20 High-Quality Internal Medicine Board Recertification Questions on Cardiovascular Diseases
The most effective approach to creating high-quality internal medicine board recertification questions on cardiovascular diseases is to focus on core competencies in cardiovascular medicine that directly impact patient morbidity, mortality, and quality of life.
Key Content Areas for Question Development
1. Atherosclerotic Cardiovascular Disease Prevention
Question: A 58-year-old male with type 2 diabetes (A1C 7.8%), hypertension, and dyslipidemia has a 10-year ASCVD risk score of 15%. Which medication has demonstrated significant reduction in cardiovascular death and should be added to his regimen?
- A) Sitagliptin
- B) Liraglutide
- C) Saxagliptin
- D) Exenatide
- E) Alogliptin
Question: A 62-year-old woman with established coronary artery disease has LDL-C of 110 mg/dL despite maximum tolerated statin therapy. Which therapy has shown the strongest evidence for cardiovascular risk reduction as the next step?
- A) Ezetimibe
- B) Fibrates
- C) Niacin
- D) PCSK9 inhibitor
- E) Bile acid sequestrants
2. Hypertension Management
Question: A 67-year-old African American male with hypertension (BP 162/94 mmHg) and stage 2 chronic kidney disease presents for medication adjustment. Which antihypertensive regimen would be most appropriate for reducing cardiovascular morbidity and mortality?
- A) Hydrochlorothiazide and amlodipine
- B) Lisinopril and metoprolol
- C) Amlodipine and valsartan
- D) Chlorthalidone and lisinopril
- E) Clonidine and hydralazine
Question: A 55-year-old woman has resistant hypertension despite therapy with amlodipine, lisinopril, and hydrochlorothiazide. Which medication is most likely contributing to her resistant hypertension?
- A) Daily multivitamin
- B) Ibuprofen 600 mg twice daily
- C) Loratadine 10 mg daily
- D) Levothyroxine 50 mcg daily
- E) Metformin 1000 mg twice daily
3. Heart Failure Management
Question: A 72-year-old male with heart failure with reduced ejection fraction (EF 35%) remains symptomatic (NYHA class II) despite optimal doses of lisinopril and metoprolol. Which medication has shown the greatest mortality benefit when added to his regimen?
- A) Digoxin
- B) Spironolactone
- C) Hydralazine/isosorbide dinitrate
- D) Ivabradine
- E) Verapamil
Question: A 68-year-old woman with heart failure with preserved ejection fraction (EF 55%) presents with worsening dyspnea. Which medication has demonstrated the most significant improvement in mortality for this condition?
- A) Spironolactone
- B) Sacubitril/valsartan
- C) Carvedilol
- D) Furosemide
- E) None of the above
4. Arrhythmia Management
Question: A 75-year-old male with paroxysmal atrial fibrillation (CHA₂DS₂-VASc score of 3) refuses anticoagulation therapy. Which intervention would most effectively reduce his stroke risk?
- A) Aspirin 81 mg daily
- B) Clopidogrel 75 mg daily
- C) Left atrial appendage closure device
- D) Aspirin plus clopidogrel
- E) Rhythm control with amiodarone alone
Question: A 62-year-old woman with non-valvular atrial fibrillation and normal renal function is being considered for anticoagulation. Which factor would most strongly influence the decision between warfarin and a direct oral anticoagulant (DOAC)?
- A) Patient's preference for once-daily dosing
- B) History of gastrointestinal bleeding 5 years ago
- C) Concurrent use of amiodarone
- D) Mechanical mitral valve replacement
- E) Cost of medication
5. Acute Coronary Syndromes
Question: A 59-year-old male presents with chest pain and ST-segment elevation in leads II, III, and aVF. After primary PCI of the right coronary artery, which medication has shown the greatest mortality benefit for long-term management?
- A) Prasugrel
- B) Ticagrelor
- C) High-intensity statin
- D) Beta-blocker
- E) ACE inhibitor
Question: A 70-year-old diabetic woman presents with non-ST elevation myocardial infarction. Which finding on coronary angiography would most strongly indicate the need for coronary artery bypass grafting rather than percutaneous intervention?
- A) 90% stenosis of the proximal LAD
- B) 80% stenosis of a large diagonal branch
- C) 85% stenosis of the mid-RCA
- D) Left main disease with 70% stenosis
- E) 90% stenosis of the proximal circumflex artery
6. Valvular Heart Disease
Question: A 78-year-old asymptomatic male has severe aortic stenosis with a valve area of 0.8 cm², mean gradient of 45 mmHg, and preserved left ventricular function. Which finding would be the strongest indication for valve replacement to reduce mortality?
