Cardiology 1 Flashcards
G.G. is a 56-year-old white man with type 2 diabetes. He is a nonsmoker and is concerned about his risk of coronary heart disease (CHD). His vital signs include blood pressure (BP) 152/98 mm Hg (average home blood pressure 150/92 mm Hg), heart rate 70 beats/minute, and body mass index (BMI) 26.5 kg/m2. His fasting laboratory test results today include serum creatinine (SCr) 0.8 mg/dL, total cholesterol (TC) 188 mg/dL, low-density lipoprotein cholesterol (LDL) 130 mg/dL, high-density lipoprotein cholesterol (HDL) 30 mg/dL, and triglycerides (TG) 90 mg/dL, and his urine albumin/creatinine ratio is 86.5 mg/g (previously 68 mg/g). The patient’s 10-year atherosclerotic cardiovascular disease (ASCVD) risk is 21%.
- Which is most appropriate to recommend for this
patient’s BP control at today’s visit?
A. Amlodipine 5 mg/day.
B. Lisinopril 10 mg/day.
C. Hydrochlorothiazide 12.5 mg/day plus amlodipine 5 mg/day.
D. Chlorthalidone 12.5 mg/day plus lisinopril 10 mg/
day.
The patient’s blood pressure is above his goal of less than 140/90 mm Hg (according to the ADA; can consider less than 130/80 mm Hg because the 10-year ASCVD risk is greater than 15%) and less than 130/80 mm Hg (according to the ACC/AHA); thus, antihypertensive therapy should be initiated.
The patient has stage 2 HTN according to the ACC/AHA guidelines; patients in this stage should be initiated on two medications of different classes, particularly
if their blood pressure is more than 20/10 mm Hg above goal; Answers A and B are incorrect because they only recommend monotherapy.
According to the 2021 ADA standards, treatment of HTN should include drug classes shown to reduce CV events in patients with diabetes (ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine CCBs), with the specific use of ACE inhibitors or ARBs if the patient has albuminuria or CAD.
The ACC/ AHA guidelines recommend ACE inhibitors and ARBs as
first-line treatment for patients with diabetes in the presence of albuminuria, making Answer D correct. Calcium channel blockers and thiazide diuretics are also recommended as first-line agents. Answer D is correct because it includes both a thiazide diuretic, which improved CV outcomes in the ALLHAT trial, and an ACE inhibitor for renal protection. Answer C is incorrect because it does not include an ACE inhibitor or an ARB, one of which is needed because the patient has albuminuria.
Correct Answer: D
G.G. is a 56-year-old white man with type 2 diabetes. He is a nonsmoker and is concerned about his risk of coronary heart disease (CHD). His vital signs include blood pressure (BP) 152/98 mm Hg (average home blood pressure 150/92 mm Hg), heart rate 70 beats/minute, and body mass index (BMI) 26.5 kg/m2. His fasting laboratory test results today include serum creatinine (SCr) 0.8 mg/dL, total cholesterol (TC) 188 mg/dL, low-density lipoprotein cholesterol (LDL) 130 mg/dL, high-density lipoprotein cholesterol (HDL) 30 mg/dL, and triglycerides (TG) 90 mg/dL, and his urine albumin/creatinine ratio is 86.5 mg/g (previously 68 mg/g). The patient’s 10-year atherosclerotic cardiovascular disease (ASCVD) risk is 21%.
- Which is best for primary prevention of CHD for this
patient?
A. Aspirin 325 mg/day.
B. Atorvastatin 10 mg/day.
C. Aspirin 81 mg/day plus atorvastatin 40 mg/day.
D. Atorvastatin 40 mg/day plus clopidogrel 75 mg/
day.
Using the PCE risk calculator, this patient has an estimated 10-year ASCVD risk of 21%. Because the patient is 40–75 years old with diabetes and has an LDL of 70–189 mg/dL, at least moderate-intensity statin therapy is indicated. However, high-intensity statin therapy can be considered if several risk factors exist or in patients 50–75 years of age, according to the 2018 AHA/ACC Multi-society cholesterol guidelines. Similarly, the ADA guidelines state that high intensity statin therapy can be considered in patients with
diabetes with several ASCVD risk factors; this patient has elevated blood pressure, dyslipidemia, and albuminuria (Answer B is incorrect). For patients with diabetes, the ADA recommends aspirin 75–162 mg for men 50 and older who have at least one other risk factor for CHD (Answer C is correct). If indicated, aspirin 81 mg can be used for primary prevention if the patient is at low risk of bleeding (Answer A is incorrect). Clopidogrel is recommended for primary prevention only if the patient has an allergy to aspirin (Answer D is incorrect). Once the patient’s lipids
and blood pressure are better controlled, it may be appropriate to discontinue aspirin therapy because the benefits of therapy are closely balanced by risks, particularly in those with a lower risk of ASCVD.
