Stable Ischemic Heart Disease Flashcards
- A 50-year-old, nonsmoking woman has no significant past medical history. A physical exam and laboratory tests reveal the following: Height 5’4” (163 cm), weight 184 lb (83.6 kg), blood pressure 134/80 mm Hg, heart rate 70 beats/min, total cholesterol 184 mg/dL (4.76 mmol/L), LDL cholesterol 110 mg/dL (2.84 mmol/L), HDL cholesterol 46 mg/dL (1.19 mmol/L), and triglycerides 140 mg/dL (1.58 mmol/L). Which of the following are risk factors
for IHD in this patient?
A. Age, hypertension, dyslipidemia
B. Obesity
C. Age, dyslipidemia
D. Obesity, hypertension
E. Hypertension, dyslipidemia
B
- Which of the following is characteristic of an atherosclerotic lesion in a patient with chronic stable angina?
A. Thick fibrous cap
B. Thrombosis
C. Large lipid core
D. Plaque rupture
E. Platelet aggregation
A
- A 47-year-old man has been prescribed sublingual nitroglycerin tablets for acute relief of angina symptoms. When counseling him on the proper use of sublingual nitroglycerin, 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 1 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
E. Take one tablet every 8 to 12 hours; call 9-1-1 if dizziness occurs
A
- A 65-year-old postmenopausal woman has a history of hypertension, dyslipidemia, and chronic stable angina. Her current medications are atenolol 50 mg PO daily, simvastatin 40 mg PO at bedtime, and SL nitroglycerin as needed. She has allergies/intolerances to aspirin
(angioedema) and enalapril (cough). Which of the following should be added to her drug regimen to reduce her risk for cardiovascular events?
A. clopidogrel
B. dipyridamole
C. niacin
D. nifedipine
E. ticagrelor
A
- A 45-year-old man diagnosed with hypertension, diabetes, and IHD was recently hospitalized for unstable angina. A coronary angiogram performed during hospitalization revealed single vessel disease not amenable to PCI. He is currently taking carvedilol 6.25 mg PO twice daily, lisinopril 10 mg PO daily, and metformin 500 mg PO twice daily. His blood pressure is 126/78 mm Hg and heart rate is 62 beats/min. A fasting lipid profile shows the following: LDL cholesterol 127 mg/dL (3.28 mmol/L), HDL cholesterol 36 mg/dL (0.93 mmol/L), and triglycerides 157 mg/dL (1.77 mmol/L). He is a current smoker. What additional therapy should
be considered to treat this patient’s IHD and lower his risk of ischemic events?
A. Add low-intensity statin (eg, pravastatin 20 mg/day).
B. Add moderate-intensity statin (eg, lovastatin 40 mg/day)
C. Add high-intensity statin (eg, atorvastatin 80 mg/day)
D. Add prasugrel
E. Add varenicline
C
- A 53-year-old woman with a history of hypertension and dyslipidemia undergoes a thorough cardiac workup for new onset chest tightness and shortness of breath on exertion. A cardiac catheterization shows no significant coronary artery obstruction. She is believed to have microvascular disease. Her blood pressure is 148/90 mm Hg and heart rate is 74 beats/min. Her
current medications include benazepril 10 mg PO daily and simvastatin 40 mg PO hs. What is the most appropriate therapy to manage her angina symptoms?
A. Increase benazepril to 20 mg daily
B. Add metoprolol
C. Add aspirin
D. Add doxazosin
E. Add hydralazine
B
- What is the recommended treatment duration of dual antiplatelet therapy following implantation of a drug eluting stent?
A. 1 week
B. 1 month
C. 3 months
D. 6 months
E. At least 12 months
E
- A 56-year-old woman was recently diagnosed with ischemic heart disease. Her current medications include conjugated estrogen 0.625 mg/day, fish oil 1 gm twice daily, aspirin 81 mg daily, atenolol 100 mg daily, lisinopril 20 mg daily, and rosuvastatin 20 mg daily. Which of the
following changes to the patient’s regimen are appropriate?
A. Add clopidogrel
B. Add vitamin E
C. Change rosuvastatin to pravastatin
D. Discontinue conjugated estrogen
E. Discontinue fish oil
D
- A 60-year-old obese woman with hypertension and dyslipidemia is being started on ranolazine for microvascular angina. Her current medications include aspirin 81 mg/day, lisinopril 10 mg daily, metoprolol 50 mg twice daily, and simvastatin 40 mg/day. A fasting lipid
profile reveals the following: LDL cholesterol 65 mg/dL (1.68 mmol/L), HDL cholesterol 54 mg/dL (1.40 mmol/L), and triglycerides 108 mg/dL (1.22 mmol/L). What changes, if any, should be made to her statin regimen?
