SARAH MICHELLE LIVE REVIEW EXAM Q&A
2026/2027 | Interactive Board Certification Prep |
Pass Guaranteed - A+ Graded
SECTION 1: CARDIOVASCULAR SYSTEM (35 Questions)
Q1: A 68-year-old male presents with progressive dyspnea on exertion, orthopnea, and
bilateral lower extremity edema. His ejection fraction is 35% on recent echocardiogram.
He is currently on lisinopril 10 mg daily and furosemide 40 mg daily. According to the
2022 AHA/ACC/HFSA Heart Failure Guidelines, what is the next best step in
management to reduce mortality?
A. Increase lisinopril to 20 mg daily
B. Add carvedilol 3.125 mg twice daily
C. Add dapagliflozin 10 mg daily [CORRECT]
D. Add digoxin 0.125 mg daily
Correct Answer: C
Rationale: The 2022 guidelines recommend SGLT2 inhibitors (dapagliflozin or
empagliflozin) as foundational therapy for HFrEF regardless of diabetes status,
alongside ACE inhibitors, evidence-based beta-blockers, and MRAs. While carvedilol is
appropriate for HFrEF, an ACE inhibitor alone without a beta-blocker is not
guideline-directed medical therapy (GDMT), and digoxin does not reduce mortality.
Q2: A 58-year-old woman with hypertension and hyperlipidemia presents for a wellness
visit. Her BP is 142/88 mmHg on two separate occasions. She reports occasional
headaches but no chest pain or dyspnea. Her 10-year ASCVD risk is 8.2%. What is the
most appropriate initial antihypertensive regimen according to JNC 8 and ACC/AHA
guidelines?
A. Start amlodipine 5 mg daily
B. Start lisinopril 10 mg daily [CORRECT]
C. Start hydrochlorothiazide 25 mg daily
D. Start metoprolol succinate 25 mg daily
Correct Answer: B
,Rationale: For non-Black patients without CKD or diabetes, thiazide diuretics, CCBs, ACE
inhibitors, or ARBs are all first-line options. However, this patient has hyperlipidemia and
elevated ASCVD risk; ACE inhibitors provide additional cardiovascular protection and
are preferred in patients with coronary risk factors. Amlodipine is acceptable but lacks
the additional vascular benefits of ACE inhibition in this population.
Q3: A 72-year-old male with a history of atrial fibrillation on warfarin (INR 2.5) presents
after a fall from standing height. He is alert and oriented. A CT scan reveals a small
subdural hematoma measuring 8 mm with mild mass effect. His vital signs are stable.
What is the most appropriate immediate management?
A. Administer IV vitamin K 10 mg and 4-factor prothrombin complex concentrate (PCC)
[CORRECT]
B. Administer fresh frozen plasma (FFP) 2 units
C. Hold next warfarin dose and observe
D. Administer subcutaneous vitamin K 10 mg
Correct Answer: A
Rationale: For life-threatening bleeding or intracranial hemorrhage in a patient on
warfarin, rapid reversal with 4-factor PCC plus IV vitamin K is the standard of care. PCC
provides rapid INR correction within 30 minutes, whereas FFP requires large volumes
and slower administration. Observation alone is inappropriate given the intracranial
location and mass effect.
Q4: A 45-year-old male presents with crushing substernal chest pain radiating to his left
arm, diaphoresis, and nausea. Troponin I is 4.2 ng/mL. EKG shows ST elevations in
leads V1-V4. He is aspirin-allergic (anaphylaxis). What is the most appropriate
immediate antiplatelet strategy before PCI?
A. Clopidogrel 600 mg loading dose only
B. Ticagrelor 180 mg loading dose and cangrelor IV bolus [CORRECT]
C. Prasugrel 60 mg loading dose only
D. Abciximab IV bolus only
Correct Answer: B
Rationale: In aspirin-allergic patients with STEMI, a P2Y12 inhibitor (ticagrelor or
prasugrel) is essential. Ticagrelor has the advantage of reversible binding and is
preferred in patients who may proceed to CABG. Cangrelor, an IV P2Y12 inhibitor,
,provides immediate platelet inhibition during PCI when oral agents have not yet taken
effect. Prasugrel is contraindicated in patients with prior stroke/TIA.
