1
ABIM Internal Medicine ITE Exam 2026/2027 Actual
Exam | Complete Questions with Verified Answers &
Detailed Explanations | In-Training Exam | Pass
Guaranteed - A+ Graded
Section 1: Cardiovascular Medicine
Q1: A 65-year-old patient with a history of hypertension and type 2 diabetes presents with
substernal chest pain radiating to the left arm, diaphoresis, and nausea. ECG shows ST-segment
elevation in leads V1-V4. Which of the following is the MOST appropriate immediate
intervention?
A. Aspirin 325 mg PO, nitroglycerin, and activate cath lab [CORRECT]
B. Obtain serial troponins
C. Order a stress test
D. Prescribe sublingual nitroglycerin and discharge
Correct Answer: A
Rationale: STEMI requires immediate reperfusion. Aspirin, nitroglycerin, and activation of cath
lab are priority. Option B (troponins) will be done but not delay reperfusion. Option C (stress
test) is contraindicated in acute MI. Option D is negligent.
Q2: A 72-year-old male presents with dyspnea on exertion, orthopnea, and lower extremity
edema. Echocardiogram reveals a left ventricular ejection fraction (LVEF) of 32%. Which of the
following medications is NOT guideline-directed medical therapy (GDMT) for reducing
mortality in this patient?
A. Lisinopril
B. Carvedilol
C. Spironolactone
D. Amlodipine [CORRECT]
Correct Answer: D
,2
Rationale: ACE inhibitors (lisinopril), Beta-blockers (carvedilol), and Mineralocorticoid
Receptor Antagonists (spironolactone) are Class I recommendations for HFrEF to reduce
mortality. Amlodipine (a calcium channel blocker) is not indicated for mortality reduction in
HFrEF and may be harmful in some cases; it is used for angina or hypertension if other agents
are insufficient.
Q3: A 55-year-old woman presents with sudden onset of severe tearing chest pain radiating to her
back. Blood pressure is 180/110 mmHg in the right arm and 160/100 mmHg in the left arm. CT
angiogram confirms a Stanford Type A aortic dissection. What is the definitive treatment?
A. IV Beta-blockers and nitroprusside
B. Surgical intervention [CORRECT]
C. Endovascular stent grafting
D. Anticoagulation with heparin
Correct Answer: B
Rationale: Stanford Type A (ascending aorta) dissections are surgical emergencies requiring
immediate operative repair to prevent catastrophic complications like aortic rupture or cardiac
tamponade. Medical management (Beta-blockers) is used for Type B dissections or as a bridge to
surgery.
Q4: A 60-year-old male with atrial fibrillation (CHA2DS2-VASc score 3) is hesitant to take
warfarin. He asks about alternative options. Which of the following is a direct oral anticoagulant
(DOAC) that is contraindicated in patients with mechanical heart valves?
A. Apixaban
B. Dabigatran
C. Rivaroxaban
D. All of the above [CORRECT]
Correct Answer: D
,3
Rationale: DOACs (apixaban, dabigatran, rivaroxaban, edoxaban) are contraindicated in patients
with mechanical heart valves due to an increased risk of thromboembolic events compared to
warfarin. Warfarin remains the standard of care for mechanical valves.
Q5: A 45-year-old male presents for a routine physical. His blood pressure is 152/92 mmHg on
three separate occasions. He has no other medical conditions. According to ACC/AHA
guidelines, what is the first-line pharmacologic treatment for his Stage 2 hypertension?
A. Thiazide diuretic
B. ACE inhibitor or ARB
C. Calcium channel blocker
D. Combination of two first-line agents [CORRECT]
Correct Answer: D
Rationale: For adults with Stage 2 hypertension (BP ≥140/90), the 2017 ACC/AHA guidelines
recommend initiating treatment with two first-line agents from different classes (e.g., ACEi/ARB
+ CCB or Thiazide) to increase the likelihood of achieving BP control.
Q6: A 30-year-old female presents with fever, fatigue, and a new murmur. Blood cultures grow
Streptococcus viridans. Echocardiogram shows a 1.2 cm vegetation on the mitral valve. What is
the most likely predisposing condition?
