1
ABFM KSA Heart Disease Exam 2026/2027 Actual Exam -
Complete Questions with Detailed Rationales | 100% Verified
Graded A+ Pass Guaranteed - A+ Graded
1. Acute Coronary Syndrome & Myocardial Infarction
Question 1
A 65-year-old female who had an ST-elevation myocardial infarction (STEMI) treated with fibrinolytic
therapy 2 days ago has a sudden onset of chest pain and shortness of breath. Clinical evaluation reveals
pulmonary edema with blood pressure 86/50 mm Hg, wet rales, a harsh holosystolic murmur along the
left sternal border radiating toward the base and apex, and an S3 gallop. A pulmonary artery catheter is
placed and oxygen saturation is found to be higher in the pulmonary artery than in the right atrium.
Which complication does the patient most likely have?
A) Acute papillary muscle rupture
B) Ventricular septal rupture
C) Ventricular free wall rupture
D) Left ventricular aneurysm
E) Severe left ventricular failure
Correct Answer✅ B) Ventricular septal rupture
Rationale: In a patient with STEMI, cardiogenic shock with pulmonary edema and hypotension should
raise concern for mechanical complications. While extensive left ventricular dysfunction causes 75% of
cases, ventricular septal rupture (VSR) is a life-threatening mechanical complication that typically
presents 2-7 days post-MI. The key diagnostic clue is the oxygen saturation step-up from the right
atrium to the pulmonary artery (oxygenation higher in the PA than the RA), which is pathognomonic for
VSR. Papillary muscle rupture causes severe mitral regurgitation (MR) but does not produce an oxygen
step-up. Free wall rupture causes tamponade, not an oxygen step-up.
Question 2
A 56-year-old man with hypertension and type 2 diabetes presents for follow-up. He has no chest pain.
His LDL is 142 mg/dL, HDL 36 mg/dL, BP 136/78 mm Hg, nonsmoker. According to current guidelines,
what is the most appropriate next step?
A) Begin low-dose aspirin therapy
B) Start moderate- to high-intensity statin therapy
C) Begin ACE inhibitor for cardioprotection
D) No therapy is indicated at this time
,2
Correct Answer✅ B) Start moderate- to high-intensity statin therapy
Rationale: Patients with diabetes between ages 40–75 should be started on a statin regardless of
baseline LDL, especially with additional ASCVD risk factors (hypertension, low HDL). This is a primary
prevention strategy that reduces cardiovascular events. Aspirin is not recommended for primary
prevention in patients with diabetes without additional high-risk features. ACE inhibitors are indicated if
blood pressure is uncontrolled, but the BP of 136/78 is within target for a patient with diabetes (target
<140/90).
Question 3
Which of the following is the most specific biomarker for diagnosing acute myocardial infarction?
A) Creatine kinase-MB (CK-MB)
B) Myoglobin
C) Cardiac troponin I or T
D) Lactate dehydrogenase (LDH)
Correct Answer✅ C) Cardiac troponin I or T
Rationale: Troponins are the most specific and sensitive markers for myocardial injury. They remain
elevated longer than CK-MB (up to 10-14 days) and have near-perfect specificity for cardiac tissue.
Myoglobin is not cardiac-specific and rises rapidly but also falls quickly. LDH is an older marker with poor
specificity.
Question 4
A 58-year-old male with a history of hypertension presents to the emergency department with acute
onset of tearing chest pain radiating to the back. His blood pressure is 180/100 mm Hg in the right arm
and 100/60 mm Hg in the left arm. What is the most appropriate initial diagnostic test?
A) Exercise treadmill test
B) Coronary angiography
C) CT angiography of the chest
D) Transthoracic echocardiogram
Correct Answer✅ C) CT angiography of the chest
Rationale: The presentation is classic for aortic dissection (tearing chest pain radiating to back, blood
pressure differential between arms). CT angiography is the diagnostic test of choice for stable patients
with suspected aortic dissection. It is rapid, widely available, and provides detailed imaging of the aorta
and branch vessels.
Question 5
,3
A 65-year-old woman presents with chest pressure that occurs with exertion and resolves with rest. ECG
is normal. Which test is most appropriate next to confirm the diagnosis of stable ischemic heart disease?