Q5: A 55-year-old female with newly diagnosed stage 2 hypertension (BP 162/96
mmHg) and a history of gout requests lifestyle counseling. She is currently
asymptomatic. Which lifestyle modification has the strongest evidence for reducing
both blood pressure and uric acid levels?
A. Adopt a DASH diet with reduced sodium intake [CORRECT]
B. Begin vigorous aerobic exercise 60 minutes daily
C. Eliminate all dietary purines
D. Start potassium supplementation 40 mEq daily
Correct Answer: A
Rationale: The DASH diet emphasizes fruits, vegetables, whole grains, and low-fat dairy
while reducing sodium and saturated fat. It has robust evidence for lowering BP by 8-14
mmHg and can reduce uric acid through weight management and improved metabolic
profile. Vigorous exercise is beneficial but 60 minutes daily is excessive for a sedentary
beginner; purine elimination is impractical and less effective than overall dietary pattern
changes.
Q6: A 62-year-old male with stable angina on metoprolol and atorvastatin reports
continued chest pain with walking two blocks. His resting heart rate is 58 bpm. What is
the next best step in management?
A. Increase metoprolol dose
B. Add amlodipine 5 mg daily [CORRECT]
C. Add ranolazine 500 mg twice daily
D. Refer for coronary angiography immediately
Correct Answer: B
Rationale: The patient has stable angina with a resting heart rate of 58 bpm, limiting
further beta-blocker titration. Adding a dihydropyridine CCB (amlodipine) provides
afterload reduction and coronary vasodilation without significantly affecting heart rate.
Ranolazine is reserved for refractory angina after beta-blocker, CCB, and nitrate
optimization. Immediate angiography is not indicated for stable, exertional symptoms.
, Q7: A 50-year-old female presents with acute-onset severe headache, "worst headache
of my life," and nuchal rigidity. CT head is negative. Lumbar puncture reveals
xanthochromia. What is the priority next step?
A. Administer nimodipine 60 mg orally every 4 hours [CORRECT]
B. Perform emergent CT angiography
C. Start empiric antibiotics for meningitis
D. Administer tissue plasminogen activator (tPA)
Correct Answer: A
Rationale: Xanthochromia confirms subarachnoid hemorrhage (SAH). Nimodipine, a
calcium channel blocker, is indicated to prevent cerebral vasospasm and delayed
ischemic deficits, beginning within 96 hours of SAH. While CTA is needed to identify the
aneurysm source, nimodipine should be initiated immediately. Antibiotics are
unnecessary unless meningitis is suspected, and tPA is absolutely contraindicated in
hemorrhagic stroke.
Q8: A 38-year-old male with hypertrophic cardiomyopathy (HCM) presents for
pre-participation sports clearance. He has never had syncope, but his father died
suddenly at age 42. Echocardiogram shows a septal thickness of 28 mm and resting
LVOT gradient of 45 mmHg. What is the most appropriate recommendation?
A. Clear for all competitive sports with beta-blocker therapy
B. Restrict from all competitive sports [CORRECT]
C. Allow low-intensity sports only with ICD placement
D. Clear after septal myectomy
Correct Answer: B
Rationale: The 2020 AHA/ACC guidelines for HCM recommend restricting patients from
competitive sports (except low-intensity class IA sports) if they have any major risk
factor for sudden cardiac death, including massive LV hypertrophy (≥30 mm), which this
patient approaches. A family history of sudden death and significant outflow
obstruction further support restriction. ICD placement does not override sports
restriction recommendations.
