Q1. A 68-year-old man with hypertension, diabetes, and CKD stage 3 has a
BP of 148/92 mmHg on amlodipine. What is the most appropriate next
step?
ANSWER : Add an ACE inhibitor or ARB. In patients with CKD and
diabetes, ACE inhibitors/ARBs are preferred second agents due to
renoprotective effects and reduction of proteinuria, with target BP
<130/80 mmHg per current guidelines.
Q2. A patient with HFrEF (EF 30%) is on optimal medical therapy. Which
device therapy has been shown to reduce all-cause mortality?
ANSWER : Implantable cardioverter-defibrillator (ICD). In patients with
HFrEF (EF ≤35%) with NYHA class II-III despite GDMT, ICD reduces
sudden cardiac death and all-cause mortality.
Q3. Which medication should be avoided in patients with HFrEF?
ANSWER : Non-dihydropyridine calcium channel blockers (diltiazem,
verapamil) should be avoided in HFrEF as they have negative inotropic
effects and may worsen heart failure. NSAIDs, thiazolidinediones, and
most antiarrhythmics also worsen HF.
Q4. A 55-year-old woman presents with acute STEMI. Door-to-balloon time
is 70 minutes. What is the preferred reperfusion strategy?
ANSWER : Primary PCI (percutaneous coronary intervention) is
preferred when door-to-balloon time is ≤90 minutes. The goal is to
achieve reperfusion as quickly as possible; if PCI cannot be performed
within 120 minutes of first medical contact, fibrinolysis should be given
within 30 minutes.
Q5. What is the first-line treatment for atrial fibrillation with rapid
ventricular response in a hemodynamically stable patient?
, ANSWER : Rate control with IV metoprolol or diltiazem. In
hemodynamically stable patients, rate control (target HR <110 bpm) is
the initial approach. If unstable, immediate electrical cardioversion is
indicated.
Q6. Which scoring system is used to assess stroke risk in atrial fibrillation,
and what score warrants anticoagulation?
ANSWER : CHA₂DS₂-VASc score. Anticoagulation is recommended for
men with score ≥2 and women with score ≥3. For men with score 1 or
women with score 2, anticoagulation may be considered on an individual
basis.
Q7. A 72-year-old with AF and CrCl of 28 mL/min needs anticoagulation.
Which DOAC is preferred?
ANSWER : Apixaban is preferred in severe CKD (CrCl 15-29 mL/min). It
has the least renal elimination (~27%) among DOACs. Warfarin remains
an option; rivaroxaban and edoxaban require caution; dabigatran is
contraindicated with CrCl <30 mL/min.
Q8. What ECG finding is pathognomonic of Wolff-Parkinson-White (WPW)
syndrome during sinus rhythm?
ANSWER : Delta wave (slurred upstroke of the QRS), short PR interval
(<120 ms), and wide QRS complex. This triad results from pre-excitation
of the ventricles through an accessory pathway (bundle of Kent).
Q9. A patient with known hypertrophic cardiomyopathy is found to have
LVOT obstruction. Which medication is contraindicated?
ANSWER : Vasodilators (nitroglycerin, hydralazine) and positive
inotropes (digoxin, dobutamine) are contraindicated as they worsen
LVOT obstruction. Beta-blockers or non-dihydropyridine CCBs are first-
line.
Q10. What is the most common cause of aortic stenosis in adults over 70
years old?
ANSWER : Calcific (degenerative) aortic stenosis due to age-related
calcium deposition on the valve leaflets is the most common cause in
elderly patients. Bicuspid aortic valve is the most common cause in
younger adults.
Q11. At what valve area or mean gradient does severe aortic stenosis meet
criteria for intervention?
, ANSWER : Severe AS: valve area <1.0 cm², mean gradient >40 mmHg,
or jet velocity >4 m/s. Intervention (SAVR or TAVR) is indicated when
symptomatic (angina, syncope, dyspnea) or when asymptomatic with EF
<50%.
Q12. Which condition is most commonly associated with mitral valve
prolapse?
