ABIM INTERNAL MEDICINE BOARDS & ITE EXAM (PDF) |
2026 QUESTIONS & ANSWERS + RATIONALES
1. A 68-year-old man with chronic HFrEF on sacubitril/valsartan, beta-blocker, and
spironethasone continues to have NYHA class III symptoms. LVEF 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: Cardiac resynchronization therapy with defibrillator (CRT-D)
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.
2. A 62-year-old man presents with exertional chest pain relieved by rest. ECG shows ST
depression in leads V4-V6. What is the most appropriate next step in management?
A) Coronary angiography
B) Start nitrates, beta-blocker, and aspirin
C) Schedule a stress echocardiogram
D) Immediate thrombolysis
Correct Answer: Start nitrates, beta-blocker, and aspirin
Rationale: Stable angina is characterized by predictable exertional chest pain relieved by rest or
nitroglycerin. Initial management includes antianginal therapy (nitrates, beta-blockers), risk
factor modification, and aspirin. Coronary angiography is indicated only if symptoms persist
despite medical therapy.
3. A 55-year-old woman with type 2 diabetes presents with painful burning in her feet.
Examination shows decreased vibration sense. What is the most appropriate first-line
treatment?
A) Gabapentin
B) Amitriptyline
C) Duloxetine
D) Capsaicin cream
Correct Answer: Duloxetine
Rationale: Diabetic peripheral neuropathy is best managed with duloxetine or pregabalin as first-
line agents. Duloxetine, an SNRI, provides both analgesic and antidepressant benefits. Tricyclics
like amitriptyline are effective but have more side effects in older adults.
, 4. 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
B) Cold and wet
C) Cold and dry
D) Warm and dry
Correct Answer: Cold and wet
Rationale: The "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.
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: Abnormal exercise test with symptoms
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.
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
Correct Answer: Cardiac tamponade
Rationale: The triad of hypotension, low voltage, and electrical alternans is classic for cardiac
tamponade. Echocardiography confirms pericardial effusion with right atrial and right ventricular
collapse.
7. A patient with hypertrophic cardiomyopathy (HCM) has a left ventricular outflow tract
gradient of 80 mm Hg at rest and symptoms of dyspnea and syncope. Which medication
is most likely to exacerbate the gradient?
A) Metoprolol
B) Verapamil
C) Disopyramide
D) Nitroglycerin
Correct Answer: Nitroglycerin
, Rationale: Nitroglycerin reduces preload and afterload, increasing outflow tract obstruction in
HCM. Beta-blockers and verapamil reduce gradient. Disopyramide is a negative inotrope used to
reduce obstruction.
8. A patient with a new diagnosis of heart failure with reduced ejection fraction (LVEF
30%) and LBBB on ECG. What is the most appropriate next step in management?
A) Implantable cardioverter-defibrillator (ICD)
B) Cardiac resynchronization therapy (CRT)
C) Medical therapy with beta-blocker and ACE inhibitor
D) Electrophysiology study
Correct Answer: Medical therapy with beta-blocker and ACE inhibitor
Rationale: Guideline-directed medical therapy (GDMT) should be initiated first. ICD and CRT
are indicated only after optimal medical therapy for at least 3-6 months if LVEF remains ≤35%
and symptoms persist.
9. A 68-year-old man with a history of hypertension and type 2 diabetes presents with
progressive dyspnea on exertion and lower extremity edema. Echocardiography reveals
LVEF of 35% with global hypokinesis. Coronary angiography shows nonobstructive
coronary artery disease. Which pharmacologic intervention has been shown to reduce
mortality in this patient population?
A) Sacubitril/valsartan
B) Ivabradine
C) Vericiguat
D) Digoxin
Correct Answer: Sacubitril/valsartan
Rationale: Sacubitril/valsartan (ARNI) reduces mortality in HFrEF compared to enalapril in the
PARADIGM-HF trial. Ivabradine reduces heart failure hospitalization but not mortality in
HFrEF with heart rate >70 bpm.
10. A 55-year-old female presents with a recent episode of syncope during exercise.
Echocardiogram shows asymmetric septal hypertrophy with a left ventricular outflow
tract gradient of 80 mm Hg at rest. What medication is most likely to worsen the
obstruction?
A) Metoprolol
B) Verapamil
C) Disopyramide
D) Nitroglycerin
Correct Answer: Nitroglycerin
Rationale: Nitroglycerin reduces preload and afterload, increasing the outflow tract gradient in
hypertrophic cardiomyopathy. Beta-blockers and verapamil reduce the gradient. Disopyramide is
a negative inotrope used to reduce obstruction.
