Q1. [Cardiovascular] A 55-year-old man with hypertension presents with
progressive exertional dyspnea and an S4 gallop. Echo shows LVEF of 62%
with diastolic dysfunction. What is the diagnosis and management?
Answer: Heart failure with preserved ejection fraction (HFpEF). Diagnosis
requires symptoms of HF, LVEF ≥50%, and evidence of diastolic dysfunction
(E/e' ratio >14, elevated filling pressures). Management: diuretics for
congestion, blood pressure control, treatment of underlying causes (AF, CAD,
obesity). SGLT2 inhibitors (empagliflozin, dapagliflozin) reduce HF
hospitalizations in HFpEF. ARNI (sacubitril/valsartan) has modest benefit in
lower EF HFpEF range.
Q2. [Cardiovascular] What is the recommended management for a patient
with newly discovered long QT syndrome (QTc >500 ms) and a family
history of sudden cardiac death?
Answer: Avoid QT-prolonging medications (antiarrhythmics, fluoroquinolones,
antipsychotics, methadone, azithromycin). Beta-blockers (nadolol or
propranolol) are first-line to prevent arrhythmia. ICD implantation for high-risk
patients (prior cardiac arrest, syncope on beta-blockers, LQTS2 or LQTS3
with QTc >500 ms). Genetic counseling and screening of first-degree relatives
is essential.
Q3. [Cardiovascular] A 68-year-old woman has a murmur that is loudest at
the right upper sternal border, radiates to the carotids, and is described as
a harsh systolic crescendo-decrescendo murmur. Echo confirms severe
aortic stenosis. When is intervention indicated?
Answer: Indications for aortic valve replacement (AVR): symptomatic severe
AS (angina, syncope, HF — any symptom triggers intervention), or
asymptomatic with LVEF <50%, very severe AS (Vmax >5 m/s), or
undergoing other cardiac surgery. TAVR (transcatheter) for high/intermediate
surgical risk; SAVR (surgical) for low risk. Avoid vasodilators (may cause
hypotension in severe AS).
ABFM ITE Review — Set 2 — 300 Q&A | Page 1 of 74
,Q4. [Cardiovascular] What is Brugada syndrome and how is it managed?
Answer: Brugada syndrome is an inherited channelopathy (SCN5A mutation
in 20–30%) causing type 1 Brugada ECG pattern (coved ST elevation >2 mm
in V1–V2 followed by negative T wave) and risk of sudden cardiac death from
VF. Management: ICD for symptomatic patients (survivors of cardiac arrest or
syncope). Avoid fever (give antipyretics promptly), avoid triggering drugs
(sodium channel blockers, TCAs, cocaine). Quinidine for frequent ICD shocks.
Q5. [Cardiovascular] A 72-year-old man with CAD is found to have a 4.8 cm
abdominal aortic aneurysm (AAA) on ultrasound screening. What is the
management?
Answer: Monitor with ultrasound surveillance: AAA 3.0–3.9 cm → every 3
years; 4.0–4.9 cm → every 12 months; 5.0–5.4 cm → every 6 months.
Elective surgical repair (open or EVAR) indicated when: diameter ≥5.5 cm in
men (≥5.0 cm in women), growth rate >1 cm/year, or symptoms develop.
Smoking cessation and statin therapy for all AAA patients.
Q6. [Cardiovascular] What is the recommended AAA screening per
USPSTF guidelines?
Answer: One-time abdominal ultrasound screening for AAA in men aged 65–
75 who have ever smoked (≥100 lifetime cigarettes). No recommendation for
women or non-smokers. Rationale: benefit of detecting asymptomatic AAA
before rupture (rupture mortality ~80%) outweighs the harms of screening in
this population. Ruptured AAA emergency repair has very high mortality.
Q7. [Cardiovascular] A patient with AF is converting from warfarin to a
DOAC. How should this transition be managed?
Answer: Stop warfarin and start DOAC when INR falls into the therapeutic
range for the specific DOAC: rivaroxaban/apixaban/edoxaban — start when
INR ≤2.5–3.0 (drug-specific); dabigatran — start when INR ≤2.0. No overlap
or bridging is needed during the warfarin-to-DOAC transition. Avoid 'double
dosing.' Monitor INR is not useful for DOACs.
