SARAH MICHELLE LIVE REVIEW STUDY GUIDE
2026/2027 | Complete Board Certification Prep | Pass
Guaranteed - A+ Graded
SECTION 1: CARDIOVASCULAR DISORDERS (30 Questions)
Q1: A 68-year-old male with a history of hypertension and type 2 diabetes presents with
progressive dyspnea on exertion, orthopnea, and bilateral lower extremity edema.
Physical exam reveals an S3 gallop, jugular venous distension, and pulmonary crackles.
Echocardiogram shows an ejection fraction of 35%. Which medication regimen
represents the evidence-based foundational therapy for this patient's heart failure with
reduced ejection fraction (HFrEF)?
A. ACE inhibitor, loop diuretic, and digoxin only
B. ACE inhibitor, beta-blocker, and MRA only
C. ACE inhibitor, beta-blocker, MRA, and SGLT2 inhibitor [CORRECT]
D. ACE inhibitor, beta-blocker, and hydralazine-isosorbide only
Correct Answer: C
Rationale: The 2022 AHA/ACC/HFSA Heart Failure Guidelines recommend quadruple
therapy for HFrEF: an ACE inhibitor (or ARB/ARNI), evidence-based beta-blocker
(metoprolol succinate, bisoprolol, or carvedilol), mineralocorticoid receptor antagonist
(MRA), and SGLT2 inhibitor. This combination reduces mortality and hospitalization.
Option A omits beta-blocker and SGLT2 inhibitor. Option B omits SGLT2 inhibitor, which
is now guideline-directed medical therapy (GDMT). Option D describes the
hydralazine-isosorbide combination reserved for African American patients or those
intolerant to ACE inhibitors/ARBs, not foundational therapy for this patient.
,Q2: A 55-year-old female presents with crushing substernal chest pain radiating to her
left arm, diaphoresis, and nausea. EKG shows ST-segment elevation in leads V1-V4.
Vital signs: BP 88/52 mmHg, HR 110 bpm, RR 24. Which is the most appropriate
immediate management priority?
A. Administer sublingual nitroglycerin and schedule urgent stress test
B. Activate the cardiac catheterization lab for primary PCI [CORRECT]
C. Begin thrombolytic therapy immediately without further assessment
D. Administer beta-blockers and heparin, then observe for 24 hours
Correct Answer: B
Rationale: This patient has an anterior ST-elevation myocardial infarction (STEMI) with
cardiogenic shock. The 2021 ACC/AHA/SCAI Guideline for Coronary Revascularization
recommends primary percutaneous coronary intervention (PCI) within 90 minutes of
first medical contact as the preferred reperfusion strategy. Option A is inappropriate as
stress testing is contraindicated in acute STEMI. Option C (thrombolytics) is reserved
when PCI cannot be performed within 120 minutes. Option D delays definitive
revascularization and is dangerous in hypotensive patients where beta-blockers may
worsen shock.
Q3: A 72-year-old male with atrial fibrillation (CHADS₂-VASc score of 4) is started on
warfarin. His INR goal is 2.0-3.0. Two weeks later, his INR is 4.8 without bleeding. He is
asymptomatic. What is the most appropriate management?
A. Administer vitamin K 10 mg orally and hold warfarin
B. Hold warfarin and administer fresh frozen plasma immediately
C. Hold warfarin and recheck INR in 2-3 days; consider low-dose oral vitamin K (1-2.5
mg) if INR >10 [CORRECT]
D. Continue warfarin at reduced dose and recheck INR in 1 week
,Correct Answer: C
Rationale: Per the 2012 CHEST Guideline and American College of Chest Physicians
recommendations, for asymptomatic supratherapeutic INR (4.5-10), hold warfarin and
recheck INR in 2-3 days. Low-dose oral vitamin K (1-2.5 mg) may be considered if INR
>10 or if bleeding risk is high. Option A uses excessive vitamin K, which can cause
warfarin resistance. Option B (FFP) is reserved for active bleeding or emergency
reversal. Option D is unsafe as it continues supratherapeutic anticoagulation.
Q4: A 45-year-old African American male has resistant hypertension despite adherence
to lisinopril 40 mg daily and chlorthalidone 25 mg daily. His home BP readings average
158/96 mmHg. Labs show potassium 3.2 mEq/L and creatinine 1.1 mg/dL. What is the
next best step in management?
