SARAH MICHELLE LIVE REVIEW STUDY GUIDE
2026/2027 | Complete Board Certification Prep | Pass
Guaranteed - A+ Graded
SECTION 1: CARDIOVASCULAR SYSTEM (35 Questions)
Subtopics: Hypertension, Heart Failure, CAD, Atrial Fibrillation, Valvular Disorders,
PVD, EKG Interpretation
Q1: A 58-year-old African American male presents for follow-up of hypertension. His BP
today is 148/92 mmHg. Current medications include lisinopril 10 mg daily. He reports
good adherence. Labs show K+ 4.2, Cr 1.1, eGFR >60. According to 2017 ACC/AHA
hypertension guidelines, what is the most appropriate next step?
A. Increase lisinopril to 20 mg daily
B. Add hydrochlorothiazide 12.5 mg daily
C. Add amlodipine 5 mg daily [CORRECT]
D. Continue current regimen and recheck in 3 months
Correct Answer: C
Rationale: The 2017 ACC/AHA guidelines define Stage 1 hypertension as BP
130-139/80-89 and Stage 2 as ≥140/90 mmHg. For Stage 2 hypertension or BP >20/10
mmHg above goal, initiation of two antihypertensives from different classes is
,recommended. This patient has uncontrolled Stage 2 hypertension on ACE inhibitor
monotherapy. Adding a calcium channel blocker (amlodipine) is preferred over thiazide
diuretic in African American patients, as CCBs demonstrate superior BP reduction in
this population. The combination of ACE inhibitor + CCB is also supported by the
ACCOMPLISH trial showing reduced cardiovascular events compared to ACE inhibitor +
thiazide.
Q2: A 72-year-old female with HFrEF (EF 35%) presents with worsening dyspnea and
peripheral edema. Current medications: lisinopril 20 mg, carvedilol 12.5 mg BID,
furosemide 40 mg daily, spironolactone 25 mg daily. Vitals: BP 98/62, HR 88. What is
the priority medication adjustment?
A. Increase furosemide to 80 mg daily
B. Add hydralazine-isosorbide dinitrate
C. Increase carvedilol to 25 mg BID [CORRECT]
D. Add digoxin 0.125 mg daily
Correct Answer: C
Rationale: According to AHA/ACC/HFSA heart failure guidelines, beta-blockers
(carvedilol, metoprolol succinate, or bisoprolol) should be titrated to maximally tolerated
evidence-based doses to reduce mortality and hospitalization. Carvedilol target dose is
25 mg BID. The patient's BP of 98/62, while low, is not hypotensive enough to prevent
beta-blocker titration if asymptomatic. Maximizing GDMT (guideline-directed medical
therapy) is the priority before adding other agents. Hydralazine-isosorbide is reserved
for African American patients with persistent symptoms or as add-on therapy. Digoxin is
for symptom control, not mortality benefit.
,Q3: A 45-year-old male presents with chest pain described as pressure-like, radiating to
left arm, occurring with exertion and relieved by rest. EKG shows normal sinus rhythm.
Troponin negative. What is the most appropriate initial diagnostic test?
A. Coronary CT angiography
B. Exercise stress test with EKG [CORRECT]
C. Dobutamine stress echocardiography
D. Cardiac catheterization
Correct Answer: B
Rationale: For a patient with intermediate-risk stable chest pain and normal EKG, able to
exercise, the exercise stress test with EKG is the appropriate initial diagnostic test
according to ACC/AHA stable ischemic heart disease guidelines. This is a functional
test that assesses for exercise-induced ischemia. Coronary CT angiography is an
anatomical test reserved for intermediate-risk patients who cannot exercise or have
uninterpretable EKG. Cardiac catheterization is invasive and reserved for high-risk
features or positive non-invasive testing. The patient's age and typical angina symptoms
warrant functional assessment first.
Q4: A 68-year-old male with newly diagnosed atrial fibrillation (CHADS₂-VASc score 4) is
started on apixaban 5 mg BID. Which monitoring parameter is most important?
A. INR every 4 weeks
B. Anti-Xa levels quarterly
C. Renal function annually [CORRECT]
D. Liver function tests every 3 months
, Correct Answer: C
Rationale: Apixaban is a direct oral anticoagulant (DOAC) that does not require routine
INR monitoring (unlike warfarin) or anti-Xa level monitoring. Per AHA/ACC/HRS atrial
fibrillation guidelines, DOACs require periodic assessment of renal function (at least
annually, more frequently if eGFR <60 or elderly) because renal impairment increases
drug accumulation and bleeding risk. Dose adjustment is needed if creatinine increases
or if two of the following: age ≥80, weight ≤60 kg, or creatinine ≥1.5. Liver function
monitoring is not routinely required for apixaban.
Q5: A 55-year-old female with mechanical mitral valve replacement presents for
pre-procedural planning. She takes warfarin with INR 2.8. She needs dental extraction.
What is the appropriate peri-procedural management?
A. Continue warfarin; no bridging needed [CORRECT]
B. Stop warfarin 5 days prior; bridge with enoxaparin
C. Stop warfarin 3 days prior; bridge with heparin
D. Continue warfarin and add aspirin 325 mg
Correct Answer: A
Rationale: For dental procedures with low bleeding risk (simple extractions), continuing
warfarin without interruption is recommended per ACC/AHA valvular heart disease
guidelines. The INR can be maintained at therapeutic levels. For higher bleeding risk
procedures, warfarin is stopped 5 days prior and bridged with heparin or LMWH if the
patient is at high thromboembolic risk. Mechanical mitral valves are high-risk for
thrombosis, but dental extractions are considered low bleeding risk procedures where
anticoagulation can be continued.
