A 58-year-old woman with no prior history of coronary artery disease presents with chest tightness at rest for 45 minutes. High-sensitivity troponin I is elevated. ECG demonstrates horizontal ST-segment depression in leads V4–V6. She is hemodynamically stable, pain-free after initial medical therapy, and has no signs of heart failure. Her GRACE score is calculated at 158. According to contemporary ESC guidelines, what is the MOST appropriate timing for invasive coronary angiography?

A 72-year-old man presents 4 days after an untreated anterior ST-elevation myocardial infarction. He suddenly develops acute pulmonary edema, hypotension, and a new harsh holosystolic murmur best heard at the cardiac apex with radiation to the axilla. Bedside echocardiography reveals severe acute mitral regurgitation with a hyperdynamic, nondilated left ventricle. Which mechanical complication is MOST likely responsible for this presentation?

A 60-year-old man with inferior STEMI receives sublingual nitrates shortly after arrival. Within minutes, his blood pressure falls from 120/75 mmHg to 80/50 mmHg. Lung fields remain clear, and jugular venous pressure is elevated. Which pathophysiologic mechanism BEST explains this hemodynamic deterioration?

A 63-year-old man presents 36 hours after the onset of chest pain that resolved spontaneously. ECG shows pathological Q waves in leads V1–V4 without ongoing ST elevation. He is asymptomatic, hemodynamically stable, and has no evidence of ongoing ischemia. What is the MOST appropriate reperfusion strategy?

A 55-year-old woman with NSTEMI is planned for invasive management. She has a prior history of spontaneous intracranial hemorrhage 3 years ago with full neurological recovery. Which antiplatelet agent is CONTRAINDICATED in this patient?

A 61-year-old man with stable multivessel coronary artery disease undergoes stress imaging that demonstrates moderate-to-severe ischemia. He reports minimal angina (CCS class I) while on optimal medical therapy. Based on the ISCHEMIA trial, which statement is MOST accurate?

An ECG obtained in a patient with chest pain shows diffuse ST-segment depression in multiple leads with ST-segment elevation in lead aVR. This pattern MOST strongly suggests:

A 57-year-old woman presents with chest pain and elevated troponin. Coronary angiography reveals no obstructive coronary lesions. Cardiac MRI demonstrates subendocardial late gadolinium enhancement in the inferior wall. Which diagnosis BEST explains these findings?

Which of the following is the MOST common cause of early (<30 days) stent thrombosis?

A 45-year-old man presents with recurrent palpitations and dizziness. ECG shows irregular wide-complex tachycardia with varying QRS morphologies. Blood pressure is 90/60 mmHg. What is the MOST appropriate immediate management?

A patient with Wolff–Parkinson–White syndrome develops atrial fibrillation with rapid ventricular response. Which drug is MOST appropriate for acute rate control?

Which antiarrhythmic drug exhibits reverse use-dependence and increases the risk of torsades de pointes at low heart rates?

A 70-year-old man with ischemic cardiomyopathy (LVEF 30%) remains symptomatic (NYHA II) despite optimal guideline-directed medical therapy. Which additional therapy provides mortality benefit regardless of diabetic status?

A patient with restrictive cardiomyopathy is MOST likely to demonstrate which echocardiographic feature?

Which physical maneuver increases the murmur intensity in hypertrophic obstructive cardiomyopathy?

A patient with constrictive pericarditis is MOST likely to exhibit which echocardiographic sign?

Which echocardiographic parameter BEST reflects left ventricular filling pressure?

A 34-year-old woman presents with exertional dyspnea. Physical examination reveals fixed splitting of the second heart sound. Echocardiography shows right atrial and right ventricular enlargement with Qp/Qs of 2.2. What is the MOST likely diagnosis?

A patient with pulmonary arterial hypertension undergoes vasoreactivity testing during right heart catheterization and demonstrates a positive response. Which therapy is MOST appropriate?

A 69-year-old man with a history of anterior myocardial infarction presents with progressive dyspnea and lower-extremity edema. Blood pressure is 100/65 mmHg, heart rate 96 bpm. Physical examination reveals bibasilar crackles and an S3 gallop. Echocardiography shows LVEF 28%, LV end-diastolic diameter 70 mm, and moderate functional mitral regurgitation. He is receiving maximally tolerated doses of ACE inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and an SGLT2 inhibitor. Which additional intervention is MOST appropriate at this stage?

A 74-year-old woman with chronic atrial fibrillation presents for elective electrical cardioversion. She has been anticoagulated with apixaban for 3 weeks but admits to missing several doses. What is the MOST appropriate next step?

