ITE Cardiovascular Disease 4 — Questions and Answers
Question 1: 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 2: 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 3: 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 4: 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 5: 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 6: 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 7: 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.
ITE Cardiovascular Disease 4
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?