Saudi Board Internal Medicine Part 1 Complete Review Guide 2026–2027

4. NSTE-ACS with refractory pain or haemodynamic instability: immediate angiography within 2 hours.
5. Wellens pattern: deep symmetrical T-wave inversion in V2 to V4 indicates critical proximal LAD stenosis needing angiography.
6. After ACS: high-intensity statin (atorvastatin 80 mg) and aspirin with ticagrelor for 12 months.
7. Cocaine chest pain: IV benzodiazepine first to reduce sympathetic drive.
8. Vasospastic angina: calcium-channel blockers such as diltiazem, with smoking cessation.
9. New holosystolic murmur after inferior MI with pulmonary oedema: posteromedial papillary muscle rupture.
10. HFrEF means LVEF of 40% or less with symptoms.
11. NT-proBNP below 125 pg/mL in the non-acute setting makes heart failure unlikely.
12. Four HFrEF pillars: ARNI (or ACEi/ARB), beta-blocker, mineralocorticoid receptor antagonist and SGLT2 inhibitor.
13. Stop the MRA if potassium exceeds 6.0 mmol/L.
14. Warm and wet acute HF: IV furosemide at or above the oral dose. Cold and wet with shock: dobutamine.
15. Primary-prevention ICD: LVEF 35% or less after 3 months of optimal therapy and more than 40 days after MI.
16. CRT: sinus rhythm, LBBB with QRS 150 ms or more, and LVEF 35% or less.
17. Ivabradine: sinus rhythm with heart rate 70/min or more despite maximal beta-blocker, and LVEF 35% or less.
18. AF with high stroke risk: a DOAC is preferred over warfarin, except with a mechanical valve or moderate to severe mitral stenosis.
19. Reduce apixaban to 2.5 mg twice daily with 2 of: age 80 or more, weight 60 kg or less, creatinine 1.5 mg/dL or more.
20. AF of 48 hours or more: anticoagulate 3 weeks before cardioversion and 4 weeks after, or exclude thrombus by TOE.
21. Torsades de pointes: IV magnesium sulfate, stop QT-prolonging drugs and correct potassium.
22. Symptomatic third-degree block without a reversible cause: permanent pacemaker. Asymptomatic Mobitz I in an athlete: reassurance.
23. Severe aortic stenosis with symptoms or LVEF below 50%: valve replacement; TAVI for older patients at high surgical risk.
24. Endocarditis: urgent surgery for heart failure from acute regurgitation, or vegetation 10 mm or more with embolism on antibiotics. S. gallolyticus needs colonoscopy.

Common mistakes in this chapter

• ✕ Nitrates or diuretics are given for hypotension in right ventricular MI. The correct step is IV fluids, since the RV is preload dependent.
• ✕ ST depression in V1 to V3 is read as anterior ischaemia. It may be posterior STEMI needing immediate reperfusion; record V7 to V9.
• ✕ Diltiazem or verapamil is added for rate control in HFrEF. They are negatively inotropic and should be avoided.
• ✕ Sacubitril–valsartan is started straight after an ACE inhibitor. A 36-hour washout is needed to avoid angioedema.
• ✕ Adenosine or an AV-nodal blocker is given in pre-excited AF. This is dangerous; use procainamide or cardioversion.
• ✕ A DOAC is prescribed with a mechanical mitral valve. Only warfarin is appropriate.
• ✕ Blood pressure is dropped to normal fast in hypertensive emergency. Lower mean pressure by no more than 25% in the first hour, except in dissection.
• ✕ An ACE inhibitor is stopped for a 20% creatinine rise. Continue with monitoring if the rise is up to 30%.