Chapter 8 Flashcards
A patient with a history of hypertension, diabetes, dyslipidemia, morbid obesity, and
chronic stable angina returns to clinic for follow-up evaluation. His current treatment
regimen includes aspirin 81 mg PO daily, metoprolol extended-release 50 mg PO daily,
candesartan 8 mg PO daily, rosuvastatin 20 mg PO daily, and nitroglycerin 0.4 mg SL as
needed. The patient is currently experiencing angina at rest and states that for the past
week the frequency of episodes has increased from once monthly to once daily. Blood
pressure is 128/64 mm Hg and heart rate is 70 beats/min. Which of the following
interventions is recommended at this time?
A. Add isosorbide mononitrate 30 mg PO daily
B. Increase metoprolol to 100 mg PO daily
C. Refer the patient to the hospital
D. Schedule an outpatient coronary angiogram
Option C: Correct. The patient’s symptoms (angina at rest, increased frequency over a
short period of time) are consistent with ACS. Referral to the hospital is warranted.
Which patient scenario portrays a typical presentation of a patient with angina due to
SIHD?
A. A 55-year-old man complaining of recurrent squeezing pain in his chest for the last
3 days that first occurred when walking his dog and is now occurring more often
and while at rest
B. A 28-year-old woman complaining of intermittent chest pressure on four to five
mornings each week that resolves in 2 to 3 hours
C. A 62-year-old woman complaining of tightness in the middle of her chest after
walking three blocks that subsides when she rests
D. A 48-year-old man complaining of a burning in his chest each evening after dinner
that resolves in 30 to 60 minutes
Option C: Correct. The patient’s symptoms (chest tightness after exertion, resolution of
the pain with rest) are most consistent with stable angina.
Which drug therapy is best for relieving acute symptoms of angina?
A. Metoprolol
B. Nitroglycerin
C. Clopidogrel
D. Diltiazem
Option B: Correct. Nitroglycerin sublingual (tablets or spray) is a short-acting nitrate for
relieving an acute anginal attack.
A 47-year-old man has been prescribed sublingual nitroglycerin (NTG) tablets for acute
relief of angina symptoms. When counseling him on the proper use of sublingual NTG,
which of the following statements is correct regarding when to call 9-1-1?
A. Call 9-1-1 if symptoms have not subsided 5 minutes after administration
B. Call 9-1-1 if symptoms have not subsided 30 minutes after administration
C. Call 9-1-1 prior to taking nitroglycerin
D. Take one tablet every 5 minutes as needed for a maximum of three doses; call 9-
1-1 if symptoms remain 5 minutes after the third dose
Option A: Correct. If angina persists more than 5 minutes after administration of the first
dose of sublingual NTG, patient is at high risk for ACS and emergency care should be
sought.
A 71-year-old woman comes into your pharmacy complaining of exertional chest pain.
She currently takes atenolol 50 mg PO daily, amlodipine 5 mg PO daily, ramipril 10 mg
PO daily, aspirin 81 mg PO daily, and rosuvastatin 10 mg PO daily. Which monitoring
parameters are needed for you to make a recommendation to relieve her angina
symptoms?
A. Blood pressure and renal function
B. Heart rate and renal function
C. Blood pressure and heart rate
D. Heart rate and potassium
Option C: Correct. The patient is on two antianginal therapies currently, atenolol and
amlodipine, and neither is at maximum doses. To determine the best recommendation,
you need to know if the dose of either agent can be increased. This would depend on
blood pressure and heart rate for atenolol and blood pressure for amlodipine.
A 64-year-old woman with a history of hypertension, atrial fibrillation, dyslipidemia,
asthma, and stable ischemic heart disease is being treated with lisinopril 2.5 mg PO daily,
diltiazem extended-release 240 mg PO daily, atorvastatin 40 mg PO daily,
fluticasone/salmeterol 250/50 mcg inhaled twice daily, and aspirin 81 mg PO daily. Her
blood pressure is 118/70 mm Hg and heart rate is 62 beats/min. The physician would like
to begin ranolazine and wants your opinion. Which is the best response?
A. Ranolazine can be used at a dose not to exceed 500 mg PO twice daily
B. Ranolazine should not be used since the patient is on a potent CYP3A4 inhibitor
C. Ranolazine can be used, but the dose of atorvastatin should be reduced to 20 mg
D. Ranolazine can be used without any restrictions
Option A: Correct. The dose of ranolazine should not exceed 500 mg PO twice daily
since the patient is taking diltiazem, a moderate CYP3A4 inhibitor.
A 55-year-old man with SIHD, hypertension, diabetes, and dyslipidemia presents to clinic
for follow-up evaluation. He does not complain of any anginal symptoms and reports no
use of sublingual NTG. His current medications include carvedilol 25 mg PO twice daily,
metformin 1000 mg PO twice daily, aspirin 162 mg PO daily, and atorvastatin 40 mg PO
daily. His blood pressure in the office is 148/96 mm Hg with heart rate of 60 beats/min.
