ITE Cardiovascular Disease — Questions and Answers

Question 1: A 58-year-old man with hypertension presents with sudden-onset tearing chest pain radiating to the back. BP is 180/100 in the right arm and 150/85 in the left arm. Which imaging study is most appropriate?

Transthoracic echocardiogram
CT angiography of the chest (Correct answer)
Coronary angiography
Ventilation-perfusion scan

Correct answer: CT angiography of the chest

CT angiography is the gold standard for diagnosing aortic dissection, which is suggested by the tearing pain and blood pressure differential between arms.

Question 2: A patient with known mitral stenosis develops sudden onset palpitations. ECG shows no P waves and irregularly irregular rhythm. What is the immediate concern?

Ventricular tachycardia
Systemic thromboembolism (Correct answer)
Cardiac tamponade
Complete heart block

Correct answer: Systemic thromboembolism

Atrial fibrillation in mitral stenosis significantly increases the risk of left atrial thrombus formation and systemic embolism, including stroke.

Question 3: Which medication class is the preferred initial treatment for heart failure with reduced ejection fraction (HFrEF) to reduce mortality?

Loop diuretics
Beta-blockers and ACE inhibitors (Correct answer)
Calcium channel blockers
Digoxin

Correct answer: Beta-blockers and ACE inhibitors

Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) and ACE inhibitors/ARBs are proven to reduce mortality in HFrEF and are the cornerstone of therapy.

Question 4: A 65-year-old woman presents with exertional dyspnea and a harsh systolic crescendo-decrescendo murmur at the right upper sternal border radiating to the carotids. Echocardiogram shows an AVA of 0.7 cm². What is the next step?

Medical management with ACE inhibitor
Referral for aortic valve replacement (Correct answer)
Cardiac catheterization to confirm
Exercise stress test

Correct answer: Referral for aortic valve replacement

An AVA <0.8 cm² with symptoms defines severe symptomatic aortic stenosis, which requires valve replacement as definitive treatment.

Question 5: A 70-year-old man is found to have a 5.6 cm infrarenal abdominal aortic aneurysm on ultrasound during screening. He is asymptomatic. What is the recommended management?

Repeat ultrasound in 5 years
Intensive blood pressure control only
Elective surgical repair (Correct answer)
CT angiography and urgent repair

Correct answer: Elective surgical repair

AAAs ≥5.5 cm in men carry high rupture risk and warrant elective repair; this patient's 5.6 cm aneurysm meets the threshold.

Question 6: Which finding on ECG is most consistent with hyperkalemia in a patient with chronic kidney disease?

Prolonged QT interval
Tall peaked T waves (Correct answer)
ST segment depression
Prominent U waves

Correct answer: Tall peaked T waves

Hyperkalemia classically produces tall, narrow, peaked T waves as one of the earliest ECG manifestations.

Question 7: A patient with systolic heart failure (EF 30%) continues to have symptoms despite optimal doses of ACE inhibitor and beta-blocker. QRS duration is 155 ms on ECG. What therapy should be added?

Digoxin
Cardiac resynchronization therapy (CRT) (Correct answer)
Ivabradine
Amiodarone

Correct answer: Cardiac resynchronization therapy (CRT)

CRT is indicated in symptomatic HFrEF with LBBB morphology and QRS ≥150 ms despite optimal medical therapy, improving symptoms and mortality.

Question 8: A 62-year-old man presents with exertional chest pain. Stress test shows 2 mm ST depression in leads V4–V6 at 85% of maximum heart rate. He has diabetes and hypertension. What is the most appropriate next step?

Reassurance and lifestyle modification only
Coronary angiography (Correct answer)
Repeat stress test in 6 months
Start aspirin and statin only

Correct answer: Coronary angiography

A strongly positive stress test (≥2 mm ST depression at submaximal heart rate) in a high-risk patient warrants coronary angiography to define anatomy and guide revascularization.

Question 9: Which lipoprotein pattern is most associated with premature atherosclerotic cardiovascular disease?

