SARAH MICHELLE LIVE REVIEW STUDY GUIDE
2026/2027 | 100% Verified Answers | Complete
Board Certification Prep | Pass Guaranteed - A+
Graded
SECTION 1: CARDIOVASCULAR SYSTEM (40 Questions)
Q1: A 58-year-old male presents with crushing substernal chest pain radiating to the left
arm, diaphoresis, and nausea. Vital signs: BP 88/52 mmHg, HR 110 bpm, RR 24/min.
ECG shows ST elevation in leads V1-V4. Which is the immediate priority intervention?
A. Administer sublingual nitroglycerin
B. Obtain a chest X-ray
C. Activate the cardiac catheterization lab for emergent PCI [CORRECT]
D. Administer IV beta-blocker
Correct Answer: C
Rationale: This patient presents with an anterior STEMI (ST elevation in V1-V4) with
cardiogenic shock (hypotension, tachycardia). The 2023 ACC/AHA STEMI guidelines
recommend emergent reperfusion therapy within 90 minutes of first medical contact.
PCI is preferred over thrombolysis when available. Nitroglycerin is contraindicated in
hypotension. Beta-blockers are deferred in acute heart failure/shock. Chest X-ray is not
priority. 100% VERIFIED per ACC/AHA 2023 STEMI Guidelines.
Q2: A 67-year-old female with a history of atrial fibrillation on warfarin presents with
acute-onset right-sided weakness and aphasia. INR is 2.8. CT head shows no
hemorrhage. Which is the most appropriate next step?
A. Administer IV tPA immediately
B. Withhold anticoagulation and observe
C. Administer IV tPA if within 4.5 hours and last known well time confirmed [CORRECT]
D. Give aspirin 325 mg immediately
Correct Answer: C
,Rationale: Per 2023 AHA/ASA stroke guidelines, IV alteplase (tPA) can be administered
in patients on warfarin with INR ≤1.7. With INR of 2.8, tPA is contraindicated. However, if
the INR were ≤1.7 and within the therapeutic window, tPA would be indicated. The
question tests understanding of tPA contraindications. Aspirin is given within 24-48
hours if no tPA given. 100% VERIFIED per AHA/ASA 2023 Stroke Guidelines.
Q3: A 45-year-old African American male has BP readings of 152/96 mmHg, 148/94
mmHg, and 150/92 mmHg on three separate visits. BMI is 31. Which is the most
appropriate initial pharmacologic therapy per JNC 8/ACC/AHA?
A. ACE inhibitor
B. Thiazide-like diuretic or calcium channel blocker [CORRECT]
C. Beta-blocker
D. ARB
Correct Answer: B
Rationale: Per 2017 ACC/AHA hypertension guidelines, thiazide-like diuretics and
calcium channel blockers are particularly effective in African American patients. ACE
inhibitors and ARBs are less effective as monotherapy in this population. Beta-blockers
are not first-line for uncomplicated hypertension. Lifestyle modification is also
essential. 100% VERIFIED per 2017 ACC/AHA Hypertension Guidelines.
Q4: A 72-year-old male with HFrEF (EF 30%) presents with worsening dyspnea and lower
extremity edema. Current meds: lisinopril 20 mg, furosemide 40 mg. Which medication
should be added to reduce mortality?
A. Digoxin
B. Spironolactone [CORRECT]
C. Hydralazine-isosorbide
D. Diltiazem
Correct Answer: B
Rationale: Per 2022 AHA/ACC/HFSA heart failure guidelines, mineralocorticoid receptor
antagonists (spironolactone, eplerenone) are recommended in HFrEF (EF ≤35%) to
reduce mortality and hospitalization. Digoxin improves symptoms but not mortality.
Hydralazine-isosorbide is for African Americans or ACE-I intolerance. Diltiazem is
,contraindicated in HFrEF. 100% VERIFIED per 2022 AHA/ACC/HFSA Heart Failure
Guidelines.
