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ABIM Interventional Cardiology study materials
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ABIM Interventional Cardiology practice questions

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Question 1Coronary Artery Disease and Percutaneous Coronary Intervention

A patient with stable angina and a single de novo lesion in a 3.0 mm native coronary artery is being planned for PCI. Which antiplatelet strategy is standard before and during the procedure in a patient not on chronic oral anticoagulation?

  1. Warfarin plus clopidogrel, with warfarin continued indefinitely
  2. Aspirin plus a P2Y12 inhibitor, with aspirin continued indefinitely Correct answer.
  3. Ticagrelor monotherapy started only after stent deployment
  4. Dual antiplatelet therapy for 4 weeks then aspirin alone regardless of stent type

Explanation

Dual antiplatelet therapy combining aspirin with a P2Y12 inhibitor is the standard periprocedural and post-stent regimen, with aspirin typically continued for life. The P2Y12 inhibitor duration depends on stent type and bleeding risk but is not routinely limited to 4 weeks.

Question 2Coronary Artery Disease and Percutaneous Coronary Intervention

Which coronary lesion characteristic is most strongly associated with an increased risk of periprocedural no-reflow during PCI?

  1. A long, heavily calcified lesion requiring atherectomy
  2. A concentric, non-calcified lesion in a proximal vessel
  3. A large thrombus burden in a saphenous vein graft Correct answer.
  4. A focal 40% stenosis in a distal branch

Explanation

Distal embolization of atherothrombotic debris is the principal mechanism of no-reflow, and lesions with large thrombus burden such as degenerated vein grafts carry the highest risk. Calcification increases complexity but is not the dominant no-reflow predictor.

Question 3Coronary Artery Disease and Percutaneous Coronary Intervention

A patient undergoing elective PCI with a drug-eluting stent has a high bleeding risk (prior GI bleed, anemia). Which DAPT duration strategy is most consistent with current guidance?

  1. Three to six months of DAPT followed by SAPT when bleeding risk is high Correct answer.
  2. Lifelong DAPT to prevent very late stent thrombosis
  3. Discontinuation of all antiplatelet therapy at 1 month
  4. Twelve months of DAPT regardless of bleeding risk

Explanation

In patients at high bleeding risk, shorter DAPT (approximately 3-6 months) followed by single antiplatelet therapy is recommended, balancing ischemic and bleeding risks. Twelve months remains a default for low-bleeding-risk patients but is individualized.

Question 4Coronary Artery Disease and Percutaneous Coronary Intervention

During PCI, which finding on fractional flow reserve (FFR) most reliably identifies a lesion warranting revascularization?

  1. FFR of 0.75 in a vessel supplying a large territory Correct answer.
  2. FFR of 0.85 in a non-culprit vessel
  3. Resting Pd/Pa of 0.94
  4. FFR of 0.92 after adenosine administration

Explanation

An FFR of 0.80 or less identifies hemodynamically significant stenosis, and values around 0.75 in a large-territory vessel clearly justify revascularization. Values above 0.80 are generally deferred to medical therapy.

Question 5Coronary Artery Disease and Percutaneous Coronary Intervention

A patient develops abrupt vessel closure with ST elevation during PCI after balloon inflation. Which is the most appropriate immediate management step?

  1. Withdraw the guidewire and transfer to the floor
  2. Deploy a stent across the occluded segment to restore flow Correct answer.
  3. Give oral beta-blocker and reassess in 30 minutes
  4. Administer intravenous thrombolytics and observe

Explanation

Abrupt closure during PCI is a catheterization-laboratory emergency requiring prompt restoration of flow, typically with stent placement across the occlusion. Intracoronary vasodilators and thrombectomy may be adjuncts depending on mechanism.

Question 6Coronary Artery Disease and Percutaneous Coronary Intervention

Which patient is most likely to benefit from chronic total occlusion (CTO) PCI rather than medical therapy alone?

  1. A patient with severe multivessel disease who is a better candidate for CABG
  2. An asymptomatic patient with a single CTO and no viability in that territory
  3. A patient with refractory angina and documented ischemia in the CTO territory despite optimal medical therapy Correct answer.
  4. A patient with a CTO in a territory already supplied by robust collaterals and no symptoms

Explanation

CTO PCI is most reasonable for patients with limiting symptoms or documented ischemia attributable to the occluded territory despite optimal medical therapy. Absence of viability or symptoms, or a better surgical option, argues against PCI.

