Study guide
1.6 Device Therapy, HFpEF & the Cardiomyopathies
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
1.6 Device Therapy, HFpEF & the Cardiomyopathies
Key Takeaways Explain This Topic AI
Hypertrophic, restrictive and dilated cardiomyopathy and cor pulmonale are individually enumerated blueprint topics.
Primary prevention defibrillator implantation generally requires at least three months of optimal medical therapy with persistent severe left ventricular dysfunction.
Cardiac resynchronization benefit is greatest with left bundle branch block and a markedly prolonged QRS duration.
Obstructive hypertrophic cardiomyopathy is treated first with negative inotropes; vasodilators and diuretics worsen the outflow gradient.
Transthyretin cardiac amyloidosis is suggested by low QRS voltage with increased wall thickness and is confirmed non-invasively by bone-avid tracer scintigraphy after excluding a monoclonal protein.
Last updated: August 2026
- 1. Device Therapy: ICD and CRT Indications
- Implantable Cardioverter-Defibrillator (ICD)
Primary Prevention Criteria (MADIT-II, SCD-HeFT):
LVEF <= 35%, NYHA Functional Class II or III symptoms on >=3 months of optimal GDMT , with reasonable expectation of meaningful survival >1 year.
Timing for Ischemic Cardiomyopathy: Must be >40 days post-myocardial infarction and >90 days post-revascularization (CABG or PCI) to allow for potential myocardial recovery.
Non-Ischemic Dilated Cardiomyopathy: >=3 months of optimal GDMT with persistent LVEF <=35% and NYHA II-III.
Secondary Prevention: Indicated for patients who have survived sustained VT, VF arrest, or hemodynamically unstable VT not attributable to a transient or reversible cause (e.g., acute ischemia, hypokalemia).
Cardiac Resynchronization Therapy (CRT / Biventricular Pacing)
Class I Indication:
- LVEF <= 35%
- Normal Sinus Rhythm
- Left Bundle Branch Block (LBBB) morphology
- QRS duration >= 150 ms
Symptomatic NYHA Class II, III, or ambulatory Class IV heart failure on optimal GDMT.
Class IIa Indications: LBBB with QRS 120-149 ms; or non-LBBB morphology with QRS >= 150 ms and LVEF <=35%.
Physiology: Corrects ventricular dyssynchrony by pacing both the right ventricle and the left ventricular lateral wall via the coronary sinus, improving cardiac output, reversing LV remodeling, and reducing mortality.
2. Management of HFpEF (LVEF >= 50%)
HFpEF accounts for >50% of heart failure cases, primarily driven by aging, hypertension, obesity, diabetes, and arterial stiffness.
SGLT2 Inhibitors (Empagliflozin, Dapagliflozin): Class 1 recommendation . Reduces CV death and HF hospitalizations in preserved EF (EMPEROR-Preserved, DELIVER trials).
Mineralocorticoid Receptor Antagonists (Spironolactone): Class 2a recommendation to reduce hospitalizations, especially in patients with LVEF near 50% (TOPCAT trial Americas subgroup).
ARNI (Sacubitril/Valsartan): Class 2b recommendation, with greatest benefit observed in patients with LVEF 45-57% and women (PARAGON-HF trial).
Loop Diuretics: Essential for symptom control and decongestion.
Blood Pressure & Comorbidity Control: Target SBP <130 mmHg; strict control of atrial fibrillation (rate and rhythm) and screening for obstructive sleep apnea.
- 3. Cardiomyopathies
- Hypertrophic Cardiomyopathy (HCM)
Genetics & Pathophysiology: Autosomal dominant mutation in cardiac sarcomere protein genes (most commonly MYBPC3 [myosin-binding protein C] and MYH7 [beta-myosin heavy chain]). Characterized by myocyte disarray, asymmetric septal hypertrophy, and dynamic left ventricular outflow tract (LVOT) obstruction in ~70% of patients due to systolic anterior motion (SAM) of the anterior mitral leaflet contacting the hypertrophied septum, producing concomitant eccentric mitral regurgitation.
Physical Examination: Harsh crescendo-decrescendo systolic ejection murmur loudest at the lower left sternal border (LLSB), radiating to the base but NOT the carotids, with a brisk bifid carotid pulse ( pulsus bisferiens ).
Dynamic Murmur Maneuvers:
Increases Murmur: Maneuvers that decrease LV preload or afterload (Valsalva strain, sudden standing, nitroglycerin administration) decrease LV chamber size, bringing the anterior mitral leaflet closer to the septum and worsening dynamic LVOT obstruction.
Decreases Murmur: Maneuvers that increase LV preload or afterload (squatting, passive leg raise, sustained handgrip) increase LV cavity volume and widen the outflow tract, reducing obstruction and softening the murmur.