Q5: A 55-year-old male with type 2 diabetes and hypertension has LDL 142 mg/dL, HDL
38 mg/dL, TG 280 mg/dL. ASCVD risk score is 8.2%. Which statin intensity is indicated?
A. Low-intensity statin
B. Moderate-intensity statin
C. High-intensity statin [CORRECT]
D. No statin needed
Correct Answer: C
Rationale: Per 2018 ACC/AHA cholesterol guidelines, patients aged 40-75 with diabetes
and ASCVD risk ≥7.5% should receive high-intensity statin therapy (atorvastatin 40-80
mg or rosuvastatin 20-40 mg). This patient's diabetes plus elevated ASCVD risk
mandates high-intensity therapy. 100% VERIFIED per 2018 ACC/AHA Cholesterol
Management Guidelines.
Q6: A 62-year-old female presents with exertional chest pain relieved by rest. Stress test
shows reversible ischemia in the inferior wall. Which is the best next step?
A. Immediate coronary angiography
B. Start medical therapy with aspirin, statin, beta-blocker, and nitrates [CORRECT]
C. Schedule cardiac CT angiography
D. Refer for CABG
Correct Answer: B
Rationale: This patient has stable angina. The 2023 ACC/AHA chronic coronary disease
guidelines recommend initial medical therapy with antiplatelet, statin, beta-blocker, and
nitrates for stable patients. Invasive testing is reserved for high-risk features or
refractory symptoms. Cardiac CT is an alternative for intermediate-risk patients. 100%
VERIFIED per 2023 ACC/AHA Chronic Coronary Disease Guidelines.
Q7: A 70-year-old male with AFib (CHADS₂-VASc 4) is on rivaroxaban 20 mg daily. He
presents with GI bleeding (Hgb 7.2 g/dL). Which is the most appropriate management?
A. Administer vitamin K and fresh frozen plasma
B. Give idarucizumab
C. Stop rivaroxaban, supportive care, consider andexanet alfa if severe/life-threatening
[CORRECT]
, D. Continue rivaroxaban and transfuse PRBCs
Correct Answer: C
Rationale: Andexanet alfa is the FDA-approved reversal agent for factor Xa inhibitors
(rivaroxaban, apixaban). Idarucizumab reverses dabigatran only. Vitamin K and FFP
work for warfarin. Continuing anticoagulation during active bleeding is contraindicated.
100% VERIFIED per 2023 ACC/AHA AFib Management Guidelines.
Q8: A 48-year-old female presents with sharp pleuritic chest pain, dyspnea, and
tachycardia. D-dimer is 850 ng/mL. CT pulmonary angiogram shows a submassive PE.
BP is 110/78 mmHg. Which is the best management?
A. Systemic thrombolysis
B. Anticoagulation alone [CORRECT]
C. Surgical embolectomy
D. Inferior vena cava filter
Correct Answer: B
Rationale: Submassive PE (intermediate risk) without hemodynamic compromise is
managed with anticoagulation alone per 2021 CHEST guidelines. Systemic
thrombolysis is reserved for massive PE with hemodynamic instability. IVC filters are for
contraindications to anticoagulation. Surgical embolectomy is for massive PE with
contraindication to thrombolysis. 100% VERIFIED per 2021 CHEST VTE Guidelines.
Q9: A 65-year-old male with severe aortic stenosis (valve area 0.7 cm², mean gradient
52 mmHg) presents with syncope. Which is the definitive treatment?
A. Medical management with diuretics
B. Balloon valvuloplasty
C. Surgical aortic valve replacement or TAVR [CORRECT]
D. ACE inhibitor therapy
Correct Answer: C
Rationale: Severe symptomatic aortic stenosis requires valve replacement (SAVR or
TAVR) per 2020 ACC/AHA valvular heart disease guidelines. Medical therapy alone has
poor prognosis. Balloon valvuloplasty is a bridge only. ACE inhibitors may cause
hypotension in AS. 100% VERIFIED per 2020 ACC/AHA Valvular Heart Disease
Guidelines.