Question 7Coronary Artery Disease and Percutaneous Coronary Intervention

Which adjunctive measure most reduces the risk of contrast-induced acute kidney injury in a patient with chronic kidney disease undergoing PCI?

  1. High-dose loop diuretic infusion before contrast
  2. Withholding all intravenous fluids to avoid volume overload
  3. Routine pre-procedure hemodialysis in all patients with CKD
  4. Using the minimum volume of iso-osmolar or low-osmolar contrast with adequate periprocedural hydration Correct answer.

Explanation

The cornerstone of prevention is minimizing contrast volume and maintaining adequate hydration with low- or iso-osmolar contrast. Routine dialysis and diuretics have not been shown to prevent and may worsen kidney injury.

Question 8Coronary Artery Disease and Percutaneous Coronary Intervention

A patient with prior PCI and a drug-eluting stent presents 8 months later with STEMI. Which is the preferred reperfusion strategy if the hospital has a catheterization laboratory available?

  1. Primary PCI of the culprit lesion Correct answer.
  2. Coronary bypass surgery as first-line therapy
  3. Fibrinolysis followed by routine transfer
  4. Elective angiography after 48 hours of medical therapy

Explanation

Primary PCI is the preferred reperfusion strategy for STEMI when available within the appropriate timeframe, offering higher reperfusion success and lower bleeding than fibrinolysis. Fibrinolysis is reserved for settings where timely PCI is not achievable.

Question 9Coronary Artery Disease and Percutaneous Coronary Intervention

Which finding on intravascular ultrasound (IVUS) most strongly predicts stent thrombosis after drug-eluting stent implantation?

  1. Stent edge dissection and incomplete stent apposition Correct answer.
  2. Adequate lesion coverage with a single stent
  3. A stent expansion index of 1.0
  4. A minimum stent area of 5.5 mm² in a large proximal vessel

Explanation

Underexpansion, edge dissection, and incomplete stent apposition are the principal IVUS correlates of stent thrombosis and restenosis. Adequate expansion and full lesion coverage reduce these risks.

Question 10Coronary Artery Disease and Percutaneous Coronary Intervention

In a patient undergoing PCI for a bifurcation lesion, which strategy best preserves the side branch while treating the main vessel?

  1. Balloon angioplasty of the main vessel only
  2. Deferring PCI and treating medically
  3. Provisional side-branch stenting after main-vessel stenting Correct answer.
  4. Routine two-stent strategy for all bifurcations

Explanation

Provisional side-branch stenting, treating the main vessel first and stenting the side branch only if compromised, is the standard approach for most bifurcation lesions. Routine two-stent techniques increase complexity without clear benefit for simple bifurcations.

Question 11Coronary Artery Disease and Percutaneous Coronary Intervention

Which patient characteristic most increases the risk of bleeding with glycoprotein IIb/IIIa inhibitor use during PCI?

  1. Single-vessel disease
  2. Prior aspirin use
  3. Normal renal function and low body weight
  4. Advanced age with chronic kidney disease Correct answer.

Explanation

Advanced age, renal impairment, low body weight, and female sex increase bleeding risk with GP IIb/IIIa inhibitors, and dosing must be adjusted or the agent avoided. Renal dysfunction impairs clearance and prolongs the antiplatelet effect.

Question 12Coronary Artery Disease and Percutaneous Coronary Intervention

Which mechanism best explains the benefit of radial over femoral arterial access for PCI?

  1. Shorter procedural time in all cases
  2. Larger guide catheter compatibility
  3. Fewer access-site bleeding complications Correct answer.
  4. Lower risk of contrast-induced nephropathy

Explanation

Radial access reduces access-site bleeding and vascular complications compared with femoral access. It does not inherently reduce contrast nephropathy or guarantee shorter procedures.

Question 13Coronary Artery Disease and Percutaneous Coronary Intervention

A patient with stable angina has a 70% stenosis in the mid-LAD by angiography. Which additional test best determines whether the stenosis is physiologically significant?

