1
COMSAE Phase 1 Form 114 \ 176 Questions and
Answers with Full Rationales Verified | Guaranteed Pass
| Latest Update | Complete Study Guide
SYSTEM 1 — CARDIOVASCULAR
Q1. A 65-year-old man presents with crushing chest pain radiating to the left arm,
diaphoresis, and nausea for 2 hours. ECG shows ST elevation in leads II, III, and aVF. Which
coronary artery is most likely occluded?
A. Left anterior descending (LAD) B. Left circumflex artery C. Right coronary artery (RCA)
✅ D. Left main coronary artery E. Posterior descending artery
Rationale: ST elevation in leads II, III, and aVF indicates an inferior STEMI, which is supplied by
the right coronary artery (RCA) in ~80% of people (right-dominant circulation). The LAD
supplies the anterior wall (V1–V4). The circumflex supplies the lateral wall (I, aVL, V5–V6).
Q2. A 72-year-old woman has a blood pressure of 165/95 mmHg on three separate occasions.
She has a history of type 2 diabetes with microalbuminuria. Which antihypertensive is MOST
appropriate as first-line therapy?
A. Hydrochlorothiazide B. Amlodipine C. Lisinopril ✅ D. Metoprolol E. Clonidine
Rationale: In patients with diabetes and microalbuminuria (early diabetic nephropathy), ACE
inhibitors (lisinopril) or ARBs are first-line. They reduce intraglomerular pressure, slow
progression of nephropathy, and provide cardiovascular protection independent of blood
pressure lowering. This is supported by JNC guidelines and ADA Standards of Care.
Q3. A 55-year-old man with a history of heart failure with reduced ejection fraction (HFrEF, EF
30%) presents for routine follow-up. He is currently on lisinopril and carvedilol. Which
additional medication has been shown to reduce mortality in this patient?
PG. 1
, 2
A. Digoxin B. Amlodipine C. Spironolactone ✅ D. Furosemide E. Hydralazine
Rationale: Aldosterone antagonists (spironolactone, eplerenone) reduce mortality in HFrEF
when added to ACE inhibitors and beta-blockers (RALES and EMPHASIS-HF trials). Furosemide
relieves symptoms but does not reduce mortality. Digoxin reduces hospitalizations but not
mortality.
Q4. A 45-year-old woman presents with sudden onset palpitations, light-headedness, and a
regular narrow complex tachycardia at 180 bpm. Vagal maneuvers are unsuccessful. What is
the MOST appropriate next step?
A. Synchronized cardioversion B. Adenosine 6 mg IV ✅ C. Amiodarone IV D. Metoprolol IV E.
Digoxin IV
Rationale: Regular narrow complex tachycardia unresponsive to vagal maneuvers is most
consistent with AVNRT (AV nodal reentrant tachycardia). Adenosine is the drug of choice — it
transiently blocks the AV node, terminating the reentrant circuit. Give 6 mg IV rapid push; if
unsuccessful, repeat with 12 mg. Cardioversion is reserved for hemodynamic instability.
Q5. A 60-year-old man has a total cholesterol of 260 mg/dL, LDL of 180 mg/dL, HDL of 35
mg/dL, and triglycerides of 225 mg/dL. He had a myocardial infarction 6 months ago. What is
the LDL goal for this patient?
A. <130 mg/dL B. <100 mg/dL C. <70 mg/dL ✅ D. <55 mg/dL E. No specific goal — treat with
high-intensity statin regardless
Rationale: Patients with established ASCVD (prior MI) are very high risk. ACC/AHA guidelines
recommend high-intensity statin therapy with an LDL goal of <70 mg/dL. Some guidelines now
target <55 mg/dL for very high-risk patients, but <70 is the most consistently tested threshold
on COMSAE.
Q6. Which of the following ECG findings is MOST consistent with hyperkalemia?
A. Prolonged QT interval B. Delta waves C. Peaked T waves ✅ D. Prominent U waves E. ST
depression
Rationale: Hyperkalemia produces a progression of ECG changes: peaked (tall, narrow,
symmetric) T waves → widened QRS → sine wave pattern → ventricular fibrillation. Prominent
PG. 2
, 3
U waves suggest hypokalemia. Prolonged QT suggests hypokalemia, hypocalcemia, or drug
effect. Delta waves indicate Wolff-Parkinson-White syndrome.
