Test 4 HTN/HF/Angina

Question 1

A 55-year-old white man with seated office blood pressure (BP) readings of 138/89 mm Hg and 136/84 mm Hg is asked to return in 2 weeks for repeat measurements, which are 138/88 mm Hg and 134/82 mm Hg. Which of the following classifies his BP per the 2017 ACC/AHA guidelines?

A. Stage 2 hypertension
B. Stage 1 hypertension
C. Elevated BP
D. Optimal BP

Answer 1

Option B: Correct. The patient’s average BP falls within the range of systolic BP of 130–139 mm Hg or diastolic BP of 80–89 mm Hg, defined as stage 1 hypertension.

Question 2

A 34-year-old black man presents to your clinic with a BP of 160/94 mm Hg. Repeat readings over the past 2 weeks average 156/92 mm Hg. The patient has no past medical history with the exception of Crohn disease, which is currently treated with chronic steroid therapy. He is also taking an over-the-counter NSAID for ongoing back pain. Physical examination and laboratory tests are unremarkable. Appropriate interventions at this time include:

A. No intervention because patient most likely has drug-induced hypertension
B. NSAID is appropriate as long as he follows the instructions on the package insert
C. Reassessment of the dose and need for long-term oral steroids
D. Initiation of antihypertensive therapy

Answer 2

Answer: C

Option A: Incorrect. Consistent elevations in BP require intervention with either treatment or evaluation of whether hypertension is secondary to alternative cause.

Option B: Incorrect. NSAID should be avoided as this can result in elevated BP and an increased risk of cardiovascular events.

Option C: Correct. It is reasonable to inquire for the need of long-term steroids and dose as this is a possible secondary cause for elevated blood pressures.

Option D: Incorrect. Prior to initiation of therapy, the secondary cause of hypertension should be ruled out or reassessed to see if treatment is necessary.

Question 3

A 45-year-old African-American woman who has resistant hypertension, heart failure with reduced ejection fraction, type 2 diabetes, and dyslipidemia comes to the clinic for a medication management visit. Her current medications include enalapril/hydrochlorothiazide (Vaseretic), metoprolol succinate, hydralazine, isosorbide dinitrate, metformin, and atorvastatin. She has been adherent to all her medications. She complains of recently developed fatigue, arthralgia, and mild peripheral edema, and a butterfly rash across her nose and upper cheeks. Which of the following statements is correct?

A. The most likely medication causing this adverse reaction is the angiotensin-converting enzyme inhibitor, enalapril
B. This is likely to be a dose-independent adverse drug reaction
C. Testing for N-acetyltransferase-1 (NAT-1) and NAT-2 genes may help to prevent this adverse effect
D. Discontinue all medications due to unknown etiology of this reaction

Answer 3

Answer: C

Option A: Incorrect. Hydralazine is the most likely medication from her medication list to cause lupus-like syndrome.

Option B: Incorrect. Hydralazine induced lupus-like syndrome is a dose-dependent adverse reaction which may be avoided by using less than 200 mg daily.

Option C: Correct. FDA listed NAT-1 and NAT-2 genes as biomarkers for the effectiveness and or toxicity of hydralazine.

Option D: Incorrect. Hydralazine induced lupus-like is reversible on discontinuation. Therefore, discontinue hydralazine first and observe for days is recommended.

Question 4

A 52-year-old Asian male is newly diagnosed with stage 1 hypertension. Significant lab values are potassium level of 4.5 mEq/L (mmol/L) and an estimated GFR of 25 mL/min/1.73 m2. His past medical history includes type 2 diabetes, chronic kidney disease (stage G4, A1), hyperlipidemia, and gout. His 10-year ASCVD risk is estimated at 10.8%. Which of the following medications would be preferred for this patient?

A. Chlorthalidone
B. Amlodipine
C. Losartan
D. Metoprolol tartrate

Answer 4

Answer: C

Option A: Incorrect. Thiazide-type diuretics, including chlorthalidone have negative metabolic effects like hyperglycemia, dyslipidemia, and hyperuricemia. Use with caution in patients with diabetes, hyperlipidemia, and gout. In addition, alternative agents are recommended in patients with estimated GFR less than 30 mL/min/1.73 m2.

Option B: Incorrect. Amlodipine can be considered a first-line agent in general. However, for patients with CKD, ACE-Is or ARBs should be initiated prior to other classes of antihypertensive agents.

Option C: Correct. ACE-Is or ARBs should be the first-line treatment for patients with CKD (stage 3 or higher or stage 1 or 2 with severely increased albuminuria) and without any contraindications (eg, history of angioedema or hypersensitivity with prior ACE-I or ARB use) regardless of age and race. These medications provide renal protective effects through reducing intraglomerular pressure.

Option D: Incorrect. Metoprolol is generally not considered as first-line treatment except for compelling indications such as post myocardial infarction or heart failure with reduced ejection fraction.