Elevated HDL with low LDL
Elevated LDL-C with small dense LDL particles (Correct answer)
Isolated hypertriglyceridemia >150 mg/dL
Elevated Lp(a) alone with normal LDL

Correct answer: Elevated LDL-C with small dense LDL particles

Small dense LDL particles are more atherogenic because they penetrate the endothelium more easily and are more susceptible to oxidation, driving plaque formation.

Question 10: A 50-year-old woman with systemic lupus erythematosus presents with dyspnea, elevated JVP, and an echocardiogram showing a thickened pericardium with respiratory variation in mitral inflow >25%. What is the diagnosis?

Dilated cardiomyopathy
Constrictive pericarditis (Correct answer)
Restrictive cardiomyopathy
Pulmonary arterial hypertension

Correct answer: Constrictive pericarditis

Constrictive pericarditis presents with elevated JVP, Kussmaul's sign, and exaggerated respiratory variation in Doppler inflow velocities, and is a known complication of SLE.

Question 11: A 48-year-old male smoker with hyperlipidemia and hypertension has a resting ECG showing Q waves in leads II, III, and aVF. He has no chest pain history. What is the most likely explanation?

Left ventricular hypertrophy
Prior inferior myocardial infarction (Correct answer)
Normal variant in these leads
Wolff-Parkinson-White syndrome

Correct answer: Prior inferior myocardial infarction

Pathological Q waves in the inferior leads (II, III, aVF) in the setting of multiple cardiovascular risk factors most likely represent a prior silent inferior MI.

Question 12: A 66-year-old woman with atrial fibrillation and a CHA₂DS₂-VASc score of 4 is started on apixaban. She asks about dietary restrictions. What is the most accurate counseling?

Avoid all green leafy vegetables as with warfarin
No significant dietary restrictions required (Correct answer)
Limit vitamin K intake to <90 mcg/day
Avoid grapefruit but monitor INR monthly

Correct answer: No significant dietary restrictions required

Unlike warfarin, apixaban (a direct oral anticoagulant) does not require dietary vitamin K restriction or routine INR monitoring.

Question 13: A 35-year-old competitive athlete collapses during a basketball game. Resuscitation is successful. ECG shows deep T-wave inversions in V1–V4 and left axis deviation. His father died suddenly at age 40. What is the most likely diagnosis?

Hypertrophic cardiomyopathy (HCM)
Arrhythmogenic right ventricular cardiomyopathy (ARVC) (Correct answer)
Long QT syndrome
Coronary artery vasospasm

Correct answer: Arrhythmogenic right ventricular cardiomyopathy (ARVC)

ARVC characteristically presents with T-wave inversions in right precordial leads, ventricular arrhythmias triggered by exercise, and a family history of sudden death.

Question 14: A 74-year-old man with EF of 25% is on optimal HFrEF therapy. He has NYHA class III symptoms. His ICD was implanted 2 years ago. QRS is 110 ms. What additional therapy should be considered to reduce hospitalization?

Hydralazine-nitrate combination
SGLT2 inhibitor (dapagliflozin or empagliflozin) (Correct answer)
Digoxin titrated to 1.5 ng/mL
Nesiritide infusion

Correct answer: SGLT2 inhibitor (dapagliflozin or empagliflozin)

SGLT2 inhibitors (dapagliflozin, empagliflozin) reduce HF hospitalization and cardiovascular death in HFrEF independent of diabetes status.

Question 15: A 55-year-old woman with class II obesity presents for cardiovascular risk assessment. Her 10-year ASCVD risk is 8%. LDL is 125 mg/dL. What is the most appropriate initial intervention?

Start high-intensity statin immediately
Lifestyle modification with shared decision-making about statin therapy (Correct answer)
Refer to cardiology before any therapy
Start fibrate therapy for triglycerides

Correct answer: Lifestyle modification with shared decision-making about statin therapy

A 10-year ASCVD risk of 7.5–10% is considered borderline; guidelines recommend shared decision-making about statin initiation after lifestyle modification counseling.