Q8. [Cardiovascular] What are the criteria for diagnosing metabolic
syndrome per the ATP III/NCEP definition?
Answer: Three or more of: (1) Waist circumference >102 cm (40 in) men /
>88 cm (35 in) women; (2) Fasting TG ≥150 mg/dL; (3) HDL <40 mg/dL men /
<50 mg/dL women; (4) BP ≥130/85 mmHg; (5) Fasting glucose ≥100 mg/dL.
Associated with 2× CV risk and 5× T2DM risk. Treatment: lifestyle modification
targeting each component.
ABFM ITE Review — Set 2 — 300 Q&A | Page 2 of 74
,Q9. [Cardiovascular] A 48-year-old woman has exertional chest pain. Stress
testing is non-diagnostic due to baseline ST changes (LBBB). What is the
next diagnostic step?
Answer: Pharmacologic stress test with imaging: adenosine or regadenoson
with nuclear perfusion imaging (MPI), or dobutamine stress echocardiography.
Exercise stress ECG is non-interpretable with LBBB, paced rhythm, LVH with
repolarization changes, or digoxin. Nuclear or echo imaging provides both
functional and anatomic information.
Q10. [Cardiovascular] What is the target LDL for a patient with established
ASCVD (prior MI) per current ACC/AHA guidelines?
Answer: For very high-risk ASCVD (multiple major ASCVD events or one
major event + multiple high-risk conditions): LDL reduction ≥50% from
baseline AND LDL <70 mg/dL. Use high-intensity statin (rosuvastatin 20–40
mg or atorvastatin 40–80 mg). Add ezetimibe if still above goal. PCSK9
inhibitors if still above goal on maximally tolerated statin + ezetimibe.
Q11. [Cardiovascular] What is the Framingham Risk Score used for and
what is its key limitation?
Answer: Framingham Risk Score (FRS) estimates 10-year risk of hard
coronary heart disease events (MI, coronary death) using age, sex, total and
HDL cholesterol, blood pressure, smoking, and diabetes. Key limitation:
developed in predominantly white populations; may underestimate risk in
certain ethnic groups. Replaced by Pooled Cohort Equations (PCE) in the
2013 ACC/AHA guidelines for ASCVD risk calculation.
Q12. [Cardiovascular] A 60-year-old man presents with exertional syncope.
Echo shows LVEF 30%, severely dilated LV, no obstructive CAD. What is
the diagnosis and management?
Answer: Nonischemic dilated cardiomyopathy (NICM). Causes: idiopathic,
viral (viral myocarditis), alcohol, peripartum, Chagas, familial. Management:
HFrEF guideline-directed medical therapy (GDMT): ACEi/ARB/ARNI + BB +
MRA + SGLT2i. ICD if LVEF ≤35% despite ≥3 months of GDMT. Consider
CRT-D if LVEF ≤35% + LBBB + QRS ≥150 ms. Genetic testing for familial
cardiomyopathy.
Q13. [Cardiovascular] What physical exam finding is classic for mitral
stenosis?
Answer: Opening snap (OS) after S2 (due to doming of stiff mitral valve
leaflets), followed by low-pitched diastolic rumble best heard at the apex in left
lateral decubitus position with the bell. Loud S1 if valve is pliable. The shorter
the S2-OS interval, the more severe the stenosis. Most common cause:
ABFM ITE Review — Set 2 — 300 Q&A | Page 3 of 74
, rheumatic heart disease. Management: diuretics for congestion;
anticoagulation for AF; valvotomy or replacement for severe symptomatic MS.
Q14. [Cardiovascular] A 45-year-old woman is found to have a high
sensitivity CRP of 4.2 mg/L. She is a non-smoker with no traditional CV risk
factors. How does this affect risk stratification?
Answer: Elevated hsCRP (>3 mg/L) is an independent cardiovascular risk
enhancer that can upgrade risk in intermediate-risk patients (7.5–20% 10-year
ASCVD risk) to justify statin therapy. The JUPITER trial showed rosuvastatin
reduced CV events in patients with normal LDL but elevated hsCRP ≥2 mg/L.