A 62-year-old man presents with syncope. ECG shows complete atrioventricular block with a junctional escape rhythm at 35 bpm. Blood pressure is stable, and he is asymptomatic at rest. What is the MOST appropriate management?

A 54-year-old woman presents with episodic chest pain occurring at rest, often in the early morning hours. Coronary angiography reveals angiographically normal coronary arteries. During acetylcholine provocation, focal coronary spasm is induced with ST elevation. What is the MOST appropriate long-term therapy?

A 48-year-old man with no prior cardiac history presents with acute heart failure following a viral prodrome. Echocardiography shows global hypokinesia with LVEF 25%. Coronary angiography is normal. Cardiac MRI shows subepicardial late gadolinium enhancement in the lateral wall. What is the MOST likely diagnosis?

A patient with long-standing hypertension presents with concentric LV hypertrophy on echocardiography. Global longitudinal strain shows relative apical sparing. Which diagnosis should be MOST strongly suspected?

A 65-year-old man with chronic kidney disease undergoes coronary angiography for NSTEMI. Which strategy MOST effectively reduces the risk of contrast-induced acute kidney injury?

A 71-year-old woman with severe aortic stenosis presents with exertional syncope. Echocardiography shows valve area 0.7 cm², mean gradient 38 mmHg, and LVEF 55%. Which finding would MOST strongly indicate the need for urgent valve intervention?

A patient with mechanical mitral valve replacement presents for routine follow-up. Which INR target is MOST appropriate?

A 60-year-old man presents with acute pericarditis. He has pleuritic chest pain relieved by sitting forward and diffuse ST elevation with PR depression. Which therapy has been shown to REDUCE recurrence?

A 56-year-old woman with pulmonary arterial hypertension undergoes right heart catheterization. Mean pulmonary artery pressure is 32 mmHg, pulmonary capillary wedge pressure 9 mmHg, and pulmonary vascular resistance 5 Wood units. This condition is BEST classified as:

A patient with chronic thromboembolic pulmonary hypertension (CTEPH) is deemed operable. What is the treatment of choice?

A 35-year-old man with repaired tetralogy of Fallot presents with reduced exercise tolerance. Cardiac MRI shows severe pulmonary regurgitation and RV end-diastolic volume index of 170 mL/m². What is the MOST appropriate next step?

A 7-year-old child presents with exertional syncope and a harsh systolic murmur. Echocardiography shows asymmetric septal hypertrophy. What is the MOST likely diagnosis?

A 78-year-old man with multiple comorbidities presents with NSTEMI. He is frail with limited functional reserve. What is the MOST important factor guiding management decisions?

A patient with cardiogenic shock has persistently elevated lactate levels despite normalization of blood pressure. What does this MOST likely indicate?

Which mechanical circulatory support device provides direct left ventricular unloading?

A patient with atrial fibrillation and CHA2DS2-VASc score of 5 is scheduled for elective surgery. What is the MOST appropriate perioperative anticoagulation strategy?

Which lifestyle intervention provides the GREATEST reduction in cardiovascular mortality?

The MOST important goal of advanced cardiovascular care is:

A 68-year-old man with chronic heart failure (LVEF 32%) and left bundle branch block presents with persistent exertional dyspnea (NYHA III) despite optimal guideline-directed medical therapy. ECG shows QRS duration of 168 ms with typical LBBB morphology. Which intervention is MOST likely to improve survival and symptoms?

A 59-year-old woman presents with palpitations and lightheadedness. ECG shows narrow-complex tachycardia at 180 bpm. Vagal maneuvers transiently terminate the arrhythmia. She remains hemodynamically stable. What is the MOST appropriate next step to prevent recurrence?

A 72-year-old man with known coronary artery disease presents with syncope. Telemetry reveals sustained monomorphic ventricular tachycardia at 160 bpm. He is hemodynamically stable after termination. Which strategy is MOST appropriate for secondary prevention of sudden cardiac death?

A 50-year-old man presents with exertional dyspnea. ECG shows right axis deviation and tall R waves in V1. Echocardiography reveals RV dilation and dysfunction. CT pulmonary angiography shows no acute thrombus. Which diagnosis is MOST likely?

A patient with suspected infective endocarditis undergoes transesophageal echocardiography, which reveals a mobile vegetation measuring 12 mm on the anterior mitral leaflet. Which factor MOST strongly supports early surgical intervention?

A 64-year-old man with chronic atrial fibrillation and heart failure has difficulty achieving adequate rate control despite maximally tolerated beta-blockers and digoxin. Which strategy is MOST appropriate to improve symptoms and ventricular function?

