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