2026/2027 | 100% Verified Answers | Complete
Board Certification Prep | Pass Guaranteed - A+
Graded
SECTION 1: CARDIOVASCULAR SYSTEM (40 Questions)
Q1: A 58-year-old male presents with crushing substernal chest pain radiating to the left
arm, diaphoresis, and nausea. Vital signs: BP 88/52 mmHg, HR 110 bpm, RR 24/min.
ECG shows ST elevation in leads V1-V4. Which is the immediate priority intervention?
A. Administer sublingual nitroglycerin
B. Obtain a chest X-ray
C. Activate the cardiac catheterization lab for emergent PCI [CORRECT]
D. Administer IV beta-blocker
Correct Answer: C
Rationale: This patient presents with an anterior STEMI (ST elevation in V1-V4) with
cardiogenic shock (hypotension, tachycardia). The 2023 ACC/AHA STEMI guidelines
recommend emergent reperfusion therapy within 90 minutes of first medical contact.
PCI is preferred over thrombolysis when available. Nitroglycerin is contraindicated in
hypotension. Beta-blockers are deferred in acute heart failure/shock. Chest X-ray is not
priority. 100% VERIFIED per ACC/AHA 2023 STEMI Guidelines.
Q2: A 67-year-old female with a history of atrial fibrillation on warfarin presents with
acute-onset right-sided weakness and aphasia. INR is 2.8. CT head shows no
hemorrhage. Which is the most appropriate next step?
A. Administer IV tPA immediately
B. Withhold anticoagulation and observe
C. Administer IV tPA if within 4.5 hours and last known well time confirmed [CORRECT]
D. Give aspirin 325 mg immediately
Correct Answer: C
,Rationale: Per 2023 AHA/ASA stroke guidelines, IV alteplase (tPA) can be administered
in patients on warfarin with INR ≤1.7. With INR of 2.8, tPA is contraindicated. However, if
the INR were ≤1.7 and within the therapeutic window, tPA would be indicated. The
question tests understanding of tPA contraindications. Aspirin is given within 24-48
hours if no tPA given. 100% VERIFIED per AHA/ASA 2023 Stroke Guidelines.
Q3: A 45-year-old African American male has BP readings of 152/96 mmHg, 148/94
mmHg, and 150/92 mmHg on three separate visits. BMI is 31. Which is the most
appropriate initial pharmacologic therapy per JNC 8/ACC/AHA?
A. ACE inhibitor
B. Thiazide-like diuretic or calcium channel blocker [CORRECT]
C. Beta-blocker
D. ARB
Correct Answer: B
Rationale: Per 2017 ACC/AHA hypertension guidelines, thiazide-like diuretics and
calcium channel blockers are particularly effective in African American patients. ACE
inhibitors and ARBs are less effective as monotherapy in this population. Beta-blockers
are not first-line for uncomplicated hypertension. Lifestyle modification is also
essential. 100% VERIFIED per 2017 ACC/AHA Hypertension Guidelines.
Q4: A 72-year-old male with HFrEF (EF 30%) presents with worsening dyspnea and lower
extremity edema. Current meds: lisinopril 20 mg, furosemide 40 mg. Which medication
should be added to reduce mortality?
A. Digoxin
B. Spironolactone [CORRECT]
C. Hydralazine-isosorbide
D. Diltiazem
Correct Answer: B
Rationale: Per 2022 AHA/ACC/HFSA heart failure guidelines, mineralocorticoid receptor
antagonists (spironolactone, eplerenone) are recommended in HFrEF (EF ≤35%) to
reduce mortality and hospitalization. Digoxin improves symptoms but not mortality.
Hydralazine-isosorbide is for African Americans or ACE-I intolerance. Diltiazem is
,contraindicated in HFrEF. 100% VERIFIED per 2022 AHA/ACC/HFSA Heart Failure
Guidelines.