Laboratory studies show total cholesterol 140 mg/dL (3.62 mmol/L), triglycerides 145
mg/dL (1.64 mmol/L), HDL cholesterol 48 mg/dL (1.24 mmol/L), LDL cholesterol 63
mg/dL (1.63 mmol/L), fasting plasma glucose 140 mg/dL (7.8 mmol/L), and hemoglobin
A 1c 8% (0.08; 64 mmol/mol Hb). All other laboratory values are within normal limits.
Which of the following changes to his care plan is most appropriate at this time?
A. Add liraglutide 0.6 mg subcutaneously daily and isosorbide mononitrate 30 mg PO
daily
B. Add empagliflozin 10 mg PO daily and increase atorvastatin to 80 mg PO daily
C. Add liraglutide 0.6 mg subcutaneously daily and benazepril 10 mg PO daily
D. Add empagliflozin 10 mg PO daily and amlodipine 5 mg PO daily
Option C: Correct. The patient’s A 1C is above goal, and since the patient has diabetes and
ASCVD, addition of GLP-1 receptor agonist is recommended. Additionally, given the
patient’s diabetes and SIHD along with uncontrolled hypertension, addition of an ACE-I
is recommended.
A 48-year-old man with a past medical history of hypertension and dyslipidemia recently
underwent evaluation for chest tightness and pressure when exerting himself (climbing
stairs, walking long distances). He was diagnosed with angina and found to have SIHD on
coronary angiography. His blood pressure is 148/92 mm Hg and heart rate is 78 beats/min
on lisinopril 5 mg PO daily. Which medication is appropriate to prevent further anginal
episodes?
A. Isosorbide mononitrate
B. Amlodipine
C. Carvedilol
D. Nitroglycerin sublingual tablets
Option C: Correct. The patient was recently diagnosed with SIHD and angina and needs
initial treatment to prevent angina occurrence. A β-blocker is the preferred initial therapy
due to the possible cardioprotective benefits.
A 63-year-old woman with a past medical history of dyslipidemia and chronic stable
angina is treated with aspirin 81 mg PO daily, metoprolol extended-release 200 mg PO
daily, simvastatin 40 mg PO daily, and sublingual nitroglycerin as needed. Her angina
symptoms are currently well controlled. Her blood pressure is 148/90 mm Hg, and heart
rate is 70 beats/min. What is the most appropriate addition to therapy to improve the
management of this patient’s stable ischemic heart disease?
A. Isosorbide dinitrate
B. Ramipril
C. Ranolazine
D. Verapamil
Option B: Correct. The patient has established SIHD, is hypertensive, and angina
symptoms are controlled. Evidence supports the use of ACE inhibitors in patients with
IHD to reduce the risk of MACE and should be considered in all patients with IHD unless
a contraindication is present.
A 69-year-old woman with a history of hypertension, hyperlipidemia, osteoporosis, and
stable ischemic heart disease is taking candesartan 8 mg PO daily, carvedilol 25 mg PO
twice daily, rosuvastatin 10 mg PO daily, alendronate 70 mg PO one time weekly, aspirin
81 mg PO daily, and nitroglycerin 0.4 mg SL as needed. She reports chest pain over the
last 4 weeks with exertion. The pain resolves when she rests, but she has had to use her
sublingual nitroglycerin at least daily. Her blood pressure is 152/88 mm Hg and heart rate
is 80 beats/minute. Which is the most appropriate recommendation to manage her anginal
symptoms?
A. Increase candesartan to 16 mg PO daily
B. Add diltiazem extended-release 120 mg PO daily
C. Add ranolazine 500 mg PO twice daily
D. No change in therapy is needed
Option B: Correct. The patient is having more angina on exertion and using more
sublingual nitroglycerin, which indicates that her angina is not controlled. She is taking
the maximum dose of carvedilol, so add-on therapy is warranted. Since her blood
pressure and heart rate are not controlled, the addition of a nondihydropyridine CCB
would be the best choice.
A 56-year-old man recently diagnosed with stable ischemic heart disease presents to clinic
for routine follow-up. Past medical history is significant for hypertension, diabetes, and
gastroesophageal reflux disease (GERD). His symptoms are well controlled allowing him
to walk on the treadmill five times weekly for 30 minutes, maintaining a body mass index
of 25 kg/m 2 . His current medications include valsartan 160 mg PO daily, carvedilol 12.5
mg PO twice daily, metformin 1000 mg PO twice daily, aspirin 81 mg PO daily, and
omeprazole 40 mg PO daily. Blood pressure is 124/74 mm Hg and heart rate is 64
beats/min. Lipid studies reveal total cholesterol 242 mg/dL (6.26 mmol/L), triglycerides
389 mg/dL (4.40 mmol/L), HDL cholesterol 39 mg/dL (1.01 mmol/L), and LDL
cholesterol 125 mg/dL (3.23 mmol/L). Which of the following changes to his care plan is
most appropriate at this time?