A) Coronary angiography
B) Exercise treadmill test
C) Echocardiogram
D) Coronary CT angiogram
Correct Answer✅ B) Exercise treadmill test
Rationale: In patients with intermediate pre-test probability and an interpretable ECG (no baseline
abnormalities, no left bundle branch block), exercise treadmill stress testing is first-line for diagnosis of
stable ischemic heart disease. The patient can walk on the treadmill while ECG and symptoms are
monitored. If the ECG is uninterpretable, imaging stress test (stress echo or nuclear) is preferred.
2. Heart Failure (HFrEF & HFpEF)
Question 6
According to the ACC/AHA classification system, which one of the following would meet the criteria for
stage B heart failure in a 58-year-old male with no additional complications?
A) A history of dyspnea on exertion
B) Well compensated heart failure
C) A grade 2/6 apical holosystolic murmur radiating to the axilla
D) Uncontrolled type 2 diabetes
Correct Answer✅ C) A grade 2/6 apical holosystolic murmur radiating to the axilla
Rationale: The ACC/AHA heart failure classification includes four stages. Stage A is absence of structural
disease in patients at high risk (hypertension, diabetes, obesity, metabolic syndrome, family history of
cardiomyopathy). Stage B is evidence of structural heart disease without current or prior symptoms.
Structural heart disease includes previous MI, asymptomatic valvular disease (such as a significant
murmur), LV hypertrophy, or low EF. A grade 2/6 apical holosystolic murmur radiating to the axilla
suggests mitral regurgitation, which is structural heart disease. Stage C is structural heart disease with
current or prior symptoms. Stage D is refractory HF requiring specialized interventions.
Question 7
A 65-year-old female with heart failure and an ejection fraction of 35% is found to have a TSH level of
13.8 µU/mL (normal 0.3-4.82). Her T3 and T4 levels are normal, and her thyroid gland is normal to
palpation. You check her levels again in 2 months and they are unchanged. What should you advise?
A) Hypothyroidism decreases her metabolic rate, which reduces the stress on her heart
B) Hypothyroidism is detrimental to her heart only if she develops hypothyroid symptoms
, 4
C) Subclinical hypothyroidism has negative effects on heart failure and treatment should be considered
D) Treatment of subclinical hypothyroidism would raise her LDL-cholesterol level
Correct Answer✅ C) Subclinical hypothyroidism has negative effects on heart failure and treatment
should be considered
Rationale: Subclinical hypothyroidism (TSH >4 µU/mL with normal or borderline low thyroid hormone
levels) has been shown to cause left ventricular systolic and diastolic dysfunction, which improves with
thyroid replacement therapy. Patients with overt or subclinical hypothyroidism and heart failure should
be treated with levothyroxine to improve cardiovascular function and decrease the potential risk of
heart failure. Thyroxine should be started at low doses and increased slowly in patients with possible
underlying coronary artery disease. Meta-analyses indicate therapy will lower, not raise, serum LDL-
cholesterol levels.
Question 8
A 58-year-old male is hospitalized with severe decompensated heart failure refractory to intravenous
inotropic therapy and guideline-directed medical therapy. You are considering referral to a tertiary care
hospital for mechanical circulatory support to bridge to transplantation. Which statement is true
regarding mechanical circulatory support bridge therapy?
A) It should be limited to patients who meet the criteria for heart transplantation
B) It should only be used in patients with biventricular heart failure
C) It is contraindicated in patients with severe renal dysfunction
D) It can be used as a bridge to candidacy in patients who do not yet meet transplant criteria
Correct Answer✅ D) It can be used as a bridge to candidacy in patients who do not yet meet
transplant criteria
Rationale: Mechanical circulatory support (MCS) can be used as a bridge to transplantation (BTT) in
eligible candidates, but also as a bridge to candidacy (BTC) in patients who may become transplant
candidates after optimization of comorbidities. MCS may also be used as destination therapy (DT) in
patients who are not transplant candidates. The decision involves a multidisciplinary team at a certified
center.
Question 9
In patients with heart failure with reduced ejection fraction (HFrEF), which medication classes are
known to reduce mortality and are considered guideline-directed medical therapy (GDMT)?
