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Cardiovascular Pathology — Step 1 practice questions
47 questions in this area, with an explanation for every answer choice.
Three samples below, free and without an account.
How this shows up on Step 1
Pathology questions in this section combine two things the exam tests separately elsewhere. Pathology is the largest discipline on Step 1. Cardiovascular questions lean heavily on physiology you can reason from first principles: pressure-volume loops, the cardiac cycle, and how preload, afterload and contractility move when something goes wrong.
Sample questions
Sample question 1
A 42-year-old woman with bilateral hilar lymphadenopathy develops complete heart block and ventricular tachycardia. Cardiac MRI shows patchy late gadolinium enhancement in the basal septum. Which of the following best explains her arrhythmias?
Explanations
A. Ischemic scar from prior myocardial infarction
Ischemic scar follows coronary territories rather than this patchy basal septal pattern.
B. Autoimmune destruction of the sinoatrial node only
The process is diffuse and granulomatous rather than isolated nodal autoimmunity.
C. Noncaseating granulomatous infiltration of the conduction system and myocardium creating both conduction block and reentrant circuits · correct
Cardiac sarcoidosis results from noncaseating granulomas infiltrating the myocardium with a predilection for the BASAL SEPTUM, where the conduction system runs — producing heart block that can be the presenting feature, often in a patient younger than expected for conduction disease. Patchy granulomas and subsequent scar also create reentrant substrate for ventricular tachycardia, and sudden cardiac death is a major risk. Treatment includes corticosteroids and, frequently, device therapy.
D. Amyloid fibril deposition
Amyloid produces diffuse thickening with low voltage.
E. Iron deposition from hemochromatosis
Iron overload causes dilated or restrictive cardiomyopathy with systemic features.
Sample question 2
A 78-year-old man with a harsh crescendo-decrescendo systolic murmur radiating to the carotids develops exertional syncope. Echocardiography confirms severe calcific aortic stenosis. Which of the following best describes the prognostic significance of his symptom?
Explanations
A. Symptoms do not alter the natural history of aortic stenosis
Symptoms mark the inflection point in survival.
B. Medical therapy with vasodilators is preferred over intervention
Vasodilators can cause dangerous hypotension in fixed obstruction.
C. Surgery should be deferred until the ejection fraction falls below 40%
Waiting for systolic dysfunction worsens surgical outcomes.
D. Symptom onset marks a sharp decline in survival, and valve replacement is indicated regardless of ejection fraction · correct
Severe aortic stenosis remains asymptomatic for years, but once the cardinal symptoms appear — angina, syncope, and dyspnea from heart failure — median survival without intervention falls dramatically (roughly 5, 3, and 2 years respectively). Symptom onset is therefore the trigger for aortic valve replacement, surgical or transcatheter, irrespective of ejection fraction.
E. Syncope is the most benign of the cardinal symptoms and warrants observation
Syncope carries a worse prognosis than angina, not a benign one.
Sample question 3
A patient with a history of prior myocardial infarction develops a wide-complex tachycardia with hemodynamic instability. Which of the following is the most appropriate immediate management?
Explanations
A. Synchronized cardioversion · correct
Hemodynamically unstable ventricular tachycardia (likely given the prior MI and scar-related reentry substrate) requires immediate synchronized cardioversion to restore a stable rhythm.
B. Oral antiarrhythmic medication
Oral medication is far too slow for a hemodynamically unstable arrhythmia requiring immediate intervention.
C. Observation only
Observation is inappropriate given hemodynamic instability from a dangerous arrhythmia.
D. Reassurance that this is benign
Hemodynamically unstable VT is a life-threatening emergency, not a benign finding.
E. Beta-blocker alone, with no other intervention
Beta-blockers alone do not provide the immediate rhythm correction needed in unstable VT.
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