A. IV drug use
B. Prosthetic valve
C. Mitral valve prolapse [CORRECT]
D. Rheumatic heart disease
Correct Answer: C
Rationale: Streptococcus viridans is a common cause of subacute bacterial endocarditis and often
colonizes damaged valves. Mitral valve prolapse is a common underlying structural abnormality
predisposing to endocarditis in this demographic.
, 4
Q7: A 50-year-old male presents with chest pain at rest. ECG shows ST-segment depression in
leads V4-V6. Cardiac biomarkers are elevated. He is given aspirin, ticagrelor, heparin, and
atorvastatin. His TIMI risk score is 4. What is the next best step in management?
A. Immediate thrombolysis
B. Discharge with stress test
C. Early invasive strategy (coronary angiography within 24 hours) [CORRECT]
D. Medical management only
Correct Answer: C
Rationale: This patient has Non-ST-Elevation Acute Coronary Syndrome (NSTE-ACS). A TIMI
score of 4 indicates intermediate to high risk. Guidelines recommend an early invasive strategy
(angiography within 24-72 hours, ideally sooner for high risk) for high-risk NSTE-ACS patients.
Q8: A 65-year-old male presents with syncope. On exam, you note a crescendo-decrescendo
systolic murmur radiating to the carotids. Echocardiogram reveals severe aortic stenosis with a
mean gradient of 45 mmHg and a valve area of 0.8 cm². He is asymptomatic. What is the
appropriate management?
A. Aortic valve replacement [CORRECT]
B. Medical management with beta-blockers
C. Watchful waiting
D. Surgical myectomy
Correct Answer: A
Rationale: While Class I guidelines recommend AVR for symptomatic severe AS, recent data
(e.g., from the RECOVERY trial) support early intervention in select patients with very severe
AS (gradient >40 or Vmax >5.0) even if asymptomatic, due to better outcomes compared to
watchful waiting. However, strictly speaking, symptom onset is the classic trigger; but in the
context of "very severe" physiology and syncope (which IS a symptom), this patient is
symptomatic. Syncope is a classic symptom of severe AS. Option A is correct.
ABIM Internal Medicine ITE Exam 2026/2027 Actual
Exam | Complete Questions with Verified Answers &
Detailed Explanations | In-Training Exam | Pass
Guaranteed - A+ Graded
Section 1: Cardiovascular Medicine
Q1: A 65-year-old patient with a history of hypertension and type 2 diabetes presents with
substernal chest pain radiating to the left arm, diaphoresis, and nausea. ECG shows ST-segment
elevation in leads V1-V4. Which of the following is the MOST appropriate immediate
intervention?
A. Aspirin 325 mg PO, nitroglycerin, and activate cath lab [CORRECT]
B. Obtain serial troponins
C. Order a stress test
D. Prescribe sublingual nitroglycerin and discharge
Correct Answer: A
Rationale: STEMI requires immediate reperfusion. Aspirin, nitroglycerin, and activation of cath
lab are priority. Option B (troponins) will be done but not delay reperfusion. Option C (stress
test) is contraindicated in acute MI. Option D is negligent.
Q2: A 72-year-old male presents with dyspnea on exertion, orthopnea, and lower extremity
edema. Echocardiogram reveals a left ventricular ejection fraction (LVEF) of 32%. Which of the
following medications is NOT guideline-directed medical therapy (GDMT) for reducing
mortality in this patient?
A. Lisinopril
B. Carvedilol
C. Spironolactone
D. Amlodipine [CORRECT]
Correct Answer: D
,2
Rationale: ACE inhibitors (lisinopril), Beta-blockers (carvedilol), and Mineralocorticoid
Receptor Antagonists (spironolactone) are Class I recommendations for HFrEF to reduce
mortality. Amlodipine (a calcium channel blocker) is not indicated for mortality reduction in
HFrEF and may be harmful in some cases; it is used for angina or hypertension if other agents
are insufficient.
Q3: A 55-year-old woman presents with sudden onset of severe tearing chest pain radiating to her
back. Blood pressure is 180/110 mmHg in the right arm and 160/100 mmHg in the left arm. CT
angiogram confirms a Stanford Type A aortic dissection. What is the definitive treatment?
