USMLE Step 3 Quiz: Chronic Coronary Disease Management

What this quiz covers

This quiz focuses on Chronic Coronary Disease Management, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 3.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

Question 1

1. Prinzmetal angina
2. Esophageal spasm
3. Anxiety-related chest pain
4. Coronary microvascular dysfunction (correct answer)

Explanation: When you encounter a patient with chest pain and positive stress testing but non-obstructive coronary disease, think beyond the major epicardial vessels. This scenario points to dysfunction at the microvascular level. Coronary microvascular dysfunction (CMD) is the correct diagnosis here. This patient demonstrates the classic triad: anginal symptoms with exertional triggers, objective evidence of ischemia (positive stress test with ST depression), and angiographically normal or near-normal coronary arteries. The 30-40% stenoses are hemodynamically insignificant and cannot explain her symptoms. CMD affects the small resistance vessels (<500 micrometers) that regulate coronary flow but aren't visible on angiography. Women are disproportionately affected, and symptoms often persist despite standard anti-anginal therapy. Option A, Prinzmetal angina, involves coronary vasospasm but typically occurs at rest, not with exertion, and would show transient ST elevation rather than depression. Option B, esophageal spasm, wouldn't produce the characteristic lateral lead ST changes or positive exercise stress test findings. Option C, anxiety-related chest pain, is a diagnosis of exclusion that doesn't explain the objective ischemic changes on stress testing. The key study tip for USMLE Step 3: When you see exertional chest pain with positive stress testing but normal coronaries, especially in middle-aged women, strongly consider microvascular dysfunction. This represents an important cause of "chest pain with normal coronaries" and requires different management approaches than typical coronary artery disease.

Question 2

1. Increase metoprolol succinate dose to 200 mg daily. (correct answer)
2. Add amlodipine 5 mg daily.
3. Schedule a coronary angiogram.
4. Add ranolazine 500 mg twice daily.

Explanation: This patient has stable coronary artery disease and is experiencing an increase in anginal symptoms despite being on guideline-directed medical therapy (GDMT). The first-line treatment for angina is beta-blockers. Before adding a second agent or proceeding to invasive testing, the initial therapy should be optimized. The maximum recommended dose for metoprolol succinate is 400 mg daily, so his current dose of 100 mg can be safely increased. Titrating the beta-blocker to the maximally tolerated dose to control heart rate and symptoms is the most appropriate next step.

Question 3

1. Continue aspirin and clopidogrel; add warfarin.
2. Discontinue clopidogrel; continue aspirin and add apixaban. (correct answer)
3. Discontinue aspirin and clopidogrel; initiate rivaroxaban.
4. Discontinue aspirin; continue clopidogrel and add dabigatran.

Explanation: This patient requires anticoagulation for atrial fibrillation (CHA₂DS₂-VASc score of 6) and is >12 months post-PCI with drug-eluting stent. Current guidelines recommend dual therapy with oral anticoagulation plus single antiplatelet therapy rather than triple therapy to reduce bleeding risk while maintaining ischemic protection. Aspirin is preferred over clopidogrel for the single antiplatelet agent in this setting. Triple therapy (option A) significantly increases bleeding risk and is not recommended for long-term use. Anticoagulation monotherapy (option C) may be considered but combination therapy is more commonly recommended. Option D uses a less optimal antiplatelet choice.

Question 4

1. Schedule an annual exercise stress echocardiogram.
2. Perform a coronary computed tomography angiography (CCTA) to assess graft patency.
3. Continue current medical management with no routine surveillance testing. (correct answer)
4. Obtain a radionuclide myocardial perfusion imaging study.

Explanation: Current guidelines do not recommend routine surveillance stress testing or anatomic imaging for asymptomatic patients with known stable CAD, including those post-revascularization (PCI or CABG). Such testing is not shown to improve outcomes and can lead to unnecessary downstream procedures and costs. Testing is reserved for patients who develop new or worsening symptoms. Since this patient is asymptomatic with a good functional capacity and her risk factors are well-managed, the most appropriate approach is to continue optimal medical therapy and clinical follow-up without further cardiac imaging.