ANSWER : Mitral regurgitation (MR) is the most common associated
finding. Severe MR from MVP is a leading indication for mitral valve
surgery. MVP is also associated with Marfan syndrome, Ehlers-Danlos
syndrome, and pectus excavatum.
Q13. What is the appropriate management of a 60-year-old with NYHA class
III heart failure and EF of 25% already on ACE inhibitor and beta-blocker?
ANSWER : Add mineralocorticoid receptor antagonist (spironolactone or
eplerenone) if GFR >30 and K+ <5.0; consider SGLT2 inhibitor
(dapagliflozin/empagliflozin); and add hydralazine/nitrate if ACE-
intolerant. ARNI (sacubitril/valsartan) should replace ACE inhibitor if
tolerated.
Q14. A patient presents with pulsus paradoxus >10 mmHg, hypotension,
and elevated JVP. What is the diagnosis?
ANSWER : Cardiac tamponade. The classic Beck's triad is hypotension,
muffled heart sounds, and elevated JVP. Pulsus paradoxus >10 mmHg
is a hallmark. Immediate pericardiocentesis is the treatment.
Q15. What ECG change is characteristic of hyperkalemia when K+ is 6.5-7.0
mEq/L?
ANSWER : Peaked (tall, narrow, symmetric) T waves are the earliest
ECG change in hyperkalemia. As K+ rises further: prolonged PR,
widened QRS, flattened P waves, sine wave pattern, and ventricular
fibrillation can occur.
Q16. Which lipid-lowering drug class has been shown to reduce
cardiovascular events independent of LDL lowering?
ANSWER : PCSK9 inhibitors (evolocumab, alirocumab) reduce MACE
by approximately 15% in patients on maximally tolerated statin therapy.
Icosapent ethyl (EPA-only fish oil) also reduces CV events independent
of LDL in high-risk patients with elevated triglycerides.
, Q17. What is the mechanism of action of sacubitril/valsartan in heart
failure?
ANSWER : Sacubitril inhibits neprilysin, an enzyme that degrades
natriuretic peptides (BNP, ANP), bradykinin, and other vasoactive
peptides, leading to vasodilation and reduced fibrosis. Valsartan blocks
the AT1 receptor. Combined, they improve symptoms and reduce
mortality in HFrEF.
Q18. A 45-year-old with a bicuspid aortic valve has an ascending aorta of
4.6 cm. When is surgery indicated?
ANSWER : In patients with bicuspid aortic valve, prophylactic surgery is
recommended when the aorta reaches ≥5.0-5.5 cm (or ≥4.5 cm if
additional risk factors like rapid growth >0.5 cm/year, family history of
dissection, or planned valve surgery).
Q19. What is the most common inherited arrhythmia syndrome that causes
sudden cardiac death in young athletes?
ANSWER : Long QT syndrome (LQTS) is the most common inherited
arrhythmia causing sudden death in the young. Brugada syndrome,
CPVT, and hypertrophic cardiomyopathy are also important. HCM is the
most common cause of sudden death in young US athletes overall.
Q20. Which finding on echocardiogram is most consistent with cardiac
amyloidosis?
ANSWER : Biventricular wall thickening with a 'granular sparkling'
appearance on echo, diastolic dysfunction, thickened valves, and small
pericardial effusion. Apical sparing on strain imaging (bull's-eye pattern)
is highly specific for cardiac amyloidosis.
Q21. What is the preferred treatment for a patient with new-onset AF lasting
<48 hours who is hemodynamically stable?
ANSWER : Pharmacological or electrical cardioversion can be
performed without prior anticoagulation if AF duration is clearly <48
hours, though anticoagulation should be started immediately and
continued for at least 4 weeks post-cardioversion. Rate control is an
alternative for those who prefer it.
Q22. A patient with dilated cardiomyopathy has a QRS duration of 160 ms
and LBBB. EF is 25%. What additional therapy is indicated?