Correct Answer: C
J.R. is a 55-year-old Hispanic man (weight 66 kg)
with a medical history significant for HTN and a
myocardial infarction (MI) 9 months ago, leading to
placement of a bare metal stent (BMS). His current
medications include aspirin 325 mg/day, clopidogrel
75 mg/day, atorvastatin 40 mg/day, and metoprolol
succinate 50 mg/day. His vital signs are BP 145/88
mm Hg and heart rate 52 beats/minute. His laboratory
test results show LDL 68 mg/dL (baseline 138 mg/dL)
and SCr 1.0 mg/dL.
Which is currently best for secondary prevention of CHD?
A. Decrease the aspirin dose to 81 mg/day and add
lisinopril to 5 mg/day.
B. Increase atorvastatin to 80 mg/day and increase
metoprolol succinate to 100 mg/day.
C. Decrease the aspirin dose to 81 mg/day and
increase metoprolol succinate to 100 mg/day.
D. Discontinue clopidogrel and increase atorvastatin
to 80 mg/day.
The patient’s heart rate is at less than 60 beats/minute.
Therefore, the metoprolol dose should not be increased
because of the risk of worsening bradycardia and heart
block, making Answers B and C incorrect. Because the
patient is taking a high-intensity statin with an adequate
response in his LDL (reduction of 50% or more from
baseline), his statin dose need not be increased, making
Answers B and D incorrect. The patient’s blood pressure is not at goal (goal less than 130/80 mm Hg according to the 2017 AHA/ACC guidelines). An ACE inhibitor guideline
is a class I recommendation for secondary prevention in
patients with HTN. The aspirin dose after PCI associated
with the lowest bleeding risk is 81 mg, making Answer A
correct. Clopidogrel is indicated for at least 1 year after
PCI in the setting of ACS, making Answer D incorrect.
Correct Answer: A
D.P. is a 60-year-old patient who is being discharged
from the hospital after admission for an ST-segment
elevation MI (STEMI). D.P. received a percutaneous
coronary intervention (PCI) with a drug-eluting stent
(DES) and is at low risk of bleeding. Which is the best
recommendation for this patient’s aspirin and P2Y12
inhibitor therapy?
A. Aspirin 325 mg indefinitely and ticagrelor for at
least 1 year.
B. Aspirin 325 mg for 1 month; then aspirin 81 mg
indefinitely and clopidogrel for 6 months.
C. Aspirin 81 mg indefinitely and clopidogrel for 1
month.
D. Aspirin 81 mg indefinitely and prasugrel for at
least 1 year.
Patients who receive a DES should be treated with DAPT with aspirin and a P2Y12 inhibitor for at least 12 months per most recent guidelines. After 12 months, patients should receive aspirin monotherapy indefinitely. The recommended aspirin dose is 81 mg/day. Answer D is correct because it recommends both the appropriate aspirin dose and the appropriate DAPT duration. Answer A is incorrect because of the aspirin dose. Answer B is incorrect because of both the aspirin dose and the DAPT duration. Answer C is incorrect because of the DAPT duration. However, it is important to note that recent literature has demonstrated that a shorter (e.g. 1 to 3 month) duration of DAPT followed by monotherapy with P2Y12 inhibitor therapy may be noninferior to 12 months of DAPT with a lower bleeding risk.
Correct Answer: D
T.S. is a patient who had an NSTEMI with everolimus DES placement 5 months ago. T.S. is scheduled
to undergo radical prostatectomy for prostate cancer.
He underwent a noninvasive stress test, with negative
findings for myocardial ischemia. His current medications include aspirin 81 mg/day and clopidogrel 75 mg/day. Which is the best recommendation regarding the patient’s dual antiplatelet therapy (DAPT)?
A. Discontinue both aspirin and clopidogrel at least 7
days before the procedure.
B. Continue clopidogrel, but discontinue aspirin at
least 5 days before the procedure.
