Internal Medicine Exam Cardiovascular Disease 5 — Questions and Answers
Question 1: A 52-year-old man with diabetes presents 90 minutes after onset of crushing chest pain. ECG shows 3 mm ST elevation in V1-V4. Which reperfusion strategy is preferred?
- Fibrinolysis with alteplase
- Primary percutaneous coronary intervention (PCI) (Correct answer)
- Conservative management with anticoagulation
- Coronary artery bypass grafting
Correct answer: Primary percutaneous coronary intervention (PCI)
Primary PCI is the preferred reperfusion strategy for STEMI when it can be performed within 90 minutes of first medical contact (door-to-balloon time), as it is superior to fibrinolysis.
Question 2: A 44-year-old woman presents with sudden onset of pulmonary edema. Echo reveals severe mitral regurgitation with a flail posterior leaflet. Her blood pressure is 85/60 mmHg. What is the most appropriate immediate intervention?
- Intra-aortic balloon pump followed by urgent surgery (Correct answer)
- High-dose furosemide IV bolus
- ACE inhibitor titration
- Coronary angiography first
Correct answer: Intra-aortic balloon pump followed by urgent surgery
Acute severe MR causing cardiogenic shock requires hemodynamic stabilization with an intra-aortic balloon pump (reduces afterload, increases coronary perfusion) as a bridge to urgent surgical repair.
Question 3: Which clinical scenario best describes Dressler syndrome?
- Chest pain 24 hours after MI due to pericardial irritation from transmural necrosis
- Fever, pleuritic chest pain, and pericarditis occurring weeks after MI or cardiac surgery (Correct answer)
- Recurrent MI at the same coronary territory within 30 days
- Pericardial effusion causing tamponade immediately post-CABG
Correct answer: Fever, pleuritic chest pain, and pericarditis occurring weeks after MI or cardiac surgery
Dressler syndrome is an autoimmune pericarditis that occurs weeks to months after MI or cardiac surgery, presenting with fever, pleurisy, and pericardial inflammation.
Question 4: A 66-year-old man with known HFrEF (EF 30%) develops worsening renal function after ACE inhibitor dose uptitration. Creatinine rose from 1.2 to 1.8 mg/dL. What is the most appropriate action?
- Discontinue ACE inhibitor immediately
- Continue ACE inhibitor if creatinine rise is ≤30% above baseline (Correct answer)
- Switch to ARB immediately
- Add aldosterone antagonist to offset renal effects
Correct answer: Continue ACE inhibitor if creatinine rise is ≤30% above baseline
A creatinine rise of up to 30-50% above baseline is acceptable when starting or uptitrating ACE inhibitors in HFrEF, as these agents provide mortality benefit that outweighs the modest GFR reduction.
Question 5: A 58-year-old woman with poorly controlled hypertension develops a new murmur. Echo shows aortic regurgitation with LV end-systolic diameter of 52 mm and EF of 48%. She is mildly symptomatic. What is the best management?
- Annual surveillance echo only
- Aortic valve replacement (Correct answer)
- Start vasodilator therapy and delay surgery
- Medical therapy until EF drops below 30%
Correct answer: Aortic valve replacement
Symptomatic severe AR with EF <50% or LVESD >50 mm is a class I indication for aortic valve replacement, as these thresholds predict irreversible LV dysfunction if surgery is further delayed.
Question 6: A 30-year-old woman in her 28th week of pregnancy develops dyspnea, orthopnea, and an EF of 35% on echo. She has no prior cardiac history. What is the most likely diagnosis?
- Pulmonary embolism
- Peripartum cardiomyopathy (Correct answer)
- Pre-eclampsia with pulmonary edema
- Amniotic fluid embolism
Correct answer: Peripartum cardiomyopathy
Peripartum cardiomyopathy presents with new-onset heart failure with reduced EF in the last month of pregnancy or within 5 months postpartum without another identifiable cause.
Question 7: A 55-year-old man with diabetes and hypertension has a 10-year ASCVD risk of 18% and LDL of 142 mg/dL. He is already on moderate-intensity statin therapy. What is the most appropriate next step?
- Add niacin to raise HDL
- Uptitrate to high-intensity statin therapy (Correct answer)
- Add a fibrate for triglyceride reduction
- Continue current therapy as LDL is acceptable
Correct answer: Uptitrate to high-intensity statin therapy
Patients with ASCVD risk ≥7.5% should receive high-intensity statin therapy aiming for ≥50% LDL reduction; if on moderate-intensity and goal not met, uptitrating is the recommended next step.
Internal Medicine Exam Cardiovascular Disease 5
A 52-year-old man with diabetes presents 90 minutes after onset of crushing chest pain.
ECG shows 3 mm ST elevation in V1-V4.
Which reperfusion strategy is preferred?