Cardiology 1 Flashcards
1
Q
Questions 1 and 2 pertain to the following case.
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%.
1. 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.
2. 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.
A
- Answer: D
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 2022 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. - Answer: C
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 Multisociety 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
2
Q
- J.R. is a 55-year-old man (weight 66 kg) with a medical history significant for HTN and a myocardial
infarction (MI) 2 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?
Cardiology I
ACCP/ASHP 2023 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
118
A. Decrease the aspirin dose to 81 mg/day and add
lisinopril 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
A
- Answer: A
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) and his LDL is less than 70 mg/dL, 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
3
Q
- 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.
A
- Answer: D
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 choice of single antiplatelet
therapy. Recent guidelines do provide the option to discontinue DAPT after 1–3 months, but if this is done, aspirin
should be discontinued and the P2Y12 inhibitor continued
4
Q
- 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
A
- Answer: D
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. The 2022 Chest
Perioperative Management of Antithrombotic Therapy recommends that in the setting of elective noncardiac surgery,
aspirin should be continued; Answers A and B are incorrect. Clopidogrel should be held 5 days prior to surgery,
not 7 days. Answer D is correct and Answer C is incorrect.
5
Q
- G.F. is a 50-year-old 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
A
- Answer: C
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).
6
Q
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.
7. 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.
8. 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
A
- Answer: D
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 - Answer: B
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.
7
Q
- 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 2.1 mg/dL (glomerular filtration
rate [GFR] 29 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.
A
- Answer: B
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.
8
Q
- B.L. is a 62-year-old 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
tartrate 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.
A
- Answer: D
According to the 2018 AHA/ACC Multisociety cholesterol guidelines, 2020 AACE/ACE consensus statement on
cholesterol management, and the 2022 ADA standards of
care, patients with clinical ASCVD should receive highintensity 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
9
Q
- A.H. is a 45-year-old 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
A
- Answer: B
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 Multisociety guidelines, because her baseline 10-year
ASCVD risk score is 20%, categorizing her as high risk.
10
Q
- P.T. is a 73-year-old 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.
A
- Answer: C
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
11
Q
- 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
A
- Answer: B
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
12
Q
- 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 bempedoic acid 180 mg/day.
B. Initiate ezetimibe 10 mg/day.
C. Initiate fenofibrate 54 mg/day.
D. Initiate colesevelam 3750 mg/day.
A
- Answer: B
This patient’s disease would be categorized into statin benefit group 2 according to the 2018 AHA/ACC Multisociety
cholesterol guidelines because of a baseline LDL of 190
mg/ dL or greater. These patients should take a highintensity 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
2022 ACC Expert Consensus Decision Pathway for nonstatin therapy recommends initiation of ezetimibe and/or a
PCSK9 mAb if the patient is on a high-intensity statin and
has achieved an LDL reduction of less than 50%, has an
LDL of 100 mg/dL or higher, or has a non-HDL of 130 mg/
dL or higher; Answer B is correct. Answer A is incorrect
because bempedoic acid is recommended after the combination of a high-intensity (or maximally tolerated) statin,
ezetimibe, and a PCSK9 mAb. 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.
13
Q
- 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
A
- Answer: A
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).
14
Q
- A 60-year-old patient has been recently diagnosed
with stable ischemic heart disease (SIHD). Their past
medical history is significant for hypertension, hyperlipidemia, and chronic obstructive pulmonary disease.
They report anginal symptoms that occur 1–2 times
per week with exertion that is relieved by rest. Current
medications include lisinopril 40 mg daily, chlorthalidone 25 mg daily, atorvastatin 40 mg daily, fluticasone
100 mcg/umeclidinium 62.5 mcg/vilanterol 25 mcg
once daily, and aspirin 81 mg daily. BP is 138/82 mm
Hg, heart rate (HR) is 78 bpm. Laboratory values are
within normal limits. What is the most appropriate
recommendation for treatment of this patient’s SIHD?
A. Initiate nadolol 40 mg daily and clopidogrel 75
mg daily.
B. Initiate bisoprolol 5 mg daily and continue aspirin
81 mg daily.
C. Initiate diltiazem 120 mg daily and increase aspirin to 325 mg daily.
D. Initiate amlodipine 5 mg daily and ticagrelor 90
mg twice daily
A
- Answer: B
Both beta-blockers and calcium channel blockers can be
used for treatment of stable angina. However, beta-blockers
are generally considered first line therapy; Answers C and
D are incorrect. Because the patient has chronic obstructive
pulmonary disease, a beta-1 selective beta-blocker should
be used, so Answer B is correct and Answer A is incorrect.
If the patient cannot tolerate the beta-blocker, or if symptoms persist with the beta-blocker, it would be appropriate
to use CCBs. Amlodipine can be used in combination with
beta-blockers and is effective for relief of angina, but the
non-dihydropyridine CCBs should be avoided in combination with beta-blockers due to risk of AV block and
bradycardia. The CHARISMA trial demonstrated no difference in CV outcomes with clopidogrel plus aspirin, but
there was an increased risk of bleeding. The THEMIS trial
evaluated ticagrelor and aspirin in patients with type 2 diabetes and stable CAD and demonstrated a reduction in CV
outcomes, but the risk of bleeding outweighed the benefit.
Based on available evidence, DAPT is not recommended
in patients with SIHD without prior stent implantation and
no history of MI ACS, or CABG within the previous 12
months; Answers A and D are incorrect. Aspirin is recommended for patients with SIHD, but low dose aspirin
71–162 mg/day are preferred, so it is most appropriate to
continue aspirin 81 mg; Answer B is correct, Answer C is
incorrect