C. Continue aspirin, but discontinue clopidogrel at
least 7 days before the procedure.
D. Continue aspirin, but discontinue clopidogrel at
least 5 days before the procedure.
Patients who have recently (less than 1 year) undergone DES placement are at higher risk of stent thrombosis after the cessation of P2Y12 inhibitor therapy. Answer D is correct. The 2016 ACC/AHA guideline focused update on the duration of DAPT states that elective noncardiac surgery after DES implantation in patients for whom P2Y12 inhibitor therapy will need to be discontinued can be considered at 3–6 months if the risk of delaying surgery is greater than the risk of stent thrombosis. If P2Y12 inhibitor therapy needs to be held in patients treated with DAPT, the guidelines recommend reinitiating therapy as soon as possible. Continuing aspirin is recommended, if possible. However, Answers A and C are incorrect because the proper timing of clopidogrel discontinuation should be 5 days, not 7 days. Answers A and B are incorrect because
aspirin should be continued in the setting of recent ACS.
Correct Answer: D
G.F. is a 50-year-old African American woman with
peripheral arterial disease (PAD). She has been unable
to tolerate angiotensin-converting enzyme (ACE)
inhibitors and angiotensin receptor blockers (ARBs)
because of hyperkalemia. Her current medication regimen is amlodipine 10 mg/day, chlorthalidone 12.5 mg/day, metoprolol succinate 25 mg/day, rosuvastatin 20 mg/day, and aspirin 81 mg/day. Her vital signs today include BP 146/82 mm Hg, repeated BP 148/85 mm Hg; heart rate 78 beats/minute; weight 69 kg (154 lb); and height 64 inches. Her laboratory tests show K
4.9 mEq/L, Na 133 mEq/L, and creatinine clearance
(CrCl) 65 mL/minute. Which is the best therapeutic
plan for this patient?
A. No medication changes are warranted.
B. Initiate hydralazine 25 mg three times daily.
C. Increase metoprolol succinate to 50 mg/day.
D. Increase chlorthalidone to 25 mg/day.
This patient’s blood pressure must be treated because it is above her blood pressure goal (goal is less than 130/80 mm Hg, according to the 2017 AHA/ACC guidelines) (Answer A is incorrect).
Chlorthalidone cannot be increased because the patient’s sodium concentration is slightly low (Answer D is incorrect).
Hydralazine would be a third- or fourth-line agent that is typically reserved for patients with resistant HTN and is not currently indicated (Answer B is incorrect). Therefore, increasing the metoprolol dose would be most appropriate at this time (Answer C is correct).
Correct Answer: C
Questions 7 and 8 pertain to the following case.
A.M. is a 32-year-old woman with type 1 diabetes and
HTN. Her current medication regimen is as follows:
ramipril 10 mg/day, chlorthalidone 25 mg/day, amlodipine 10 mg/ day, ethinyl estradiol 20 mcg/norethindrone 1 mg (for the past 2 years), and insulin as directed. Her vital signs today include BP 145/83 mm Hg, repeated BP 145/81 mm Hg, heart rate 82 beats/minute, height 66 inches, weight 70
kg (155 pounds), and BMI 24.5 kg/m2. A.M. would prefer not to take any more drugs, if possible.
- Which is the best clinical plan for A.M.?
A. No change in therapy is currently warranted.
B. Advise weight loss and recheck her blood pressure in 3 months.
C. Change chlorthalidone to hydrochlorothiazide.
D. Discuss changing her contraceptive method.
- A.M. and her husband have decided that they are
ready to have children. Which is best regarding A.M.’s
antihypertensive regimen?
A. No change in therapy is currently warranted.
B. Discontinue ramipril and replace it with labetalol
100 mg twice daily.
C. Increase chlorthalidone to 50 mg/day.
D. Discontinue all antihypertensive therapy.
- Oral contraceptives, specifically estrogen, can increase
blood pressure, and risk can increase with duration of use. An alternative contraceptive without estrogen would be less likely to contribute to the patient’s HTN, making Answer D correct. Answers A and B are incorrect because the patient’s blood pressure requires better control, but weight loss is unlikely to help because the patient’s BMI is normal. Answer C is incorrect because hydrochlorothiazide is no more potent than chlorthalidone, and chlorthalidone reduced CV events in the ALLHAT trial.