Question 16: A 60-year-old man is admitted for acute decompensated heart failure. He is volume-overloaded with creatinine 1.4 mg/dL. IV furosemide is started. What laboratory finding would indicate adequate diuresis response?

Serum BNP rising by 20%
Urine output >0.5 mL/kg/hr and weight loss of 0.5–1 kg/day (Correct answer)
Serum sodium increasing to >145 mEq/L
Central venous pressure rising to 12 mmHg

Correct answer: Urine output >0.5 mL/kg/hr and weight loss of 0.5–1 kg/day

Adequate decongestion is monitored by urine output and daily weight loss of 0.5–1 kg/day, balancing diuresis against worsening renal function.

Question 17: A 38-year-old woman presents with dyspnea and is found to have a systolic BP of 160/90 in both arms and diastolic murmur over the back. CXR shows rib notching. What is the diagnosis?

Essential hypertension
Coarctation of the aorta (Correct answer)
Renal artery stenosis
Marfan syndrome with aortic regurgitation

Correct answer: Coarctation of the aorta

Coarctation of the aorta presents with upper extremity hypertension, a diastolic murmur over the back from collaterals, and rib notching from intercostal artery enlargement.

Question 18: A 67-year-old man with known CAD presents with inferior ST-segment elevation. He has no contraindications. The nearest PCI-capable hospital is 3 hours away. What is the most appropriate reperfusion strategy?

Transfer immediately for primary PCI regardless of delay
Fibrinolytic therapy within 30 minutes, then transfer (Correct answer)
Medical management only with antiplatelet therapy
Emergent CABG at current facility

Correct answer: Fibrinolytic therapy within 30 minutes, then transfer

When PCI cannot be performed within 120 minutes of first medical contact, fibrinolytic therapy should be given within 30 minutes followed by transfer for angiography.

Question 19: Which finding would most support a diagnosis of pulmonary arterial hypertension (PAH) rather than pulmonary hypertension due to left heart disease?

PCWP of 20 mmHg on right heart catheterization
Mean PAP >25 mmHg with PCWP ≤15 mmHg (Correct answer)
Bilateral pleural effusions on CXR
Elevated BNP with dilated left atrium

Correct answer: Mean PAP >25 mmHg with PCWP ≤15 mmHg

PAH is defined as mean PAP >25 mmHg with a normal wedge pressure (PCWP ≤15 mmHg), distinguishing it from pulmonary hypertension driven by elevated left-sided filling pressures.

Question 20: A 72-year-old woman with permanent atrial fibrillation and prior TIA is on warfarin with INR 2.5. She develops hematuria. Cystoscopy is negative for malignancy. What is the most appropriate next step in anticoagulation management?

Stop warfarin permanently due to bleeding risk
Continue warfarin; bleeding risk outweighs stroke risk (Correct answer)
Switch to aspirin alone for anticoagulation
Reduce warfarin dose targeting INR 1.5–2.0

Correct answer: Continue warfarin; bleeding risk outweighs stroke risk

In AF with prior TIA, stroke risk is high; warfarin should be continued because the annual stroke risk far exceeds the bleeding risk from hematuria with a negative workup.

Question 21: A 58-year-old man presents with symmetric leg swelling, ascites, and elevated JVP that increases with inspiration (Kussmaul's sign). Echo shows normal LV function with a thick bright pericardium. What hemodynamic pattern is expected on right heart catheterization?

Elevated PCWP with low cardiac output only
Equalization of diastolic pressures across all chambers (Correct answer)
Pulmonary artery systolic pressure >60 mmHg
Low right atrial pressure with high PCWP

Correct answer: Equalization of diastolic pressures across all chambers

Constrictive pericarditis produces equalization of diastolic pressures (right atrial, RV end-diastolic, PCWP all within 5 mmHg) due to the rigid pericardial shell.

ITE Cardiovascular Disease

A 58-year-old man with hypertension presents with sudden-onset tearing chest pain radiating to the back.
BP is 180/100 in the right arm and 150/85 in the left arm.
Which imaging study is most appropriate?

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