Question 5

1. Initiate ezetimibe 10 mg daily. (correct answer)
2. Prescribe fenofibrate 145 mg daily.
3. Advise a trial of low-dose rosuvastatin 5 mg daily.
4. Start niacin extended-release 500 mg at bedtime.

Explanation: This patient has statin intolerance and an LDL level above the goal of <70 mg/dL (and often <55 mg/dL in very high-risk patients like this one). While trying a different statin at a low dose (C) is a reasonable strategy for statin-associated muscle symptoms, the patient is currently unwilling to do so. Therefore, the next best step is to add a non-statin agent. Ezetimibe is the first-line non-statin agent recommended by guidelines to lower LDL cholesterol. Fenofibrate (B) primarily targets triglycerides and has limited LDL-lowering effects and no proven mortality benefit in this setting. Niacin (D) is no longer recommended for routine use due to side effects and lack of proven benefit on cardiovascular outcomes when added to a statin.

Question 6

1. Add amlodipine 5 mg daily.
2. Add ranolazine 500 mg twice daily.
3. Increase isosorbide mononitrate to 120 mg daily.
4. Proceed with coronary angiography. (correct answer)

Explanation: This patient has lifestyle-limiting angina despite being on maximal or near-maximal doses of two antianginal agents (beta-blocker and long-acting nitrate). His heart rate and blood pressure are at the lower limits of normal, limiting further dose titration of beta-blockers or nitrates, and making the addition of a calcium channel blocker (amlodipine) problematic due to potential hypotension. While adding ranolazine (B) is an option for medical therapy, the severity of his symptoms despite an aggressive medical regimen makes him a candidate for revascularization. Therefore, the most appropriate next step is to proceed with coronary angiography to define his coronary anatomy and assess options for percutaneous coronary intervention or coronary artery bypass grafting.

Question 7

1. Continue both aspirin and ticagrelor through surgery.
2. Hold both aspirin and ticagrelor for 5 days before surgery.
3. Hold ticagrelor 3-5 days before surgery, but continue aspirin. (correct answer)
4. Hold aspirin, continue ticagrelor, and bridge with an intravenous GPIIb/IIIa inhibitor.

Explanation: This patient requires urgent surgery less than one month after receiving a drug-eluting stent (DES), placing him at very high risk for stent thrombosis if antiplatelet therapy is interrupted. The ideal scenario is to postpone elective surgery for at least 6 months. However, this surgery is urgent. The current consensus for managing dual antiplatelet therapy (DAPT) in this high-risk situation is to continue aspirin throughout the perioperative period to provide some protection against stent thrombosis, while holding the P2Y12 inhibitor (ticagrelor) for a short period (3-5 days) to reduce surgical bleeding risk. Continuing both (A) poses a very high bleeding risk. Holding both (B) poses an unacceptably high risk of stent thrombosis. Bridging therapy (D) is complex, expensive, and its efficacy in this setting is not well established; holding aspirin is also incorrect.

Question 8

1. Lisinopril
2. Amlodipine (correct answer)
3. Ranolazine
4. Hydrochlorothiazide

Explanation: This patient needs additional therapy for both hypertension and angina. Amlodipine, a dihydropyridine calcium channel blocker, is an effective antihypertensive and antianginal agent. It is safe in chronic kidney disease and would be a good choice. Lisinopril (A) is an excellent antihypertensive and is indicated in CKD, but it has minimal antianginal effects. Ranolazine (C) is an antianginal but has little effect on blood pressure and requires dose adjustment in severe CKD. Hydrochlorothiazide (D) is ineffective as an antihypertensive when eGFR is <30 mL/min/1.73 m² and has no antianginal properties. Amlodipine addresses both of the patient's clinical needs appropriately.

