 4
A patient presenting with chest pain has a HEART score of 7.
What is the recommended management course?