A. Change to a low-intensity statin (eg, pravastatin 20 mg/day)
B. Change to a high-intensity statin (eg, rosuvastatin 20 mg/day.
C. Continue simvastatin 40 mg/day
D. Reduce the dose of simvastatin to 20 mg/day
E. Increase the dose of simvastatin to 80 mg/day
D
- A 58-year-old woman with hypertension and coronary artery disease underwent percutaneous coronary intervention with placement of two drug eluting stents one week ago. Genotyping is done and reveals that she has the CYP2C19 poor metabolizer phenotype. Which of the following
is the most appropriate antiplatelet therapy for this patient?
A. Clopidogrel plus aspirin
B. Clopidogrel plus prasugrel
C. Prasugrel plus aspirin
D. High dose aspirin
E. Dipyridamole plus aspirin
C
- A 60-year-old man with a history of hypertension, diabetes, and dyslipidemia is being treated with lisinopril 10 mg PO daily, simvastatin 20 mg PO daily, and metformin XR PO 500 mg daily. His current blood pressure is 150/88 mm Hg and heart rate is 80 beats/min. He presents
with complaints of chest pressure and shortness of breath occurring with exertion. He is diagnosed with variant angina. In addition to sublingual nitroglycerin, what is the most
appropriate change to his drug therapy?
A. Add amlodipine
B. Add isosorbide mononitrate
C. Add metoprolol
D. Add ranolazine
E. Add thiazide diuretic (eg, chlorthalidone)
A
- A 55-year-old man with a history of dyslipidemia and ischemic heart disease had a myocardial infarction 3 months ago. His current medications are aspirin 81 mg PO once daily, metoprolol XL 200 mg PO daily, simvastatin 40 mg PO at bedtime, and sublingual nitroglycerin as needed. He continues to experience occasional symptoms of angina with exertion. His blood pressure is 124/70 mm Hg, and his pulse is 60 beats/min. What is the most appropriate pharmacologic intervention?
A. Taper off metoprolol and start verapamil
B. Add isosorbide mononitrate
C. Taper off metoprolol and start nifedipine
D. Add diltiazem
E. Switch metoprolol to atenolol
B
- A 63-year-old woman with a past medical history of dyslipidemia and chronic stable angina treated with aspirin 81 mg PO once daily, atenolol 100 mg PO once daily, simvastatin 40 mg PO
once daily, and sublingual nitroglycerin as needed. Her angina symptoms are currently well controlled. Her blood pressure is 148/90 mm Hg, and her pulse is 70 beats/min. What is the most appropriate addition to therapy to improve the management of this patient’s ischemic heart disease?
A. ramipril
B. isosorbide dinitrate
C. ranolazine
D. verapamil
E. bupropion
A
- A 59-year-old man has a history of hypertension, dyslipidemia, ischemic heart disease, and pulmonary hypertension. He is currently taking aspirin 81 mg PO daily, atorvastatin 40 mg PO daily, ramipril 5 mg PO daily, metoprolol XL 100 mg PO daily, and sildenafil 20 mg PO thrice daily. His blood pressure is 102/76 mm Hg and heart rate is 60 beats/min. He continues to
experience ischemic symptoms with minimal exertion. What is the most appropriate addition to therapy to improve the management of this patient’s ischemic heart disease?
A. Add felodipine
B. Add isosorbide mononitrate
C. Add ranolazine
D. Decrease metoprolol XL to 50 mg daily
E. Increase metoprolol XL to 200 mg daily
C
- A 68-year-old man with a history of hypertension, dyslipidemia, and chronic obstructive pulmonary disease was recently diagnosed with chronic stable angina. His current medications
are chlorthalidone 25 mg PO daily, atorvastatin 40 mg PO at bedtime, salmeterol one inhalation
every 12 hours, fluticasone MDI two puffs twice a day, and albuterol MDI one to two puffs every 4 hours prn. His vital signs are a heart rate of 86 beats/min and blood pressure of 150/90 mm Hg. In addition to sublingual nitroglycerin, what is the most appropriate change to his drug
therapy?
A. Start propranolol
B. Start ranolazine
C. Start amlodipine
D. Start isosorbide mononitrate
E. Start verapamil
E
- 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
C
- Which drug therapy is best for relieving acute symptoms of angina?
A. Metoprolol
B. Nitroglycerin
C. Clopidogrel
D. Diltiazem
B
- 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
C
- 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
A
- 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
C
- 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
A
- 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
C
- 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
C
- 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
B
- 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
B
- 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 12.5mg 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
A
- 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
B
- 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
D
- 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
A
- 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 81mg 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
A