Question 9

1. Initiation of ranolazine.
2. Referral for enhanced external counterpulsation (EECP). (correct answer)
3. Addition of a short-acting nitrate patch.
4. Enrollment in a cardiac rehabilitation program.

Explanation: This patient has refractory angina, defined as persistent symptoms despite optimal medical and revascularization therapies. He is already on three agents, and his hemodynamics limit further titration or additions of traditional drugs (e.g., ranolazine is an option, but another may be better). Enhanced external counterpulsation (EECP) is a non-invasive therapy indicated for patients with refractory angina who are not candidates for revascularization. It has been shown to improve anginal symptoms and quality of life. Adding another nitrate (C) is unlikely to help given he is on a long-acting one and is borderline hypotensive. Cardiac rehabilitation (D) is beneficial but may be difficult for a patient with class III angina to participate in fully; EECP directly targets the pathophysiology of his refractory symptoms.

Question 10

1. Spironolactone
2. High-dose beta-blocker (correct answer)
3. Isosorbide mononitrate
4. Eplerenone

Explanation: Beta-blockers are a cornerstone of post-MI care. They have been shown to reduce mortality, reinfarction, and sudden cardiac death. They should be initiated in all patients post-MI unless contraindicated. The benefit is most established in patients with reduced ejection fraction, but they are still recommended for at least three years in patients with preserved EF. Aldosterone antagonists like spironolactone (A) and eplerenone (D) are indicated post-MI only in patients with an LVEF ≤40% and either heart failure symptoms or diabetes. Long-acting nitrates (C) are used for symptom control of angina and do not provide a mortality benefit.

Question 11

1. Metoprolol tartrate
2. Propranolol
3. Ranolazine (correct answer)
4. Isosorbide dinitrate

Explanation: This patient requires an additional antianginal agent. While beta-blockers are first-line, her history of asthma makes them relatively contraindicated, especially non-selective agents like propranolol (B). Even cardioselective beta-blockers like metoprolol (A) can potentially cause bronchospasm and should be used with caution. Nitrates (D) are an option, but ranolazine (C) is an excellent choice here. It reduces anginal frequency without affecting heart rate or blood pressure, making it a safe option in this patient who has a normal heart rate and blood pressure. It also has no adverse effects on bronchospasm or PAD symptoms.

Question 12

1. Discontinue him from the cardiac rehabilitation program.
2. Initiate an oral beta-blocker and continue with rehabilitation. (correct answer)
3. Admit the patient to the hospital for electrophysiology study.
4. Prescribe amiodarone for arrhythmia suppression.

Explanation: This patient has a reduced ejection fraction post-MI and is not on a beta-blocker, which is a key component of guideline-directed medical therapy for mortality reduction and arrhythmia prevention. Asymptomatic NSVT in this setting is common and, while it is a marker of increased risk, the first step is to ensure the patient is on optimal medical therapy. Initiating a beta-blocker (e.g., carvedilol, metoprolol succinate) is the most appropriate next step. Discontinuing rehab (A) is premature. Immediate admission for an EP study (C) is not warranted for asymptomatic NSVT without optimizing medical therapy first. Amiodarone (D) is reserved for symptomatic or sustained arrhythmias and does not have a mortality benefit for primary prevention in this setting.

Question 13

1. Angiotensin receptor blocker (ARB)
2. Digoxin
3. Loop diuretic
4. Sodium-glucose cotransporter-2 (SGLT2) inhibitor (correct answer)