A. Increase lisinopril to 80 mg daily
B. Add amlodipine 10 mg daily
C. Evaluate for primary aldosteronism with aldosterone-to-renin ratio [CORRECT]
D. Add clonidine 0.1 mg twice daily
Correct Answer: C
Rationale: The 2017 ACC/AHA Hypertension Guideline defines resistant hypertension as
BP above goal despite three antihypertensives (including a diuretic) or controlled BP
requiring four agents. This African American patient has hypokalemia and resistant
hypertension—classic features warranting screening for primary aldosteronism using
the aldosterone-to-renin ratio. Option A exceeds maximum ACE inhibitor dosing. Option
B (adding amlodipine) is reasonable if no secondary cause is suspected, but the
hypokalemia strongly suggests hyperaldosteronism. Option D (clonidine) is not first-line
for resistant hypertension before evaluating secondary causes.
, Q5: A 62-year-old female presents with sudden-onset severe tearing chest pain radiating
to her back. She is diaphoretic and hypotensive (BP 82/48). Chest X-ray shows widened
mediastinum. What is the definitive diagnostic study and immediate management?
A. CT coronary angiography and immediate beta-blockade
B. Transesophageal echocardiography and urgent surgical consultation
C. CT angiography of chest/abdomen/pelvis and immediate IV beta-blockade with
blood pressure control [CORRECT]
D. Cardiac catheterization and initiation of heparin infusion
Correct Answer: C
Rationale: This presentation is classic for thoracic aortic dissection. The 2010
ACC/AHA/AATS guidelines recommend CT angiography as the definitive diagnostic
imaging. Immediate IV beta-blockade (esmolol or labetalol) is critical to reduce shear
stress by lowering heart rate and blood pressure before vasodilators are added. Option
A (CT coronary angiography) evaluates coronary anatomy, not aortic dissection. Option
B (TEE) is useful but CT angiography is preferred for initial diagnosis. Option D (cardiac
cath and heparin) is contraindicated in aortic dissection and may worsen bleeding.
Q6: A 58-year-old male with known coronary artery disease presents for follow-up. His
LDL cholesterol is 142 mg/dL despite atorvastatin 40 mg daily. He had an MI 6 months
ago. According to 2018 AHA/ACC/Multi-Society Cholesterol Guideline, what is the most
appropriate management?
A. Continue current atorvastatin dose and recheck in 6 months
B. Switch to rosuvastatin 20 mg daily
C. Add ezetimibe 10 mg daily; consider PCSK9 inhibitor if LDL remains ≥70 mg/dL
[CORRECT]
D. Add niacin 1000 mg daily to current regimen
2026/2027 | Complete Board Certification Prep | Pass
Guaranteed - A+ Graded
SECTION 1: CARDIOVASCULAR DISORDERS (30 Questions)
Q1: A 68-year-old male with a history of hypertension and type 2 diabetes presents with
progressive dyspnea on exertion, orthopnea, and bilateral lower extremity edema.
Physical exam reveals an S3 gallop, jugular venous distension, and pulmonary crackles.
Echocardiogram shows an ejection fraction of 35%. Which medication regimen
represents the evidence-based foundational therapy for this patient's heart failure with
reduced ejection fraction (HFrEF)?
A. ACE inhibitor, loop diuretic, and digoxin only
B. ACE inhibitor, beta-blocker, and MRA only
C. ACE inhibitor, beta-blocker, MRA, and SGLT2 inhibitor [CORRECT]
D. ACE inhibitor, beta-blocker, and hydralazine-isosorbide only
Correct Answer: C
Rationale: The 2022 AHA/ACC/HFSA Heart Failure Guidelines recommend quadruple
therapy for HFrEF: an ACE inhibitor (or ARB/ARNI), evidence-based beta-blocker
(metoprolol succinate, bisoprolol, or carvedilol), mineralocorticoid receptor antagonist
(MRA), and SGLT2 inhibitor. This combination reduces mortality and hospitalization.
Option A omits beta-blocker and SGLT2 inhibitor. Option B omits SGLT2 inhibitor, which
is now guideline-directed medical therapy (GDMT). Option D describes the
hydralazine-isosorbide combination reserved for African American patients or those
intolerant to ACE inhibitors/ARBs, not foundational therapy for this patient.
,Q2: A 55-year-old female presents with crushing substernal chest pain radiating to her
left arm, diaphoresis, and nausea. EKG shows ST-segment elevation in leads V1-V4.
Vital signs: BP 88/52 mmHg, HR 110 bpm, RR 24. Which is the most appropriate
immediate management priority?
