Cardiology 2 Flashcards
- B.C., a 40-year-old woman (height, 65 inches; weight, 75 kg), presents to the emergency department (ED) with shortness of breath and lower extremity swelling in her left leg. Her diagnosis is a new acute pulmonary embolism, which was identified on chest computed tomography. Her medical history includes deep vein thrombosis (DVT) 2 years ago (treated with anticoagulation therapy for 3 months and then stopped), factor V Leiden mutation, hypertension (HTN), and dyslipidemia. Her medications are lisinopril 40 mg orally daily, atorvastatin 10 mg orally daily, and aspirin 81 mg orally daily. Initial laboratory values include hematocrit (HCT) 40% (normal 42%–52%), prothrombin time (PT) 9.9 seconds (normal 9.9–11.2 seconds), international normalized ratio (INR) 1.1, activated partial thromboplastin time (aPTT) 30 seconds (normal 24–36 seconds), platelet (Plt) count 300,000/mm3 (normal 150,000–300,000/mm3), and creatinine clearance (CrCl) 67 mL/minute. How long should this patient be treated with anticoagulation therapy?
A. 3 months.
B. 6 months.
C. 12 months.
D. Indefinitely.
With this being a recurrent VTE event and known factor V
Leiden deficiency, life-long therapy with anticoagulation is indicated, making answer D correct. Answers A, B, and C are incorrect because they are shorter lengths of treatment, which is not the best because she has known a factor V Leiden mutation and now has had two VTE events warranting life-long treatment.
Correct Answer: D
B.C., a 40-year-old woman (height, 65 inches; weight, 75 kg), presents to the emergency department (ED) with shortness of breath and lower extremity swelling in her left leg. Her diagnosis is a new acute pulmonary embolism, which was identified on chest computed tomography. Her medical history includes deep vein thrombosis (DVT) 2 years ago (treated with anticoagulation therapy for 3 months and then stopped), factor V Leiden mutation, hypertension (HTN), and dyslipidemia. Her medications are lisinopril 40 mg orally daily, atorvastatin 10 mg orally daily, and aspirin 81 mg orally daily. Initial laboratory values include hematocrit (HCT) 40% (normal 42%–52%), prothrombin time (PT) 9.9 seconds (normal 9.9–11.2 seconds), international normalized ratio (INR) 1.1, activated partial thromboplastin time (aPTT) 30 seconds (normal 24–36 seconds), platelet (Plt) count 300,000/mm3 (normal 150,000–300,000/mm3), and creatinine clearance (CrCl) 67 mL/minute. What is the most appropriate choice for anticoagulation for this patient?
A. Apixaban 5 mg orally twice daily.
B. Rivaroxaban 15 mg orally twice daily for 3 weeks
then 20 mg orally daily thereafter.
C. Enoxaparin 80 mg subcutaneous twice daily continued until INR is 2–3 with warfarin 5 mg orally
daily and titrated to goal INR range.
D. Aspirin 81 mg plus clopidogrel 75 mg orally daily.
Answer A is incorrect because the dosing is not appropriate for the treatment of a VTE. Answer B is correct because the CHEST guidelines recommend use of a DOAC over a VKA to treat a VTE, despite fewer data with DOACs than with warfarin in patients with thrombophilias like factor V Leiden mutation. Answer C is incorrect because DOACs are preferred to VKAs to treat VTE according to the CHEST guidelines, even though this is correct dosing for LMWH and warfarin. Aspirin plus clopidogrel is not an anticoagulant therapy, making answer D incorrect.
Correct Answer: B
B.G. is a 36-year-old man with a medical history of
dyslipidemia, hypertension, chronic obstructive pulmonary disease (COPD), and heart failure with reduced ejection fraction. His blood pressure today in clinic is 128/80 mm Hg with a heart rate of 60 beats/minute. His current medication regimen includes furosemide 20 mg orally once daily, metoprolol succinate 200 mg orally once daily, atorvastatin 20 mg orally once daily, tiotropium one 18-mcg inhalation once daily, and amlodipine 5 mg orally once daily. He has a history of lisinopril-induced angioedema. Which of the following is the best modification to his medication regimen based on the American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) heart failure guideline recommendations?