ANSWER : Cardiac resynchronization therapy (CRT) with or without
ICD. CRT is indicated for HFrEF patients with LVEF ≤35%, sinus rhythm,
BP of 148/92 mmHg on amlodipine. What is the most appropriate next
step?
ANSWER : Add an ACE inhibitor or ARB. In patients with CKD and
diabetes, ACE inhibitors/ARBs are preferred second agents due to
renoprotective effects and reduction of proteinuria, with target BP
<130/80 mmHg per current guidelines.
Q2. A patient with HFrEF (EF 30%) is on optimal medical therapy. Which
device therapy has been shown to reduce all-cause mortality?
ANSWER : Implantable cardioverter-defibrillator (ICD). In patients with
HFrEF (EF ≤35%) with NYHA class II-III despite GDMT, ICD reduces
sudden cardiac death and all-cause mortality.
Q3. Which medication should be avoided in patients with HFrEF?
ANSWER : Non-dihydropyridine calcium channel blockers (diltiazem,
verapamil) should be avoided in HFrEF as they have negative inotropic
effects and may worsen heart failure. NSAIDs, thiazolidinediones, and
most antiarrhythmics also worsen HF.
Q4. A 55-year-old woman presents with acute STEMI. Door-to-balloon time
is 70 minutes. What is the preferred reperfusion strategy?
ANSWER : Primary PCI (percutaneous coronary intervention) is
preferred when door-to-balloon time is ≤90 minutes. The goal is to
achieve reperfusion as quickly as possible; if PCI cannot be performed
within 120 minutes of first medical contact, fibrinolysis should be given
within 30 minutes.
Q5. What is the first-line treatment for atrial fibrillation with rapid
ventricular response in a hemodynamically stable patient?
, ANSWER : Rate control with IV metoprolol or diltiazem. In
hemodynamically stable patients, rate control (target HR <110 bpm) is
the initial approach. If unstable, immediate electrical cardioversion is
indicated.
Q6. Which scoring system is used to assess stroke risk in atrial fibrillation,
and what score warrants anticoagulation?
ANSWER : CHA₂DS₂-VASc score. Anticoagulation is recommended for
men with score ≥2 and women with score ≥3. For men with score 1 or
women with score 2, anticoagulation may be considered on an individual
basis.
Q7. A 72-year-old with AF and CrCl of 28 mL/min needs anticoagulation.
Which DOAC is preferred?
ANSWER : Apixaban is preferred in severe CKD (CrCl 15-29 mL/min). It
has the least renal elimination (~27%) among DOACs. Warfarin remains
an option; rivaroxaban and edoxaban require caution; dabigatran is
contraindicated with CrCl <30 mL/min.
Q8. What ECG finding is pathognomonic of Wolff-Parkinson-White (WPW)
syndrome during sinus rhythm?
ANSWER : Delta wave (slurred upstroke of the QRS), short PR interval
(<120 ms), and wide QRS complex. This triad results from pre-excitation
of the ventricles through an accessory pathway (bundle of Kent).
Q9. A patient with known hypertrophic cardiomyopathy is found to have
LVOT obstruction. Which medication is contraindicated?
ANSWER : Vasodilators (nitroglycerin, hydralazine) and positive
inotropes (digoxin, dobutamine) are contraindicated as they worsen
LVOT obstruction. Beta-blockers or non-dihydropyridine CCBs are first-
line.
Q10. What is the most common cause of aortic stenosis in adults over 70
years old?
ANSWER : Calcific (degenerative) aortic stenosis due to age-related
calcium deposition on the valve leaflets is the most common cause in
elderly patients. Bicuspid aortic valve is the most common cause in
younger adults.
Q11. At what valve area or mean gradient does severe aortic stenosis meet
criteria for intervention?
, ANSWER : Severe AS: valve area <1.0 cm², mean gradient >40 mmHg,
or jet velocity >4 m/s. Intervention (SAVR or TAVR) is indicated when
symptomatic (angina, syncope, dyspnea) or when asymptomatic with EF
<50%.
Q12. Which condition is most commonly associated with mitral valve
prolapse?