A 70-year-old woman with hypertension presents with progressive dyspnea. Echocardiography shows concentric LV hypertrophy, preserved EF, enlarged left atrium, and elevated E/e′ ratio. Which diagnosis BEST explains these findings?

A 55-year-old man presents with chest pain. ECG shows diffuse ST elevation with PR depression. Troponin is mildly elevated. Echocardiography shows no regional wall motion abnormality. Which diagnosis is MOST likely?

A patient with nonischemic dilated cardiomyopathy (LVEF 28%) and no prior arrhythmic events is evaluated for primary prevention. Which criterion supports ICD implantation?

A 62-year-old man presents with acute pulmonary edema and hypertension. Blood pressure is 190/110 mmHg. ECG shows LV hypertrophy. What is the MOST appropriate immediate therapy?

A 58-year-old woman with systemic sclerosis presents with progressive dyspnea. Right heart catheterization shows mPAP 36 mmHg, PCWP 8 mmHg, PVR 6 Wood units. Which pulmonary hypertension classification applies?

A patient with long-standing atrial fibrillation undergoes successful catheter ablation. Sinus rhythm is restored. Which statement regarding anticoagulation is MOST accurate?

A patient with severe symptomatic mitral regurgitation and high surgical risk is referred for transcatheter intervention. Which condition BEST predicts benefit from transcatheter edge-to-edge repair?

A 60-year-old man with diabetes is found to have asymptomatic carotid artery stenosis of 75%. What is the MOST appropriate management?

A patient presents with syncope during exertion. ECG shows prolonged QT interval. Which intervention MOST reduces the risk of sudden cardiac death?

A patient with chronic kidney disease on dialysis develops severe calcific aortic stenosis. Which intervention is MOST appropriate?

A 45-year-old man presents with chest pain after emotional stress. ECG shows ST elevation in precordial leads. Coronary angiography is normal. Echo shows apical ballooning. What is the MOST likely diagnosis?

A patient with persistent atrial flutter undergoes catheter ablation. Which anatomic structure is the typical ablation target?

A patient with severe tricuspid regurgitation presents with ascites and peripheral edema. Which physical finding is MOST characteristic?

Which population-based intervention has produced the LARGEST decline in cardiovascular mortality over the past decades?

A 67-year-old man with long-standing hypertension and diabetes presents with exertional dyspnea and decreased exercise tolerance. Echocardiography reveals concentric LV hypertrophy, preserved LVEF (60%), enlarged left atrium, and elevated E/e′ ratio. BNP is mildly elevated. Which pathophysiologic mechanism MOST strongly explains his symptoms?

A 59-year-old woman presents with sudden onset pleuritic chest pain and dyspnea. CT pulmonary angiography confirms acute pulmonary embolism. Blood pressure is 110/70 mmHg, heart rate 105 bpm. Troponin is mildly elevated, and echocardiography shows RV dilation. How should this pulmonary embolism be BEST classified?

A 72-year-old man with ischemic cardiomyopathy (LVEF 25%) and NYHA class III symptoms is evaluated for advanced therapies. Peak VO2 on cardiopulmonary exercise testing is 10 mL/kg/min despite optimal therapy. What is the MOST appropriate next step?

A 54-year-old woman with systemic lupus erythematosus presents with chest pain and fever. ECG shows diffuse ST elevation. Echocardiography reveals a moderate pericardial effusion without tamponade physiology. What is the MOST appropriate initial therapy?

A 61-year-old man with known coronary artery disease presents with recurrent angina despite optimal medical therapy. Stress PET imaging shows balanced ischemia with globally reduced myocardial blood flow reserve. Which coronary pathology is MOST likely?

A 70-year-old woman undergoes TAVR for severe aortic stenosis. Post-procedure ECG shows new-onset left bundle branch block. Which complication is she at INCREASED risk for?

A 48-year-old man presents with syncope during exercise. ECG shows bidirectional ventricular tachycardia. Genetic testing confirms a RyR2 mutation. Which diagnosis BEST explains this presentation?

A 63-year-old man with atrial fibrillation and prior ischemic stroke is on warfarin with subtherapeutic INR values. He reports difficulty with frequent monitoring. Which anticoagulation strategy is MOST appropriate?

A patient with severe chronic mitral regurgitation remains asymptomatic. Echocardiography shows LVEF 55% and LV end-systolic diameter 42 mm. Which management strategy is MOST appropriate?

A 58-year-old man presents with acute decompensated heart failure and severe hypertension (BP 200/120 mmHg). He is dyspneic with pulmonary edema. Which therapy MOST rapidly improves symptoms?

A 46-year-old woman presents with progressive dyspnea. Echocardiography shows RV hypertrophy and dilation. Right heart catheterization demonstrates mPAP 38 mmHg, PCWP 22 mmHg. Which etiology of pulmonary hypertension is MOST likely?