A. Add valsartan 80 mg orally daily.
B. Add eplerenone 50 mg orally daily.
C. Change furosemide to bumetanide 2 mg orally
daily.
D. Change metoprolol succinate to carvedilol 25 mg
orally twice daily
An angiotensin-converting enzyme (ACE) inhibitor or
ARB would be the next indicated heart failure medication, based on the ACCF/AHA heart failure guideline recommendations and clinical trial results. Starting the ARB valsartan 80 mg daily is the best choice for B.G. because of his lisinopril-induced angioedema, making answer A correct. Answer B is not correct because starting the aldosterone antagonist eplerenone is not appropriate for B.G., as he should be taking an ACE inhibitor or an ARB in addition to the β-blocker metoprolol succinate before adding an aldosterone antagonist. Answer C is not correct because hanging furosemide to bumetanide is not appropriate, as there is no evidence that B.G. is having issues with edema.
Answer D is not correct because changing metoprolol to
carvedilol is not appropriate, as there is no evidence to
support a preference for the use of carvedilol instead of
metoprolol succinate for the chronic management of heart failure based on morbidity or mortality.
Correct Answer: A
P.Y. is a 57-year-old woman who states that she has
had increased swelling in her legs over the last 2 weeks and increased shortness of breath in the last week. On physical examination, she has 2+ pitting edema bilaterally and no abnormal lung findings. She has a medical history of hypertension, heart failure with reduced ejection fraction (HFrEF), gout, hypothyroidism, and dyslipidemia. Her blood pressure today in clinic is 170/96 mm Hg with a heart rate of 76 beats per minute. Which of the following is the most likely cause of her symptoms in clinic today?
A. Uncontrolled hypertension.
B. Exacerbation of heart failure.
C. Acute myocardial infarction.
D. Peripheral artery disease.
Answer B is correct because exacerbation of heart failure is based on her history of heart failure and her presentation with fluid in her lungs and lower extremity edema. Answer A is incorrect because the patient would not develop pulmonary edema from elevation in blood pressure unless she was presenting with extreme blood pressure elevation and
hypertensive crisis. Her blood pressure today (170/96 mm Hg) is not extremely elevated to be consistent with hypertensive crisis. Answer C is incorrect because the patient’s presentation is not consistent with an acute myocardial infarction and because her symptoms have been occurring for 1–2 weeks and no chest pain is described. Answer D is incorrect because the patient does not have a history of peripheral artery disease and she is not reporting the pain that is typical in patients with peripheral artery disease.
Correct Answer: B
R.R. is a 62-year-old woman with congestive heart
failure is taking furosemide 80 mg orally twice daily,
lisinopril 40 mg orally once daily, and metoprolol
succinate 100 mg orally once daily. At her last clinic
visit, her serum creatinine had increased to 2.0 mg/
dL (her serum creatinine was 1.5 mg/dL 1 year ago).
This change was accompanied by a 12-lb weight loss
leaving her 5 lb less than her typical dry weight. The
patient states that she feels well. Which of the following treatment options is best for this patient?
A. Discontinue lisinopril and furosemide and recheck
labs in 1 week.
B. Discontinue lisinopril and recheck labs in 1 week.
C. Discontinue furosemide and recheck labs in 1
week.
D. Continue current therapy and recheck labs in 1
week.
Answer C is correct because discontinuing furosemide
and rechecking laboratory values in 1 week is the correct answer, and because the patient’s weight loss and increase in serum creatinine probably are the result of excessive diuresis. Her serum creatinine should decrease after stopping furosemide. Furosemide can be resumed at a future visit if the patient shows signs or symptoms of fluid overload, but a lower dose should be used at that time. Answer A is incorrect because lisinopril might be contributing to the rise in serum creatinine, but the drug seldom needs to be discontinued in this setting. Answer B is incorrect because the patient’s recent weight loss and increase in serum creatinine are the result of excessive diuresis and likely not related to her use of lisinopril. Answer D is incorrect because continuing current therapy and rechecking laboratory values in 1 week is incorrect, and the patient’s recent
weight loss and increase in serum creatinine are the result of excessive diuresis.