Q7. A 70-year-old man is found to have a harsh systolic ejection murmur at the right upper
sternal border radiating to the carotids, with a diminished and delayed carotid pulse (pulsus
parvus et tardus). What is the MOST likely diagnosis?
A. Mitral regurgitation B. Hypertrophic obstructive cardiomyopathy C. Aortic stenosis ✅ D.
Pulmonary stenosis E. Aortic regurgitation
Rationale: The classic triad of aortic stenosis: angina, syncope, and heart failure. The murmur is
a harsh crescendo-decrescendo systolic ejection murmur at the right upper sternal border (2nd
intercostal space) radiating to the carotids. Pulsus parvus et tardus (weak and delayed carotid
pulse) is pathognomonic. Average survival after symptom onset without intervention is 2–3
years.
Q8. A patient with a known history of atrial fibrillation presents for anticoagulation
management. His CHA₂DS₂-VASc score is 4. What is the MOST appropriate management?
A. Aspirin alone B. No anticoagulation needed C. Warfarin or a DOAC ✅ D. Aspirin plus
clopidogrel E. Heparin infusion
Rationale: A CHA₂DS₂-VASc score ≥2 in men or ≥3 in women indicates high stroke risk and
warrants oral anticoagulation. DOACs (apixaban, rivaroxaban, dabigatran) are preferred over
warfarin for non-valvular AFib due to superior efficacy, safety, and convenience. Aspirin alone is
insufficient for stroke prevention in AFib.
SYSTEM 2 — PULMONARY
Q9. A 68-year-old man with a 50 pack-year smoking history presents with progressive dyspnea
and chronic productive cough for the past 3 years. PFTs show FEV1/FVC ratio of 0.58, FEV1 of
55% predicted. What is the MOST likely diagnosis?
A. Asthma B. Restrictive lung disease C. COPD — moderate (GOLD Stage 2) ✅ D. Pulmonary
fibrosis E. Bronchiectasis
PG. 3
, 4
Rationale: COPD is defined by a post-bronchodilator FEV1/FVC <0.70. GOLD staging: Stage 1
(FEV1 ≥80%), Stage 2 (FEV1 50–79%) , Stage 3 (FEV1 30–49%), Stage 4 (FEV1 <30%). Asthma
typically shows reversible obstruction. Restrictive disease shows reduced FVC with normal or
elevated FEV1/FVC ratio.
Q10. A 25-year-old woman with known asthma presents with wheezing, dyspnea, and cough.
Her peak flow is 55% of personal best. She has used her albuterol inhaler 4 times today
without sustained relief. What is the MOST appropriate next step?
A. Increase frequency of albuterol use B. Add montelukast C. Systemic corticosteroids ✅ D.
Start omalizumab E. Intubation
Rationale: Peak flow 40–69% of personal best with incomplete response to short-acting beta-
agonists (SABA) indicates moderate-to-severe exacerbation. Systemic corticosteroids (oral
prednisone or IV methylprednisolone) are indicated to reduce airway inflammation and
prevent relapse. Albuterol should continue every 20 minutes in the acute setting.
Q11. A 35-year-old man develops sudden onset pleuritic chest pain and dyspnea after a long
flight. He has no prior medical history. Chest X-ray shows a Hampton's hump and Westermark
sign. CT pulmonary angiography confirms pulmonary embolism. What is the MOST
appropriate initial treatment?
A. Warfarin B. Aspirin C. Heparin anticoagulation ✅ D. Thrombolytics E. Inferior vena cava
filter
Rationale: For hemodynamically stable PE, initial treatment is anticoagulation —
unfractionated heparin, LMWH, or a DOAC (rivaroxaban or apixaban can be started directly).
Thrombolytics are reserved for massive PE with hemodynamic instability (systolic BP <90
mmHg). Hampton's hump = wedge-shaped pleural-based opacity. Westermark sign = oligemia
distal to the clot.
Q12. A 55-year-old man presents with progressive dyspnea, dry cough, and bilateral basal
crackles. CT shows honeycombing with basal and subpleural predominance. PFTs show a
restrictive pattern with reduced DLCO. Biopsy shows usual interstitial pneumonia (UIP)
pattern. What is the diagnosis?