A) Beta-blockers, ACE inhibitors/ARBs, aldosterone antagonists, SGLT2 inhibitors
B) Calcium channel blockers, digoxin, nitrates, hydralazine
C) Loop diuretics, nitrates, digoxin only
D) Antiarrhythmics, anticoagulants, aspirin
Correct Answer✅ A) Beta-blockers, ACE inhibitors/ARBs, aldosterone antagonists, SGLT2 inhibitors
ABFM KSA Heart Disease Exam 2026/2027 Actual Exam -
Complete Questions with Detailed Rationales | 100% Verified
Graded A+ Pass Guaranteed - A+ Graded
1. Acute Coronary Syndrome & Myocardial Infarction
Question 1
A 65-year-old female who had an ST-elevation myocardial infarction (STEMI) treated with fibrinolytic
therapy 2 days ago has a sudden onset of chest pain and shortness of breath. Clinical evaluation reveals
pulmonary edema with blood pressure 86/50 mm Hg, wet rales, a harsh holosystolic murmur along the
left sternal border radiating toward the base and apex, and an S3 gallop. A pulmonary artery catheter is
placed and oxygen saturation is found to be higher in the pulmonary artery than in the right atrium.
Which complication does the patient most likely have?
A) Acute papillary muscle rupture
B) Ventricular septal rupture
C) Ventricular free wall rupture
D) Left ventricular aneurysm
E) Severe left ventricular failure
Correct Answer✅ B) Ventricular septal rupture
Rationale: In a patient with STEMI, cardiogenic shock with pulmonary edema and hypotension should
raise concern for mechanical complications. While extensive left ventricular dysfunction causes 75% of
cases, ventricular septal rupture (VSR) is a life-threatening mechanical complication that typically
presents 2-7 days post-MI. The key diagnostic clue is the oxygen saturation step-up from the right
atrium to the pulmonary artery (oxygenation higher in the PA than the RA), which is pathognomonic for
VSR. Papillary muscle rupture causes severe mitral regurgitation (MR) but does not produce an oxygen
step-up. Free wall rupture causes tamponade, not an oxygen step-up.
Question 2
A 56-year-old man with hypertension and type 2 diabetes presents for follow-up. He has no chest pain.
His LDL is 142 mg/dL, HDL 36 mg/dL, BP 136/78 mm Hg, nonsmoker. According to current guidelines,
what is the most appropriate next step?
A) Begin low-dose aspirin therapy
B) Start moderate- to high-intensity statin therapy
C) Begin ACE inhibitor for cardioprotection
D) No therapy is indicated at this time
,2
Correct Answer✅ B) Start moderate- to high-intensity statin therapy
Rationale: Patients with diabetes between ages 40–75 should be started on a statin regardless of
baseline LDL, especially with additional ASCVD risk factors (hypertension, low HDL). This is a primary
prevention strategy that reduces cardiovascular events. Aspirin is not recommended for primary
prevention in patients with diabetes without additional high-risk features. ACE inhibitors are indicated if
blood pressure is uncontrolled, but the BP of 136/78 is within target for a patient with diabetes (target
<140/90).
Question 3
Which of the following is the most specific biomarker for diagnosing acute myocardial infarction?
A) Creatine kinase-MB (CK-MB)
B) Myoglobin
C) Cardiac troponin I or T
D) Lactate dehydrogenase (LDH)
Correct Answer✅ C) Cardiac troponin I or T
Rationale: Troponins are the most specific and sensitive markers for myocardial injury. They remain
elevated longer than CK-MB (up to 10-14 days) and have near-perfect specificity for cardiac tissue.
Myoglobin is not cardiac-specific and rises rapidly but also falls quickly. LDH is an older marker with poor
specificity.
Question 4
A 58-year-old male with a history of hypertension presents to the emergency department with acute
onset of tearing chest pain radiating to the back. His blood pressure is 180/100 mm Hg in the right arm
and 100/60 mm Hg in the left arm. What is the most appropriate initial diagnostic test?
A) Exercise treadmill test
B) Coronary angiography
C) CT angiography of the chest
D) Transthoracic echocardiogram
Correct Answer✅ C) CT angiography of the chest
Rationale: The presentation is classic for aortic dissection (tearing chest pain radiating to back, blood
pressure differential between arms). CT angiography is the diagnostic test of choice for stable patients
with suspected aortic dissection. It is rapid, widely available, and provides detailed imaging of the aorta
and branch vessels.
Question 5
,3
A 65-year-old woman presents with chest pressure that occurs with exertion and resolves with rest. ECG
is normal. Which test is most appropriate next to confirm the diagnosis of stable ischemic heart disease?
