COMSAE Phase 2 – Form 119: Board-Style
Questions with Detailed Answers &
Rationales
Cardiology
,1. A 67-year-old man presents with crushing substernal chest pain radiating to his left arm. ECG
shows ST-segment elevations in leads II, III, and aVF. Which coronary artery is most likely
occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Posterior descending artery
Answer: C. Right coronary artery
Rationale: Inferior wall myocardial infarctions classically produce ST elevations in leads II, III, and
aVF and are most commonly caused by occlusion of the right coronary artery. The LAD supplies
the anterior wall (V1-V4), while the circumflex often supplies the lateral wall (I, aVL, V5-V6).
Recognition of infarct localization is a high-yield COMSAE concept .
,2. A 57-year-old man with hypertension and type 2 diabetes presents with acute substernal chest
pain radiating to the left arm. ECG shows ST elevations in leads II, III, and aVF. What is the most
appropriate next step?
A. Aspirin and immediate PCI
B. Aspirin and IV tPA
C. Aspirin and clopidogrel with medical management
D. Aspirin and urgent CABG
Answer: A. Aspirin and immediate PCI
Rationale: Acute STEMI requires emergent reperfusion. Primary PCI is preferred if available within
90 minutes of first medical contact. Aspirin should be administered immediately. Fibrinolysis is an
alternative if PCI is not available within the recommended timeframe .
, 3. A 72-year-old man with hypertension presents with new-onset atrial fibrillation. His CHA2DS2-
VASc score is 4, and his CrCl is 25 mL/min. Which anticoagulant is most appropriate?
A. Warfarin
B. Apixaban 5 mg BID
C. Dabigatran 150 mg BID
D. Aspirin
Answer: A. Warfarin
Rationale: CrCl <30 mL/min is a contraindication for dabigatran. Warfarin is safest in severe CKD
with appropriate INR monitoring. Apixaban requires dose adjustment if age ≥80, weight ≤60 kg, or
Cr ≥1.5, and is not recommended if CrCl <25 mL/min .
Questions with Detailed Answers &
Rationales
Cardiology
,1. A 67-year-old man presents with crushing substernal chest pain radiating to his left arm. ECG
shows ST-segment elevations in leads II, III, and aVF. Which coronary artery is most likely
occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Posterior descending artery
Answer: C. Right coronary artery
Rationale: Inferior wall myocardial infarctions classically produce ST elevations in leads II, III, and
aVF and are most commonly caused by occlusion of the right coronary artery. The LAD supplies
the anterior wall (V1-V4), while the circumflex often supplies the lateral wall (I, aVL, V5-V6).
Recognition of infarct localization is a high-yield COMSAE concept .
,2. A 57-year-old man with hypertension and type 2 diabetes presents with acute substernal chest
pain radiating to the left arm. ECG shows ST elevations in leads II, III, and aVF. What is the most
appropriate next step?
A. Aspirin and immediate PCI
B. Aspirin and IV tPA
C. Aspirin and clopidogrel with medical management
D. Aspirin and urgent CABG
Answer: A. Aspirin and immediate PCI
Rationale: Acute STEMI requires emergent reperfusion. Primary PCI is preferred if available within
90 minutes of first medical contact. Aspirin should be administered immediately. Fibrinolysis is an
alternative if PCI is not available within the recommended timeframe .
, 3. A 72-year-old man with hypertension presents with new-onset atrial fibrillation. His CHA2DS2-
VASc score is 4, and his CrCl is 25 mL/min. Which anticoagulant is most appropriate?
A. Warfarin
B. Apixaban 5 mg BID
C. Dabigatran 150 mg BID
D. Aspirin
Answer: A. Warfarin
Rationale: CrCl <30 mL/min is a contraindication for dabigatran. Warfarin is safest in severe CKD
with appropriate INR monitoring. Apixaban requires dose adjustment if age ≥80, weight ≤60 kg, or
Cr ≥1.5, and is not recommended if CrCl <25 mL/min .