Question 5

A 55-year-old black woman has a history of left ventricular hypertrophy with a left ventricular ejection fraction of 55% (0.55). She has had hypertension for 10 years and is currently taking chlorthalidone 25 mg daily, metoprolol succinate 50 mg daily, and amlodipine 2.5 mg daily. Her averaged BP is 152/94 mm Hg with a heart rate of 54 beats/min. Her physical examination is unremarkable and basic metabolic panel reveals serum creatinine of 0.8 mg/dL (71 µmol/L) and potassium of 3.9 mEq/L (mmol/L). She reports allergies to fosinopril and aspirin. Which of the following represents the optimal course of action?

A. Increase amlodipine to 5 mg and have her take it at bedtime
B. Increase metoprolol succinate to 100 mg daily
C. Add lisinopril 5 mg daily
D. Add spironolactone 50 mg daily

Answer 5

Answer: A

Option A: Correct. Amlodipine may be further titrated to a maximum dose of 10 mg daily to achieve BP control rather than adding new medications.

Option B: Incorrect. With an average heart rate of 54 beats/min, further titration of metoprolol succinate may result in bradycardia and result in patient harm.

Option C: Incorrect. The patient has an existing allergy to fosinopril. It would be best to avoid alternative ACE inhibitors.

Option D: Incorrect. It may be reasonable to add spironolactone if uncontrolled at future visits when current medications are titrated to optimal doses.

Question 6

A 65-year-old black male presents to the clinic today with average BP of 148/88 mm Hg and heart rate of 70 beats/min. He has past medical history of type 2 diabetes and chronic obstructive pulmonary disease (group B). His most recent serum potassium is 3.6 mEq/L (mmol/L), serum creatinine is 0.9 mg/dL (80 µmol/L), calculated creatinine clearance is 92 mL/min (1.54 mL/s) and urine albumin is within normal limits. His current medication list includes atorvastatin, metformin, and inhaled tiotropium. Which of the following antihypertensives would be the most appropriate initial therapy?

A. Amlodipine
B. Chlorthalidone
C. Atenolol
D. Lisinopril

Answer 6

Answer: A

Option A: Correct. CCBs are appropriate as the initial therapy for this patient.

Option B: Incorrect. Thiazide-type diuretics can cause significant hypokalemia and this patient’s serum potassium is at the lower limit. In addition, the patient has type 2 diabetes and thiazide-type diuretics can have negative effect on glucose control.

Option C: Incorrect. β-Blockers are not first line medications for BP management without compelling indications. β-Blockers should also be avoided in patients with pulmonary diseases.

Option D: Incorrect. ACE inhibitors and ARBs should not be used as the first-line agent for African American patients with hypertension but no CKD due to their attenuated response in this population and higher risk for angioedema.

Question 7

A 67-year-old Asian man with a recent non-ST segment elevation myocardial infarction (MI) (2 weeks ago) has an average BP of 138/86 mm Hg and a heart rate of 76 beats/min. Which of the following antihypertensive agents is preferred in this setting?

A. Metoprolol tartrate
B. Acebutolol
C. Hydrochlorothiazide
D. Spironolactone

Answer 7

Answer: A

Option A: Correct. Metoprolol tartrate and other β-blockers without intrinsic sympathomimetic activity are indicated in patients who are post-MI as a compelling indication for therapy.

Option B: Incorrect. Acebutolol despite being a β-blocker, also has intrinsic sympathomimetic activity and therefore would be cautioned in a patient with coronary artery disease.

Option C: Incorrect. Hydrochlorothiazide is a reasonable option if the patient did not have a compelling indication for alternative therapy.

Option D: Incorrect. Based on the information provided, spironolactone is not indicated at this time. It may be a reasonable option if the patient was later found to have a reduced left ventricular ejection fraction.

Question 8

A 58-year old Indian American male presents to urgent care with chief complaints of severe headache, confusion, and blurred vision. Upon examination, his vital signs and relevant lab values include: BP 218/124 mm Hg; HR 92 beats/min; RR 18 breaths/min; serum potassium 4.8 mEq/L (mmol/L); serum creatinine 2.4 mg/dL (212 µmol/L); blood urea nitrogen 45 mg/dL (16.1 mmol/L); serum glucose 145 mg/dL (8.0 mmol/L); hemoglobin A1C 6.4% (0.064; 46 mmol/mol Hb); AST 28 U/L (0.47 µkat/L); ALT 20 U/L (0.33 µkat/L); urinalysis shows positive of proteins and negative of ketones. He has medical history of hypertension but no history of renal or hepatic impairment. According to the pharmacists, his antihypertensive medications are overdue for a refill by 2 months. Which of the following statements is most accurate?

