Internal Medicine Exam Cardiovascular Disease Management 4 — Questions and Answers
Question 1: A 75-year-old man with peripheral artery disease and claudication has an ABI of 0.6. He is a non-smoker on a statin and aspirin. What additional therapy improves walking distance?
- Cilostazol (Correct answer)
- Warfarin
- Dipyridamole alone
- Clopidogrel plus aspirin (dual antiplatelet)
Correct answer: Cilostazol
Cilostazol, a phosphodiesterase III inhibitor, is the only FDA-approved medication shown to improve claudication symptoms and walking distance in PAD.
Question 2: A 55-year-old man presents with sharp, positional chest pain that worsens when lying flat and improves when leaning forward. Temperature is 38.4°C. ECG shows diffuse ST elevation with PR depression. What is the most likely diagnosis?
- Acute pericarditis (Correct answer)
- Aortic dissection
- STEMI
- Pleuritis
Correct answer: Acute pericarditis
Diffuse (saddle-shaped) ST elevation with PR depression, pleuritic positional pain, and low-grade fever are classic findings of acute pericarditis.
Question 3: A 68-year-old woman with newly diagnosed atrial flutter undergoes successful cardioversion to sinus rhythm. How long should anticoagulation be continued after cardioversion?
- At least 4 weeks post-cardioversion, then ongoing based on stroke risk score (Correct answer)
- 48 hours only
- No anticoagulation is needed after successful cardioversion
- Anticoagulation for 3 months then stop regardless of risk
Correct answer: At least 4 weeks post-cardioversion, then ongoing based on stroke risk score
Post-cardioversion anticoagulation for at least 4 weeks is mandatory (due to atrial stunning), followed by long-term anticoagulation guided by CHA₂DS₂-VASc score.
Question 4: A 52-year-old man with type 2 diabetes and established cardiovascular disease has an eGFR of 55 mL/min and is on metformin. Which additional agent has the most evidence for reducing cardiovascular mortality?
- GLP-1 receptor agonist (e.g., liraglutide or semaglutide) (Correct answer)
- Sulfonylurea
- DPP-4 inhibitor
- Thiazolidinedione
Correct answer: GLP-1 receptor agonist (e.g., liraglutide or semaglutide)
GLP-1 receptor agonists (LEADER, SUSTAIN-6 trials) have demonstrated significant reduction in MACE and cardiovascular mortality in patients with T2DM and established CVD.
Question 5: A patient in the ICU develops a wide-complex tachycardia at 180 bpm. She is hypotensive with BP of 78/50 mmHg. What is the immediate treatment?
- Synchronized direct current cardioversion (Correct answer)
- IV adenosine
- IV amiodarone infusion over 10 minutes
- IV verapamil
Correct answer: Synchronized direct current cardioversion
Unstable wide-complex tachycardia with hemodynamic compromise requires immediate synchronized DC cardioversion regardless of the underlying rhythm.
Question 6: A 58-year-old man with an ICD for ischemic cardiomyopathy receives three appropriate shocks in 24 hours for ventricular tachycardia (electrical storm). What is the next best step?
- IV amiodarone plus IV beta-blocker and urgent electrophysiology consultation (Correct answer)
- Increase ICD shock energy only
- Oral mexiletine and discharge
- Deactivate the ICD temporarily
Correct answer: IV amiodarone plus IV beta-blocker and urgent electrophysiology consultation
Electrical storm requires combined IV amiodarone and beta-blocker to suppress VT triggers, along with urgent EP evaluation for catheter ablation consideration.
Question 7: A 63-year-old woman is diagnosed with pulmonary arterial hypertension (WHO Group 1). Her 6-minute walk distance is 340 meters and she is WHO FC III. Which medication is NOT appropriate as initial monotherapy?
- High-dose calcium channel blocker without prior vasoreactivity testing (Correct answer)
- Ambrisentan (endothelin receptor antagonist)
- Sildenafil (PDE-5 inhibitor)
- Riociguat (sGC stimulator)
Correct answer: High-dose calcium channel blocker without prior vasoreactivity testing
High-dose CCBs are only appropriate in the rare vasoreactive PAH patients confirmed by acute vasoreactivity testing; using them without testing is dangerous and can worsen PAH.
Internal Medicine Exam Cardiovascular Disease Management 4
A 75-year-old man with peripheral artery disease and claudication has an ABI of 0.6.
He is a non-smoker on a statin and aspirin.
What additional therapy improves walking distance?