Correct Answer: D
- Angiotensin-converting enzyme inhibitor therapy is contraindicated in pregnancy because of teratogenicity, and discontinuing ramipril is the most important next step, making Answer B correct and Answers A and C incorrect. Answer D is incorrect because this patient will require very good blood pressure control during her pregnancy, given that untreated HTN is associated with adverse events in the mother, fetus, and infant.
Correct Answer: B
A.D. is a 45-year-old woman with chronic kidney
disease (CKD) and worsening HTN. Her home BP
readings have been in the range of 130–149 mm
Hg (systolic) over 70–79 mm Hg (diastolic) for the
past month. Her current antihypertensive regimen
includes lisinopril 40 mg/day, felodipine 10 mg/day,
and carvedilol 25 mg twice daily. Her vital signs today
include BP 139/75 mm Hg, repeated BP 138/72 mm Hg; heart rate 58 beats/minute; weight 56 kg (125
pounds); and height 62 inches. Her laboratory values
are as follows: SCr 1.9 mg/dL (glomerular filtration
rate [GFR] 30.1 mL/minute/1.73 m2), K 5.1 mEq/L,
Na 145 mEq/L, fasting blood glucose (FBG) 97 mg/
dL, TSH 2.65 mIU/mL, and albumin/creatinine ratio
66 mg/dL. Which is the next best step to better control
her BP?
A. Add spironolactone 12.5 mg/day.
B. Add furosemide 20 mg twice daily.
C. Change lisinopril to losartan 100 mg/day.
D. Increase carvedilol to 50 mg twice daily.
This patient’s blood pressure goal is less than 130/80 mm Hg according to the ACC/AHA guidelines, and additional treatment is needed.
Loop diuretics (Answer B) work well for patients with renal insufficiency.
Answer A is incorrect because this patient’s potassium concentration is above the recommended concentration to initiate spironolactone (greater than 5 mEq/L), and her GFR is too low for therapy to benefit.
Answer C is incorrect because changing from lisinopril to losartan would probably not lower blood pressure. Answer D is incorrect because carvedilol for this patient is at the maximum recommended dose.
Correct Answer: B
B.L. is a 62-year-old white man who has had type 2
diabetes for the past 25 years. He is a moderate alcohol consumer (3 drinks per night, with occasional binges) and is obese (BMI 40.1 kg/m2). In the past year, he had an MI and 5-vessel coronary artery bypass graft
(CABG). He has well-controlled HTN (125/70 mm
Hg). He currently takes metformin 1000 mg twice
daily, liraglutide 1.8 mg subcutaneously once daily,
aspirin 81 mg/day, rosuvastatin 10 mg/day, metoprolol
25 mg twice daily, lisinopril 40 mg/day, and nitroglycerin 0.4 mg sublingually as needed. Fasting laboratory test results show TC 148 mg/dL, TG 220 mg/dL, HDL 32 mg/dL, LDL 72 mg/dL, non-HDL 116 mg/dL, SCr 1.3 mg/dL, Na 142 mEq/L, K 4.5 mEq/L, hemoglobin A1C (A1C) 6.8%, and alanine aminotransferase (ALT) 75 IU/L (history of ALT readings of 56–92 IU/L during the past 3 years). His primary care physician asks you about his chronically elevated ALT concentration and about continuing his statin therapy. Which is the best response?
A. Decrease rosuvastatin to 5 mg/day.
B. Change rosuvastatin to ezetimibe 10 mg/day.
C. Continue rosuvastatin 10 mg/day.
D. Increase rosuvastatin to 20 mg/day.
According to the 2018 AHA/ACC Multi-society cholesterol guidelines, 2020 AACE/ACE consensus statement on cholesterol management, and the 2021 ADA standards of care, patients with clinical ASCVD should receive high intensity statin therapy. The only high-intensity statin therapy included in the options for this case is rosuvastatin 20 mg/day mg/day, making Answer D correct.
Answer C is incorrect because rosuvastatin 10 mg/day is considered moderate intensity.
Answer A is incorrect because a mild, chronic ALT elevation will not be adversely affected by statin therapy, and lowering the dose will not likely improve this.
Answer B is incorrect because ezetimibe monotherapy has not reduced morbidity or mortality in clinical trials to date. Additionally, per the 2020 AACE/ACE consensus statement, this patient would be considered
extreme risk due to having ASCVD and diabetes, making the LDL goal <55 mg/dL.