Correct Answer: C
R.R. is a 65-year-old white woman with a medical history of type 2 diabetes mellitus, dyslipidemia, atrial
fibrillation (AF), and gastroesophageal reflux disease
(GERD) presents for comprehensive medication management. Her AF was diagnosed about 2 years ago, and has been titrated to up to metoprolol succinate 200 mg daily. She currently has a blood pressure of 140/90 mm Hg and a heart rate of 98 beats/minute. She reports that she is still experiencing symptoms of AF with palpitations almost daily despite taking her metoprolol each day. Which one of the following target heart rates is best to recommend as a rate-control strategy for this patient?
A. Less than 150 beats/minute.
B. Less than 110 beats/minute.
C. Less than 80 beats/minute.
D. Less than 60 beats/minute.
The ACC/AHA guidelines recommend targeting a heart
rate goal of less than 110 beats/minute as the initial target
and then the more aggressive target of less than 80 beats/minute if the patient is still symptomatic at the higher goal (answer C is correct). The guidelines do not advocate a heart target of less than 150 beats/minute or less than 60 beats/minute (answers A and D are incorrect). The guidelines recommend that the more aggressive target of less than 80 beats/minute can be used if the patient is still symptomatic at the higher goal of less than 110 beats/minute (Answer B is incorrect).
Correct Answer: C
T.T. is a 68-year-old woman who presents to the
cardiology clinic for a routine follow-up. Her medical
history is significant for HTN, dyslipidemia, a transient
ischemic attack (TIA) 2 weeks ago, paroxysmal AF,
and HFrEF with an ejection fraction (EF) of 30%.
Implantable cardioverter-defibrillator interrogations
over the past year reveal that she has remained in
sinus rhythm. Her current cardiac medications include
aspirin 81 mg daily, metoprolol succinate 100 mg
daily, atorvastatin 40 mg daily, losartan 50 mg daily,
digoxin 125 mcg daily, amiodarone 200 mg daily, and
apixaban 5 mg twice daily. Her vital signs in the clinic are blood pressure 105/70 mm Hg and heart rate 62
beats/minute. Today, as you review her medications,
the patient says that she wishes she did not have to take so many medications. Which one of the following is best to recommend for discontinuation in this patient?
A. Aspirin.
B. Digoxin.
C. Amiodarone.
D. Metoprolol.
This patient has been in sinus rhythm for the past 12
months, and her current heart rate is within goal; therefore, digoxin would be the most appropriate medication to discontinue at this time (answer B is correct). Discontinuing digoxin would also avoid a drug–drug interaction with amiodarone, which should not be discontinued because the patient is currently in sinus rhythm (answer C is incorrect). Given her recent transient ischemic attack, discontinuing aspirin at this time would not be the best option, but this could be considered in the future (answer A is incorrect). Metoprolol should not be discontinued because the patient has HFrEF (answer D is incorrect).
Correct Answer: B
F.C. is a 72-year-old woman (weight 51 kg) who presents to the ED with tachycardia and shortness of breath and receives a diagnosis of AF. Her medical history is notable for HTN, type 2 diabetes, GERD, coronary artery disease (CAD), hyperlipidemia, and COPD. Her serum creatinine (SCr) is 0.6 mg/dL. Which one of the following is best to recommend for this patient’s stroke prevention?
A. Edoxaban.
B. Rivaroxaban.
C. Dabigatran.
D. Warfarin.
The ENGAGE AF-TIMI subanalysis examined 8474
patients older than 75 years to evaluate the risk-benefit
of edoxaban in older adults. No significant interaction
occurred between the treatment groups (edoxaban 30 mg vs. warfarin or edoxaban 60 mg vs. warfarin) and subgroups defined according to age younger than 75 or 75 and older in subgroup analysis of ENGAGE AF-TIMI 48 for the primary efficacy end point of stroke or systemic embolism, or for the primary safety end point of major bleeding, making answer A correct. In the subanalysis of the ROCKET-AF and RE-LY trials, no interaction was noted for age, but these agents were associated with an increase in GI bleeding, making answers B and C incorrect. DOACs are recommended over warfarin, making answer D incorrect.