Q9: A 70-year-old female with heart failure with preserved ejection fraction (HFpEF) and
a BMI of 38 presents with worsening dyspnea and 5-pound weight gain. Her current
2026/2027 | Interactive Board Certification Prep |
Pass Guaranteed - A+ Graded
SECTION 1: CARDIOVASCULAR SYSTEM (35 Questions)
Q1: A 68-year-old male presents with progressive dyspnea on exertion, orthopnea, and
bilateral lower extremity edema. His ejection fraction is 35% on recent echocardiogram.
He is currently on lisinopril 10 mg daily and furosemide 40 mg daily. According to the
2022 AHA/ACC/HFSA Heart Failure Guidelines, what is the next best step in
management to reduce mortality?
A. Increase lisinopril to 20 mg daily
B. Add carvedilol 3.125 mg twice daily
C. Add dapagliflozin 10 mg daily [CORRECT]
D. Add digoxin 0.125 mg daily
Correct Answer: C
Rationale: The 2022 guidelines recommend SGLT2 inhibitors (dapagliflozin or
empagliflozin) as foundational therapy for HFrEF regardless of diabetes status,
alongside ACE inhibitors, evidence-based beta-blockers, and MRAs. While carvedilol is
appropriate for HFrEF, an ACE inhibitor alone without a beta-blocker is not
guideline-directed medical therapy (GDMT), and digoxin does not reduce mortality.
Q2: A 58-year-old woman with hypertension and hyperlipidemia presents for a wellness
visit. Her BP is 142/88 mmHg on two separate occasions. She reports occasional
headaches but no chest pain or dyspnea. Her 10-year ASCVD risk is 8.2%. What is the
most appropriate initial antihypertensive regimen according to JNC 8 and ACC/AHA
guidelines?
A. Start amlodipine 5 mg daily
B. Start lisinopril 10 mg daily [CORRECT]
C. Start hydrochlorothiazide 25 mg daily
D. Start metoprolol succinate 25 mg daily
Correct Answer: B
,Rationale: For non-Black patients without CKD or diabetes, thiazide diuretics, CCBs, ACE
inhibitors, or ARBs are all first-line options. However, this patient has hyperlipidemia and
elevated ASCVD risk; ACE inhibitors provide additional cardiovascular protection and
are preferred in patients with coronary risk factors. Amlodipine is acceptable but lacks
the additional vascular benefits of ACE inhibition in this population.
Q3: A 72-year-old male with a history of atrial fibrillation on warfarin (INR 2.5) presents
after a fall from standing height. He is alert and oriented. A CT scan reveals a small
subdural hematoma measuring 8 mm with mild mass effect. His vital signs are stable.
What is the most appropriate immediate management?
A. Administer IV vitamin K 10 mg and 4-factor prothrombin complex concentrate (PCC)
[CORRECT]
B. Administer fresh frozen plasma (FFP) 2 units
C. Hold next warfarin dose and observe
D. Administer subcutaneous vitamin K 10 mg
Correct Answer: A
Rationale: For life-threatening bleeding or intracranial hemorrhage in a patient on
warfarin, rapid reversal with 4-factor PCC plus IV vitamin K is the standard of care. PCC
provides rapid INR correction within 30 minutes, whereas FFP requires large volumes
and slower administration. Observation alone is inappropriate given the intracranial
location and mass effect.
Q4: A 45-year-old male presents with crushing substernal chest pain radiating to his left
arm, diaphoresis, and nausea. Troponin I is 4.2 ng/mL. EKG shows ST elevations in
leads V1-V4. He is aspirin-allergic (anaphylaxis). What is the most appropriate
immediate antiplatelet strategy before PCI?
A. Clopidogrel 600 mg loading dose only
B. Ticagrelor 180 mg loading dose and cangrelor IV bolus [CORRECT]
C. Prasugrel 60 mg loading dose only
D. Abciximab IV bolus only
Correct Answer: B
Rationale: In aspirin-allergic patients with STEMI, a P2Y12 inhibitor (ticagrelor or
prasugrel) is essential. Ticagrelor has the advantage of reversible binding and is
preferred in patients who may proceed to CABG. Cangrelor, an IV P2Y12 inhibitor,
,provides immediate platelet inhibition during PCI when oral agents have not yet taken
effect. Prasugrel is contraindicated in patients with prior stroke/TIA.