  1. Fractional flow reserve measurement Correct answer.
  2. Transthoracic echocardiography
  3. Resting ECG
  4. Coronary CT angiography

Explanation

FFR directly assesses the hemodynamic significance of an intermediate stenosis under hyperemia and guides revascularization decisions. Anatomic tests such as CT angiography do not establish physiologic significance.

Question 14Coronary Artery Disease and Percutaneous Coronary Intervention

Which complication is most specifically associated with rotational atherectomy of heavily calcified coronary lesions?

  1. Burr entrapment and guidewire fracture Correct answer.
  2. Stent thrombosis at 1 year
  3. Contrast-induced nephropathy
  4. Coronary vasospasm only in the right coronary artery

Explanation

Rotational atherectomy carries unique risks of burr entrapment, guidewire fracture, and dissection, particularly in heavily calcified lesions. These mechanical complications reflect the device's interaction with rigid plaque.

Question 15Coronary Artery Disease and Percutaneous Coronary Intervention

A patient with diabetes and multivessel coronary disease including a proximal LAD lesion is being considered for revascularization. Which factor most favors CABG over multivessel PCI?

  1. Normal left ventricular function
  2. Patient preference for a same-day procedure
  3. Single discrete lesion in the LAD
  4. Presence of diabetes with complex multivessel disease Correct answer.

Explanation

In patients with diabetes and complex multivessel disease, CABG confers a survival advantage over multivessel PCI in randomized trials. Lesion complexity and diabetes are key factors favoring surgery.

Question 16Coronary Artery Disease and Percutaneous Coronary Intervention

Which is the most appropriate antithrombotic approach for a patient on chronic oral anticoagulation for atrial fibrillation who requires PCI?

  1. Warfarin alone without antiplatelet therapy
  2. Shortened triple therapy followed by dual therapy with an anticoagulant plus a P2Y12 inhibitor Correct answer.
  3. Triple therapy indefinitely
  4. Aspirin plus clopidogrel without anticoagulation

Explanation

Patients with atrial fibrillation requiring PCI typically receive a brief period of triple therapy followed by dual therapy with an oral anticoagulant plus a P2Y12 inhibitor, then anticoagulant monotherapy. This balances stroke prevention against bleeding.

Question 17Coronary Artery Disease and Percutaneous Coronary Intervention

Which statement about stent thrombosis is most accurate?

  1. It is more common with bare-metal than drug-eluting stents at all time points
  2. It is prevented by discontinuing antiplatelet therapy early
  3. It occurs only within the first 24 hours after implantation
  4. It presents most often as acute myocardial infarction and requires emergent angiography Correct answer.

Explanation

Stent thrombosis typically presents as STEMI or sudden cardiac death and mandates emergent angiography and revascularization. It can occur acutely, subacutely, late, or very late, and early antiplatelet discontinuation increases risk.

Question 18Coronary Artery Disease and Percutaneous Coronary Intervention

Which finding on coronary angiography is most consistent with a hemodynamically significant left main stenosis?

  1. A 20% stenosis with TIMI 3 flow
  2. A 50% stenosis with an FFR of 0.75 Correct answer.
  3. A 40% stenosis with an iFR of 0.95
  4. A 30% stenosis with normal FFR

Explanation

A left main lesion with an FFR of 0.75 indicates hemodynamic significance and generally warrants revascularization, usually with CABG. FFR values above 0.80 or non-hyperemic indices above threshold suggest non-significant disease.

Question 19Coronary Artery Disease and Percutaneous Coronary Intervention

Which patient is at highest risk for contrast-induced acute kidney injury after PCI?

  1. A patient with eGFR 60 and hypertension
  2. A patient with normal renal function and prior MI
  3. A patient with eGFR 30 and diabetes Correct answer.
  4. A patient with eGFR 80 and no diabetes

Explanation

Reduced baseline eGFR, particularly below 30, combined with diabetes substantially increases the risk of contrast-associated acute kidney injury. Normal or mildly reduced renal function carries lower risk.

Question 20Coronary Artery Disease and Percutaneous Coronary Intervention

Which statement best describes the role of the instantaneous wave-free ratio (iFR) compared with FFR?