ABI, coronary artery calcium (CAC) score, and ankle-brachial index are other
risk-enhancing factors.
Q15. [Cardiovascular] What is the coronary artery calcium (CAC) score and
how is it used in clinical decision-making?
Answer: CAC score (Agatston score) quantifies calcified plaque burden in
coronary arteries by non-contrast CT. Used as a risk-refining tool in
intermediate-risk patients uncertain about statin therapy. CAC = 0: very low
10-year risk, can defer statin (if no DM, smoking, or family history); CAC 1–99:
favor statin; CAC ≥100 or ≥75th percentile: statin recommended (high risk).
CAC is additive to Pooled Cohort Equations.
Q16. [Cardiovascular] What is the mechanism of action of ivabradine and
when is it used in heart failure?
Answer: Ivabradine selectively blocks the funny current (If) in the SA node,
reducing heart rate without affecting contractility or blood pressure. Indicated
in stable HFrEF patients with LVEF ≤35%, sinus rhythm, HR ≥70 bpm despite
maximally tolerated beta-blocker dose (or intolerant to beta-blockers).
Reduces HF hospitalizations. Not used in AF (no SA node activity).
Q17. [Cardiovascular] A patient with hypertension reports waking with
morning headaches and has a BP of 165/105 at 7 AM. Home readings at
other times average 130/82. What should be evaluated?
Answer: Morning hypertension surge may indicate uncontrolled nocturnal
hypertension or early morning surge. Order 24-hour ambulatory blood
pressure monitoring (ABPM) to evaluate BP variability, nocturnal dipping, and
overall 24-hour control. Non-dipping (nocturnal BP fail to decrease ≥10%) is
associated with increased cardiovascular risk. May require chronotherapy
(evening dosing of antihypertensives).
Q18. [Cardiovascular] What is the most appropriate management of a
STEMI patient presenting 14 hours after symptom onset?
ABFM ITE Review — Set 2 — 300 Q&A | Page 4 of 74
progressive exertional dyspnea and an S4 gallop. Echo shows LVEF of 62%
with diastolic dysfunction. What is the diagnosis and management?
Answer: Heart failure with preserved ejection fraction (HFpEF). Diagnosis
requires symptoms of HF, LVEF ≥50%, and evidence of diastolic dysfunction
(E/e' ratio >14, elevated filling pressures). Management: diuretics for
congestion, blood pressure control, treatment of underlying causes (AF, CAD,
obesity). SGLT2 inhibitors (empagliflozin, dapagliflozin) reduce HF
hospitalizations in HFpEF. ARNI (sacubitril/valsartan) has modest benefit in
lower EF HFpEF range.
Q2. [Cardiovascular] What is the recommended management for a patient
with newly discovered long QT syndrome (QTc >500 ms) and a family
history of sudden cardiac death?
Answer: Avoid QT-prolonging medications (antiarrhythmics, fluoroquinolones,
antipsychotics, methadone, azithromycin). Beta-blockers (nadolol or
propranolol) are first-line to prevent arrhythmia. ICD implantation for high-risk
patients (prior cardiac arrest, syncope on beta-blockers, LQTS2 or LQTS3
with QTc >500 ms). Genetic counseling and screening of first-degree relatives
is essential.
Q3. [Cardiovascular] A 68-year-old woman has a murmur that is loudest at
the right upper sternal border, radiates to the carotids, and is described as
a harsh systolic crescendo-decrescendo murmur. Echo confirms severe
aortic stenosis. When is intervention indicated?
Answer: Indications for aortic valve replacement (AVR): symptomatic severe
AS (angina, syncope, HF — any symptom triggers intervention), or
asymptomatic with LVEF <50%, very severe AS (Vmax >5 m/s), or
undergoing other cardiac surgery. TAVR (transcatheter) for high/intermediate
surgical risk; SAVR (surgical) for low risk. Avoid vasodilators (may cause
hypotension in severe AS).
