lOMoAR cPSD| 57629747
ABIM Internal Medicine Boards ITE
, lOMoAR cPSD| 57629747
ABIM Internal Medicine Boards ITE – Comprehensive
2025/2026 Study Guide 150 Question and correct
detailed answers with Explanation.
SECTION 1: CARDIOVASCULAR DISEASE
Question 1
A patient with chronic heart failure with reduced ejection fraction (HFrEF) on
optimal medical therapy including sacubitril/valsartan, beta-blocker, and
spironolactone continues to have NYHA class III symptoms. Left ventricular
ejection fraction is 30%. There is no significant coronary disease. Which
intervention has been shown to reduce mortality in this population?
A) Implantable cardioverter-defibrillator (ICD) alone
B) Cardiac resynchronization therapy with defibrillator (CRT-D)
C) Left ventricular assist device (LVAD) as destination therapy
D) Heart transplantation listing
Correct Answer: B
Rationale: In patients with HFrEF, wide QRS (>150 ms) and LBBB, CRT-D reduces
mortality and hospitalizations. ICD alone does not improve symptoms. LVAD and
transplantation are reserved for advanced disease with refractory symptoms.
Question 2
A patient with acute decompensated heart failure presents with severe dyspnea,
cool extremities, and a blood pressure of 85/50 mm Hg. Which hemodynamic
profile is most consistent with these findings?
A) Warm and wet
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B) Cold and wet
C) Cold and dry
D) Warm and dry
Correct Answer: B
Rationale: Cold and wet profile indicates low cardiac output (cold extremities) and
congestion (wet). This patient requires inotropic support and vasodilators if
tolerated, but hypotension limits vasodilator use.
Question 3
A patient with known coronary artery disease develops chest pain at rest with
transient ST-segment elevation on ECG. Cardiac troponin is elevated. Which is the
most appropriate next step in management?
A) Immediate coronary angiography with PCI
B) Stress echocardiography
C) Medical management with dual antiplatelet therapy and heparin
D) CT coronary angiography
Correct Answer: A
Rationale: STEMI requires emergent reperfusion. Immediate angiography with PCI
is indicated within 90 minutes. Stress testing is contraindicated in acute MI.
Medical management alone is insufficient.
Question 4
A patient with atrial fibrillation and a CHA₂DS₂-VASc score of 4 is started on
apixaban. Which laboratory parameter most directly affects the anticoagulant
effect of apixaban and requires dose adjustment?
A) Prothrombin time
B) Activated partial thromboplastin time
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C) Serum creatinine and body weight
D) Platelet count
Correct Answer: C
Rationale: Apixaban is partially renally cleared and dose-adjusted based on serum
creatinine (CrCl <25 mL/min) and body weight (<60 kg). PT and aPTT are not
reliable for monitoring. Platelet count does not alter dosing.
Question 5
A patient with severe aortic stenosis (valve area 0.8 cm², mean gradient 50 mm
Hg) is asymptomatic. Which finding would be an indication for aortic valve
replacement?
A) Left ventricular ejection fraction 55%
B) Abnormal exercise test with symptoms
C) Moderate mitral regurgitation
D) Left atrial enlargement
Correct Answer: B
Rationale: In severe aortic stenosis, even if asymptomatic, an abnormal exercise
test (development of symptoms, fall in blood pressure) is a class I indication for
valve replacement. LVEF >50% is not an indication.
Question 6
A patient presents with acute-onset chest pain, dyspnea, and hypotension. ECG
shows low voltage and electrical alternans. Which is the most likely diagnosis?
A) Acute myocardial infarction
B) Pulmonary embolism
C) Cardiac tamponade
D) Aortic dissection
Downloaded by Collins Mwaniki ()
ABIM Internal Medicine Boards ITE
, lOMoAR cPSD| 57629747
ABIM Internal Medicine Boards ITE – Comprehensive
2025/2026 Study Guide 150 Question and correct
detailed answers with Explanation.
SECTION 1: CARDIOVASCULAR DISEASE
Question 1
A patient with chronic heart failure with reduced ejection fraction (HFrEF) on
optimal medical therapy including sacubitril/valsartan, beta-blocker, and
spironolactone continues to have NYHA class III symptoms. Left ventricular
ejection fraction is 30%. There is no significant coronary disease. Which
intervention has been shown to reduce mortality in this population?
A) Implantable cardioverter-defibrillator (ICD) alone
B) Cardiac resynchronization therapy with defibrillator (CRT-D)
C) Left ventricular assist device (LVAD) as destination therapy
D) Heart transplantation listing
Correct Answer: B
Rationale: In patients with HFrEF, wide QRS (>150 ms) and LBBB, CRT-D reduces
mortality and hospitalizations. ICD alone does not improve symptoms. LVAD and
transplantation are reserved for advanced disease with refractory symptoms.
Question 2
A patient with acute decompensated heart failure presents with severe dyspnea,
cool extremities, and a blood pressure of 85/50 mm Hg. Which hemodynamic
profile is most consistent with these findings?
A) Warm and wet
Downloaded by Collins Mwaniki ()
, lOMoAR cPSD| 57629747
B) Cold and wet
C) Cold and dry
D) Warm and dry
Correct Answer: B
Rationale: Cold and wet profile indicates low cardiac output (cold extremities) and
congestion (wet). This patient requires inotropic support and vasodilators if
tolerated, but hypotension limits vasodilator use.
Question 3
A patient with known coronary artery disease develops chest pain at rest with
transient ST-segment elevation on ECG. Cardiac troponin is elevated. Which is the
most appropriate next step in management?
A) Immediate coronary angiography with PCI
B) Stress echocardiography
C) Medical management with dual antiplatelet therapy and heparin
D) CT coronary angiography
Correct Answer: A
Rationale: STEMI requires emergent reperfusion. Immediate angiography with PCI
is indicated within 90 minutes. Stress testing is contraindicated in acute MI.
Medical management alone is insufficient.
Question 4
A patient with atrial fibrillation and a CHA₂DS₂-VASc score of 4 is started on
apixaban. Which laboratory parameter most directly affects the anticoagulant
effect of apixaban and requires dose adjustment?
A) Prothrombin time
B) Activated partial thromboplastin time
Downloaded by Collins Mwaniki ()
, lOMoAR cPSD| 57629747
C) Serum creatinine and body weight
D) Platelet count
Correct Answer: C
Rationale: Apixaban is partially renally cleared and dose-adjusted based on serum
creatinine (CrCl <25 mL/min) and body weight (<60 kg). PT and aPTT are not
reliable for monitoring. Platelet count does not alter dosing.
Question 5
A patient with severe aortic stenosis (valve area 0.8 cm², mean gradient 50 mm
Hg) is asymptomatic. Which finding would be an indication for aortic valve
replacement?
A) Left ventricular ejection fraction 55%
B) Abnormal exercise test with symptoms
C) Moderate mitral regurgitation
D) Left atrial enlargement
Correct Answer: B
Rationale: In severe aortic stenosis, even if asymptomatic, an abnormal exercise
test (development of symptoms, fall in blood pressure) is a class I indication for
valve replacement. LVEF >50% is not an indication.
Question 6
A patient presents with acute-onset chest pain, dyspnea, and hypotension. ECG
shows low voltage and electrical alternans. Which is the most likely diagnosis?
A) Acute myocardial infarction
B) Pulmonary embolism
C) Cardiac tamponade
D) Aortic dissection
Downloaded by Collins Mwaniki ()