  1. iFR is measured at rest without hyperemia and uses a threshold of about 0.89 Correct answer.
  2. iFR is equivalent to angiography for assessing lesion severity
  3. iFR requires adenosine hyperemia and has a threshold of 0.80
  4. iFR cannot be used to assess intermediate lesions

Explanation

iFR is a non-hyperemic pressure ratio measured during the wave-free period of diastole, with a threshold of about 0.89. It avoids the need for adenosine and correlates well with FFR.

Question 21Coronary Artery Disease and Percutaneous Coronary Intervention

A patient develops hypotension and bradycardia with inferior STEMI and is found to have an occluded right coronary artery. Which intervention is most appropriate?

  1. Medical therapy alone
  2. Emergent primary PCI of the right coronary artery Correct answer.
  3. Fibrinolysis followed by observation
  4. Elective PCI after 72 hours

Explanation

Inferior STEMI with hemodynamic compromise from an occluded RCA warrants emergent primary PCI to restore flow. Right ventricular involvement may also require fluid support.

Question 22Coronary Artery Disease and Percutaneous Coronary Intervention

Which factor most increases the risk of coronary perforation during PCI?

  1. Use of radial access
  2. Use of a low-profile balloon
  3. Use of a hydrophilic guidewire with aggressive wiring of a tortuous, calcified vessel Correct answer.
  4. Use of a drug-eluting stent

Explanation

Coronary perforation most often results from guidewire injury, particularly with hydrophilic wires in tortuous or calcified vessels, or from aggressive balloon/stent oversizing. Device selection and technique are key modifiable factors.

Question 23Coronary Artery Disease and Percutaneous Coronary Intervention

A patient with a calcified lesion has inadequate stent expansion after high-pressure balloon inflation. Which adjunctive strategy is most appropriate?

  1. Deploy a second stent at low pressure
  2. Withdraw and refer for medical therapy
  3. Accept the result and complete the procedure
  4. Use intravascular lithotripsy or rotational atherectomy to modify calcium before further dilation Correct answer.

Explanation

When calcium prevents adequate stent expansion, plaque modification with intravascular lithotripsy or atherectomy followed by high-pressure dilation improves expansion. Accepting underexpansion increases restenosis and thrombosis risk.

Question 24Coronary Artery Disease and Percutaneous Coronary Intervention

Which is the most appropriate management of a patient with stable angina and a single 60% stenosis in a non-proximal vessel with FFR of 0.88?

  1. CABG
  2. Emergent angiography
  3. PCI of the lesion
  4. Guideline-directed medical therapy without PCI Correct answer.

Explanation

An FFR above 0.80 indicates a non-hemodynamically significant lesion, so PCI is not indicated and medical therapy is appropriate. Revascularization is reserved for physiologically significant lesions or refractory symptoms.

Question 25Coronary Artery Disease and Percutaneous Coronary Intervention

Which patient is most appropriate for same-day discharge after uncomplicated elective PCI?

  1. A patient with stable angina, radial access, no complications, and adequate home support Correct answer.
  2. A patient with a large hematoma and ongoing bleeding
  3. A patient with STEMI and cardiogenic shock
  4. A patient with severe contrast-associated AKI

Explanation

Same-day discharge is reasonable after uncomplicated elective PCI in stable patients with radial access, no access-site complications, and adequate social support. Complications such as bleeding, shock, or AKI require observation.

Question 26Coronary Artery Disease and Percutaneous Coronary Intervention

A 62-year-old man with stable angina undergoes coronary angiography, which shows a 60% stenosis in the mid-left circumflex artery. He has no symptoms at rest and his angina is well controlled with medical therapy. What is the most appropriate next step in management?

  1. Proceed with percutaneous coronary intervention of the lesion
  2. Refer for coronary artery bypass grafting
  3. Perform fractional flow reserve to assess lesion significance
  4. Continue optimal medical therapy and reassess symptoms Correct answer.

Explanation

For stable angina, revascularization is generally reserved for lesions that are hemodynamically significant (e.g., FFR ≤0.80) or for patients with refractory symptoms despite medical therapy. A 60% stenosis in a non-proximal vessel is unlikely to be flow-limiting, and the patient is well controlled on medical therapy. Therefore, continuing optimal medical therapy is appropriate.

