Self-Assessment Questions Flashcards
A 62-year-old man presents to the emergency
department (ED) with the chief concern of chest
pain that woke him from sleep and radiates to
his jaw. An electrocardiogram (ECG) reveals
ST-segment depression in leads II, III, and aVF.
His blood pressure is 112/62 mm Hg and heart rate
is 60 beats/minute. Cardiac enzymes have been
obtained, and the first troponin result was slightly
positive. Preparations are under way to take the
patient to the cardiac catheterization laboratory
for evaluation. Which medication regimen is most
appropriate for this patient at this time?
A. Aspirin 325 mg, clopidogrel 600-mg loading dose (LD), and unfractionated heparin
(UFH) infusion 80-unit/kg bolus, followed
by 18 units/kg/hour and metoprolol 5 mg
intravenously.
B. Aspirin 81 mg; prasugrel 60-mg LD; UFH
infusion 60-unit/kg bolus, followed by 12
units/kg/hour; and intravenous enalaprilat.
C. Aspirin 325 mg, ticagrelor 180-mg LD, and
UFH infusion 60-unit/kg bolus, followed by
12 units/kg/hour.
D. Aspirin 81 mg, prasugrel 60-mg LD, nitroglycerin infusion at 10 mcg/minute, and
bivalirudin 0.75-mg/kg bolus and 1.75-mg/kg/
hour infusion.
Answer: C
This patient’s chest pain, ST-segment depression on
ECG, and positive biomarkers for myocardial necrosis suggest NSTE-ACS. Because of his presentation
characteristics, he is at a high enough risk to warrant
cardiac catheterization (invasive strategy). This invasive strategy is used to determine whether occluded or
partly occluded epicardial arteries exist, which ones
can be intervened on, and whether to do PCI (percutaneous transluminal coronary angioplasty with or without stenting). Initial therapy for ACS usually consists of
morphine, oxygen, nitroglycerin, and aspirin, but only
aspirin has been shown to reduce mortality from these
initial treatments. Aspirin should be given as soon
as possible after hospital presentation and continued
indefinitely, if tolerated. According to clinical trials,
guidelines, and experience, an initial dose of 162–325
mg is recommended (Answers B and D are not the
best choices of dosing for an acute episode). Aspirin,
together with a P2Y12 receptor antagonist, is indicated
for an early invasive strategy in the management of UA/
NSTEMI, improving outcomes. The 2014 NSTE-ACS
guidelines give a class I recommendation for clopidogrel, ticagrelor, and prasugrel in ACS for patients
undergoing PCI. The choice of which P2Y12 receptor
antagonist to use in the ACS setting depends on patient
presentation, contraindications, and whether PCI is
involved; in this case, any of the three P2Y12 antagonists
would be appropriate. The anticoagulation strategy
treatment for ACS generally includes one anticoagulant
(UFH, low-molecular-weight heparin, fondaparinux, or
bivalirudin). When UFH is chosen as an anticoagulant
strategy, the dose used for ACS is a 60-unit/kg bolus
and a 12-unit/kg/hour infusion (Answer A is incorrect).
Regarding dosing, bivalirudin (Answer D) would be an
appropriate anticoagulation strategy; however, the initial aspirin dose should be higher, and a nitroglycerin
drip would not be the best choice, given his right-sided
MI (low blood pressure, low heart rate). Answer A is
reasonable in patients without contraindications when
hypertension or ongoing ischemia is a concern; however, initiating oral therapy within 24 hours is preferred
in most patients as long as they have no signs of HF,
evidence of low output state, increased risk of cardiogenic shock, or other contraindications to β-blockade.
β-Blockers should initially be avoided in this patient,
given his blood pressure and decreased baseline heart rate. An intravenous ACE inhibitor (Answer B) should
not be given to patients within the first 24 hours of ACS
because of the increased risk of hypotension. Answer C
includes DAPT and an appropriate anticoagulant dose
(Answer C is correct).
An 81-year-old African American man (weight 90
kg) presents to the ED with chest pressure (10/10
on a pain scale). His ECG reveals ST-segment
depression in the inferior leads. His medical history is significant for hypertension and chronic
kidney disease. Pertinent laboratory results are troponin 5.8 ng/L, serum creatinine (SCr) 3.7 mg/dL,
and estimated creatinine clearance (eCrCl) 20 mL/
minute. The patient has been given aspirin 325
mg single dose; a nitroglycerin drip, initiated at 5
mcg/minute, will be titrated to chest pain relief and
blood pressure. The patient consents for cardiac
catheterization after adequate hydration. Which
anticoagulation strategy is most appropriate to initiate in this patient?
