ITE Cardiovascular Disease Questions and Answers

Question 1

A 68-year-old male with a history of hypertension and type 2 diabetes presents with a 2-month history of exertional chest pain. An exercise stress test is positive for ischemia. Coronary angiography reveals three-vessel coronary artery disease with 80% stenosis in the left main coronary artery. His left ventricular ejection fraction is 45%. According to the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization, which of the following is the most appropriate next step in management?

Accepted Answer

Coronary artery bypass grafting (CABG)

Answer

For patients with significant left main coronary artery disease, especially with multivessel disease and reduced ejection fraction, coronary artery bypass grafting (CABG) is recommended to improve survival compared to medical therapy or PCI. A Heart Team approach is recommended to make a final decision, but CABG is the preferred revascularization strategy in this high-risk patient.

Question 2

A 62-year-old female presents to the emergency department with an acute onset of shortness of breath. Her medical history is significant for hypertension. On examination, her blood pressure is 155/95 mmHg, heart rate is 105 bpm, and respiratory rate is 24 breaths/min. She has bilateral crackles on lung auscultation and 2+ pitting edema in her lower extremities. A B-type natriuretic peptide (BNP) level is markedly elevated. Transthoracic echocardiogram reveals a left ventricular ejection fraction of 35%. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure, which of the following medication classes should be initiated in this patient, in addition to a diuretic, once she is hemodynamically stable?

Accepted Answer

All of the above

Answer

The 2022 AHA/ACC/HFSA Heart Failure Guideline recommends quadruple therapy for heart failure with reduced ejection fraction (HFrEF). This includes an ARNI (or ACE inhibitor/ARB), an evidence-based beta-blocker, a mineralocorticoid receptor antagonist (MRA), and a sodium-glucose cotransporter-2 (SGLT2) inhibitor. These four classes of medications are the cornerstone of guideline-directed medical therapy (GDMT) and should be initiated as tolerated to improve symptoms and reduce mortality.

Question 3

A 75-year-old asymptomatic female is found to have a harsh, crescendo-decrescendo systolic murmur at the right upper sternal border that radiates to the carotid arteries during a routine physical exam. A transthoracic echocardiogram confirms severe aortic stenosis with a valve area of 0.8 cm², a mean gradient of 50 mmHg, and a left ventricular ejection fraction of 60%. According to the 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease, which of the following is the most appropriate recommendation?

Accepted Answer

Referral for aortic valve replacement

Answer

Even in asymptomatic patients, intervention is indicated for severe aortic stenosis when certain high-risk features are present, such as a very severe stenosis (e.g., mean gradient >40 mmHg or valve area <1.0 cm²), or reduced left ventricular function. Given her severe aortic stenosis based on the echocardiographic findings, she should be referred for consideration of aortic valve replacement (either surgical or transcatheter) to prevent the onset of symptoms and adverse cardiac events.

Question 4

According to the 2023 AHA/ACC Guideline for the Management of Patients With Chronic Coronary Disease, which of the following statements regarding the long-term use of beta-blockers is correct?

Accepted Answer

Their long-term use is not recommended to improve outcomes in patients with CCD without a history of MI in the past year or an LVEF ≤50%.

Answer

The 2023 guidelines updated the recommendations for beta-blocker use in chronic coronary disease (CCD). Long-term beta-blocker therapy is no longer recommended to improve outcomes for all patients with CCD. Their use for this purpose is reserved for patients who have had a myocardial infarction within the past year, have a left ventricular ejection fraction of 50% or less, or have another primary indication for the therapy. For stable angina, they are still considered a first-line antianginal therapy.

Question 5

A 45-year-old woman presents to the clinic for a follow-up visit. Her blood pressure today is 148/92 mmHg. A reading last month was 145/90 mmHg. She has no other medical problems. According to the JNC 8 guidelines, what is the recommended initial treatment for her hypertension?

Accepted Answer

Hydrochlorothiazide

Answer

For the general non-black population, including those with diabetes, the JNC 8 guidelines recommend one of four classes of medications as initial therapy: a thiazide-type diuretic, a calcium channel blocker (CCB), an angiotensin-converting enzyme inhibitor (ACEI), or an angiotensin receptor blocker (ARB). All four options presented are considered acceptable first-line agents in this patient. However, thiazide diuretics have been a long-standing and well-supported choice.

ITE - Internal Medicine In-Training Exam Practice Test

ITE - Internal Medicine In-Training Exam Practice Test

ITE Cardiovascular Disease Questions and Answers