PG. 4
COMSAE Phase 1 Form 114 \ 176 Questions and
Answers with Full Rationales Verified | Guaranteed Pass
| Latest Update | Complete Study Guide
SYSTEM 1 — CARDIOVASCULAR
Q1. A 65-year-old man presents with crushing chest pain radiating to the left arm,
diaphoresis, and nausea for 2 hours. ECG shows ST elevation in leads II, III, and aVF. Which
coronary artery is most likely occluded?
A. Left anterior descending (LAD) B. Left circumflex artery C. Right coronary artery (RCA)
✅ D. Left main coronary artery E. Posterior descending artery
Rationale: ST elevation in leads II, III, and aVF indicates an inferior STEMI, which is supplied by
the right coronary artery (RCA) in ~80% of people (right-dominant circulation). The LAD
supplies the anterior wall (V1–V4). The circumflex supplies the lateral wall (I, aVL, V5–V6).
Q2. A 72-year-old woman has a blood pressure of 165/95 mmHg on three separate occasions.
She has a history of type 2 diabetes with microalbuminuria. Which antihypertensive is MOST
appropriate as first-line therapy?
A. Hydrochlorothiazide B. Amlodipine C. Lisinopril ✅ D. Metoprolol E. Clonidine
Rationale: In patients with diabetes and microalbuminuria (early diabetic nephropathy), ACE
inhibitors (lisinopril) or ARBs are first-line. They reduce intraglomerular pressure, slow
progression of nephropathy, and provide cardiovascular protection independent of blood
pressure lowering. This is supported by JNC guidelines and ADA Standards of Care.
Q3. A 55-year-old man with a history of heart failure with reduced ejection fraction (HFrEF, EF
30%) presents for routine follow-up. He is currently on lisinopril and carvedilol. Which
additional medication has been shown to reduce mortality in this patient?
PG. 1
, 2
A. Digoxin B. Amlodipine C. Spironolactone ✅ D. Furosemide E. Hydralazine
Rationale: Aldosterone antagonists (spironolactone, eplerenone) reduce mortality in HFrEF
when added to ACE inhibitors and beta-blockers (RALES and EMPHASIS-HF trials). Furosemide
relieves symptoms but does not reduce mortality. Digoxin reduces hospitalizations but not
mortality.
Q4. A 45-year-old woman presents with sudden onset palpitations, light-headedness, and a
regular narrow complex tachycardia at 180 bpm. Vagal maneuvers are unsuccessful. What is
the MOST appropriate next step?
A. Synchronized cardioversion B. Adenosine 6 mg IV ✅ C. Amiodarone IV D. Metoprolol IV E.
Digoxin IV
Rationale: Regular narrow complex tachycardia unresponsive to vagal maneuvers is most
consistent with AVNRT (AV nodal reentrant tachycardia). Adenosine is the drug of choice — it
transiently blocks the AV node, terminating the reentrant circuit. Give 6 mg IV rapid push; if
unsuccessful, repeat with 12 mg. Cardioversion is reserved for hemodynamic instability.
Q5. A 60-year-old man has a total cholesterol of 260 mg/dL, LDL of 180 mg/dL, HDL of 35
mg/dL, and triglycerides of 225 mg/dL. He had a myocardial infarction 6 months ago. What is
the LDL goal for this patient?
A. <130 mg/dL B. <100 mg/dL C. <70 mg/dL ✅ D. <55 mg/dL E. No specific goal — treat with
high-intensity statin regardless
Rationale: Patients with established ASCVD (prior MI) are very high risk. ACC/AHA guidelines
recommend high-intensity statin therapy with an LDL goal of <70 mg/dL. Some guidelines now
target <55 mg/dL for very high-risk patients, but <70 is the most consistently tested threshold
on COMSAE.
Q6. Which of the following ECG findings is MOST consistent with hyperkalemia?
A. Prolonged QT interval B. Delta waves C. Peaked T waves ✅ D. Prominent U waves E. ST
depression
Rationale: Hyperkalemia produces a progression of ECG changes: peaked (tall, narrow,
symmetric) T waves → widened QRS → sine wave pattern → ventricular fibrillation. Prominent
PG. 2
, 3
U waves suggest hypokalemia. Prolonged QT suggests hypokalemia, hypocalcemia, or drug
effect. Delta waves indicate Wolff-Parkinson-White syndrome.