Correct Answer: D
A.H. is a 45-year-old African American woman with
chronic obstructive pulmonary disease and atrial fibrillation for whom metoprolol was changed to verapamil today because of severe lung disease. Today, her BP is 126/78 mm Hg. She has been taking simvastatin 40 mg/day for cholesterol for the past 4 years. Her fasting laboratory test results show TC 196 mg/dL, TG 85 mg/dL, HDL 50 mg/dL, LDL 129 mg/dL, non-HDL 146 mg/dL, SCr 1.3 mg/dL, Na 141 mEq/L, and K 4.0 mEq/L. Her baseline 10-year ASCVD risk score is
20%. Which is best to address her lipid values?
A. No change in therapy is currently warranted.
B. Change simvastatin to rosuvastatin 20 mg/day.
C. Change simvastatin to lovastatin 40 mg twice
daily.
D. Increase the simvastatin dose to 80 mg/day
Answer A is incorrect; a therapy change is needed because simvastatin is metabolized primarily by the CYP3A4 isoenzyme system, and verapamil competes for this same metabolic pathway. Answer C is incorrect; the maximal dose of lovastatin has similar risks. Answer D is incorrect; although the coadministration of simvastatin and verapamil is not contraindicated, the simvastatin dose should be decreased to 10 mg/day to reduce the risk of rhabdomyolysis. Rosuvastatin is metabolized through an alternative pathway and does not interact with verapamil, making Answer B correct. In addition, high-intensity statin therapy is indicated for this patient, according to the 2018 AHA/ACC Multi-society guidelines, because her baseline 10-year ASCVD risk score is 20%.
Correct Answer: B
P.T. is a 73-year-old Asian woman with a history of
coronary artery disease (CAD; with stent placement
5 years ago). She has adhered to her medication regimen since her stent placement without problems. Her primary care physician checked her CK concentration because of muscle pain that she described as moderate in severity. Her medication regimen has been stable
for the past 3 years and includes atorvastatin 40 mg/
day, aspirin 81 mg/day, carvedilol 6.25 mg twice daily,
and omeprazole 20 mg as needed. Fasting laboratory
test results show TC 135 mg/dL, TG 85 mg/ dL, HDL
50 mg/dL, LDL 68 mg/dL, non-HDL 85 mg/dL, SCr
1.2 mg/dL (CrCl [ideal body weight {IBW}] 32 mL/
minute), Na 141 mEq/L, K 4.0 mEq/L, and CK 503
U/L (normal limits 20–200 U/L). Which is the next
best step for P.T.?
A. Continue atorvastatin 40 mg/day and continue
monitoring patient symptoms.
B. Discontinue atorvastatin permanently because the
patient is statin intolerant.
C. Hold atorvastatin and reassess the patient’s symptoms in 2–4 weeks.
D. Lower the atorvastatin dose to 20 mg every evening and continue monitoring patient symptoms.
This patient has moderate symptoms with a CK elevation
less than 10 times the ULN; hence, statin therapy should be held and symptoms reassessed in 2–4 weeks. If symptoms have resolved, the patient can be rechallenged with the same statin at the same dose, the same statin at a lower dose, or a different statin. Answers A and D are incorrect because they continue atorvastatin. Answer B is incorrect because
patients are not defined as statin intolerant until they have had symptoms on two or three different statins, preferably those with alternative metabolic pathways, at least one of which was at the lowest dose when the symptoms occurred. Answer C is correct because statin therapy is being held and the patient is being reassessed at an appropriate time.
Correct Answer: C
J.M. is a 41-year-old African American man who arrives
at the clinic for a follow-up. Three months ago, he was
told for the first time that his cholesterol concentration
was high and that he had to work on his diet and exercise. He is otherwise healthy, does not smoke, and takes no prescription medications. His BP today is 121/68 mm Hg. Fasting laboratory test results today show TC 262 mg/dL (down from 273 mg/dL), TG 145 mg/dL (down from 160 mg/dL), HDL 42 mg/dL (no change), LDL 191 mg/dL (down from 199 mg/dL), non-HDL 220 mg/dL (down from 231 mg/dL), and SCr 1.0 mg/dL. Which is best for treating his cholesterol, according to the 2018 American Heart Association (AHA)/American College of Cardiology (ACC) Multisociety treatment guidelines for blood cholesterol?
A. Continue to work on diet and exercise; no
medications are needed.