A) Coronary angiography
B) Exercise treadmill test
C) Echocardiogram
D) Coronary CT angiogram
Correct Answer✅ B) Exercise treadmill test
Rationale: In patients with intermediate pre-test probability and an interpretable ECG (no baseline
abnormalities, no left bundle branch block), exercise treadmill stress testing is first-line for diagnosis of
stable ischemic heart disease. The patient can walk on the treadmill while ECG and symptoms are
monitored. If the ECG is uninterpretable, imaging stress test (stress echo or nuclear) is preferred.
2. Heart Failure (HFrEF & HFpEF)
Question 6
According to the ACC/AHA classification system, which one of the following would meet the criteria for
stage B heart failure in a 58-year-old male with no additional complications?
A) A history of dyspnea on exertion
B) Well compensated heart failure
C) A grade 2/6 apical holosystolic murmur radiating to the axilla
D) Uncontrolled type 2 diabetes
Correct Answer✅ C) A grade 2/6 apical holosystolic murmur radiating to the axilla
Rationale: The ACC/AHA heart failure classification includes four stages. Stage A is absence of structural
disease in patients at high risk (hypertension, diabetes, obesity, metabolic syndrome, family history of
cardiomyopathy). Stage B is evidence of structural heart disease without current or prior symptoms.
Structural heart disease includes previous MI, asymptomatic valvular disease (such as a significant
murmur), LV hypertrophy, or low EF. A grade 2/6 apical holosystolic murmur radiating to the axilla
suggests mitral regurgitation, which is structural heart disease. Stage C is structural heart disease with
current or prior symptoms. Stage D is refractory HF requiring specialized interventions.
Question 7
A 65-year-old female with heart failure and an ejection fraction of 35% is found to have a TSH level of
13.8 µU/mL (normal 0.3-4.82). Her T3 and T4 levels are normal, and her thyroid gland is normal to
palpation. You check her levels again in 2 months and they are unchanged. What should you advise?
A) Hypothyroidism decreases her metabolic rate, which reduces the stress on her heart
B) Hypothyroidism is detrimental to her heart only if she develops hypothyroid symptoms
, 4
C) Subclinical hypothyroidism has negative effects on heart failure and treatment should be considered
D) Treatment of subclinical hypothyroidism would raise her LDL-cholesterol level
Correct Answer✅ C) Subclinical hypothyroidism has negative effects on heart failure and treatment
should be considered
Rationale: Subclinical hypothyroidism (TSH >4 µU/mL with normal or borderline low thyroid hormone
levels) has been shown to cause left ventricular systolic and diastolic dysfunction, which improves with
thyroid replacement therapy. Patients with overt or subclinical hypothyroidism and heart failure should
be treated with levothyroxine to improve cardiovascular function and decrease the potential risk of
heart failure. Thyroxine should be started at low doses and increased slowly in patients with possible
underlying coronary artery disease. Meta-analyses indicate therapy will lower, not raise, serum LDL-
cholesterol levels.
Question 8
A 58-year-old male is hospitalized with severe decompensated heart failure refractory to intravenous
inotropic therapy and guideline-directed medical therapy. You are considering referral to a tertiary care
hospital for mechanical circulatory support to bridge to transplantation. Which statement is true
regarding mechanical circulatory support bridge therapy?
A) It should be limited to patients who meet the criteria for heart transplantation
B) It should only be used in patients with biventricular heart failure
C) It is contraindicated in patients with severe renal dysfunction
D) It can be used as a bridge to candidacy in patients who do not yet meet transplant criteria
Correct Answer✅ D) It can be used as a bridge to candidacy in patients who do not yet meet
transplant criteria
Rationale: Mechanical circulatory support (MCS) can be used as a bridge to transplantation (BTT) in
eligible candidates, but also as a bridge to candidacy (BTC) in patients who may become transplant
candidates after optimization of comorbidities. MCS may also be used as destination therapy (DT) in
patients who are not transplant candidates. The decision involves a multidisciplinary team at a certified
center.
Question 9
In patients with heart failure with reduced ejection fraction (HFrEF), which medication classes are
known to reduce mortality and are considered guideline-directed medical therapy (GDMT)?
A) Beta-blockers, ACE inhibitors/ARBs, aldosterone antagonists, SGLT2 inhibitors
B) Calcium channel blockers, digoxin, nitrates, hydralazine
C) Loop diuretics, nitrates, digoxin only
D) Antiarrhythmics, anticoagulants, aspirin
Correct Answer✅ A) Beta-blockers, ACE inhibitors/ARBs, aldosterone antagonists, SGLT2 inhibitors