A. Intravenous heparin 4000-unit intravenous
bolus, followed by a 1000-unit/hour continuous infusion.
B. Enoxaparin 90 mg subcutaneously every 12
hours.
C. Fondaparinux 2.5 mg subcutaneously daily.
D. Bivalirudin 67.5-mg bolus, followed by a 157-
mg/hour infusion
Answer: A
The NSTE-ACS guidelines recommend the use of one
anticoagulant during an acute event. Enoxaparin, UFH,
and bivalirudin are all recommended as class I agents
for the invasive management of NSTE-ACS. However,
fondaparinux (Answer C) is not optimal because of the
increased risk of catheter-related thrombosis associated with its use in the catheterization laboratory. The
NSTE-ACS guidelines advise the use of an additional
anticoagulant with class IIa activity (heparin or bivalirudin) if fondaparinux was an initial anticoagulant
when the patient underwent intervention, whereas the
PCI guidelines give fondaparinux a class III or harmful
recommendation. Of the remaining three options, UFH
(Answer A) is preferred because of its dosage and rapid
clearance regardless of renal function. The UFH bolus
should be limited to 4000 units, and the initial infusion
should be limited to 1000 units/hour. Both enoxaparin (Answer B) and bivalirudin (Answer D) would be
appropriate but would need to be dose adjusted, given
this patient’s CrCl of less than 30 mL/minute. However,
the doses in Answers B and D would be appropriate for
patients with a normal CrCl.
A 56-year-old man presents to the hospital with
the chief concern of chest pain that was unrelieved
at home with sublingual nitroglycerin. His ECG
reveals ST-segment depression and T-wave inversion. Cardiac markers show an elevated troponin I.
The cardiologist has requested that the patient go
to the cardiac catheterization laboratory for further
evaluation. The patient has a history of coronary
artery disease (CAD) and had a myocardial infarction (MI) about 6 months ago. During his previous
hospitalization, he was confirmed to have developed heparin-induced thrombocytopenia (HIT)
after his platelet count (Plt) dropped to 40,000/
mm3
and he had a positive ELISA (enzyme-linked
immunosorbent assay) upon serologic testing after
his previous catheterization. Given this patient’s
diagnosis and history, which treatment regimen
would be most appropriate during his cardiac
catheterization?
A. Abciximab.
B. Bivalirudin.
C. Enoxaparin.
D. Tenecteplase.
Answer: B
An anticoagulant is required for PCI. Options include
UFH, bivalirudin, and enoxaparin. Because this patient
had a significantly low Plt with his most recent heparin exposure and was confirmed to have HIT, using any
of the GP IIb/IIIa inhibitors (Answers A and C) would
be unwise for ACS treatment because these agents are
usually combined with UFH. Furthermore, GP IIb/
IIIa inhibitors are antiplatelets, and the patient will still
need an additional agent with anticoagulant activity.
Thrombolytic therapy is not recommended for NSTEACS and would be inappropriate in this patient (Answer
D is incorrect). Answer D is also incorrect because
enoxaparin carries a 10% risk of cross-reactivity if HIT
is suspected. Bivalirudin (Answer B), a direct thrombin
inhibitor, would be the treatment of choice in patients
with HIT undergoing PCI.
A 62-year-old man presents to the ED after several hours of chest discomfort. His ECG reveals
a 1- to 2-mm ST-segment elevation with positive
troponins. He has also had increasing shortness of
breath and lower-extremity swelling over the past
2–3 weeks. His medical history is significant for
tobacco use for 40 years, chronic obstructive pulmonary disease, diabetes, and hypertension. His
blood pressure is 102/76 mm Hg and heart rate is
111 beats/minute. He has rales in both lungs and
2–3+ pitting edema in his extremities. His echocardiogram reveals an ejection fraction (EF) of 25%.
After primary percutaneous coronary intervention
(PCI), he is transferred to the cardiac intensive
care unit. Which best describes the acute use of
β-blocker therapy in this patient?
A. Give 12.5 mg of oral carvedilol within the first
24 hours.
B. Give 5 mg of intravenous metoprolol at the
bedside.
C. Give 50 mg of oral metoprolol succinate at
discharge.
