ABIM Internal Medicine ITE Test Bank –
Complete Practice Questions with
Verified Answers & Explanations –
Updated 2025/2026 In-Training Exam
Prep
SECTION 1: CARDIOVASCULAR DISEASE
1. A 62-year-old man with hypertension and diabetes presents with substernal
chest pressure radiating to the jaw, occurring at rest and lasting 15 minutes.
ECG shows ST depression in V4–V6. Troponin is elevated. What is the most
appropriate next step?
• A) Exercise stress test
• B) Aspirin, clopidogrel, heparin, and urgent catheterization
• C) Outpatient cardiology referral
• D) Nitroglycerin and discharge with aspirin
Rationale: This patient has non-ST elevation myocardial infarction (NSTEMI) based
on symptoms, ECG changes, and elevated troponin. High-risk features (diabetes,
ongoing symptoms) warrant urgent invasive strategy (within 24 hours) with dual
antiplatelet therapy (DAPT) and anticoagulation.
,2. A 68-year-old man with hypertension and diabetes presents with exertional
dyspnea. Echocardiography reveals concentric left ventricular hypertrophy,
normal ejection fraction, and impaired relaxation. BNP is mildly elevated.
Which finding most strongly supports the diagnosis of heart failure with
preserved ejection fraction (HFpEF)?
• A) Reduced left ventricular end-diastolic volume
• B) Elevated pulmonary capillary wedge pressure during exercise
• C) QRS prolongation on ECG
• D) Reduced stroke volume at rest
Rationale: HFpEF is characterized by normal systolic function but impaired
diastolic filling. Hemodynamic testing often reveals elevated filling pressures during
exertion, even when resting pressures are normal.
3. A patient with chronic heart failure with reduced ejection fraction (HFrEF) on
optimal medical therapy including sacubitril/valsartan, beta-blocker, and
spironolactone continues to have NYHA class III symptoms. LVEF is 30%.
There is no significant coronary disease. Which intervention has been shown to
reduce mortality in this population?
• A) Implantable cardioverter-defibrillator (ICD) alone
• B) Cardiac resynchronization therapy with defibrillator (CRT-D)
• C) Left ventricular assist device (LVAD) as destination therapy
• D) Heart transplantation listing
Rationale: In patients with HFrEF, wide QRS (≥150 ms) and LBBB, CRT-D reduces
mortality and hospitalizations. ICD alone does not improve symptoms.
,4. A patient with acute decompensated heart failure presents with severe
dyspnea, cool extremities, and a blood pressure of 85/50 mm Hg. Which
hemodynamic profile is most consistent with these findings?
• A) Warm and wet
• B) Cold and wet
• C) Cold and dry
• D) Warm and dry
Rationale: Cold and wet profile indicates low cardiac output (cold extremities) and
congestion (wet). This patient requires inotropic support; vasodilators are limited
by hypotension.
5. A patient with known coronary artery disease develops chest pain at rest
with transient ST-segment elevation on ECG. Cardiac troponin is elevated.
Which is the most appropriate next step?
• A) Immediate coronary angiography with PCI
• B) Stress echocardiography
• C) Medical management with DAPT and heparin
• D) CT coronary angiography
Rationale: STEMI requires emergent reperfusion. Immediate angiography with PCI
is indicated within 90 minutes. Stress testing is contraindicated in acute MI.
, 6. A patient with atrial fibrillation and a CHA₂DS₂-VASc score of 4 is started on
apixaban. Which laboratory parameter most directly affects the anticoagulant
effect of apixaban and requires dose adjustment?
• A) Prothrombin time
• B) Activated partial thromboplastin time
• C) Serum creatinine and body weight
• D) Platelet count
Rationale: Apixaban is partially renally cleared and dose-adjusted based on serum
creatinine (CrCl <25 mL/min) and body weight (<60 kg). PT and aPTT are not
reliable for monitoring.
7. A 55-year-old man reports palpitations. ECG shows irregularly irregular
rhythm with no P waves and ventricular rate of 140 bpm. What is the most
likely diagnosis?
• A) Atrial flutter
• B) Atrial fibrillation
• C) Multifocal atrial tachycardia
• D) Sinus arrhythmia
Rationale: Atrial fibrillation is characterized by an irregularly irregular rhythm with
absent P waves and variable ventricular response.
8. A 72-year-old man with hypertension presents with a blood pressure of
180/100 mmHg. He has no symptoms. Which of the following is the most
appropriate initial management?