A. IV Beta-blockers and nitroprusside
B. Surgical intervention [CORRECT]
C. Endovascular stent grafting
D. Anticoagulation with heparin
Correct Answer: B
Rationale: Stanford Type A (ascending aorta) dissections are surgical emergencies requiring
immediate operative repair to prevent catastrophic complications like aortic rupture or cardiac
tamponade. Medical management (Beta-blockers) is used for Type B dissections or as a bridge to
surgery.
Q4: A 60-year-old male with atrial fibrillation (CHA2DS2-VASc score 3) is hesitant to take
warfarin. He asks about alternative options. Which of the following is a direct oral anticoagulant
(DOAC) that is contraindicated in patients with mechanical heart valves?
A. Apixaban
B. Dabigatran
C. Rivaroxaban
D. All of the above [CORRECT]
Correct Answer: D
,3
Rationale: DOACs (apixaban, dabigatran, rivaroxaban, edoxaban) are contraindicated in patients
with mechanical heart valves due to an increased risk of thromboembolic events compared to
warfarin. Warfarin remains the standard of care for mechanical valves.
Q5: A 45-year-old male presents for a routine physical. His blood pressure is 152/92 mmHg on
three separate occasions. He has no other medical conditions. According to ACC/AHA
guidelines, what is the first-line pharmacologic treatment for his Stage 2 hypertension?
A. Thiazide diuretic
B. ACE inhibitor or ARB
C. Calcium channel blocker
D. Combination of two first-line agents [CORRECT]
Correct Answer: D
Rationale: For adults with Stage 2 hypertension (BP ≥140/90), the 2017 ACC/AHA guidelines
recommend initiating treatment with two first-line agents from different classes (e.g., ACEi/ARB
+ CCB or Thiazide) to increase the likelihood of achieving BP control.
Q6: A 30-year-old female presents with fever, fatigue, and a new murmur. Blood cultures grow
Streptococcus viridans. Echocardiogram shows a 1.2 cm vegetation on the mitral valve. What is
the most likely predisposing condition?
A. IV drug use
B. Prosthetic valve
C. Mitral valve prolapse [CORRECT]
D. Rheumatic heart disease
Correct Answer: C
Rationale: Streptococcus viridans is a common cause of subacute bacterial endocarditis and often
colonizes damaged valves. Mitral valve prolapse is a common underlying structural abnormality
predisposing to endocarditis in this demographic.
, 4
Q7: A 50-year-old male presents with chest pain at rest. ECG shows ST-segment depression in
leads V4-V6. Cardiac biomarkers are elevated. He is given aspirin, ticagrelor, heparin, and
atorvastatin. His TIMI risk score is 4. What is the next best step in management?
A. Immediate thrombolysis
B. Discharge with stress test
C. Early invasive strategy (coronary angiography within 24 hours) [CORRECT]
D. Medical management only
Correct Answer: C
Rationale: This patient has Non-ST-Elevation Acute Coronary Syndrome (NSTE-ACS). A TIMI
score of 4 indicates intermediate to high risk. Guidelines recommend an early invasive strategy
(angiography within 24-72 hours, ideally sooner for high risk) for high-risk NSTE-ACS patients.
Q8: A 65-year-old male presents with syncope. On exam, you note a crescendo-decrescendo
systolic murmur radiating to the carotids. Echocardiogram reveals severe aortic stenosis with a
mean gradient of 45 mmHg and a valve area of 0.8 cm². He is asymptomatic. What is the
appropriate management?
A. Aortic valve replacement [CORRECT]
B. Medical management with beta-blockers
C. Watchful waiting
D. Surgical myectomy
Correct Answer: A
Rationale: While Class I guidelines recommend AVR for symptomatic severe AS, recent data
(e.g., from the RECOVERY trial) support early intervention in select patients with very severe
AS (gradient >40 or Vmax >5.0) even if asymptomatic, due to better outcomes compared to
watchful waiting. However, strictly speaking, symptom onset is the classic trigger; but in the
context of "very severe" physiology and syncope (which IS a symptom), this patient is
symptomatic. Syncope is a classic symptom of severe AS. Option A is correct.