Correct Answer: A
S.G. is a 54-year-old male patient who presents to the
ED with a chief complaint of intermittent palpitations
and shortness of breath for the past 3 weeks. The initial assessment reveals a blood pressure of 154/88 mmHg and heart rate 86 bpm, and an electrocardiogram (ECG) reveals atrial fibrillation. The team is considering synchronized cardioversion for this patient. Which of the following treatment recommendations is most appropriate for this patient at this time?
A. Anticoagulation is not needed before cardioversion, but it should be followed by 4 weeks of
anticoagulation with dose-adjusted warfarin.
B. Start treatment-dose heparin immediately, but
delay cardioversion by 48 hours, followed by 4
weeks of anticoagulation with dose-adjusted warfarin after cardioversion.
C. Start treatment-dose heparin immediately and
proceed with cardioversion now, followed by 4
weeks of anticoagulation with dose-adjusted warfarin after cardioversion.
D. Delay cardioversion, and begin anticoagulation
with dose-adjusted warfarin for 3 weeks before
and 4 weeks after cardioversion.
In a patient with a duration of atrial fibrillation greater
than 48 hours or unknown, the preferred recommendation is to administer anticoagulation for at least 3 weeks before and for at least 4 weeks after cardioversion (answer D is correct). This treatment strategy would reduce the risk of stroke associated with cardioversion, although the success of cardioversion does decrease as the duration of atrial fibrillation increases. Treatment options for anticoagulation before cardioversion include warfarin (INR 2–3), LMWH or UFH at treatment doses, dabigatran, rivaroxaban, or apixaban. It is important to note that this recommendation applies only to patients in which a delay in cardioversion would be acceptable. In those patients in need of emergent cardioversion (e.g., hemodynamically unstable), anticoagulation should not delay cardioversion.
Finally, as noted above, a transesophageal echocardiogram can be performed before cardioversion to evaluate for thrombus and to guide the duration of anticoagulation therapy. Answers A, B, and C are incorrect.
Correct Answer: D
P.L. is unresponsive to initiation of vasodilator treatment with a calcium channel blocker. The patient is classified as having pulmonary arterial hypertension
(PAH) functional class (FC) II. Which is the best next
combination therapy for treatment of PAH?
A. Riociguat and tafalafil.
B. Ambrisentan and tadalafil.
C. Bosentan and sildenafil.
D. Macitentan and sildenafil.
Answer B is correct because the combination of ambrisentan and tadalafil are recommended for PAH FC II. Answers A, C, and D are incorrect because they are all
recommended individually as monotherapy in PAH FC II,
but they are not recommended as combination therapy.
Correct Answer: B
What is the IV administration dose for unfractionated heparin for acute venous thromboembolism
Initial bolus and the initial rate of the continuous infusion can either be weight adjusted (80 units/kg IV bolus, followed by 18 units/kg/hr infusion) or a fixed dose (bolus 5000 units, followed by 1000 units/hr). Adjust subsequent doses to attain a goal aPTT or anti-Xa based on the institution specific therapeutic range
What is the SC administration dose for unfractionated heparin for acute venous thromboembolism
250 units/kg given every 12 hours (an initial 5000 unit IV bolus dose is recommended to attain rapid anticoagulation). Adjust subsequent doses to attain a goal aPTT based on the institution specific therapeutic range or 333 units/kg followed by 250 units/kg every 12 hours (fixed dose unmonitored dosing regimen) not practical for patients weighing > 80 kg (176lbs)
What is the SC dosing of fondaparinux
For body weight less than 50 kg (110 lb) use 5mg SC QD
For body weight 50 to 100 kg (110-220lb) use 7.5mg SC QD
For body weight greater than 100 kg (220lb) use 10 mg SC QD
CI in CrCl <30
What are the major adverse effects of amiodarone
CHOPTHS
Cardiac: prolong qt, sinus bradycardia
Hepatic: sx hepatitis, inc serum aminotransferase conc
Ocular: photophobia, blurred vision, halo vision
Pulmonary: interstitial pneumonitis, nonproductive cough, dyspnea
Thyroid: hypo, hyper
Skin: photosensitivity, bluish -slate grey discoloration
What is the apixaban dosing regimen for DVT
Oral:10 mg twice daily for 7 days followed by 5 mg twice daily.