Explanation: Heart failure with reduced ejection fraction (HFrEF) management follows evidence-based guidelines that prioritize medications with proven mortality benefits. This patient has optimal guideline-directed medical therapy with an ACE inhibitor, beta-blocker, and mineralocorticoid receptor antagonist, plus she has diabetes—a key detail for considering newer therapeutic options. SGLT2 inhibitors represent a breakthrough in HFrEF treatment. Large randomized trials (DAPA-HF, EMPEROR-Reduced) demonstrated that drugs like dapagliflozin and empagliflozin reduce cardiovascular death and heart failure hospitalizations in patients with HFrEF, regardless of diabetes status. The mechanism involves improved cardiac metabolism, reduced preload, and potential direct cardioprotective effects beyond glucose lowering. Option A (ARB) would typically only be considered if the patient couldn't tolerate an ACE inhibitor, as adding both provides no additional mortality benefit and increases hyperkalemia risk. Option B (digoxin) can improve symptoms and reduce hospitalizations but doesn't reduce mortality—the RADIANCE and DIG trials showed no survival benefit. Option C (loop diuretic) treats volume overload symptoms but has no mortality benefit; this patient shows no signs of fluid retention requiring diuretic therapy. For USMLE Step 3, remember that heart failure questions increasingly test knowledge of newer evidence-based therapies. When you see a diabetic patient with optimized HFrEF therapy, think SGLT2 inhibitors—they're now Class I recommendations in heart failure guidelines. Focus on which medications actually improve survival, not just symptoms.

Question 14

1. Reassure her that her LDL level is at goal.
2. Add ezetimibe to her current regimen. (correct answer)
3. Switch from atorvastatin to rosuvastatin.
4. Add fenofibrate for additional risk reduction.

Explanation: This patient has atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes, placing her in the very high-risk category. For such patients, the LDL cholesterol goal is <70 mg/dL, and some guidelines suggest a goal of <55 mg/dL. Her LDL is 75 mg/dL on a maximally tolerated high-intensity statin. Therefore, her LDL is not at goal (A). The next step according to guidelines is to add a non-statin agent. Ezetimibe is the recommended first-choice add-on therapy. Switching to an equivalent or more potent statin (C) is unlikely to provide significant additional LDL reduction as she is already on a high-intensity dose. Fenofibrate (D) is not indicated for LDL lowering and has not been shown to reduce cardiovascular events when added to a statin in this population.

Question 15

1. Discontinue metoprolol and start diltiazem. (correct answer)
2. Decrease metoprolol tartrate to 25 mg twice daily.
3. Switch from metoprolol to carvedilol.
4. Advise the patient to take sildenafil as needed.

Explanation: The patient is experiencing common side effects of a beta-blocker (fatigue, erectile dysfunction), likely exacerbated by the negative chronotropic effect (HR 54/min). While decreasing the dose (B) might help, it could reduce the antianginal benefit. Switching to another beta-blocker like carvedilol (C) is unlikely to resolve these class-specific side effects. Prescribing sildenafil (D) addresses one symptom but not the fatigue or bradycardia, and it does not address the root cause. The most appropriate step is to switch to a different class of antianginal medication that does not cause these side effects. A non-dihydropyridine calcium channel blocker like diltiazem is an excellent alternative for symptom control in stable angina, as it also provides rate control without the beta-blocker side effect profile.

Question 16

1. Proceed with surgery without further cardiac testing. (correct answer)
2. Perform a preoperative exercise stress test.
3. Obtain a preoperative transthoracic echocardiogram.
4. Schedule a coronary angiogram to assess for new disease.

Explanation: This patient is scheduled for a low-to-intermediate risk non-cardiac surgery. According to the ACC/AHA guidelines for perioperative cardiovascular evaluation, if a patient has a good functional capacity (≥4 metabolic equivalents [METs], e.g., climbing two flights of stairs), no further cardiac testing is needed, regardless of their cardiac history. The patient is asymptomatic and on optimal medical therapy. Therefore, he can proceed with the scheduled surgery. Performing stress testing (B), echocardiography (C), or angiography (D) would not change management and is not indicated.

Question 17

1. Discontinue aspirin permanently due to bleeding risk.
2. Switch from aspirin to clopidogrel and add a proton pump inhibitor.
3. Resume aspirin immediately along with a proton pump inhibitor. (correct answer)
4. Withhold aspirin for 4 weeks to allow for gut healing.

