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1.1 Ischemic Heart Disease & Acute Coronary Syndromes

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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

1.1 Ischemic Heart Disease & Acute Coronary Syndromes

Key Takeaways Explain This Topic AI

Ischemic heart disease is a blueprint subsection of Cardiovascular Disease, the largest category on the exam at 14%.

Type 1 myocardial infarction reflects plaque rupture with thrombus; type 2 reflects supply-demand mismatch and is managed by correcting the precipitant.

NSTE-ACS risk scores such as TIMI and GRACE determine whether an early invasive or an ischemia-guided strategy is appropriate.

Primary PCI is preferred when it can be delivered within the guideline door-to-balloon window; fibrinolysis is the fallback when timely PCI is unavailable.

Non-cardiac chest pain and coronary spasm are explicitly named blueprint topics and appear as distractors in ACS vignettes.

Last updated: August 2026

Acute coronary syndromes (ACS) represent a spectrum of acute myocardial ischemia ranging from unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) to ST-segment elevation myocardial infarction (STEMI). Mastery of ACS diagnosis, emergency triage, invasive versus conservative pathways, antithrombotic pharmacology, and post-infarction complications is a cornerstone of the ABIM Internal Medicine certification exam.

1. Pathophysiology and Spectrum of Ischemic Heart Disease

Coronary atherosclerosis begins with endothelial injury, subendothelial accumulation of low-density lipoprotein (LDL) particles, leukocyte recruitment, and foam cell formation. Over decades, this process generates fibroatheromatous plaques characterized by a lipid-rich necrotic core covered by a fibrous cap composed of vascular smooth muscle cells and extracellular collagen matrix.

Mechanisms of Acute Coronary Occlusion

Plaque Rupture (~70% of ACS): Thin-cap fibroatheromas (cap thickness <65 µm) infiltrated by activated macrophages that secrete matrix metalloproteinases (MMPs). Rupture exposes highly thrombogenic subendothelial core components (tissue factor, collagen) to circulating blood, initiating platelet adhesion, activation, and thrombin generation resulting in an occlusive red (erythrocyte-fibrin rich) or non-occlusive white (platelet-rich) thrombus.

Plaque Erosion (~25-30% of ACS): Endothelial denudation without cap rupture, more frequent in premenopausal women, smokers, and non-calcified plaques. Platelet-rich thrombus forms directly on a proteoglycan- and hyaluronan-rich matrix.

MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries): Defined as acute MI criteria met with <50% stenosis on invasive angiography. Etiologies include epicardial coronary vasospasm (Prinzmetal/variant angina), coronary microvascular dysfunction, spontaneous coronary artery dissection (SCAD), coronary embolism/thrombus with spontaneous lysis, and myocarditis or Takotsubo cardiomyopathy mimicking ACS.

Clinical & Diagnostic Differentiation of Chest Pain Syndromes

Feature Stable Angina Unstable Angina (UA) NSTEMI STEMI

Pathophysiology Fixed flow-limiting stenosis (>70%) Subtotal thrombus / transient occlusion Subtotal thrombus causing myocardial necrosis Total transmural coronary artery occlusion

Symptom Pattern Predictable on exertion, relieved by rest/sublingual nitroglycerin <5 min Occurs at rest (>20 min), new onset (CCS Class III), or crescendo pattern Prolonged rest pain (>20 min), chest pressure radiating to left arm/jaw Severe, persistent substernal crushing pain >30 min, diaphoresis, dyspnea

High-Sensitivity Troponin Normal (<99th percentile URL) Normal (<99th percentile URL) Elevated with dynamic rise/fall above 99th percentile Elevated with dynamic rise/fall above 99th percentile

12-Lead ECG Findings Normal or non-specific ST-T changes at rest Transient ST depression (>=0.5 mm), T-wave inversions, or non-diagnostic ST-segment depression (>=0.5 mm), deep T-wave inversions, or transient ST elevation Persistent ST elevation (>=1 mm in >=2 contiguous limb leads; >=2.0 mm in men >=40y / >=2.5 mm in men <40y / >=1.5 mm in women in V2-V3) or new LBBB with Sgarbossa criteria

ECG Pearl — Posterior MI & Sgarbossa Criteria:

Posterior STEMI: ST depressions in leads V1–V3 with tall, wide R waves (R/S ratio >1) and upright T waves represent reciprocal changes of the posterior wall (LCx or PDA occlusion). Always obtain posterior leads (V7–V9); ST elevation >=0.5 mm in V7–V9 confirms posterior STEMI and warrants immediate primary PCI.

