ABIM INTERNAL MEDICINE BOARDS &
ITE EXAM 2026 Practice Questions with
Verified Answers & Detailed Rationales
QUESTION 1: Cardiology – Acute Coronary Syndrome
A 50-year-old man with hypertension and type 2 diabetes presents with substernal
chest pressure during exertion for the past two weeks. An exercise stress test
reveals 2 mm ST depression in leads V4–V6. What is the most appropriate next
step?
A. Initiate high-intensity statin and aspirin
B. Coronary CT angiography
C. Invasive coronary angiography
D. Percutaneous coronary intervention
Correct Answer: C
Rationale: In a patient with moderate-to-high pretest probability and a positive stress
test showing significant ST depression (≥2 mm), invasive coronary angiography is the
gold standard to define coronary anatomy and guide revascularization. High-risk stress
test features (early positivity, >2 mm ST depression, hemodynamic instability) warrant
invasive angiography. Initiating statin and aspirin is appropriate but insufficient as a
standalone next step when high-risk findings are present .
QUESTION 2: Cardiology – Atrial Fibrillation with RVR
A 55-year-old woman presents with acute onset dyspnea and palpitations. She has
a history of hypertension. Vital signs: BP 110/70 mmHg, HR 136 bpm (irregularly
irregular), RR 22/min. Lungs are clear. What is the most appropriate immediate
management?
,A. IV Diltiazem
B. Synchronized cardioversion
C. IV Amiodarone
D. IV Metoprolol
Correct Answer: A
Rationale: The patient is in atrial fibrillation with rapid ventricular response (RVR) but
is hemodynamically stable (no hypotension, chest pain, or altered mental status). Rate
control with a non-dihydropyridine calcium channel blocker (IV Diltiazem) or a beta-
blocker is first-line management. Synchronized cardioversion is reserved for
hemodynamic instability. Metoprolol is reasonable, but IV Diltiazem is often more
effective for acute rate control in this setting .
QUESTION 3: Cardiology – Severe Aortic Stenosis
A 72-year-old man with a bicuspid aortic valve presents with exertional dyspnea
and syncope. On exam, there is a harsh late-peaking systolic murmur at the right
upper sternal border radiating to the carotids. The carotid pulse is delayed and
diminished (pulsus parvus et tardus). Which is the most likely diagnosis?
A. Aortic regurgitation
B. Hypertrophic obstructive cardiomyopathy
C. Severe aortic stenosis
D. Mitral valve prolapse
Correct Answer: C
Rationale: The classic triad of exertional dyspnea, syncope, and angina, combined with
a harsh systolic murmur and pulsus parvus et tardus, is pathognomonic for severe
aortic stenosis. Aortic regurgitation causes a diastolic decrescendo murmur. HOCM
causes a systolic murmur that increases with Valsalva, not the carotid findings
described .
,QUESTION 4: Cardiology – HFrEF Guideline-Directed
Therapy
A 65-year-old man with ischemic cardiomyopathy (LVEF 30%) presents with
worsening dyspnea and orthopnea. He is on lisinopril, carvedilol, and furosemide.
Labs show K+ 5.8 mEq/L and creatinine 1.8 mg/dL. What is the best next step?
A. Increase lisinopril dose
B. Add spironolactone
C. Hold lisinopril and recheck potassium
D. Add hydralazine and isosorbide dinitrate
Correct Answer: C
Rationale: Hyperkalemia (K+ >5.5) in a patient on an ACE inhibitor requires holding the
ACE inhibitor and rechecking potassium. Spironolactone is contraindicated in this
setting. Hydralazine/isosorbide dinitrate may be indicated in African American patients
or those intolerant to ACE inhibitors/ARBs, but the immediate concern is hyperkalemia
management .
QUESTION 5: Cardiology – Constrictive Pericarditis
A 68-year-old man with dyspnea, jugular venous distention, and Kussmaul sign is
evaluated. Echocardiogram shows thickened pericardium. What is the next best
step?
A. Colchicine
B. NSAIDs
C. Pericardectomy
D. Diuretics
Correct Answer: C
Rationale: Constrictive pericarditis presents with elevated JVP, Kussmaul sign, and
pericardial thickening. Pericardectomy is the definitive treatment. Colchicine and
NSAIDs are used for acute pericarditis, not chronic constrictive pericarditis .
, QUESTION 6: Cardiology – STEMI Management
A patient presents with an anterior STEMI on ECG, symptom onset 45 minutes ago.
After aspirin and oxygen, what is the next step?
A. Heparin drip
B. Emergent PCI
C. Tenecteplase
D. Nitroglycerin drip
Correct Answer: B
Rationale: Primary PCI within 90 minutes of first medical contact is the standard of care
for STEMI. Fibrinolytic therapy (e.g., tenecteplase) is indicated if PCI is delayed >120
minutes .
QUESTION 7: Cardiology – Calcium Channel Blocker Toxicity
A patient on diltiazem and metoprolol presents with HR 38 bpm, BP 90/60 mmHg.
What is the most appropriate treatment?
A. Atropine
B. IV calcium gluconate
C. Transvenous pacing
D. Aminophylline
Correct Answer: B
Rationale: Calcium channel blocker toxicity causes bradycardia and hypotension. IV
calcium gluconate is the specific antidote for calcium channel blocker toxicity. Atropine
may be used but is less effective. Aminophylline is used for beta-blocker toxicity .