Explanation: For patients with stable CAD who experience a GI bleed, the risk of a major adverse cardiac event from discontinuing aspirin often outweighs the risk of re-bleeding, especially once the source is controlled. Guidelines recommend resuming aspirin as soon as it is considered safe from a GI perspective, which is often before discharge or immediately upon discharge. To mitigate the risk of a future bleed, a proton pump inhibitor (PPI) should be co-administered. Discontinuing aspirin permanently (A) would increase his cardiovascular risk. Switching to clopidogrel (B) is not superior to aspirin plus a PPI for preventing re-bleeding and may even carry a similar risk. Withholding aspirin for an extended period (D) unnecessarily exposes the patient to thrombotic risk.

Question 18

1. Annual low-dose computed tomography of the chest.
2. Serum prostate-specific antigen (PSA) test.
3. Carotid duplex ultrasound for stenosis.
4. Abdominal ultrasound for aortic aneurysm. (correct answer)

Explanation: When evaluating an older male patient with cardiovascular risk factors, you need to consider screening recommendations based on specific risk profiles and evidence-based guidelines. This 67-year-old man with a significant smoking history (40 pack-years) and cardiovascular disease warrants screening for abdominal aortic aneurysm (AAA). The U.S. Preventive Services Task Force recommends one-time AAA screening with abdominal ultrasound for men aged 65-75 who have ever smoked. This patient fits these criteria perfectly - he's 67 and is a former smoker. AAA screening is particularly important because rupture carries extremely high mortality, but elective repair has good outcomes when aneurysms are detected early. Answer A is incorrect because low-dose CT chest screening is recommended for current smokers or those who quit within 15 years, aged 50-80, with 20+ pack-year history. As a "former smoker," we don't know his quit timeline, making this less definitively indicated than AAA screening. Answer B is wrong because PSA screening remains controversial with mixed recommendations. The USPSTF gives it a "C" recommendation (selective screening after discussion), making it less clearly indicated than AAA screening. Answer C is incorrect because carotid duplex screening isn't routinely recommended for asymptomatic patients, even those with cardiovascular risk factors, due to lack of evidence for improved outcomes. Remember for Step 3: Focus on well-established, evidence-based screening guidelines rather than "nice to have" tests. AAA screening has clear criteria and strong evidence for benefit in high-risk populations like older male smokers.

Question 19

1. Switch clopidogrel to ticagrelor as a precaution.
2. Discontinue clopidogrel since he is almost at the 12-month mark.
3. Advise him that drug allergies are not hereditary and he should continue clopidogrel. (correct answer)
4. Perform genetic testing for clopidogrel metabolism before making a change.

Explanation: This question tests communication and patient education. Drug allergies, particularly hypersensitivity reactions like the rash described, are idiosyncratic immune responses and are not inherited in a simple Mendelian fashion. The patient's concern is based on a misunderstanding. The most appropriate response is to educate the patient, reassure him that his wife's allergy does not confer risk to him, and advise him to continue his essential medication. Switching to ticagrelor (A) is not indicated without evidence of an allergy or treatment failure. Discontinuing clopidogrel early (B) increases the risk of stent thrombosis. Genetic testing (D) is for assessing metabolic activity (e.g., CYP2C19 status), not for predicting hypersensitivity reactions.

Question 20

1. Rivaroxaban and aspirin.
2. Rivaroxaban alone. (correct answer)
3. Warfarin and aspirin.
4. Warfarin, aspirin, and clopidogrel.

Explanation: This patient has two separate indications for antithrombotic therapy: stable CAD (years after stent) and VTE. For patients with stable CAD (defined as >1 year post-MI or revascularization without recurrent events), long-term anticoagulation alone is generally sufficient if an indication for anticoagulation arises. Continuing aspirin with an anticoagulant (options A and C) increases the risk of bleeding without providing significant additional benefit in preventing coronary events in the stable phase. This is supported by several trials (e.g., AFIRE, OAC-ALONE). Triple therapy (D) is definitely not indicated and carries a very high bleeding risk. Therefore, treatment with a DOAC like rivaroxaban alone is the most appropriate choice.