2026 QUESTIONS & ANSWERS + RATIONALES
1. A 68-year-old man with chronic HFrEF on sacubitril/valsartan, beta-blocker, and
spironethasone continues to have NYHA class III symptoms. LVEF 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: Cardiac resynchronization therapy with defibrillator (CRT-D)
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.
2. A 62-year-old man presents with exertional chest pain relieved by rest. ECG shows ST
depression in leads V4-V6. What is the most appropriate next step in management?
A) Coronary angiography
B) Start nitrates, beta-blocker, and aspirin
C) Schedule a stress echocardiogram
D) Immediate thrombolysis
Correct Answer: Start nitrates, beta-blocker, and aspirin
Rationale: Stable angina is characterized by predictable exertional chest pain relieved by rest or
nitroglycerin. Initial management includes antianginal therapy (nitrates, beta-blockers), risk
factor modification, and aspirin. Coronary angiography is indicated only if symptoms persist
despite medical therapy.
3. A 55-year-old woman with type 2 diabetes presents with painful burning in her feet.
Examination shows decreased vibration sense. What is the most appropriate first-line
treatment?
A) Gabapentin
B) Amitriptyline
C) Duloxetine
D) Capsaicin cream
Correct Answer: Duloxetine
Rationale: Diabetic peripheral neuropathy is best managed with duloxetine or pregabalin as first-
line agents. Duloxetine, an SNRI, provides both analgesic and antidepressant benefits. Tricyclics
like amitriptyline are effective but have more side effects in older adults.
, 4. 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
B) Cold and wet
C) Cold and dry
D) Warm and dry
Correct Answer: Cold and wet
Rationale: The "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.
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: Abnormal exercise test with symptoms
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.
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
Correct Answer: Cardiac tamponade
Rationale: The triad of hypotension, low voltage, and electrical alternans is classic for cardiac
tamponade. Echocardiography confirms pericardial effusion with right atrial and right ventricular
collapse.
7. A patient with hypertrophic cardiomyopathy (HCM) has a left ventricular outflow tract
gradient of 80 mm Hg at rest and symptoms of dyspnea and syncope. Which medication
is most likely to exacerbate the gradient?
A) Metoprolol
B) Verapamil
C) Disopyramide
D) Nitroglycerin
Correct Answer: Nitroglycerin
, Rationale: Nitroglycerin reduces preload and afterload, increasing outflow tract obstruction in
HCM. Beta-blockers and verapamil reduce gradient. Disopyramide is a negative inotrope used to
reduce obstruction.
8. A patient with a new diagnosis of heart failure with reduced ejection fraction (LVEF
30%) and LBBB on ECG. What is the most appropriate next step in management?
A) Implantable cardioverter-defibrillator (ICD)
B) Cardiac resynchronization therapy (CRT)
C) Medical therapy with beta-blocker and ACE inhibitor
D) Electrophysiology study
Correct Answer: Medical therapy with beta-blocker and ACE inhibitor
Rationale: Guideline-directed medical therapy (GDMT) should be initiated first. ICD and CRT
are indicated only after optimal medical therapy for at least 3-6 months if LVEF remains ≤35%
and symptoms persist.
9. A 68-year-old man with a history of hypertension and type 2 diabetes presents with
progressive dyspnea on exertion and lower extremity edema. Echocardiography reveals
LVEF of 35% with global hypokinesis. Coronary angiography shows nonobstructive
coronary artery disease. Which pharmacologic intervention has been shown to reduce
mortality in this patient population?
A) Sacubitril/valsartan
B) Ivabradine
C) Vericiguat
D) Digoxin
Correct Answer: Sacubitril/valsartan
Rationale: Sacubitril/valsartan (ARNI) reduces mortality in HFrEF compared to enalapril in the
PARADIGM-HF trial. Ivabradine reduces heart failure hospitalization but not mortality in
HFrEF with heart rate >70 bpm.
10. A 55-year-old female presents with a recent episode of syncope during exercise.
Echocardiogram shows asymmetric septal hypertrophy with a left ventricular outflow
tract gradient of 80 mm Hg at rest. What medication is most likely to worsen the
obstruction?
A) Metoprolol
B) Verapamil
C) Disopyramide
D) Nitroglycerin
Correct Answer: Nitroglycerin
Rationale: Nitroglycerin reduces preload and afterload, increasing the outflow tract gradient in
hypertrophic cardiomyopathy. Beta-blockers and verapamil reduce the gradient. Disopyramide is
a negative inotrope used to reduce obstruction.
