ITE - Internal Medicine In-Training Valvular Heart Disease Management Questions and Answers

Question 1

A 72-year-old male with a history of hypertension presents for a routine evaluation.
He denies chest pain, dyspnea, or syncope.
On physical exam, you note a grade 3/6 late-peaking systolic ejection murmur at the right upper sternal border that radiates to the carotids.
An echocardiogram reveals a calcified aortic valve with a peak velocity of 4.5 m/s, a mean gradient of 50 mm Hg, and an aortic valve area of 0.8 cm².
His left ventricular ejection fraction (LVEF) is 65%.
Which of the following is the most appropriate next step in management?

Accepted Answer

Perform an exercise stress test to confirm asymptomatic status.

Answer

Initiate medical therapy with a beta-blocker and schedule a follow-up in one year.

Answer

Refer for surgical aortic valve replacement (SAVR).

Answer

Begin afterload reduction with an ACE inhibitor.

Question 2

A 65-year-old female is diagnosed with severe, symptomatic, degenerative mitral regurgitation (MR) and is referred for surgical evaluation. Her LVEF is 65% and left ventricular end-systolic dimension (LVESD) is 38 mm. Which of the following is the preferred surgical approach?

Accepted Answer

Mitral valve repair.

Answer

Mitral valve replacement with a bioprosthetic valve.

Answer

Mitral valve replacement with a mechanical valve.

Answer

Transcatheter edge-to-edge repair (TEER).

Question 3

A 58-year-old male with a bicuspid aortic valve is found to have severe chronic aortic regurgitation (AR) on a routine echocardiogram. He is completely asymptomatic. His LVEF is 52% and his LV end-diastolic dimension is 72 mm. Blood pressure is 130/50 mmHg. According to the most recent guidelines, which of the following is the strongest indication for aortic valve replacement in this patient?

Accepted Answer

The left ventricular ejection fraction.

Answer

The presence of a bicuspid aortic valve.

Answer

The wide pulse pressure.

Answer

The severe degree of regurgitation.

Question 4

A 45-year-old female immigrant from Southeast Asia presents with progressive exertional dyspnea. She has a history of rheumatic fever in childhood. On exam, she has an opening snap and a low-pitched diastolic rumble at the apex. She is found to be in atrial fibrillation with a rapid ventricular response. Echocardiography confirms severe rheumatic mitral stenosis (valve area 0.9 cm²). Which of the following medications is contraindicated for anticoagulation in this patient?

Accepted Answer

Dabigatran.

Answer

Warfarin.

Answer

Heparin.

Answer

Enoxaparin.

Question 5

Which of the following is an established indication for intervention in a patient with asymptomatic severe primary mitral regurgitation?

Accepted Answer

Pulmonary artery systolic pressure (PASP) at rest of 55 mmHg.

Answer

Left ventricular end-systolic dimension (LVESD) of 38 mm.

Answer

Left ventricular ejection fraction (LVEF) of 65%.

Answer

Age greater than 75 years.

Question 6

A 68-year-old female with severe chronic aortic regurgitation and an LVEF of 35% is symptomatic with dyspnea on exertion despite being on optimal medical therapy for heart failure, including a beta-blocker and diuretic. Her blood pressure is 145/70 mmHg. Which medication class, if added, would be most beneficial for afterload reduction in this patient?

Accepted Answer

Angiotensin-converting enzyme (ACE) inhibitors.

Answer

Non-dihydropyridine calcium channel blockers.

Answer

Hydralazine.

Answer

Digoxin.