Question 27Coronary Artery Disease and Percutaneous Coronary Intervention

A 70-year-old woman with a history of PCI with a drug-eluting stent 2 years ago presents with an acute STEMI. Coronary angiography reveals a thrombotic occlusion of the previously stented segment. What is the most likely mechanism of stent thrombosis in this patient?

  1. Stent malapposition
  2. Neoatherosclerosis Correct answer.
  3. Stent fracture
  4. Hypersensitivity reaction

Explanation

Very late stent thrombosis (>1 year) is often due to neoatherosclerosis, which is the development of new atherosclerotic plaque within the stented segment. This can rupture and cause thrombosis. Stent malapposition and fracture are more typically associated with early or late stent thrombosis, and hypersensitivity is rare.

Question 28Coronary Artery Disease and Percutaneous Coronary Intervention

A 65-year-old man with chronic kidney disease (baseline creatinine 1.8 mg/dL) is scheduled for elective PCI. He is not currently on dialysis. Which of the following is the most effective strategy to reduce the risk of contrast-induced acute kidney injury?

  1. Adequate hydration with isotonic saline Correct answer.
  2. Intravenous sodium bicarbonate infusion
  3. Oral N-acetylcysteine
  4. Use of low-osmolar contrast media

Explanation

Adequate hydration with isotonic saline is the cornerstone of prevention for contrast-induced acute kidney injury. While low-osmolar contrast may reduce risk compared to high-osmolar, hydration is the most established and effective measure. Sodium bicarbonate and N-acetylcysteine have not consistently shown benefit.

Question 29Coronary Artery Disease and Percutaneous Coronary Intervention

A 58-year-old woman with stable angina undergoes PCI of the left anterior descending artery with a drug-eluting stent. During the procedure, the operator notes that the stent is under-expanded despite high-pressure balloon inflation. Which adjunctive tool is most appropriate to optimize stent expansion?

  1. Optical coherence tomography (OCT)
  2. Coronary computed tomography angiography (CCTA)
  3. Intravascular ultrasound (IVUS) Correct answer.
  4. Fractional flow reserve (FFR)

Explanation

IVUS is commonly used to assess stent expansion and guide post-dilation. It provides real-time cross-sectional imaging to identify under-expansion, malapposition, and edge dissections. OCT can also be used but IVUS is more widely available and often preferred for stent optimization.

Question 30Coronary Artery Disease and Percutaneous Coronary Intervention

A 75-year-old man with severe aortic stenosis and a history of coronary artery disease presents with angina. He is considered for transcatheter aortic valve replacement (TAVR). Which of the following is the most appropriate management of his coronary artery disease before TAVR?

  1. Perform PCI of any stenosis ≥70%
  2. Refer for surgical aortic valve replacement and CABG
  3. Proceed with TAVR without coronary revascularization
  4. Perform PCI only if the stenosis is flow-limiting by FFR Correct answer.

Explanation

In patients undergoing TAVR, the decision to revascularize should be based on the hemodynamic significance of coronary lesions. FFR can be used to assess lesion significance, and PCI is generally reserved for flow-limiting stenoses. Routine revascularization of all angiographic stenoses is not recommended.

Question 31Coronary Artery Disease and Percutaneous Coronary Intervention

A 60-year-old woman with a history of PCI to the right coronary artery presents with recurrent angina. Coronary angiography shows a 90% in-stent restenosis. Which of the following is the most appropriate treatment?

  1. Balloon angioplasty alone
  2. Implantation of a drug-eluting stent Correct answer.
  3. Implantation of a bare-metal stent
  4. Referral for coronary artery bypass grafting

Explanation

For in-stent restenosis, drug-eluting stent implantation is superior to balloon angioplasty or bare-metal stenting in reducing recurrent restenosis. CABG is generally reserved for multivessel disease or complex anatomy not amenable to PCI.