Sgarbossa Criteria in LBBB / Paced Rhythm: (1) Concordant ST elevation >=1 mm in any lead (5 points); (2) Concordant ST depression >=1 mm in V1–V3 (3 points); (3) Modified Smith-Sgarbossa: Excessively discordant ST elevation >=1 mm with ST/S ratio <= -0.25 (2 points). A score >=3 has >90% specificity for acute STEMI.

Loading diagram... Clinical Decision Algorithm for Acute Coronary Syndromes (ACS)

2. Risk Stratification in NSTE-ACS

Risk stratification determines whether an invasive (coronary angiography +/- revascularization) or conservative (ischemia-guided) strategy is indicated, as well as the optimal timing of catheterization.

Clinical Risk Scores

TIMI Risk Score for UA/NSTEMI (7 variables, 1 point each):

  • A ge >= 65 years
  • >=3 CAD risk factors (HTN, DM, hyperlipidemia, smoking, family history)
  • K nown CAD (coronary stenosis >= 50%)
  • A spirin use in the past 7 days
  • S evere angina (>=2 episodes in past 24 hours)
  • S T-segment deviation >= 0.5 mm
  • P ositive cardiac biomarkers (elevated troponin)

Score interpretation: 0-2 = Low risk (4.7-8.3% 14-day death/MI/urgent revascularization); 3-4 = Intermediate risk (13.2-19.9%); 5-7 = High risk (26.2-40.9%).

GRACE Risk Score: Calculates in-hospital and 6-month mortality using 8 variables: age, heart rate, systolic BP, serum creatinine, Killip class, cardiac arrest at admission, ST-segment deviation, and elevated biomarkers. A GRACE score >140 indicates high risk.

HEART Score for Emergency Department Chest Pain:

  • H istory (highly suspicious = 2, moderately = 1, slightly = 0)
  • E CG (significant ST depression = 2, non-specific repolarization = 1, normal = 0)
  • A ge (>=65y = 2, 45-64y = 1, <45y = 0)
  • R isk factors (>=3 risk factors or known CAD = 2, 1-2 risk factors = 1, none = 0)
  • T roponin (>=3x normal = 2, 1-3x normal = 1, <=normal = 0)

Score 0-3: Low risk (0.9-1.7% 6-week MACE); candidates for early discharge without inpatient admission.

Score 4-6: Moderate risk (12-16.6% MACE); requires observation and provocative testing.

Score 7-10: High risk (50-65% MACE); mandates admission and early invasive angiography.

3. Acute STEMI Management & Reperfusion Timing

Every minute of coronary occlusion correlates with progressive transmural myocardial necrosis. Time is myocardium.

Primary Percutaneous Coronary Intervention (PCI)

First-line reperfusion therapy: Primary PCI is superior to fibrinolysis in reducing mortality, recurrent MI, and intracranial hemorrhage when performed expeditiously.

Time benchmarks:

Door-to-Balloon (D2B) time <= 90 minutes for patients presenting directly to a PCI-capable facility.

Door-to-Balloon time <= 120 minutes (First Medical Contact to Device) for patients presenting to a non-PCI center requiring inter-hospital transfer.

Intravenous Fibrinolysis

Indication: Indicated for patients with symptom onset <=12 hours when the anticipated transfer time to primary PCI exceeds 120 minutes.

Time benchmark: Door-to-Needle (D2N) time <= 30 minutes .

Agent of choice: Single weight-based IV bolus Tenecteplase (TNK-tPA) (30 mg for <60 kg up to 50 mg for >=90 kg) due to lower non-cerebral bleeding rates and ease of administration compared to Alteplase.

Absolute Contraindications to Fibrinolysis:

  • Any prior intracranial hemorrhage (ICH)
  • Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
  • Known malignant intracranial neoplasm (primary or metastatic)
  • Ischemic stroke within the preceding 3 months (excluding acute ischemic stroke <4.5 hours)
  • Suspected aortic dissection
  • Active internal bleeding or bleeding diathesis (excluding menses)
  • Significant closed-head or facial trauma within the preceding 3 months

Pharmacoinvasive Strategy: Following fibrinolysis, all patients should be transferred to a PCI-capable facility for routine angiography and PCI within 2 to 24 hours , or emergent rescue PCI if fibrinolysis fails (<50% ST resolution at 60-90 minutes, ongoing chest pain, hemodynamic instability).