B. Continue to work on diet and exercise, and initiate
atorvastatin 80 mg/day.
C. Continue to work on diet and exercise, and initiate
lovastatin 20 mg/day.
D. Continue to work on diet and exercise, and initiate
simvastatin 40 mg every evening.
Because the patient’s LDL remains greater than 190
mg/ dL, the 2018 ACC/AHA Multisociety cholesterol
guidelines recommend a high-intensity statin such as atorvastatin 80 mg/day, making Answer B correct and Answer A incorrect. Answers C and D are incorrect because they recommend initiating moderate- and low-intensity statins, respectively.
Correct Answer: B
J.T. is a 36-year-old man with heterozygous familial
hypercholesterolemia (HeFH) who arrives at the primary care clinic for a follow-up. He currently takes
atorvastatin 80 mg/day. He reports adherence to his
medication and states that he follows a low-fat diet and exercises 40 minutes/day 4 days/week. Fasting laboratory test results today show TC 275 mg/dL (baseline 320 mg/dL), TG 204 mg/dL (baseline 265 mg/dL), HDL 75 mg/dL (increased from 50 mg/dL), LDL 160 mg/dL (down from 217 mg/dL), and non-HDL 200
mg/dL (down from 270 mg/dL). Which would best
treat his cholesterol according to the 2018 AHA/ACC
Mutisociety cholestrol guidelines?
A. Initiate alirocumab 75 mg subcutaneously every
2 weeks.
B. Initiate ezetimibe 10 mg/day.
C. Initiate fenofibrate 54 mg/day.
D. Initiate colesevelam 3750 mg/day.
This patient’s disease would be categorized into statin benefit group 2 according to the 2018 AHA/ACC Multi-society cholesterol guidelines because of a baseline LDL of 190 mg/dL or greater. These patients should take a high-intensity statin to achieve 50% or more LDL lowering.
The patient is currently receiving maximum doses of both atorvastatin and has achieved around 26% LDL lowering. The guidelines state that adding ezetimibe is reasonable if the LDL remains 100 mg/dL or greater after patients have received maximally tolerated statin therapy; Answer B is correct.
Answer A is incorrect because PCSK9 inhibitors are
considered only after patients have received maximally tolerated statin therapy plus ezetimibe and their LDL remains at 100 mg/dL or greater.
Fenofibrate is primarily used for TG lowering and can increase LDL values, making Answer C incorrect. Although bile acid sequestrants provide additional LDL lowering, they can also increase TG values and have a relative contraindication with TG concentrations greater than 200 mg/dL, making Answer D incorrect.
Correct Answer: B
A 65-year-old woman who had a minor ischemic
stroke (National Institutes of Health Stroke Scale
[NIHSS] score of −2) 3 weeks ago presents for a
follow-up. Her current medications include aspirin
81 mg/day (taking before the stroke), clopidogrel 75
mg/day, chlorthalidone 25 mg/day, lisinopril 40 mg/
day, and atorvastatin 80 mg/day. The medical resident
has requested an evaluation of the patient’s antiplatelet therapy. Which recommendation would best reduce the patient’s risk of recurrent stroke while minimizing the risks of bleeding?
A. Continue clopidogrel and aspirin for a total of 90
days and then continue clopidogrel indefinitely.
B. Continue both aspirin and clopidogrel indefinitely.
C. Discontinue both clopidogrel and aspirin and initiate ticagrelor 90 mg twice daily indefinitely.
D. Discontinue clopidogrel and increase aspirin dose
to 325 mg/day indefinitely
The 2021 AHA/ASA secondary stroke prevention guidelines recommend that, for a minor ischemic stroke (NIHSS score 3 or less) or high-risk TIA (ABCD score 4 or greater), DAPT with aspirin and clopidogrel should be initiated early (ideally within 12–24 hours of symptom onset and at least within 7 days of onset), which can be continued for 21–90 days, followed by SAPT indefinitely (Answer A is correct).
Continuing DAPT indefinitely is not recommended because of a higher risk of bleeding (Answer B is incorrect).
Ticagrelor has no evidence to support indefinite use for secondary stroke prevention (Answer C is incorrect). There is no evidence that increasing aspirin to 325 mg/day is more effective in secondary stroke prevention, but it does increase bleeding risk (Answer D is incorrect)
Correct Answer: A
Name two non DHP meds
Verapamil and Diltiazem