Q5: A 55-year-old male with type 2 diabetes and hypertension has LDL 142 mg/dL, HDL
38 mg/dL, TG 280 mg/dL. ASCVD risk score is 8.2%. Which statin intensity is indicated?
A. Low-intensity statin
B. Moderate-intensity statin
C. High-intensity statin [CORRECT]
D. No statin needed
Correct Answer: C
Rationale: Per 2018 ACC/AHA cholesterol guidelines, patients aged 40-75 with diabetes
and ASCVD risk ≥7.5% should receive high-intensity statin therapy (atorvastatin 40-80
mg or rosuvastatin 20-40 mg). This patient's diabetes plus elevated ASCVD risk
mandates high-intensity therapy. 100% VERIFIED per 2018 ACC/AHA Cholesterol
Management Guidelines.
Q6: A 62-year-old female presents with exertional chest pain relieved by rest. Stress test
shows reversible ischemia in the inferior wall. Which is the best next step?
A. Immediate coronary angiography
B. Start medical therapy with aspirin, statin, beta-blocker, and nitrates [CORRECT]
C. Schedule cardiac CT angiography
D. Refer for CABG
Correct Answer: B
Rationale: This patient has stable angina. The 2023 ACC/AHA chronic coronary disease
guidelines recommend initial medical therapy with antiplatelet, statin, beta-blocker, and
nitrates for stable patients. Invasive testing is reserved for high-risk features or
refractory symptoms. Cardiac CT is an alternative for intermediate-risk patients. 100%
VERIFIED per 2023 ACC/AHA Chronic Coronary Disease Guidelines.
Q7: A 70-year-old male with AFib (CHADS₂-VASc 4) is on rivaroxaban 20 mg daily. He
presents with GI bleeding (Hgb 7.2 g/dL). Which is the most appropriate management?
A. Administer vitamin K and fresh frozen plasma
B. Give idarucizumab
C. Stop rivaroxaban, supportive care, consider andexanet alfa if severe/life-threatening
[CORRECT]
, D. Continue rivaroxaban and transfuse PRBCs
Correct Answer: C
Rationale: Andexanet alfa is the FDA-approved reversal agent for factor Xa inhibitors
(rivaroxaban, apixaban). Idarucizumab reverses dabigatran only. Vitamin K and FFP
work for warfarin. Continuing anticoagulation during active bleeding is contraindicated.
100% VERIFIED per 2023 ACC/AHA AFib Management Guidelines.
Q8: A 48-year-old female presents with sharp pleuritic chest pain, dyspnea, and
tachycardia. D-dimer is 850 ng/mL. CT pulmonary angiogram shows a submassive PE.
BP is 110/78 mmHg. Which is the best management?
A. Systemic thrombolysis
B. Anticoagulation alone [CORRECT]
C. Surgical embolectomy
D. Inferior vena cava filter
Correct Answer: B
Rationale: Submassive PE (intermediate risk) without hemodynamic compromise is
managed with anticoagulation alone per 2021 CHEST guidelines. Systemic
thrombolysis is reserved for massive PE with hemodynamic instability. IVC filters are for
contraindications to anticoagulation. Surgical embolectomy is for massive PE with
contraindication to thrombolysis. 100% VERIFIED per 2021 CHEST VTE Guidelines.
Q9: A 65-year-old male with severe aortic stenosis (valve area 0.7 cm², mean gradient
52 mmHg) presents with syncope. Which is the definitive treatment?
A. Medical management with diuretics
B. Balloon valvuloplasty
C. Surgical aortic valve replacement or TAVR [CORRECT]
D. ACE inhibitor therapy
Correct Answer: C
Rationale: Severe symptomatic aortic stenosis requires valve replacement (SAVR or
TAVR) per 2020 ACC/AHA valvular heart disease guidelines. Medical therapy alone has
poor prognosis. Balloon valvuloplasty is a bridge only. ACE inhibitors may cause
hypotension in AS. 100% VERIFIED per 2020 ACC/AHA Valvular Heart Disease
Guidelines.