Q5: A 55-year-old female with newly diagnosed stage 2 hypertension (BP 162/96
mmHg) and a history of gout requests lifestyle counseling. She is currently
asymptomatic. Which lifestyle modification has the strongest evidence for reducing
both blood pressure and uric acid levels?
A. Adopt a DASH diet with reduced sodium intake [CORRECT]
B. Begin vigorous aerobic exercise 60 minutes daily
C. Eliminate all dietary purines
D. Start potassium supplementation 40 mEq daily
Correct Answer: A
Rationale: The DASH diet emphasizes fruits, vegetables, whole grains, and low-fat dairy
while reducing sodium and saturated fat. It has robust evidence for lowering BP by 8-14
mmHg and can reduce uric acid through weight management and improved metabolic
profile. Vigorous exercise is beneficial but 60 minutes daily is excessive for a sedentary
beginner; purine elimination is impractical and less effective than overall dietary pattern
changes.
Q6: A 62-year-old male with stable angina on metoprolol and atorvastatin reports
continued chest pain with walking two blocks. His resting heart rate is 58 bpm. What is
the next best step in management?
A. Increase metoprolol dose
B. Add amlodipine 5 mg daily [CORRECT]
C. Add ranolazine 500 mg twice daily
D. Refer for coronary angiography immediately
Correct Answer: B
Rationale: The patient has stable angina with a resting heart rate of 58 bpm, limiting
further beta-blocker titration. Adding a dihydropyridine CCB (amlodipine) provides
afterload reduction and coronary vasodilation without significantly affecting heart rate.
Ranolazine is reserved for refractory angina after beta-blocker, CCB, and nitrate
optimization. Immediate angiography is not indicated for stable, exertional symptoms.
, Q7: A 50-year-old female presents with acute-onset severe headache, "worst headache
of my life," and nuchal rigidity. CT head is negative. Lumbar puncture reveals
xanthochromia. What is the priority next step?
A. Administer nimodipine 60 mg orally every 4 hours [CORRECT]
B. Perform emergent CT angiography
C. Start empiric antibiotics for meningitis
D. Administer tissue plasminogen activator (tPA)
Correct Answer: A
Rationale: Xanthochromia confirms subarachnoid hemorrhage (SAH). Nimodipine, a
calcium channel blocker, is indicated to prevent cerebral vasospasm and delayed
ischemic deficits, beginning within 96 hours of SAH. While CTA is needed to identify the
aneurysm source, nimodipine should be initiated immediately. Antibiotics are
unnecessary unless meningitis is suspected, and tPA is absolutely contraindicated in
hemorrhagic stroke.
Q8: A 38-year-old male with hypertrophic cardiomyopathy (HCM) presents for
pre-participation sports clearance. He has never had syncope, but his father died
suddenly at age 42. Echocardiogram shows a septal thickness of 28 mm and resting
LVOT gradient of 45 mmHg. What is the most appropriate recommendation?
A. Clear for all competitive sports with beta-blocker therapy
B. Restrict from all competitive sports [CORRECT]
C. Allow low-intensity sports only with ICD placement
D. Clear after septal myectomy
Correct Answer: B
Rationale: The 2020 AHA/ACC guidelines for HCM recommend restricting patients from
competitive sports (except low-intensity class IA sports) if they have any major risk
factor for sudden cardiac death, including massive LV hypertrophy (≥30 mm), which this
patient approaches. A family history of sudden death and significant outflow
obstruction further support restriction. ICD placement does not override sports
restriction recommendations.
Q9: A 70-year-old female with heart failure with preserved ejection fraction (HFpEF) and
a BMI of 38 presents with worsening dyspnea and 5-pound weight gain. Her current