D. Give no β-blocker at this time.
Answer: D
β-Blocker therapy can cause HF decompensation, particularly when the β-blocker is titrated too quickly or
initiated in patients who are not euvolemic. Although
administering β-blockers within the first 24 hours is
beneficial in STEMI, this patient hasseveral risk factors
that would be considered contraindications to initial
β-blockade. This patient’s clinical condition suggests
he is not euvolemic, and aggressive diuresis should be
tried before a β-blocker is initiated for him. In addition, intravenous β-blocker therapy (Answer B) would
place him at an even greater risk of cardiogenic shock.
Answers A and C are inappropriate because the doses
are fairly aggressive for a patient with an EF of 25% and
marginal blood pressure. Answer D is correct; however,
before discharge, this patient should be reevaluated for
the initiation of low-dose β-blocker therapy.
A 60-year-old man (weight 75 kg) presents to
the ED with crushing substernal chest pain and
ST-segment elevations on ECG. He has a medical
history of diabetes and a 40 pack-year history of
smoking. He is taken immediately to the catheterization laboratory for primary PCI, and a drugeluting stent is placed in his left anterior descending artery. In addition to aspirin, which regimen
would best maintain this patient’s stent patency?
A. Clopidogrel 300-mg LD, followed by 75 mg
daily for 12 months.
B. Prasugrel 60-mg LD, followed by 10 mg daily
for 12 months.
C. Ticagrelor 180-mg LD, followed by 90 mg
daily for 6 months.
D. Clopidogrel 600-mg LD, followed by 75 mg
daily for 6 months.
Answer: B
Dual antiplatelet therapy is recommended for at least 12
months in patients presenting with ACS. Early discontinuation of DAPT is reasonable when the risk of morbidity
exceeds the expected benefit (class IIa), as in the case of
bleeding. Answers C and D do not represent the minimum time interval, given that the patient has no known
risk of bleeding. Prasugrel (Answer B) would be preferable to clopidogrel (Answer A) in this scenario because it
would be faster in onset; clopidogrel would take about 6
hours for maximal platelet inhibition after a 300-mg LD.
Subgroup analysis of a randomized placebo-controlled
trial comparing the effectiveness of prasugrel and clopidogrel showed the superiority of prasugrel, especially for
patients presenting with a STEMI (Answer B is correct)
A 60-year-old woman with New York Heart
Association (NYHA) class IV heart failure (HF)
(heart failure with reduced ejection fraction
[HFrEF]) is admitted for increased shortness of
breath and dyspnea at rest. Her extremities appear well perfused, but she has 3+ pitting edema in her
lower extremities. Her vital signs include blood
pressure 125/70 mm Hg, heart rate 92 beats/
minute, and oxygen saturation (Sao2
) 89% on 100%
facemask. After initiating an intravenous diuretic,
which intravenous agent is best to rapidly treat this
patient’s pulmonary symptoms?
A. Dobutamine.
B. Milrinone.
C. Nitroglycerin.
D. Metoprolol.
. Answer: C
This patient is well perfused and can be classified in
Forrester hemodynamic subset II (warm and wet).
Because the patient has pulmonary congestion (shortness of breath, dyspnea at rest), intravenous diuretics are
first-line therapy. Nitroglycerin (Answer C) is best in
this setting because vasodilatory agents can be used in
conjunction with intravenous diuretics to improve acute
pulmonary edema. When adjunctive therapy is needed
in addition to loop diuretics, intravenous vasodilators
should be considered over inotropic agents when blood
pressure is adequate. Dobutamine (Answer A) and milrinone (Answer B) primarily increase CO, which is not
a problem in warm and wet exacerbations. In addition,
the adverse effects of these agents (increased mortality, proarrhythmia) limit their use. Intravenous metoprolol (Answer D) should be used extremely cautiously
because of its negative inotropic effects and because
this patient is not in a euvolemic state.
A 75-year-old woman admitted for pneumonia
has a history of several non–ST-segment elevation
myocardial infarctions (NSTEMIs). She had an
episode of sustained ventricular tachycardia (VT)
during this hospitalization. Her corrected QT (QTc)
interval was 380 milliseconds on the telemetry.
Her left ventricular ejection fraction (LVEF) was
found to be 25%. Her serum potassium and magnesium were 4.6 mEq/L and 2.2 mg/dL, respectively.
Which intravenous agent is most appropriate for
this patient’s ventricular arrhythmias?
A. Procainamide.
B. Metoprolol.
C. Magnesium.
D. Amiodarone.
Answer: D
This patient has a depressed LVEF less than 40%;
therefore, her AAD therapy options are limited.