ANSWER : Mitral regurgitation (MR) is the most common associated
finding. Severe MR from MVP is a leading indication for mitral valve
surgery. MVP is also associated with Marfan syndrome, Ehlers-Danlos
syndrome, and pectus excavatum.
Q13. What is the appropriate management of a 60-year-old with NYHA class
III heart failure and EF of 25% already on ACE inhibitor and beta-blocker?
ANSWER : Add mineralocorticoid receptor antagonist (spironolactone or
eplerenone) if GFR >30 and K+ <5.0; consider SGLT2 inhibitor
(dapagliflozin/empagliflozin); and add hydralazine/nitrate if ACE-
intolerant. ARNI (sacubitril/valsartan) should replace ACE inhibitor if
tolerated.
Q14. A patient presents with pulsus paradoxus >10 mmHg, hypotension,
and elevated JVP. What is the diagnosis?
ANSWER : Cardiac tamponade. The classic Beck's triad is hypotension,
muffled heart sounds, and elevated JVP. Pulsus paradoxus >10 mmHg
is a hallmark. Immediate pericardiocentesis is the treatment.
Q15. What ECG change is characteristic of hyperkalemia when K+ is 6.5-7.0
mEq/L?
ANSWER : Peaked (tall, narrow, symmetric) T waves are the earliest
ECG change in hyperkalemia. As K+ rises further: prolonged PR,
widened QRS, flattened P waves, sine wave pattern, and ventricular
fibrillation can occur.
Q16. Which lipid-lowering drug class has been shown to reduce
cardiovascular events independent of LDL lowering?
ANSWER : PCSK9 inhibitors (evolocumab, alirocumab) reduce MACE
by approximately 15% in patients on maximally tolerated statin therapy.
Icosapent ethyl (EPA-only fish oil) also reduces CV events independent
of LDL in high-risk patients with elevated triglycerides.
, Q17. What is the mechanism of action of sacubitril/valsartan in heart
failure?
ANSWER : Sacubitril inhibits neprilysin, an enzyme that degrades
natriuretic peptides (BNP, ANP), bradykinin, and other vasoactive
peptides, leading to vasodilation and reduced fibrosis. Valsartan blocks
the AT1 receptor. Combined, they improve symptoms and reduce
mortality in HFrEF.
Q18. A 45-year-old with a bicuspid aortic valve has an ascending aorta of
4.6 cm. When is surgery indicated?
ANSWER : In patients with bicuspid aortic valve, prophylactic surgery is
recommended when the aorta reaches ≥5.0-5.5 cm (or ≥4.5 cm if
additional risk factors like rapid growth >0.5 cm/year, family history of
dissection, or planned valve surgery).
Q19. What is the most common inherited arrhythmia syndrome that causes
sudden cardiac death in young athletes?
ANSWER : Long QT syndrome (LQTS) is the most common inherited
arrhythmia causing sudden death in the young. Brugada syndrome,
CPVT, and hypertrophic cardiomyopathy are also important. HCM is the
most common cause of sudden death in young US athletes overall.
Q20. Which finding on echocardiogram is most consistent with cardiac
amyloidosis?
ANSWER : Biventricular wall thickening with a 'granular sparkling'
appearance on echo, diastolic dysfunction, thickened valves, and small
pericardial effusion. Apical sparing on strain imaging (bull's-eye pattern)
is highly specific for cardiac amyloidosis.
Q21. What is the preferred treatment for a patient with new-onset AF lasting
<48 hours who is hemodynamically stable?
ANSWER : Pharmacological or electrical cardioversion can be
performed without prior anticoagulation if AF duration is clearly <48
hours, though anticoagulation should be started immediately and
continued for at least 4 weeks post-cardioversion. Rate control is an
alternative for those who prefer it.
Q22. A patient with dilated cardiomyopathy has a QRS duration of 160 ms
and LBBB. EF is 25%. What additional therapy is indicated?
ANSWER : Cardiac resynchronization therapy (CRT) with or without
ICD. CRT is indicated for HFrEF patients with LVEF ≤35%, sinus rhythm,