A patient with nonischemic cardiomyopathy and LVEF 30% has QRS duration of 110 ms. Which device therapy is MOST appropriate?

A 60-year-old man with severe symptomatic tricuspid regurgitation presents with fatigue and edema. He is deemed high surgical risk. Which transcatheter therapy is MOST appropriate?

A patient with suspected cardiac amyloidosis undergoes nuclear scintigraphy with technetium-99m pyrophosphate. Which result MOST strongly supports transthyretin amyloidosis?

A 52-year-old man presents with recurrent syncope. ECG shows alternating bundle branch block. What is the MOST appropriate management?

A patient with acute inferior MI develops hypotension, clear lungs, and elevated JVP. Which additional ECG lead would MOST likely show ST elevation?

A patient with atrial fibrillation undergoes left atrial appendage occlusion. Which patient profile MOST benefits from this strategy?

A 65-year-old man with chronic heart failure presents with worsening renal function after initiation of ACE inhibitor. Which interpretation is MOST appropriate?

A 55-year-old woman presents with acute chest pain. ECG shows ST elevation in leads I, aVL, V5–V6. Which coronary artery is MOST likely occluded?

A patient with advanced heart failure has persistent symptoms despite maximal therapy and expresses concern about quality of life. Which approach is MOST appropriate?

A 64-year-old man with long-standing hypertension presents with exertional chest discomfort. Stress echocardiography demonstrates inducible ischemia in the anterior wall at moderate workload. Resting echocardiography shows concentric LV hypertrophy with preserved EF. Which mechanism MOST likely explains his exertional ischemia?

A 70-year-old woman with permanent atrial fibrillation presents with progressive dyspnea. Echocardiography shows severe tricuspid regurgitation, dilated right atrium, and preserved RV systolic function. Which mechanism MOST likely underlies her tricuspid regurgitation?

A 58-year-old man presents with syncope. ECG shows Brugada type 1 pattern. He has no structural heart disease. Which management strategy is MOST appropriate?

A patient with chronic heart failure (LVEF 30%) is initiated on sacubitril/valsartan. Two weeks later, serum potassium is 5.6 mmol/L. What is the MOST appropriate management?

A 62-year-old man with chest pain has ECG showing ST depression in V1–V3 with tall R waves. Posterior leads demonstrate ST elevation. Which diagnosis is MOST consistent?

A 47-year-old woman presents with episodic palpitations. ECG during symptoms shows narrow-complex tachycardia with short RP interval. Which arrhythmia is MOST likely?

A patient with advanced chronic kidney disease presents with acute coronary syndrome. Coronary angiography is planned. Which strategy MOST reduces contrast exposure?

A 71-year-old man with severe symptomatic aortic stenosis undergoes TAVR. One month later, echocardiography shows paravalvular aortic regurgitation. Which factor MOST strongly predicts worse long-term outcomes?

A patient with suspected infective endocarditis has persistently negative blood cultures. Which organism is MOST likely?

A 60-year-old woman with nonischemic cardiomyopathy presents with worsening dyspnea. Cardiac MRI shows patchy mid-wall late gadolinium enhancement. What does this finding MOST strongly predict?

A 55-year-old man presents with chest pain. ECG shows ST elevation in leads II, III, and aVF with ST depression in V1–V3. Which coronary artery is MOST likely involved?

A patient with pulmonary arterial hypertension is treated with dual oral therapy. He remains intermediate-high risk on follow-up. What is the MOST appropriate next escalation?

A 65-year-old man with ischemic cardiomyopathy and LVEF 28% undergoes successful CRT implantation. Which parameter BEST predicts response to CRT?

A patient with suspected constrictive pericarditis undergoes echocardiography. Which finding MOST supports this diagnosis?

A 52-year-old woman presents with exertional syncope. Echocardiography shows severe hypertrophic obstructive cardiomyopathy. Which maneuver would REDUCE the murmur intensity?

A patient with atrial fibrillation has CHA2DS2-VASc score of 1 (male). Which strategy is MOST appropriate?

A patient with cardiogenic shock is supported with VA-ECMO. Pulmonary edema worsens. Which adjunctive strategy BEST addresses this problem?

A 73-year-old woman presents with NSTEMI. Coronary angiography shows severe multivessel disease and diabetes mellitus. Which revascularization strategy MOST improves long-term survival?

A patient with repaired atrial septal defect presents in adulthood with atrial arrhythmias. Which long-term complication is MOST common?

A patient with advanced cardiovascular disease asks about goals of care. Which principle BEST defines high-quality cardiovascular care?