Complete Practice Questions with
Verified Answers & Explanations –
Updated 2025/2026 In-Training Exam
Prep
SECTION 1: CARDIOVASCULAR DISEASE
1. A 62-year-old man with hypertension and diabetes presents with substernal
chest pressure radiating to the jaw, occurring at rest and lasting 15 minutes.
ECG shows ST depression in V4–V6. Troponin is elevated. What is the most
appropriate next step?
• A) Exercise stress test
• B) Aspirin, clopidogrel, heparin, and urgent catheterization
• C) Outpatient cardiology referral
• D) Nitroglycerin and discharge with aspirin
Rationale: This patient has non-ST elevation myocardial infarction (NSTEMI) based
on symptoms, ECG changes, and elevated troponin. High-risk features (diabetes,
ongoing symptoms) warrant urgent invasive strategy (within 24 hours) with dual
antiplatelet therapy (DAPT) and anticoagulation.
,2. A 68-year-old man with hypertension and diabetes presents with exertional
dyspnea. Echocardiography reveals concentric left ventricular hypertrophy,
normal ejection fraction, and impaired relaxation. BNP is mildly elevated.
Which finding most strongly supports the diagnosis of heart failure with
preserved ejection fraction (HFpEF)?
• A) Reduced left ventricular end-diastolic volume
• B) Elevated pulmonary capillary wedge pressure during exercise
• C) QRS prolongation on ECG
• D) Reduced stroke volume at rest
Rationale: HFpEF is characterized by normal systolic function but impaired
diastolic filling. Hemodynamic testing often reveals elevated filling pressures during
exertion, even when resting pressures are normal.
3. A patient with chronic heart failure with reduced ejection fraction (HFrEF) on
optimal medical therapy including sacubitril/valsartan, beta-blocker, and
spironolactone continues to have NYHA class III symptoms. LVEF is 30%.
There is no significant coronary disease. Which intervention has been shown to
reduce mortality in this population?
• A) Implantable cardioverter-defibrillator (ICD) alone
• B) Cardiac resynchronization therapy with defibrillator (CRT-D)
• C) Left ventricular assist device (LVAD) as destination therapy
• D) Heart transplantation listing
Rationale: In patients with HFrEF, wide QRS (≥150 ms) and LBBB, CRT-D reduces
mortality and hospitalizations. ICD alone does not improve symptoms.
,4. A patient with acute decompensated heart failure presents with severe
dyspnea, cool extremities, and a blood pressure of 85/50 mm Hg. Which
hemodynamic profile is most consistent with these findings?
• A) Warm and wet
• B) Cold and wet
• C) Cold and dry
• D) Warm and dry
Rationale: Cold and wet profile indicates low cardiac output (cold extremities) and
congestion (wet). This patient requires inotropic support; vasodilators are limited
by hypotension.
5. A patient with known coronary artery disease develops chest pain at rest
with transient ST-segment elevation on ECG. Cardiac troponin is elevated.
Which is the most appropriate next step?
• A) Immediate coronary angiography with PCI
• B) Stress echocardiography
• C) Medical management with DAPT and heparin
• D) CT coronary angiography
Rationale: STEMI requires emergent reperfusion. Immediate angiography with PCI
is indicated within 90 minutes. Stress testing is contraindicated in acute MI.
, 6. A patient with atrial fibrillation and a CHA₂DS₂-VASc score of 4 is started on
apixaban. Which laboratory parameter most directly affects the anticoagulant
effect of apixaban and requires dose adjustment?
• A) Prothrombin time
• B) Activated partial thromboplastin time
• C) Serum creatinine and body weight
• D) Platelet count
Rationale: Apixaban is partially renally cleared and dose-adjusted based on serum
creatinine (CrCl <25 mL/min) and body weight (<60 kg). PT and aPTT are not
reliable for monitoring.
7. A 55-year-old man reports palpitations. ECG shows irregularly irregular
rhythm with no P waves and ventricular rate of 140 bpm. What is the most
likely diagnosis?
• A) Atrial flutter
• B) Atrial fibrillation
• C) Multifocal atrial tachycardia
• D) Sinus arrhythmia
Rationale: Atrial fibrillation is characterized by an irregularly irregular rhythm with
absent P waves and variable ventricular response.
8. A 72-year-old man with hypertension presents with a blood pressure of
180/100 mmHg. He has no symptoms. Which of the following is the most
appropriate initial management?