Question 32Coronary Artery Disease and Percutaneous Coronary Intervention

A 68-year-old man with diabetes and multivessel coronary disease is being evaluated for revascularization. He has a SYNTAX score of 25 and is a suitable candidate for both PCI and CABG. Which of the following factors most strongly favors CABG over PCI in this patient?

  1. Age over 65
  2. Presence of diabetes Correct answer.
  3. Left ventricular ejection fraction of 50%
  4. SYNTAX score of 25

Explanation

In patients with diabetes and multivessel disease, CABG has been shown to improve survival compared to PCI, particularly when the internal mammary artery is used to graft the LAD. A SYNTAX score of 25 indicates intermediate complexity, where the choice is less clear, but diabetes remains a strong factor favoring CABG.

Question 33Coronary Artery Disease and Percutaneous Coronary Intervention

A 55-year-old man undergoes PCI of the left anterior descending artery. During the procedure, the patient develops severe chest pain and hypotension. Angiography reveals a perforation of the vessel with contrast extravasation. Which of the following is the most appropriate initial management?

  1. Immediate pericardiocentesis
  2. Prolonged balloon inflation at the site of perforation Correct answer.
  3. Refer for emergency coronary artery bypass grafting
  4. Administer intravenous fluids and vasopressors

Explanation

The initial management of coronary perforation is to control the leak by inflating a balloon at the site of perforation to tamponade the vessel. This should be done immediately while preparing for further interventions such as covered stent placement or surgery. Fluid resuscitation and pericardiocentesis are supportive measures but do not treat the underlying perforation.

Question 34Coronary Artery Disease and Percutaneous Coronary Intervention

A 72-year-old woman with severe calcific aortic stenosis and a history of coronary artery disease is scheduled for TAVR. She has a 70% stenosis in the proximal left anterior descending artery that is not flow-limiting by FFR. What is the most appropriate management of this coronary lesion?

  1. Refer for surgical aortic valve replacement and CABG
  2. Defer revascularization and proceed with TAVR Correct answer.
  3. Perform PCI with a drug-eluting stent
  4. Perform balloon angioplasty alone

Explanation

Coronary revascularization in patients undergoing TAVR should be guided by physiological assessment. If the lesion is not flow-limiting by FFR, revascularization can be deferred. Proceeding with TAVR is appropriate.

Question 35Coronary Artery Disease and Percutaneous Coronary Intervention

A 60-year-old man with stable angina undergoes coronary angiography, which shows a 70% stenosis in the mid-right coronary artery. FFR of the lesion is 0.85. What is the most appropriate management?

  1. Proceed with PCI of the lesion
  2. Refer for CABG
  3. Repeat FFR after nitroglycerin administration
  4. Continue medical therapy Correct answer.

Explanation

An FFR value greater than 0.80 indicates that the stenosis is not hemodynamically significant. In such cases, medical therapy is preferred over revascularization. PCI would be indicated if FFR were ≤0.80.

Question 36Coronary Artery Disease and Percutaneous Coronary Intervention

A 65-year-old woman with a history of PCI to the left circumflex artery presents with recurrent angina 6 months later. Angiography shows a 90% in-stent restenosis. Which of the following is the most appropriate treatment?

  1. Implantation of a drug-eluting stent Correct answer.
  2. Implantation of a bare-metal stent
  3. Referral for coronary artery bypass grafting
  4. Balloon angioplasty alone

Explanation

For in-stent restenosis, drug-eluting stent implantation is superior to balloon angioplasty or bare-metal stenting in reducing recurrent restenosis. CABG is generally reserved for multivessel disease or complex anatomy not amenable to PCI.

Question 37Coronary Artery Disease and Percutaneous Coronary Intervention

A 70-year-old man with a history of PCI to the left anterior descending artery 1 year ago presents with STEMI. Angiography shows stent thrombosis. Which of the following is the most likely contributing factor?

  1. Stent fracture
  2. Stent malapposition
  3. Premature discontinuation of dual antiplatelet therapy Correct answer.
  4. Neoatherosclerosis

Explanation

Premature discontinuation of dual antiplatelet therapy is a major risk factor for stent thrombosis, especially within the first year after stent implantation. Malapposition and fracture are also causes but are less common than premature DAPT cessation in this timeframe.