ITE EXAM 2026 Practice Questions with
Verified Answers & Detailed Rationales
QUESTION 1: Cardiology – Acute Coronary Syndrome
A 50-year-old man with hypertension and type 2 diabetes presents with substernal
chest pressure during exertion for the past two weeks. An exercise stress test
reveals 2 mm ST depression in leads V4–V6. What is the most appropriate next
step?
A. Initiate high-intensity statin and aspirin
B. Coronary CT angiography
C. Invasive coronary angiography
D. Percutaneous coronary intervention
Correct Answer: C
Rationale: In a patient with moderate-to-high pretest probability and a positive stress
test showing significant ST depression (≥2 mm), invasive coronary angiography is the
gold standard to define coronary anatomy and guide revascularization. High-risk stress
test features (early positivity, >2 mm ST depression, hemodynamic instability) warrant
invasive angiography. Initiating statin and aspirin is appropriate but insufficient as a
standalone next step when high-risk findings are present .
QUESTION 2: Cardiology – Atrial Fibrillation with RVR
A 55-year-old woman presents with acute onset dyspnea and palpitations. She has
a history of hypertension. Vital signs: BP 110/70 mmHg, HR 136 bpm (irregularly
irregular), RR 22/min. Lungs are clear. What is the most appropriate immediate
management?
,A. IV Diltiazem
B. Synchronized cardioversion
C. IV Amiodarone
D. IV Metoprolol
Correct Answer: A
Rationale: The patient is in atrial fibrillation with rapid ventricular response (RVR) but
is hemodynamically stable (no hypotension, chest pain, or altered mental status). Rate
control with a non-dihydropyridine calcium channel blocker (IV Diltiazem) or a beta-
blocker is first-line management. Synchronized cardioversion is reserved for
hemodynamic instability. Metoprolol is reasonable, but IV Diltiazem is often more
effective for acute rate control in this setting .
QUESTION 3: Cardiology – Severe Aortic Stenosis
A 72-year-old man with a bicuspid aortic valve presents with exertional dyspnea
and syncope. On exam, there is a harsh late-peaking systolic murmur at the right
upper sternal border radiating to the carotids. The carotid pulse is delayed and
diminished (pulsus parvus et tardus). Which is the most likely diagnosis?
A. Aortic regurgitation
B. Hypertrophic obstructive cardiomyopathy
C. Severe aortic stenosis
D. Mitral valve prolapse
Correct Answer: C
Rationale: The classic triad of exertional dyspnea, syncope, and angina, combined with
a harsh systolic murmur and pulsus parvus et tardus, is pathognomonic for severe
aortic stenosis. Aortic regurgitation causes a diastolic decrescendo murmur. HOCM
causes a systolic murmur that increases with Valsalva, not the carotid findings
described .
,QUESTION 4: Cardiology – HFrEF Guideline-Directed
Therapy
A 65-year-old man with ischemic cardiomyopathy (LVEF 30%) presents with
worsening dyspnea and orthopnea. He is on lisinopril, carvedilol, and furosemide.
Labs show K+ 5.8 mEq/L and creatinine 1.8 mg/dL. What is the best next step?
A. Increase lisinopril dose
B. Add spironolactone
C. Hold lisinopril and recheck potassium
D. Add hydralazine and isosorbide dinitrate
Correct Answer: C
Rationale: Hyperkalemia (K+ >5.5) in a patient on an ACE inhibitor requires holding the
ACE inhibitor and rechecking potassium. Spironolactone is contraindicated in this
setting. Hydralazine/isosorbide dinitrate may be indicated in African American patients
or those intolerant to ACE inhibitors/ARBs, but the immediate concern is hyperkalemia
management .
QUESTION 5: Cardiology – Constrictive Pericarditis
A 68-year-old man with dyspnea, jugular venous distention, and Kussmaul sign is
evaluated. Echocardiogram shows thickened pericardium. What is the next best
step?
A. Colchicine
B. NSAIDs
C. Pericardectomy
D. Diuretics
Correct Answer: C
Rationale: Constrictive pericarditis presents with elevated JVP, Kussmaul sign, and
pericardial thickening. Pericardectomy is the definitive treatment. Colchicine and
NSAIDs are used for acute pericarditis, not chronic constrictive pericarditis .
, QUESTION 6: Cardiology – STEMI Management
A patient presents with an anterior STEMI on ECG, symptom onset 45 minutes ago.
After aspirin and oxygen, what is the next step?
A. Heparin drip
B. Emergent PCI
C. Tenecteplase
D. Nitroglycerin drip
Correct Answer: B
Rationale: Primary PCI within 90 minutes of first medical contact is the standard of care
for STEMI. Fibrinolytic therapy (e.g., tenecteplase) is indicated if PCI is delayed >120
minutes .
QUESTION 7: Cardiology – Calcium Channel Blocker Toxicity
A patient on diltiazem and metoprolol presents with HR 38 bpm, BP 90/60 mmHg.
What is the most appropriate treatment?
A. Atropine
B. IV calcium gluconate
C. Transvenous pacing
D. Aminophylline
Correct Answer: B
Rationale: Calcium channel blocker toxicity causes bradycardia and hypotension. IV
calcium gluconate is the specific antidote for calcium channel blocker toxicity. Atropine
may be used but is less effective. Aminophylline is used for beta-blocker toxicity .