Medical Management:
First-line: Non-vasodilating Beta-blockers (Metoprolol, Propranolol, Atenolol) or non-dihydropyridine Calcium Channel Blockers (Verapamil, Diltiazem) to prolong diastole, increase ventricular filling, and reduce LVOT gradient.
Second-line / Add-on: Disopyramide (Class IA antiarrhythmic with negative inotropic properties).
Targeted Cardiac Myosin Inhibitors: Mavacamten (Camzyos) selectively inhibits cardiac myosin ATPase, reducing excessive actin-myosin cross-bridging and abolishing LVOT obstruction in symptomatic obstructive HCM (EXPLORER-HCM trial).
Contraindicated Drugs: Pure vasodilators (dihydropyridine CCBs like amlodipine, nitrates, ACEi/ARBs) and excessive diuretics, which decrease LV volume and trigger hemodynamic collapse from severe LVOT obstruction.
Invasive Septal Reduction: Surgical septal myectomy (Morrow procedure) or alcohol septal ablation for drug-refractory NYHA III-IV symptoms with resting or provoked LVOT gradient >= 50 mmHg.
Sudden Cardiac Death (SCD) Risk & ICD Indications: Primary prevention ICD recommended if >=1 major risk factor: massive LV hypertrophy (wall thickness >= 30 mm), unexplained recent syncope, family history of premature SCD in a first-degree relative, LV apical aneurysm, LVEF < 50%, or extensive late gadolinium enhancement (LGE >=15% of LV mass) on cardiac MRI.
Dilated Cardiomyopathy (DCM)
Characterized by LV dilation and systolic dysfunction (LVEF <50%) in the absence of abnormal loading conditions (severe HTN/valvular disease) or CAD.
Etiologies: Genetic ( TTN [titin] truncating mutations, lamin A/C LMNA associated with high-grade AV block and ventricular arrhythmias), viral myocarditis (Parvovirus B19, HHV-6, Coxsackie B), toxic (alcohol, cocaine, anthracyclines [doxorubicin: dose-dependent irreversible vs trastuzumab: non-dose-dependent reversible], checkpoint inhibitors), peripartum cardiomyopathy (last month of pregnancy to 5 months postpartum; avoid future pregnancies if EF remains <50%), tachycardia-induced cardiomyopathy (reversible with rate/rhythm control).
Restrictive Cardiomyopathies (RCM)
Characterized by non-dilated, rigid ventricles with severe diastolic dysfunction, biatrial enlargement, and normal or near-normal systolic function.
Cardiac Amyloidosis:
AL Amyloidosis: Clonal plasma cell dyscrasia producing monoclonal immunoglobulin light chains (lambda > kappa). Associated with macroglossia, periorbital purpura (raccoon eyes), nephrotic syndrome, and peripheral neuropathy. Screen with serum free light chains (kappa/lambda ratio) and serum/urine immunofixation electrophoresis (IFE). Confirm with tissue biopsy (fat pad, bone marrow, or endomyocardial biopsy showing apple-green birefringence under polarized light with Congo red stain) and mass spectrometry. Treatment: Chemotherapy (Daratumumab + CyBorD) and autologous stem cell transplant.
ATTR Amyloidosis (Transthyretin): Wild-type (senile, elderly men, associated with carpal tunnel syndrome, spinal stenosis, and bicep tendon rupture) or Variant/Hereditary ( TTR gene mutation, e.g., Val122Ile in African Americans). Diagnostic pathway: Technetium-99m Pyrophosphate (99mTc-PYP) bone scintigraphy demonstrating Grade 2 or 3 cardiac uptake in the absence of monoclonal proteins in serum/urine confirms ATTR without requiring heart biopsy. Treatment: Tafamidis (Vyndaqel/Vyndamax), a TTR tetramer stabilizer that reduces all-cause mortality and cardiovascular hospitalizations (ATTR-ACT trial).
ECG-Echo Discordance: Classic board finding of low voltage QRS complexes on ECG despite prominent concentric ventricular wall thickening on echocardiogram .
Hemochromatosis: Autosomal recessive HFE gene mutation (C282Y); iron deposition in myocardium causing dilated or restrictive phenotype, bronze diabetes, arthropathy, cirrhosis. Screen with transferrin saturation (>45%) and ferritin (>1000 ng/mL); confirm with cardiac MRI (T2* relaxation time <20 ms indicating myocardial iron overload). Treatment: Therapeutic phlebotomy or iron chelation (deferasirox, deferoxamine).
Cardiac Sarcoidosis: Non-caseating granulomas in young-to-middle-aged adults. Frequently presents with high-grade AV block, ventricular tachycardia, or sudden cardiac death. Cardiac MRI reveals patchy non-ischemic mid-wall or epicardial LGE; 18F-FDG PET scan shows active myocardial inflammation. Treatment: High-dose systemic corticosteroids (Prednisone 0.5-1 mg/kg/day), steroid-sparing immunosuppressants (Methotrexate), and early ICD implantation.