Question 38Coronary Artery Disease and Percutaneous Coronary Intervention

A 55-year-old man with stable angina undergoes PCI of the left anterior descending artery with a drug-eluting stent. During the procedure, the operator notes that the stent is under-expanded despite high-pressure balloon inflation. Which adjunctive tool is most appropriate to optimize stent expansion?

  1. Optical coherence tomography (OCT)
  2. Fractional flow reserve (FFR)
  3. Intravascular ultrasound (IVUS) Correct answer.
  4. Coronary computed tomography angiography (CCTA)

Explanation

IVUS is commonly used to assess stent expansion and guide post-dilation. It provides real-time cross-sectional imaging to identify under-expansion, malapposition, and edge dissections. OCT can also be used but IVUS is more widely available and often preferred for stent optimization.

Question 39Coronary Artery Disease and Percutaneous Coronary Intervention

A 68-year-old woman with severe aortic stenosis and a history of coronary artery disease is scheduled for TAVR. She has a 80% stenosis in the mid-left anterior descending artery that is flow-limiting by FFR. What is the most appropriate management?

  1. Proceed with TAVR without revascularization
  2. Refer for surgical aortic valve replacement and CABG
  3. Perform balloon angioplasty alone
  4. Perform PCI with a drug-eluting stent before TAVR Correct answer.

Explanation

In patients undergoing TAVR, revascularization is recommended for flow-limiting coronary lesions (FFR ≤0.80) to improve outcomes. PCI with a drug-eluting stent is appropriate before TAVR.

Question 40Coronary Artery Disease and Percutaneous Coronary Intervention

A 60-year-old man with stable angina undergoes coronary angiography, which shows a 70% stenosis in the mid-right coronary artery. FFR of the lesion is 0.75. What is the most appropriate management?

  1. Proceed with PCI of the lesion Correct answer.
  2. Continue medical therapy
  3. Repeat FFR after nitroglycerin administration
  4. Refer for CABG

Explanation

An FFR value ≤0.80 indicates that the stenosis is hemodynamically significant. In such cases, revascularization with PCI is indicated to improve symptoms and outcomes. Medical therapy alone would be insufficient.

Question 41Coronary Artery Disease and Percutaneous Coronary Intervention

A 75-year-old man with severe aortic stenosis and a history of coronary artery disease presents with angina. He is considered for TAVR. Which of the following is the most appropriate management of his coronary artery disease before TAVR?

  1. Refer for surgical aortic valve replacement and CABG
  2. Perform PCI only if the stenosis is flow-limiting by FFR Correct answer.
  3. Perform PCI of any stenosis ≥70%
  4. Proceed with TAVR without coronary revascularization

Explanation

In patients undergoing TAVR, the decision to revascularize should be based on the hemodynamic significance of coronary lesions. FFR can be used to assess lesion significance, and PCI is generally reserved for flow-limiting stenoses. Routine revascularization of all angiographic stenoses is not recommended.

Question 42Coronary Artery Disease and Percutaneous Coronary Intervention

Which coronary lesion characteristic is best assessed by fractional flow reserve (FFR) rather than by visual estimation alone?

  1. Stenosis with angiographic thrombus
  2. Intermediate stenosis of 40% to 70% severity Correct answer.
  3. Aneurysmal segment with slow flow
  4. Total occlusion with TIMI 0 flow

Explanation

FFR is used to determine the hemodynamic significance of intermediate coronary stenoses, where angiography alone correlates poorly with ischemia. Lesions with obvious severe flow limitation or angiographic thrombus are not appropriate targets for physiologic assessment.

Question 43Coronary Artery Disease and Percutaneous Coronary Intervention

A patient undergoes PCI with a drug-eluting stent. Which antithrombotic strategy reflects standard dual antiplatelet therapy after elective PCI?

  1. A P2Y12 inhibitor alone lifelong
  2. Warfarin plus aspirin indefinitely
  3. Aspirin plus a P2Y12 inhibitor for a defined duration Correct answer.
  4. Aspirin plus a direct oral anticoagulant

Explanation

Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is the standard after stent placement to prevent stent thrombosis. The duration is individualized based on bleeding and ischemic risk.

