Internal Medicine Exam Cardiovascular Disease 3 — Questions and Answers
Question 1: A 62-year-old man presents with sudden-onset tearing chest pain radiating to the back. CT angiography shows an intimal flap in the descending aorta without involvement of the ascending aorta. What is the first-line management?
- Emergency surgery
- Medical therapy with heart rate and blood pressure control (Correct answer)
- Endovascular stent grafting
- Thrombolysis
Correct answer: Medical therapy with heart rate and blood pressure control
Uncomplicated Type B aortic dissection (involving only the descending aorta) is managed medically with IV beta-blockers to achieve heart rate <60 bpm and SBP 100-120 mmHg.
Question 2: Which ECG finding is most specific for left ventricular hypertrophy?
- QRS duration >120 ms
- Sokolow-Lyon voltage criteria (S in V1 + R in V5 ≥35 mm) (Correct answer)
- Prolonged PR interval
- Right axis deviation
Correct answer: Sokolow-Lyon voltage criteria (S in V1 + R in V5 ≥35 mm)
The Sokolow-Lyon criterion (S in V1 + R in V5 or V6 ≥35 mm) is the most widely used voltage criterion for left ventricular hypertrophy on ECG.
Question 3: A 40-year-old woman presents with progressive dyspnea. Echo shows a mean mitral valve gradient of 12 mmHg and mitral valve area of 1.0 cm². She is in sinus rhythm with no left atrial thrombus. What is the preferred intervention?
- Mitral valve replacement
- Percutaneous mitral balloon commissurotomy (Correct answer)
- Medical therapy with diuretics
- Mitral valve repair
Correct answer: Percutaneous mitral balloon commissurotomy
Percutaneous mitral balloon commissurotomy (PMBC) is the preferred treatment for symptomatic severe mitral stenosis with favorable valve morphology and no thrombus.
Question 4: A patient develops cardiogenic shock after an anterior STEMI. Right heart catheterization shows: CI 1.6 L/min/m², PCWP 24 mmHg. Which agent is most appropriate as initial hemodynamic support?
- Norepinephrine alone
- Dobutamine (Correct answer)
- Vasopressin
- Phenylephrine
Correct answer: Dobutamine
Dobutamine is the preferred inotrope in cardiogenic shock with high filling pressures and low cardiac index to improve contractility and cardiac output.
Question 5: What is the most common cause of secondary hypertension in adults under 40 years of age?
- Primary aldosteronism
- Renal artery stenosis due to fibromuscular dysplasia (Correct answer)
- Obstructive sleep apnea
- Pheochromocytoma
Correct answer: Renal artery stenosis due to fibromuscular dysplasia
Fibromuscular dysplasia causing renal artery stenosis is the most common cause of renovascular hypertension in young women and secondary hypertension in adults under 40.
Question 6: A 68-year-old man with NYHA class III heart failure has a biventricular pacemaker (CRT). His EF was 25% six months ago. Repeat echo now shows EF of 42%. Which statement about his ICD is most accurate?
- The ICD should be removed since EF has recovered
- The ICD should be kept given his prior indication (Correct answer)
- ICD therapy is contraindicated with EF >35%
- ICD should be upgraded to a subcutaneous device
Correct answer: The ICD should be kept given his prior indication
Even with EF recovery, the ICD should be kept because patients retain ongoing risk of sudden cardiac death and the original indication for implantation remains valid.
Question 7: A 72-year-old woman with known bicuspid aortic valve has an aortic root diameter of 4.8 cm on surveillance imaging. She is asymptomatic with normal valve function. When is surgical intervention indicated?
- At 5.5 cm regardless of risk factors
- At 5.0 cm in patients with bicuspid aortic valve (Correct answer)
- Only when symptoms develop
- At 4.5 cm in all patients
Correct answer: At 5.0 cm in patients with bicuspid aortic valve
Current guidelines recommend surgical repair of the ascending aorta at a threshold of 5.0 cm in patients with bicuspid aortic valve given the higher risk of dissection at smaller diameters than tricuspid valves.
Internal Medicine Exam Cardiovascular Disease 3
A 62-year-old man presents with sudden-onset tearing chest pain radiating to the back.
CT angiography shows an intimal flap in the descending aorta without involvement of the ascending aorta.
What is the first-line management?