A. Add atorvastatin 80 mg PO daily
B. Increase aerobic exercise to 60 minutes five times weekly
C. Increase aspirin to 325 mg PO daily
D. Increase carvedilol to 25 mg PO twice daily
Option A: Correct. The patient has untreated dyslipidemia and stable ischemic heart
disease. Therefore, a high-intensity statin like atorvastatin is indicated.
A 66-year-old woman with stable ischemic heart disease, hypertension, and peptic ulcer
disease is referred for an elective coronary angiogram after complaining of increased
frequency of angina. The angiography reveals an 80% occlusion in the left anterior
descending coronary artery for which percutaneous coronary intervention is performed and a drug-eluting stent is placed. The patient is prescribed aspirin 81 mg PO daily and clopidogrel 75 mg PO daily. What is the minimum length of time this patient should be
treated with dual antiplatelet therapy?
A. 1 month
B. 6 months
C. 12 months
D. Indefinitely
Option B: Correct. Based on recent guidelines, patients with SIHD who undergo PCI
with DES placement should be treated for a minimum of 6 months with DAPT.
A 32-year-old woman with a history of anxiety is taking fluoxetine 20 mg PO daily. She is
an occasional smoker and does CrossFit four times per week. She presented complaining
of chest tightness that wakes her up at 6 am each morning for the last 6 weeks. The pain
lasts for about 10 minutes but will recur intermittently until around 11 AM. After a cardiac work-up, she was diagnosed with variant angina (or Prinzmetal angina). Her blood
pressure is 134/86 mm Hg and heart rate is 78 beats/min. The medical intern is not
familiar with the diagnosis and asks your recommendation on the best management for the patient. What is your recommendation?
A. Add metoprolol extended-release 12.5 mg PO daily
B. Add aspirin 81 mg PO daily
C. Add isosorbide dinitrate slow-release 40 mg PO twice daily at 8 AM and 2 PM
D. Add verapamil extended-release 120 mg PO daily
Option D: Correct. The patient was diagnosed with variant or Prinzmetal angina, which is
angina caused by vasospasm. A calcium channel blocker, such as verapamil, is the
preferred treatment.
A 62-year-old man with a history of hypertension, dyslipidemia, diabetes, stable ischemic heart disease, and remote history of myocardial infarction presents to his initial visit with his new primary care physician. Currently, the patient is asymptomatic and denies any
recent episodes of chest pain. Current medications include bisoprolol 5 mg PO daily,
valsartan 160 mg PO daily, atorvastatin 40 mg PO daily, glipizide 5 mg PO twice daily,
and nitroglycerin 0.4 mg SL as needed for chest pain. Vital signs reveal a blood pressure
of 118/78 mm Hg and heart rate of 68 beats/min. Which of the following medications
should be added to his regimen?
A. Aspirin 81 mg PO daily
B. Clopidogrel 75 mg PO daily
C. Felodipine 5 mg PO daily
D. Lisinopril 10 mg PO daily
Option A: Correct. Aspirin has been consistently shown to decrease risk of MACE in
patients with SIHD and should be added to all patients with SIHD unless a
contraindication is present.
A 75-year-old woman with a history of myocardial infarction, heart failure with reduced
ejection fraction (left ventricular ejection fraction 35% [0.35]), hypertension,
dyslipidemia, diabetes, and chronic obstructive pulmonary disease presents to the clinic
for routine follow-up evaluation. She complains of stable but persistent episodes of chest
tightness when riding her stationary bike, limiting her ability to complete her exercise
program. Her current medications include carvedilol 12.5 mg PO twice daily, aspirin 81
mg PO daily, rosuvastatin 20 mg PO daily, enalapril 10 mg PO twice daily, metformin
1000 mg PO twice daily, tiotropium 18 mcg via inhalation daily, and an albuterol inhaler
as needed. Vital signs include blood pressure 146/92 mm Hg and heart rate 62 beats/min.
On physical examination, she has mild jugular venous distention and 1+ lower extremity
edema in her ankles consistent with a mild, acute heart failure exacerbation. What is the
most appropriate intervention to prevent recurrent angina symptoms in this patient?
A. Add amlodipine 2.5 mg daily
B. Add nitroglycerin 0.4 mg SL as needed
C. Add ranolazine 500 mg PO twice daily
D. Increase carvedilol to 25 mg PO twice daily
Option A: Correct. Amlodipine is an effective adjunct to β-blockers to reduce symptoms
of angina. In addition, amlodipine will also treat the patient’s uncontrolled blood
pressure.
