ITE Cardiovascular Medicine 3 — Questions and Answers
Question 1: A 55-year-old man with diabetes and hypertension has a resting ECG showing left bundle branch block. He presents with 2 hours of chest pain. Which statement is correct regarding diagnosis?
- LBBB excludes ST-elevation MI diagnosis
- New or presumably new LBBB with ischemic symptoms should be treated as STEMI equivalent (Correct answer)
- Troponin levels are unreliable in the setting of LBBB
- Emergent echocardiography is required before reperfusion therapy
Correct answer: New or presumably new LBBB with ischemic symptoms should be treated as STEMI equivalent
Per Sgarbossa criteria and current guidelines, new or presumably new LBBB with ischemic symptoms should be managed as a STEMI equivalent with emergent reperfusion therapy.
Question 2: A patient with long-standing hypertension presents with an aortic dissection beginning just distal to the left subclavian artery (Type B). Blood pressure is 165/95 mmHg and he is pain-free. What is the preferred initial management?
- Emergency surgical repair
- Thoracic endovascular aortic repair (TEVAR)
- Medical management with IV beta-blockers targeting HR <60 and SBP 100-120 mmHg (Correct answer)
- Anticoagulation with heparin to prevent thrombosis
Correct answer: Medical management with IV beta-blockers targeting HR <60 and SBP 100-120 mmHg
Uncomplicated Type B (Stanford) aortic dissections are initially managed medically with heart rate and blood pressure control using IV beta-blockers.
Question 3: Which of the following is the most common cause of sudden cardiac death in athletes under 35 years of age in the United States?
- Anomalous coronary artery origin
- Hypertrophic cardiomyopathy (Correct answer)
- Arrhythmogenic right ventricular cardiomyopathy
- Long QT syndrome
Correct answer: Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in young US athletes, typically from ventricular arrhythmias during intense exertion.
Question 4: A 62-year-old woman with heart failure with reduced ejection fraction (HFrEF, EF 30%) is on optimal medical therapy. QRS duration is 155ms with LBBB morphology. Which intervention improves mortality?
- Implantable cardioverter-defibrillator alone
- Cardiac resynchronization therapy with defibrillator (CRT-D) (Correct answer)
- Cardiac contractility modulation device
- Surgical ventricular reconstruction
Correct answer: Cardiac resynchronization therapy with defibrillator (CRT-D)
CRT-D is indicated in HFrEF patients with LBBB and QRS ≥150ms on GDMT, reducing mortality and hospitalization by resynchronizing ventricular contraction.
Question 5: A 48-year-old man is found to have an LDL of 310 mg/dL despite high-intensity statin therapy. Genetic testing confirms heterozygous familial hypercholesterolemia. What is the most appropriate add-on therapy?
- Niacin 2g daily
- Cholestyramine 8g twice daily
- Ezetimibe plus a PCSK9 inhibitor (Correct answer)
- Omega-3 fatty acids 4g daily
Correct answer: Ezetimibe plus a PCSK9 inhibitor
Ezetimibe plus a PCSK9 inhibitor (evolocumab or alirocumab) provides additive LDL lowering and is recommended for FH patients not at goal on maximally tolerated statins.
Question 6: A 70-year-old man with ischemic cardiomyopathy (EF 25%) has a fasting blood glucose of 115 mg/dL. Which antidiabetic agent has demonstrated cardiovascular mortality benefit in patients with heart failure with reduced EF?
- Metformin
- Sitagliptin (DPP-4 inhibitor)
- Empagliflozin (SGLT2 inhibitor) (Correct answer)
- Liraglutide (GLP-1 agonist)
Correct answer: Empagliflozin (SGLT2 inhibitor)
SGLT2 inhibitors like empagliflozin and dapagliflozin reduce cardiovascular death and heart failure hospitalizations in HFrEF, even in patients without diabetes.
Question 7: A 53-year-old woman presents with exertional dyspnea. Echo shows mean pulmonary arterial pressure 35 mmHg, normal left heart filling pressures (PCWP 10 mmHg), and PVR 4.5 Wood units. What is the most likely diagnosis?
- Group 2 pulmonary hypertension due to left heart disease
- Group 1 pulmonary arterial hypertension (Correct answer)
- Group 3 pulmonary hypertension due to lung disease
- Exercise-induced pulmonary hypertension
Correct answer: Group 1 pulmonary arterial hypertension
Elevated mPAP (>25 mmHg), normal PCWP (<15 mmHg), and elevated PVR (>3 Wood units) define pre-capillary pulmonary hypertension consistent with Group 1 PAH.
ITE Cardiovascular Medicine 3
A 55-year-old man with diabetes and hypertension has a resting ECG showing left bundle branch block.
He presents with 2 hours of chest pain.
Which statement is correct regarding diagnosis?