Internal Medicine Exam Cardiovascular Disease 4 — Questions and Answers
Question 1: A 50-year-old man with no cardiac history presents with palpitations. ECG shows a short PR interval, delta waves, and wide QRS complexes. He develops rapid atrial fibrillation. Which drug is contraindicated?
- Procainamide
- Adenosine (Correct answer)
- Ibutilide
- Electrical cardioversion
Correct answer: Adenosine
Adenosine (and AV nodal blocking agents like digoxin and verapamil) are contraindicated in WPW with AF because blocking the AV node can accelerate conduction down the accessory pathway, potentially causing ventricular fibrillation.
Question 2: A 55-year-old man with hypertension presents with progressive dyspnea. Echo shows EF 30%, LV dilation, and no significant valvular disease. Coronary angiography shows normal coronaries. What is the diagnosis?
- Ischemic cardiomyopathy
- Dilated cardiomyopathy (Correct answer)
- Hypertrophic cardiomyopathy
- Restrictive cardiomyopathy
Correct answer: Dilated cardiomyopathy
Dilated cardiomyopathy is characterized by LV dilation, reduced EF (<40%), and systolic dysfunction in the absence of coronary artery disease or abnormal loading conditions.
Question 3: A 48-year-old woman presents with dyspnea, peripheral edema, and a JVP that rises with inspiration (Kussmaul's sign). Echo shows preserved EF with septal bounce. What is the most likely diagnosis?
- Cardiac tamponade
- Constrictive pericarditis (Correct answer)
- Restrictive cardiomyopathy
- Pulmonary embolism
Correct answer: Constrictive pericarditis
Kussmaul's sign (JVP rise with inspiration) combined with septal bounce and preserved EF on echo points to constrictive pericarditis, where inspiration cannot augment RV filling.
Question 4: A 35-year-old athlete collapses during a basketball game. ECG shows asymmetric septal hypertrophy and dynamic LVOT obstruction of 50 mmHg. Which medication is most appropriate for symptom management?
- Amlodipine
- Metoprolol succinate (Correct answer)
- Nitroglycerin
- Furosemide
Correct answer: Metoprolol succinate
Beta-blockers like metoprolol are first-line therapy for symptomatic hypertrophic obstructive cardiomyopathy as they reduce heart rate, decrease LV contractility, and lessen dynamic outflow obstruction.
Question 5: A 65-year-old woman presents with worsening dyspnea and is found to have severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg). She has severe COPD with FEV1 40% predicted and is deemed high surgical risk. What is the preferred intervention?
- Aortic balloon valvuloplasty
- Transcatheter aortic valve replacement (TAVR) (Correct answer)
- Surgical aortic valve replacement (SAVR)
- Medical management with diuretics
Correct answer: Transcatheter aortic valve replacement (TAVR)
TAVR is preferred over SAVR in patients with severe symptomatic aortic stenosis who are at high or prohibitive surgical risk, as shown in the PARTNER trials.
Question 6: A 60-year-old man with ESRD on hemodialysis presents with acute onset sharp chest pain that improves when leaning forward. ECG shows diffuse ST elevation with PR depression. What is the most likely diagnosis?
- STEMI
- Acute pericarditis (Correct answer)
- Aortic dissection
- Pulmonary embolism
Correct answer: Acute pericarditis
Diffuse ST elevation with PR depression in a uremic patient with positional chest pain is classic for acute pericarditis, which is common in ESRD due to uremic toxin accumulation.
Question 7: A 78-year-old man presents with syncope. ECG shows alternating left and right bundle branch block. What is the most appropriate management?
- Holter monitoring for 30 days
- Permanent pacemaker implantation (Correct answer)
- Electrophysiology study only
- Antiarrhythmic therapy
Correct answer: Permanent pacemaker implantation
Alternating bundle branch block indicates severe infranodal conduction disease with a high risk of complete heart block, and permanent pacemaker implantation is indicated.
Internal Medicine Exam Cardiovascular Disease 4
A 50-year-old man with no cardiac history presents with palpitations.
ECG shows a short PR interval, delta waves, and wide QRS complexes.
He develops rapid atrial fibrillation.
Which drug is contraindicated?