2026/2027 | Complete Board Certification Prep | Pass
Guaranteed - A+ Graded
SECTION 1: CARDIOVASCULAR SYSTEM (35 Questions)
Subtopics: Hypertension, Heart Failure, CAD, Atrial Fibrillation, Valvular Disorders,
PVD, EKG Interpretation
Q1: A 58-year-old African American male presents for follow-up of hypertension. His BP
today is 148/92 mmHg. Current medications include lisinopril 10 mg daily. He reports
good adherence. Labs show K+ 4.2, Cr 1.1, eGFR >60. According to 2017 ACC/AHA
hypertension guidelines, what is the most appropriate next step?
A. Increase lisinopril to 20 mg daily
B. Add hydrochlorothiazide 12.5 mg daily
C. Add amlodipine 5 mg daily [CORRECT]
D. Continue current regimen and recheck in 3 months
Correct Answer: C
Rationale: The 2017 ACC/AHA guidelines define Stage 1 hypertension as BP
130-139/80-89 and Stage 2 as ≥140/90 mmHg. For Stage 2 hypertension or BP >20/10
mmHg above goal, initiation of two antihypertensives from different classes is
,recommended. This patient has uncontrolled Stage 2 hypertension on ACE inhibitor
monotherapy. Adding a calcium channel blocker (amlodipine) is preferred over thiazide
diuretic in African American patients, as CCBs demonstrate superior BP reduction in
this population. The combination of ACE inhibitor + CCB is also supported by the
ACCOMPLISH trial showing reduced cardiovascular events compared to ACE inhibitor +
thiazide.
Q2: A 72-year-old female with HFrEF (EF 35%) presents with worsening dyspnea and
peripheral edema. Current medications: lisinopril 20 mg, carvedilol 12.5 mg BID,
furosemide 40 mg daily, spironolactone 25 mg daily. Vitals: BP 98/62, HR 88. What is
the priority medication adjustment?
A. Increase furosemide to 80 mg daily
B. Add hydralazine-isosorbide dinitrate
C. Increase carvedilol to 25 mg BID [CORRECT]
D. Add digoxin 0.125 mg daily
Correct Answer: C
Rationale: According to AHA/ACC/HFSA heart failure guidelines, beta-blockers
(carvedilol, metoprolol succinate, or bisoprolol) should be titrated to maximally tolerated
evidence-based doses to reduce mortality and hospitalization. Carvedilol target dose is
25 mg BID. The patient's BP of 98/62, while low, is not hypotensive enough to prevent
beta-blocker titration if asymptomatic. Maximizing GDMT (guideline-directed medical
therapy) is the priority before adding other agents. Hydralazine-isosorbide is reserved
for African American patients with persistent symptoms or as add-on therapy. Digoxin is
for symptom control, not mortality benefit.
,Q3: A 45-year-old male presents with chest pain described as pressure-like, radiating to
left arm, occurring with exertion and relieved by rest. EKG shows normal sinus rhythm.
Troponin negative. What is the most appropriate initial diagnostic test?
A. Coronary CT angiography
B. Exercise stress test with EKG [CORRECT]
C. Dobutamine stress echocardiography
D. Cardiac catheterization
Correct Answer: B
Rationale: For a patient with intermediate-risk stable chest pain and normal EKG, able to
exercise, the exercise stress test with EKG is the appropriate initial diagnostic test
according to ACC/AHA stable ischemic heart disease guidelines. This is a functional
test that assesses for exercise-induced ischemia. Coronary CT angiography is an
anatomical test reserved for intermediate-risk patients who cannot exercise or have
uninterpretable EKG. Cardiac catheterization is invasive and reserved for high-risk
features or positive non-invasive testing. The patient's age and typical angina symptoms
warrant functional assessment first.
Q4: A 68-year-old male with newly diagnosed atrial fibrillation (CHADS₂-VASc score 4) is
started on apixaban 5 mg BID. Which monitoring parameter is most important?
A. INR every 4 weeks
B. Anti-Xa levels quarterly
C. Renal function annually [CORRECT]
D. Liver function tests every 3 months
, Correct Answer: C
Rationale: Apixaban is a direct oral anticoagulant (DOAC) that does not require routine
INR monitoring (unlike warfarin) or anti-Xa level monitoring. Per AHA/ACC/HRS atrial
fibrillation guidelines, DOACs require periodic assessment of renal function (at least
annually, more frequently if eGFR <60 or elderly) because renal impairment increases
drug accumulation and bleeding risk. Dose adjustment is needed if creatinine increases
or if two of the following: age ≥80, weight ≤60 kg, or creatinine ≥1.5. Liver function
monitoring is not routinely required for apixaban.
Q5: A 55-year-old female with mechanical mitral valve replacement presents for
pre-procedural planning. She takes warfarin with INR 2.8. She needs dental extraction.
What is the appropriate peri-procedural management?
A. Continue warfarin; no bridging needed [CORRECT]
B. Stop warfarin 5 days prior; bridge with enoxaparin
C. Stop warfarin 3 days prior; bridge with heparin
D. Continue warfarin and add aspirin 325 mg
Correct Answer: A
Rationale: For dental procedures with low bleeding risk (simple extractions), continuing
warfarin without interruption is recommended per ACC/AHA valvular heart disease
guidelines. The INR can be maintained at therapeutic levels. For higher bleeding risk
procedures, warfarin is stopped 5 days prior and bridged with heparin or LMWH if the
patient is at high thromboembolic risk. Mechanical mitral valves are high-risk for
thrombosis, but dental extractions are considered low bleeding risk procedures where
anticoagulation can be continued.