Procainamide (Answer A) is indicated only in secondary prevention of sustained VT in patients with a normal LVEF greater than 40%; if given to this patient, it
could worsen her HF. Metoprolol (Answer B) is indicated for treating patients with asymptomatic nonsustained VT and SVT associated with CAD. This patient
had an episode of sustained VT; therefore, therapy
beyond β-blockade is warranted. Her QTc interval is
not prolonged at 380 milliseconds, and her serum magnesium concentration is within normal limits; thus, she
does not need intravenous magnesium therapy (Answer
C). Amiodarone (Answer D) is first line for patients
without contraindications because of its efficacy and
safety in patients with an LVEF less than 40%.
A 53-year-old woman is admitted to the hospital
after the worst headache she has ever had. Her
medical history includes exertional asthma, poorly
controlled hypertension, glaucoma, and hyperlipidemia. She is nonadherent to her medications
and has not taken her prescribed blood pressure
medications for 4 days. Vital signs include blood
pressure 220/100 mm Hg and heart rate 65 beats/
minute. She has retinal hemorrhaging on funduscopic examination. Which is most appropriate for
this patient’s hypertensive emergency?
A. Fenoldopam 0.1 mcg/kg/minute.
B. Nicardipine 5 mg/hour.
C. Labetalol 0.5 mg/minute.
D. Enalaprilat 0.625 mg intravenously every 6
hour
Answer: B
This patient has target-organ damage from poorly
controlled hypertension in the form of retinal hemorrhaging. Fenoldopam is contraindicated for treating
hypertensive emergencies in the setting of glaucoma
(Answer A is incorrect). Nicardipine is appropriate for
this patient, given the details of this case (Answer B
is correct). Although labetalol is effective for treating
hypertensive emergency, this patient has a history of
asthma and a low heart rate, making labetalol a lessthan-ideal option for treating her symptoms (Answer C
is incorrect). The antihypertensive effects of enalaprilat
depend on a patient’s renin activity, which is unknown
in this case. Therefore, the blood pressure–reducing
effects may be more difficult to control than when using
a drug having a more consistent effect in individuals.
In addition, the bolus nature of the drug is not ideal for
tightly controlling blood pressure with no more than a
25% reduction in MAP. Continuous infusion drugs are
preferable for easier titration to effect in a hypertensive
emergency (Answer D is incorrect)
A 52-year-old woman has a witnessed cardiac
arrest in a shopping mall and is resuscitated with
an automatic external defibrillator device. On electrophysiologic study, she has inducible VT. Which
is most appropriate for reducing the secondary
incidence of sudden cardiac death (SCD)?
A. Propafenone.
B. Amiodarone.
C. Implantable cardioverter-defibrillator (ICD).
D. Metoprolol.
Answer: C
The Cardiac Arrest Study Hamburg trial compared ICD
with AAD in survivors of cardiac arrest for secondary
prevention of SCD. The propafenone (Answer A) study arm was discontinued early because of its significantly
(61%) higher mortality rate compared with the ICD arm
(Answer A is incorrect). Although this trial had a small
sample size that prevented a statistically significant difference in total mortality in ICD-treated patients versus
patients treated with either amiodarone or metoprolol,
the incidence of sudden death was significantly lower in
patients with an ICD (Answer C is correct; 33% vs. 13%;
p=0.005). The Antiarrhythmics Versus Implantable
Defibrillators trial also evaluated ICD implantation versus AAD therapy (primarily amiodarone) in survivors
of SCD. Patients with ICDs had a significantly higher
rate of survival than did those treated with drug therapy
(89% vs. 82%; p<0.02), making Answer C preferable to
all the other options (Answers B and D are incorrect).
The Sudden Cardiac Death in Heart Failure trial
evaluated the efficacy of amiodarone or an ICD
versus placebo in preventing all-cause mortality
in ischemic and nonischemic patients with NYHA
class II and III HF. There was a 7.2% absolute risk
reduction and a 23% relative risk reduction in allcause mortality at 60 months with an ICD versus
placebo. Which best shows the number of patients
needed to treat with an ICD to prevent one death
versus placebo?
A. 1.
B. 4.
C. 14.
D. 43.
Answer: C
The number needed to treat can be calculated as 1/absolute risk reduction. Because the absolute risk reduction
in mortality at 60 months was 7.2% with ICD versus placebo, 1/0.072 would be used to calculate the number of
patients needed to treat to prevent one death during this
time. About 14 patients (Answer C) would need to be
treated with ICD to prevent one death in 60 months versus placebo. Other calculations in this fashion, including
relative risk reduction and 100% minus the absolute or
relative risk reduction, provide no useful information
for interpreting the trial results and yield an incorrect
number of patients (Answers A, B, and D are incorrect).