A. Administer sublingual nitroglycerin and schedule urgent stress test
B. Activate the cardiac catheterization lab for primary PCI [CORRECT]
C. Begin thrombolytic therapy immediately without further assessment
D. Administer beta-blockers and heparin, then observe for 24 hours
Correct Answer: B
Rationale: This patient has an anterior ST-elevation myocardial infarction (STEMI) with
cardiogenic shock. The 2021 ACC/AHA/SCAI Guideline for Coronary Revascularization
recommends primary percutaneous coronary intervention (PCI) within 90 minutes of
first medical contact as the preferred reperfusion strategy. Option A is inappropriate as
stress testing is contraindicated in acute STEMI. Option C (thrombolytics) is reserved
when PCI cannot be performed within 120 minutes. Option D delays definitive
revascularization and is dangerous in hypotensive patients where beta-blockers may
worsen shock.
Q3: A 72-year-old male with atrial fibrillation (CHADS₂-VASc score of 4) is started on
warfarin. His INR goal is 2.0-3.0. Two weeks later, his INR is 4.8 without bleeding. He is
asymptomatic. What is the most appropriate management?
A. Administer vitamin K 10 mg orally and hold warfarin
B. Hold warfarin and administer fresh frozen plasma immediately
C. Hold warfarin and recheck INR in 2-3 days; consider low-dose oral vitamin K (1-2.5
mg) if INR >10 [CORRECT]
D. Continue warfarin at reduced dose and recheck INR in 1 week
,Correct Answer: C
Rationale: Per the 2012 CHEST Guideline and American College of Chest Physicians
recommendations, for asymptomatic supratherapeutic INR (4.5-10), hold warfarin and
recheck INR in 2-3 days. Low-dose oral vitamin K (1-2.5 mg) may be considered if INR
>10 or if bleeding risk is high. Option A uses excessive vitamin K, which can cause
warfarin resistance. Option B (FFP) is reserved for active bleeding or emergency
reversal. Option D is unsafe as it continues supratherapeutic anticoagulation.
Q4: A 45-year-old African American male has resistant hypertension despite adherence
to lisinopril 40 mg daily and chlorthalidone 25 mg daily. His home BP readings average
158/96 mmHg. Labs show potassium 3.2 mEq/L and creatinine 1.1 mg/dL. What is the
next best step in management?
A. Increase lisinopril to 80 mg daily
B. Add amlodipine 10 mg daily
C. Evaluate for primary aldosteronism with aldosterone-to-renin ratio [CORRECT]
D. Add clonidine 0.1 mg twice daily
Correct Answer: C
Rationale: The 2017 ACC/AHA Hypertension Guideline defines resistant hypertension as
BP above goal despite three antihypertensives (including a diuretic) or controlled BP
requiring four agents. This African American patient has hypokalemia and resistant
hypertension—classic features warranting screening for primary aldosteronism using
the aldosterone-to-renin ratio. Option A exceeds maximum ACE inhibitor dosing. Option
B (adding amlodipine) is reasonable if no secondary cause is suspected, but the
hypokalemia strongly suggests hyperaldosteronism. Option D (clonidine) is not first-line
for resistant hypertension before evaluating secondary causes.
, Q5: A 62-year-old female presents with sudden-onset severe tearing chest pain radiating
to her back. She is diaphoretic and hypotensive (BP 82/48). Chest X-ray shows widened
mediastinum. What is the definitive diagnostic study and immediate management?
A. CT coronary angiography and immediate beta-blockade
B. Transesophageal echocardiography and urgent surgical consultation
C. CT angiography of chest/abdomen/pelvis and immediate IV beta-blockade with
blood pressure control [CORRECT]
D. Cardiac catheterization and initiation of heparin infusion
Correct Answer: C
Rationale: This presentation is classic for thoracic aortic dissection. The 2010
ACC/AHA/AATS guidelines recommend CT angiography as the definitive diagnostic
imaging. Immediate IV beta-blockade (esmolol or labetalol) is critical to reduce shear
stress by lowering heart rate and blood pressure before vasodilators are added. Option
A (CT coronary angiography) evaluates coronary anatomy, not aortic dissection. Option
B (TEE) is useful but CT angiography is preferred for initial diagnosis. Option D (cardiac
cath and heparin) is contraindicated in aortic dissection and may worsen bleeding.
Q6: A 58-year-old male with known coronary artery disease presents for follow-up. His
LDL cholesterol is 142 mg/dL despite atorvastatin 40 mg daily. He had an MI 6 months
ago. According to 2018 AHA/ACC/Multi-Society Cholesterol Guideline, what is the most
appropriate management?
A. Continue current atorvastatin dose and recheck in 6 months
B. Switch to rosuvastatin 20 mg daily
C. Add ezetimibe 10 mg daily; consider PCSK9 inhibitor if LDL remains ≥70 mg/dL
[CORRECT]
D. Add niacin 1000 mg daily to current regimen
