ITE Cardiovascular Medicine 2 — Questions and Answers
Question 1: A 58-year-old man presents with exertional chest pain. Stress testing shows 2mm ST depression in leads V4-V6 at 5 METs. What is the most appropriate next step?
- Start long-acting nitrates and retest in 3 months
- Refer for coronary angiography (Correct answer)
- Perform cardiac MRI stress perfusion imaging
- Increase beta-blocker dosage and repeat stress test
Correct answer: Refer for coronary angiography
High-risk stress test findings (≥2mm ST depression, low exercise capacity <5 METs) warrant prompt coronary angiography for definitive evaluation.
Question 2: A 72-year-old woman with atrial fibrillation and a CHA₂DS₂-VASc score of 5 is started on apixaban. Which monitoring parameter is most important at follow-up?
- INR level every 4 weeks
- Renal function annually or with clinical changes (Correct answer)
- Anti-Xa level to confirm therapeutic dosing
- Platelet count every 3 months
Correct answer: Renal function annually or with clinical changes
DOACs like apixaban are renally cleared, so renal function should be monitored at least annually (or more frequently if declining) to guide dose adjustments.
Question 3: Which finding on transthoracic echocardiography best distinguishes cardiac tamponade from constrictive pericarditis?
- Pericardial effusion with right atrial collapse in systole (Correct answer)
- Respiratory variation in mitral inflow >25%
- Septal bounce on M-mode
- Elevated E/e' ratio on tissue Doppler
Correct answer: Pericardial effusion with right atrial collapse in systole
Right atrial collapse during systole (and right ventricular diastolic collapse) are hallmarks of cardiac tamponade physiology due to elevated pericardial pressure.
Question 4: A 45-year-old with hypertrophic obstructive cardiomyopathy (HOCM) has persistent symptoms despite medical therapy. Which intervention is most appropriate?
- Cardiac transplantation
- Implantable cardioverter-defibrillator placement
- Septal reduction therapy (surgical myectomy or alcohol ablation) (Correct answer)
- Addition of digoxin to current regimen
Correct answer: Septal reduction therapy (surgical myectomy or alcohol ablation)
Septal reduction therapy — either surgical myectomy or alcohol septal ablation — is indicated for HOCM patients with persistent NYHA Class III-IV symptoms despite optimal medical therapy.
Question 5: A patient with known coronary artery disease develops hypotension and pulmonary edema 3 days after an anterior MI. Echo shows a new VSD. What is the definitive treatment?
- Intravenous furosemide and vasopressors
- Emergency surgical repair of the VSD (Correct answer)
- Percutaneous VSD closure as first-line therapy
- Intra-aortic balloon pump as definitive therapy
Correct answer: Emergency surgical repair of the VSD
Post-MI VSD with cardiogenic shock carries very high mortality and requires emergency surgical repair, often with mechanical circulatory support as a bridge.
Question 6: A 35-year-old woman on oral contraceptives develops sudden-onset pleuritic chest pain and dyspnea. CT angiography confirms pulmonary embolism. Which anticoagulant is preferred for long-term treatment?
- Warfarin with INR target 2-3
- Rivaroxaban or apixaban (DOAC) (Correct answer)
- Dabigatran following 5-10 days of parenteral anticoagulation
- Aspirin 325mg daily
Correct answer: Rivaroxaban or apixaban (DOAC)
DOACs (rivaroxaban or apixaban) are first-line for PE treatment in non-pregnant patients without antiphospholipid syndrome, offering convenience with non-inferior efficacy.
Question 7: A 66-year-old man with severe aortic stenosis (valve area 0.7 cm², mean gradient 50 mmHg) is asymptomatic. What is the most appropriate management?
- Proceed to aortic valve replacement immediately
- Watchful waiting with serial echocardiography every 6-12 months (Correct answer)
- Start ACE inhibitor to reduce afterload
- Perform balloon aortic valvuloplasty as a bridge
Correct answer: Watchful waiting with serial echocardiography every 6-12 months
Asymptomatic severe AS with preserved LV function is managed with close surveillance (echo every 6-12 months) and prompt referral once symptoms develop or LV function declines.
ITE Cardiovascular Medicine 2
A 58-year-old man presents with exertional chest pain.
Stress testing shows 2mm ST depression in leads V4-V6 at 5 METs.
What is the most appropriate next step?