ABFM ITE Review — Set 2 — 300 Q&A | Page 1 of 74
,Q4. [Cardiovascular] What is Brugada syndrome and how is it managed?
Answer: Brugada syndrome is an inherited channelopathy (SCN5A mutation
in 20–30%) causing type 1 Brugada ECG pattern (coved ST elevation >2 mm
in V1–V2 followed by negative T wave) and risk of sudden cardiac death from
VF. Management: ICD for symptomatic patients (survivors of cardiac arrest or
syncope). Avoid fever (give antipyretics promptly), avoid triggering drugs
(sodium channel blockers, TCAs, cocaine). Quinidine for frequent ICD shocks.
Q5. [Cardiovascular] A 72-year-old man with CAD is found to have a 4.8 cm
abdominal aortic aneurysm (AAA) on ultrasound screening. What is the
management?
Answer: Monitor with ultrasound surveillance: AAA 3.0–3.9 cm → every 3
years; 4.0–4.9 cm → every 12 months; 5.0–5.4 cm → every 6 months.
Elective surgical repair (open or EVAR) indicated when: diameter ≥5.5 cm in
men (≥5.0 cm in women), growth rate >1 cm/year, or symptoms develop.
Smoking cessation and statin therapy for all AAA patients.
Q6. [Cardiovascular] What is the recommended AAA screening per
USPSTF guidelines?
Answer: One-time abdominal ultrasound screening for AAA in men aged 65–
75 who have ever smoked (≥100 lifetime cigarettes). No recommendation for
women or non-smokers. Rationale: benefit of detecting asymptomatic AAA
before rupture (rupture mortality ~80%) outweighs the harms of screening in
this population. Ruptured AAA emergency repair has very high mortality.
Q7. [Cardiovascular] A patient with AF is converting from warfarin to a
DOAC. How should this transition be managed?
Answer: Stop warfarin and start DOAC when INR falls into the therapeutic
range for the specific DOAC: rivaroxaban/apixaban/edoxaban — start when
INR ≤2.5–3.0 (drug-specific); dabigatran — start when INR ≤2.0. No overlap
or bridging is needed during the warfarin-to-DOAC transition. Avoid 'double
dosing.' Monitor INR is not useful for DOACs.
Q8. [Cardiovascular] What are the criteria for diagnosing metabolic
syndrome per the ATP III/NCEP definition?
Answer: Three or more of: (1) Waist circumference >102 cm (40 in) men /
>88 cm (35 in) women; (2) Fasting TG ≥150 mg/dL; (3) HDL <40 mg/dL men /
<50 mg/dL women; (4) BP ≥130/85 mmHg; (5) Fasting glucose ≥100 mg/dL.
Associated with 2× CV risk and 5× T2DM risk. Treatment: lifestyle modification
targeting each component.
ABFM ITE Review — Set 2 — 300 Q&A | Page 2 of 74
,Q9. [Cardiovascular] A 48-year-old woman has exertional chest pain. Stress
testing is non-diagnostic due to baseline ST changes (LBBB). What is the
next diagnostic step?
Answer: Pharmacologic stress test with imaging: adenosine or regadenoson
with nuclear perfusion imaging (MPI), or dobutamine stress echocardiography.
Exercise stress ECG is non-interpretable with LBBB, paced rhythm, LVH with
repolarization changes, or digoxin. Nuclear or echo imaging provides both
functional and anatomic information.
Q10. [Cardiovascular] What is the target LDL for a patient with established
ASCVD (prior MI) per current ACC/AHA guidelines?
Answer: For very high-risk ASCVD (multiple major ASCVD events or one
major event + multiple high-risk conditions): LDL reduction ≥50% from
baseline AND LDL <70 mg/dL. Use high-intensity statin (rosuvastatin 20–40
mg or atorvastatin 40–80 mg). Add ezetimibe if still above goal. PCSK9
inhibitors if still above goal on maximally tolerated statin + ezetimibe.
Q11. [Cardiovascular] What is the Framingham Risk Score used for and
what is its key limitation?
