ITE Cardiovascular Medicine 5 — Questions and Answers
Question 1: A 65-year-old woman with HFpEF (EF 60%) presents with recurrent hospitalizations for fluid overload. Her BNP is 450 pg/mL. Which treatment has the strongest evidence for reducing HFpEF hospitalizations?
- ACE inhibitor (enalapril)
- Beta-blocker (carvedilol)
- SGLT2 inhibitor (empagliflozin) (Correct answer)
- Aldosterone antagonist (spironolactone)
Correct answer: SGLT2 inhibitor (empagliflozin)
SGLT2 inhibitors (empagliflozin, dapagliflozin) are the first drug class to demonstrate significant reduction in cardiovascular death and worsening HF hospitalizations in HFpEF.
Question 2: A 50-year-old man undergoes a nuclear stress test. Imaging shows a fixed perfusion defect in the inferior wall and a transient ischemic dilation of the LV cavity. What does transient ischemic dilation indicate?
- Inferior wall myocardial infarction with good collateral flow
- Severe, extensive coronary artery disease with stress-induced LV dysfunction (Correct answer)
- Right ventricular overload mimicking LV dilation
- Artifact from patient motion during stress imaging
Correct answer: Severe, extensive coronary artery disease with stress-induced LV dysfunction
Transient ischemic dilation (TID) of the LV during stress reflects subendocardial ischemia causing apparent cavity enlargement and is a marker of severe, multivessel CAD.
Question 3: A 58-year-old man with no prior cardiac history is found to have a calcium score of 320 Agatston units. His 10-year ASCVD risk is 12%. What is the most appropriate action?
- Continue lifestyle modification without statin therapy
- Start moderate-intensity statin therapy
- Start high-intensity statin therapy (Correct answer)
- Refer for coronary CTA to assess stenosis severity
Correct answer: Start high-intensity statin therapy
A coronary artery calcium score ≥300 reclassifies the patient to high risk and supports initiation of high-intensity statin therapy regardless of calculated ASCVD risk.
Question 4: A 74-year-old woman with a mechanical mitral valve on warfarin requires elective knee replacement surgery. What is the appropriate perioperative anticoagulation strategy?
- Stop warfarin 5 days before surgery with UFH bridging; restart warfarin post-op (Correct answer)
- Stop warfarin without bridging as risk of thrombosis is low
- Switch to rivaroxaban perioperatively for ease of management
- Continue warfarin at half-dose throughout the perioperative period
Correct answer: Stop warfarin 5 days before surgery with UFH bridging; restart warfarin post-op
Mechanical mitral valves carry high thromboembolic risk, requiring bridging with unfractionated or low-molecular-weight heparin when warfarin is held perioperatively.
Question 5: A 29-year-old woman with Marfan syndrome is found to have an aortic root diameter of 4.8 cm. She wishes to become pregnant. What counseling is most appropriate?
- Pregnancy is safe if aortic root is <5.0 cm; proceed without intervention
- Prophylactic aortic root repair is recommended before pregnancy given high dissection risk at this diameter (Correct answer)
- Beta-blockers should be discontinued in favor of calcium channel blockers during pregnancy
- Elective cesarean delivery eliminates the risk of aortic dissection
Correct answer: Prophylactic aortic root repair is recommended before pregnancy given high dissection risk at this diameter
In Marfan syndrome, prophylactic aortic root repair is recommended before pregnancy when the aortic root is ≥4.5 cm, given the substantial risk of dissection during pregnancy and delivery.
Question 6: A 68-year-old man with non-ischemic dilated cardiomyopathy (EF 22%) is on optimal GDMT. He experiences an episode of sustained VT terminated by his ICD. Which medication change is most appropriate?
- Add amiodarone for secondary prevention of VT recurrence (Correct answer)
- Discontinue beta-blocker to prevent proarrhythmic effects
- Increase digoxin dose to improve cardiac output
- Switch from sacubitril/valsartan to ACE inhibitor alone
Correct answer: Add amiodarone for secondary prevention of VT recurrence
Amiodarone is the most effective antiarrhythmic for reducing ICD shocks in patients with structural heart disease and sustained VT, used as secondary prevention.
Question 7: A 55-year-old man presents with exertional syncope. Physical exam reveals a harsh mid-systolic crescendo-decrescendo murmur at the right upper sternal border radiating to the carotids. Carotid upstroke is diminished and delayed (pulsus parvus et tardus). What is the most likely diagnosis?
- Hypertrophic obstructive cardiomyopathy
- Severe aortic stenosis (Correct answer)
- Pulmonary stenosis with right heart failure
- Aortic regurgitation with wide pulse pressure
Correct answer: Severe aortic stenosis
Pulsus parvus et tardus (small, slow-rising carotid pulse) with a calcific mid-systolic murmur radiating to carotids and exertional syncope are classic findings of severe calcific aortic stenosis.
ITE Cardiovascular Medicine 5
A 65-year-old woman with HFpEF (EF 60%) presents with recurrent hospitalizations for fluid overload.
Her BNP is 450 pg/mL.
Which treatment has the strongest evidence for reducing HFpEF hospitalizations?