You are working on a review article about newer
treatment strategies for hypertensive crises. You
want to ensure that you retrieve all relevant clinical trials and related articles on your subject.
Which comprehensive database is most appropriate to search to ensure that you have not missed key
articles?
A. International Pharmaceutical Abstracts.
B. Iowa Drug Information Service.
C. Clin-Alert.
D. Excerpta Medica.
Answer: D
International Pharmaceutical Abstracts (Answer A) is a
database of primarily pharmaceutical abstracts in more
than 750 journals, including foreign and state pharmacy
journals, in addition to key U.S. medical and pharmacy
journals. Many of the citations are not included on
Medline, so a broader search can be done; however, subject descriptors are not consistently defined in a uniform
way, and multiword terms are often cited backward.
The Iowa Drug Information Service database (Answer
B) offers full-text articles from 1966 to the present in
about 200 medical and pharmacy journals (based primarily in the United States). This database is updated
monthly, and newly available articles may take longer
to access from this service. The Clin-Alert database
(Answer C) contains more than 100 medical and pharmacy journals focused on adverse events, drug interactions, and medical-legal issues. This database is used
primarily to look up adverse events (especially recent reports) associated with medications. Excerpta Medica
(Answer D) is a comprehensive database of more than
7000 journals from 74 countries dating from 1974 to
the present. Recently published articles appear in the
system within 10 days of article publication, and it often
contains data not found in a typical Medline search.
A physician on your team asks that you report
an adverse drug reaction (ADR) experienced by
a patient taking nitroprusside. The patient had
severe hypotension after the initial bolus dose of
nitroprusside, though his blood pressure was in the
normal range before therapy initiation. The hypotension led to reduced renal perfusion, resulting in oliguric acute kidney injury and subsequent hemodialysis. The patient had no known renal insufficiency before developing this complication. Which
statement best describes The Joint Commission
requirements for institutional ADR reporting?
A. A MedWatch form must be completed that
explains the situation in which the ADR
occurred.
B. Institutions must create their own definition of
ADR with which practitioners will be familiar.
C. Hospital staff members must use the Naranjo algorithm to assess the severity of the ADR.
D. Only severe or life-threatening ADRs need to be reported
Answer: B
MedWatch is a post-FDA approval program established
by the FDA for health care professionals to report the
adverse events that occur after a drug is approved.
Although MedWatch is commonly used only for reporting serious reactions to the FDA and would not be mandatory in this case (Answer A is incorrect), it can be used
to report any adverse event. Information recorded on
these forms is reported to the manufacturer and used to
determine whether black box warnings are necessary or
whether new adverse effects occur with a drug. The Joint
Commission requires that all institutions have a definition of an ADR that can be understood and remembered
by all health care professionals at the institution (Answer
B is correct). In addition, The Joint Commission requires
that each drug dose administered be monitored for
adverse effects, that each institution have a system in
place for reporting ADRs, and that the institution ensure
that the reporting mechanism identifies all key ADRs.
The Naranjo algorithm is used to determine the likelihood of cause and effect from a presumed drug-induced
event but is not required (Answer C is incorrect). Answer
D is incorrect because serious adverse effects are reportable to the FDA, as are severe and life-threatening events.
Your pharmacy and therapeutics committee wants
you to do a pharmacoeconomic analysis of a new
drug available to treat decompensated HF. This
drug has a unique mechanism of action. Unlike
other available inotropic therapies that can increase
mortality, this drug appears to reduce long-term
mortality. However, its cost is 10-fold greater than
other available drugs. Which pharmacoeconomic
analysis would best determine whether this new
drug is a better formulary choice than the currently
available agents?
A. Cost-minimization.
B. Cost-effectiveness.
C. Cost-benefit.
D. Cost-utility
Answer: B
Because the pharmacy and therapeutics committee
wants to discover whether the new drug is worth the
extra cost for the added mortality benefits it can provide for patients with decompensated HF compared
with available therapies, a cost-effectiveness analysis
(Answer B is correct) is the best pharmacoeconomic
analysis. Cost-minimization analysis (Answer A is
incorrect) determines whether a therapeutically equivalent drug within a class that provides the same therapeutic outcome as other available drugs can be used for
less cost. Cost-utility analysis (Answer D is incorrect)
determines whether a drug can improve the quality of a
patient’s life more than other available therapies. Costbenefit analysis (Answer C is incorrect) evaluates new
programs or services to determine whether they provide enough benefit to justify their cost.