- A) New-onset atrial fibrillation
- B) Exercise-induced hypotension
- C) Mild mitral regurgitation
- D) Left ventricular hypertrophy on ECG
- E) Mild pulmonary hypertension
Question: A 55-year-old woman with rheumatic mitral stenosis (valve area 1.2 cm²) develops new-onset atrial fibrillation. Which intervention would most effectively reduce her risk of thromboembolism?
- A) Aspirin therapy
- B) Warfarin with target INR 2-3
- C) Direct oral anticoagulant
- D) Left atrial appendage closure
- E) Cardioversion followed by aspirin
7. Cardiac Device Management
Question: A 66-year-old male with ischemic cardiomyopathy (EF 25%) and NYHA class II symptoms is being considered for an implantable cardioverter-defibrillator. Which factor would be a contraindication to device implantation?
- A) History of sustained ventricular tachycardia
- B) Life expectancy less than 1 year
- C) Chronic kidney disease stage 3
- D) Type 2 diabetes with A1C of 8.5%
- E) Prior CABG 5 years ago
Question: A 72-year-old woman with a dual-chamber pacemaker implanted for sick sinus syndrome requires an MRI of the lumbar spine. Which statement regarding MRI compatibility is most accurate?
- A) All pacemakers implanted after 2015 are MRI-conditional
- B) MRI can be performed if the pacemaker is programmed to VOO mode
- C) The specific pacemaker model must be verified as MRI-conditional
- D) MRI can be safely performed if the device is deactivated
- E) Only 1.0 Tesla MRI scanners are safe for patients with pacemakers
8. Peripheral Vascular Disease
Question: A 68-year-old male smoker with diabetes presents with claudication and an ankle-brachial index of 0.65. Which intervention has shown the greatest improvement in walking distance and quality of life?
- A) Cilostazol
- B) Pentoxifylline
- C) Supervised exercise program
- D) Aspirin
- E) Percutaneous angioplasty
Question: A 70-year-old woman is found to have an abdominal aortic aneurysm measuring 4.8 cm on ultrasound. Which management approach would most effectively reduce mortality?
- A) Immediate surgical repair
- B) Endovascular repair
- C) Beta-blocker therapy and surveillance imaging in 6 months
- D) Antiplatelet therapy and surveillance imaging in 3 months
- E) Anticoagulation therapy
9. Cardiac Rehabilitation
- Question: A 65-year-old male has completed coronary artery bypass grafting for three-vessel disease. Which statement about cardiac rehabilitation is most accurate regarding its effect on mortality?
- A) Benefits are limited to improved exercise capacity
- B) Reduces cardiovascular mortality by approximately 25%
- C) Benefits are equivalent to those of statins
- D) Only benefits patients with reduced ejection fraction
- E) Is contraindicated in patients over 70 years old
10. Cardiovascular Risk Assessment
Question: A 45-year-old asymptomatic woman has a family history of premature coronary artery disease. Her father had a myocardial infarction at age 48. Which test would be most appropriate for initial risk stratification?
- A) Exercise stress test
- B) Coronary calcium score
- C) Carotid intima-media thickness
- D) Coronary CT angiography
- E) C-reactive protein level
Question: A 58-year-old male with hypertension and hyperlipidemia has a 10-year ASCVD risk score of 8%. His LDL-C is 125 mg/dL despite moderate-intensity statin therapy. Which finding would most strongly support escalation to high-intensity statin therapy?
- A) Coronary calcium score of 350 Agatston units
- B) C-reactive protein of 2.5 mg/L
- C) Carotid intima-media thickness of 0.9 mm
- D) Family history of stroke at age 75
- E) Metabolic syndrome
Question: A 50-year-old woman with type 2 diabetes, hypertension, and obesity (BMI 33 kg/m²) wants to reduce her cardiovascular risk. Which intervention has shown the greatest impact on reducing cardiovascular events in this population?
- A) Weight loss of at least 10% of body weight
- B) Intensive glucose control to A1C <6.5%
- C) Addition of aspirin 81 mg daily
- D) Stress reduction techniques
- E) Vitamin D supplementation
Question Development Principles
When creating these questions, I've focused on several key principles based on the American College of Cardiology competency guidelines 1:
- Clinical relevance: Questions address common cardiovascular conditions that significantly impact morbidity and mortality
- Evidence-based management: Answers reflect current guidelines and high-quality evidence
- Focus on decision points: Questions target critical clinical decisions that affect patient outcomes
- Comprehensive coverage: Questions span the breadth of cardiovascular disease management including prevention, diagnosis, and treatment
- Practical application: Questions test knowledge that directly translates to improved patient care
These questions assess knowledge in key cardiovascular competency domains including atherosclerosis prevention, hypertension management, lipid disorders, heart failure, arrhythmias, valvular heart disease, and cardiac device management 1.