Question 44Coronary Artery Disease and Percutaneous Coronary Intervention

Which finding on coronary angiography is most consistent with a vulnerable, thin-cap fibroatheroma plaque?

  1. A smooth eccentric plaque with a thick fibrous cap
  2. A large necrotic core with a thin fibrous cap on intravascular imaging Correct answer.
  3. A heavily calcified nodule with minimal lipid
  4. A focal spasm provoked by ergonovine

Explanation

Thin-cap fibroatheroma is characterized by a large lipid-rich necrotic core covered by a thin fibrous cap, predisposing to rupture. Intravascular imaging such as OCT or IVUS identifies these features.

Question 45Coronary Artery Disease and Percutaneous Coronary Intervention

Which periprocedural medication has been shown to reduce the risk of contrast-induced acute kidney injury in patients undergoing PCI?

  1. Intravenous furosemide
  2. Oral mannitol
  3. High-dose dopamine infusion
  4. Intravenous isotonic saline hydration Correct answer.

Explanation

Isotonic saline hydration is the cornerstone of prevention of contrast-induced acute kidney injury. Other agents such as furosemide, mannitol, or dopamine have not demonstrated consistent benefit and may cause harm.

Question 46Coronary Artery Disease and Percutaneous Coronary Intervention

Which coronary artery is most commonly involved in supplying the atrioventricular node?

  1. Right coronary artery Correct answer.
  2. Left main coronary artery
  3. Left circumflex artery
  4. Left anterior descending artery

Explanation

In most individuals the atrioventricular node is supplied by a branch of the right coronary artery, usually the posterior descending artery. This explains the association of inferior myocardial infarction with heart block.

Question 47Coronary Artery Disease and Percutaneous Coronary Intervention

Which lesion characteristic makes PCI technically more challenging and increases the risk of stent underexpansion?

  1. Eccentric noncalcified plaque
  2. A focal lesion in a large vessel
  3. Severe superficial calcification Correct answer.
  4. A bifurcation with a small side branch

Explanation

Severe superficial calcification resists balloon expansion and predisposes to stent underexpansion and malapposition. Adjunctive techniques such as atherectomy or intravascular lithotripsy may be required.

Question 48Coronary Artery Disease and Percutaneous Coronary Intervention

A patient with stable angina is found to have a 65% stenosis in the mid-LAD. FFR is measured at 0.78. What is the most appropriate next step?

  1. Repeat FFR after intracoronary nitroglycerin
  2. Defer revascularization and continue medical therapy
  3. Refer for coronary artery bypass grafting
  4. Proceed with PCI of the LAD lesion Correct answer.

Explanation

An FFR of 0.80 or less indicates hemodynamically significant stenosis and identifies a lesion likely to benefit from revascularization. PCI of the LAD is appropriate in this setting.

Question 49Coronary Artery Disease and Percutaneous Coronary Intervention

A patient develops abrupt closure of the treated vessel immediately after stent deployment, with angiographic evidence of a large intraluminal filling defect. What is the most appropriate initial management?

  1. Administration of intravenous beta-blocker
  2. Balloon angioplasty of a remote vessel
  3. Intracoronary or intravenous glycoprotein IIb/IIIa inhibitor and aspiration thrombectomy Correct answer.
  4. Immediate discharge with oral anticoagulation

Explanation

Acute stent thrombosis presents with abrupt vessel closure and thrombus and is managed with antiplatelet and antithrombotic therapy plus thrombus removal, often with aspiration and glycoprotein IIb/IIIa inhibitors. Restoring flow promptly is critical.

Question 50Coronary Artery Disease and Percutaneous Coronary Intervention

A patient with diabetes and a long diffusely diseased LAD lesion is being planned for PCI. Which stent characteristic is most important in this setting?

  1. A drug-eluting stent with a thin strut and proven efficacy in long lesions Correct answer.
  2. A bare-metal stent to shorten dual antiplatelet duration
  3. A self-expanding stent designed for the venous system
  4. A bioabsorbable polymer stent with no antiproliferative drug

Explanation

Drug-eluting stents reduce restenosis compared with bare-metal stents, particularly in long lesions and in patients with diabetes. Thin-strut platforms with proven long-lesion performance are preferred.