Q7. A 70-year-old man is found to have a harsh systolic ejection murmur at the right upper
sternal border radiating to the carotids, with a diminished and delayed carotid pulse (pulsus
parvus et tardus). What is the MOST likely diagnosis?
A. Mitral regurgitation B. Hypertrophic obstructive cardiomyopathy C. Aortic stenosis ✅ D.
Pulmonary stenosis E. Aortic regurgitation
Rationale: The classic triad of aortic stenosis: angina, syncope, and heart failure. The murmur is
a harsh crescendo-decrescendo systolic ejection murmur at the right upper sternal border (2nd
intercostal space) radiating to the carotids. Pulsus parvus et tardus (weak and delayed carotid
pulse) is pathognomonic. Average survival after symptom onset without intervention is 2–3
years.
Q8. A patient with a known history of atrial fibrillation presents for anticoagulation
management. His CHA₂DS₂-VASc score is 4. What is the MOST appropriate management?
A. Aspirin alone B. No anticoagulation needed C. Warfarin or a DOAC ✅ D. Aspirin plus
clopidogrel E. Heparin infusion
Rationale: A CHA₂DS₂-VASc score ≥2 in men or ≥3 in women indicates high stroke risk and
warrants oral anticoagulation. DOACs (apixaban, rivaroxaban, dabigatran) are preferred over
warfarin for non-valvular AFib due to superior efficacy, safety, and convenience. Aspirin alone is
insufficient for stroke prevention in AFib.
SYSTEM 2 — PULMONARY
Q9. A 68-year-old man with a 50 pack-year smoking history presents with progressive dyspnea
and chronic productive cough for the past 3 years. PFTs show FEV1/FVC ratio of 0.58, FEV1 of
55% predicted. What is the MOST likely diagnosis?
A. Asthma B. Restrictive lung disease C. COPD — moderate (GOLD Stage 2) ✅ D. Pulmonary
fibrosis E. Bronchiectasis
PG. 3
, 4
Rationale: COPD is defined by a post-bronchodilator FEV1/FVC <0.70. GOLD staging: Stage 1
(FEV1 ≥80%), Stage 2 (FEV1 50–79%) , Stage 3 (FEV1 30–49%), Stage 4 (FEV1 <30%). Asthma
typically shows reversible obstruction. Restrictive disease shows reduced FVC with normal or
elevated FEV1/FVC ratio.
Q10. A 25-year-old woman with known asthma presents with wheezing, dyspnea, and cough.
Her peak flow is 55% of personal best. She has used her albuterol inhaler 4 times today
without sustained relief. What is the MOST appropriate next step?
A. Increase frequency of albuterol use B. Add montelukast C. Systemic corticosteroids ✅ D.
Start omalizumab E. Intubation
Rationale: Peak flow 40–69% of personal best with incomplete response to short-acting beta-
agonists (SABA) indicates moderate-to-severe exacerbation. Systemic corticosteroids (oral
prednisone or IV methylprednisolone) are indicated to reduce airway inflammation and
prevent relapse. Albuterol should continue every 20 minutes in the acute setting.
Q11. A 35-year-old man develops sudden onset pleuritic chest pain and dyspnea after a long
flight. He has no prior medical history. Chest X-ray shows a Hampton's hump and Westermark
sign. CT pulmonary angiography confirms pulmonary embolism. What is the MOST
appropriate initial treatment?
A. Warfarin B. Aspirin C. Heparin anticoagulation ✅ D. Thrombolytics E. Inferior vena cava
filter
Rationale: For hemodynamically stable PE, initial treatment is anticoagulation —
unfractionated heparin, LMWH, or a DOAC (rivaroxaban or apixaban can be started directly).
Thrombolytics are reserved for massive PE with hemodynamic instability (systolic BP <90
mmHg). Hampton's hump = wedge-shaped pleural-based opacity. Westermark sign = oligemia
distal to the clot.
Q12. A 55-year-old man presents with progressive dyspnea, dry cough, and bilateral basal
crackles. CT shows honeycombing with basal and subpleural predominance. PFTs show a
restrictive pattern with reduced DLCO. Biopsy shows usual interstitial pneumonia (UIP)
pattern. What is the diagnosis?
PG. 4