Answer: Framingham Risk Score (FRS) estimates 10-year risk of hard
coronary heart disease events (MI, coronary death) using age, sex, total and
HDL cholesterol, blood pressure, smoking, and diabetes. Key limitation:
developed in predominantly white populations; may underestimate risk in
certain ethnic groups. Replaced by Pooled Cohort Equations (PCE) in the
2013 ACC/AHA guidelines for ASCVD risk calculation.
Q12. [Cardiovascular] A 60-year-old man presents with exertional syncope.
Echo shows LVEF 30%, severely dilated LV, no obstructive CAD. What is
the diagnosis and management?
Answer: Nonischemic dilated cardiomyopathy (NICM). Causes: idiopathic,
viral (viral myocarditis), alcohol, peripartum, Chagas, familial. Management:
HFrEF guideline-directed medical therapy (GDMT): ACEi/ARB/ARNI + BB +
MRA + SGLT2i. ICD if LVEF ≤35% despite ≥3 months of GDMT. Consider
CRT-D if LVEF ≤35% + LBBB + QRS ≥150 ms. Genetic testing for familial
cardiomyopathy.
Q13. [Cardiovascular] What physical exam finding is classic for mitral
stenosis?
Answer: Opening snap (OS) after S2 (due to doming of stiff mitral valve
leaflets), followed by low-pitched diastolic rumble best heard at the apex in left
lateral decubitus position with the bell. Loud S1 if valve is pliable. The shorter
the S2-OS interval, the more severe the stenosis. Most common cause:
ABFM ITE Review — Set 2 — 300 Q&A | Page 3 of 74
, rheumatic heart disease. Management: diuretics for congestion;
anticoagulation for AF; valvotomy or replacement for severe symptomatic MS.
Q14. [Cardiovascular] A 45-year-old woman is found to have a high
sensitivity CRP of 4.2 mg/L. She is a non-smoker with no traditional CV risk
factors. How does this affect risk stratification?
Answer: Elevated hsCRP (>3 mg/L) is an independent cardiovascular risk
enhancer that can upgrade risk in intermediate-risk patients (7.5–20% 10-year
ASCVD risk) to justify statin therapy. The JUPITER trial showed rosuvastatin
reduced CV events in patients with normal LDL but elevated hsCRP ≥2 mg/L.
ABI, coronary artery calcium (CAC) score, and ankle-brachial index are other
risk-enhancing factors.
Q15. [Cardiovascular] What is the coronary artery calcium (CAC) score and
how is it used in clinical decision-making?
Answer: CAC score (Agatston score) quantifies calcified plaque burden in
coronary arteries by non-contrast CT. Used as a risk-refining tool in
intermediate-risk patients uncertain about statin therapy. CAC = 0: very low
10-year risk, can defer statin (if no DM, smoking, or family history); CAC 1–99:
favor statin; CAC ≥100 or ≥75th percentile: statin recommended (high risk).
CAC is additive to Pooled Cohort Equations.
Q16. [Cardiovascular] What is the mechanism of action of ivabradine and
when is it used in heart failure?
Answer: Ivabradine selectively blocks the funny current (If) in the SA node,
reducing heart rate without affecting contractility or blood pressure. Indicated
in stable HFrEF patients with LVEF ≤35%, sinus rhythm, HR ≥70 bpm despite
maximally tolerated beta-blocker dose (or intolerant to beta-blockers).
Reduces HF hospitalizations. Not used in AF (no SA node activity).
Q17. [Cardiovascular] A patient with hypertension reports waking with
morning headaches and has a BP of 165/105 at 7 AM. Home readings at
other times average 130/82. What should be evaluated?
Answer: Morning hypertension surge may indicate uncontrolled nocturnal
hypertension or early morning surge. Order 24-hour ambulatory blood
pressure monitoring (ABPM) to evaluate BP variability, nocturnal dipping, and
overall 24-hour control. Non-dipping (nocturnal BP fail to decrease ≥10%) is
associated with increased cardiovascular risk. May require chronotherapy
(evening dosing of antihypertensives).
Q18. [Cardiovascular] What is the most appropriate management of a
STEMI patient presenting 14 hours after symptom onset?
ABFM ITE Review — Set 2 — 300 Q&A | Page 4 of 74