A. He is experiencing hypertensive urgency
B. Goal is to reduce systolic blood pressure by up to 25% within an hour
C. Goal is to reduce systolic blood pressure by 25% to 50% within an hour
D. Administration of short-acting oral antihypertensive such as labetalol or clonidine is appropriate

Answer 8

Answer: B

Option A: Incorrect. He is experiencing hypertensive emergency because his BP is greater than 180/120 mm Hg with evidence of acute renal injury (elevated serum creatinine and protein in the urine)

Option B: Correct

Option C: Incorrect. Goal is to reduce systolic blood pressure by up to 25% within minutes to hours to prevent ischemic complications (decrease BP too rapidly) or further end organ damage (decrease BP too slowly).

Option D: Incorrect. Parenteral therapy such as nitroprusside or labetalol is required for hypertensive emergencies.

Question 9

A 72-year-old black man with history of hypertension, prior MI, and benign prostatic hypertrophy, is currently receiving amlodipine 5 mg QAM and carvedilol 12.5 mg twice daily. He has an average 24-hour Ambulatory Blood Pressure of 156/92 mm Hg and HR of 60 beats/min with notable nocturnal hypertension. He complains of nocturia but states that the swelling in his feet improved when his amlodipine dose was reduced. Which of the following presents the most clinically appropriate course of action?

A. Increase amlodipine to 10 mg daily and change to bedtime
B. Increase carvedilol to 25 mg twice daily
C. Initiate chlorthalidone 50 mg daily in AM
D. Initiate lisinopril 5 mg once daily at bedtime

Answer 9

Answer: D

Option A: Incorrect. Patient reports an adverse event with higher doses of amlodipine, and it would be best to not titrate further.

Option B: Incorrect. With an average heart rate of 60 beats per minute, further titration of carvedilol may result in bradycardia and result in patient harm.

Option C: Incorrect. Chlorthalidone may worsen nocturia and does not have suggestion of compelling indication at this time. Also, this dose of chlorthalidone is high and would increase patient’s risk of metabolic and electrolyte adverse effects especially if initiated at this low dose.

Option D: Correct. Lisinopril administered in the evening is the best option due to the compelling indication of a prior MI and to attempt to control the patient’s nocturnal hypertension. Additionally, evening administration of at least one antihypertensive has been shown to reduce cardiovascular events.

Question 10

A 57-year-old white woman has type 2 diabetes, morbid obesity, and hypertension. She is currently taking only lisinopril 20 mg daily and her office blood pressures are consistently at goal less than 130/80 mm Hg, but her home readings are significantly higher. Which of the following is a possible explanation for her elevated home readings?

A. Her home BP cuff is too small
B. She has white coat hypertension
C. Her home BP cuff is too large
D. She checks her blood pressure immediately after exercise

Answer 10

Answer: A

Option A: Correct. It is important to have the correct BP cuff size as cuffs that are too small will result in falsely elevated BP readings.

Option B: Incorrect. White coat hypertension would be suspected if results of office BP were routinely elevated but with normal home BP logs.

Option C: Incorrect. A BP cuff that is too large would likely provide falsely low measurement and would not explain the elevated home numbers.

Option D: Incorrect. It is unlikely that the patient is taking blood pressure readings directly following exercise and not the best answer.

Question 11

A 72-year-old black man with history of heart failure with reduced left ventricular ejection fraction, dyslipidemia and peripheral arterial disease presents for risk factor reduction follow-up. His weight does not change from the baseline and he lacks any signs and symptoms for fluid retention. His blood pressure in clinic is 142/75 mm Hg initially and 140/77 mm Hg on repeat. Current medications include bisoprolol 10 mg once daily and valsartan 160 mg twice daily along with furosemide 20 mg as needed for edema. Current labs are stable and within normal limits with serum creatinine of 1.4 mg/dL (124 µmol/L) and potassium of 5.1 mEq/L (mmol/L). Which of the following additions to his medication regimen would be most appropriate at this time?

A. Amlodipine
B. Furosemide on regular daily basis
C. Hydralazine/Isosorbide dinitrate
D. Minoxidil

Answer 11

Answer: C

Option A: Incorrect. Amlodipine could be used in this patient but is not the best choice as dihydropyridine calcium channel blockers have not been tied to reduction in cardiovascular events in patients with HFrEF.

Option B: Incorrect. Furosemide and other loop diuretics are typically used for symptomatic benefit in heart failure patients and not primarily for blood pressure control.

Option C: Correct. The combination of nitrates and hydralazine is the best option due to a mortality benefit in black patients with symptomatic HFrEF.

Option D: Incorrect. Minoxidil is reserved for resistant hypertension refractory to most antihypertensive therapies and does not have an established role in heart failure patients and could potentially worsen edema.

Question 12

A 63-year-old black man with a past medical history significant for hypertension and left ventricular hypertrophy is sent for 24-hour ambulatory blood pressure monitoring. Current medications include lisinopril 40 mg daily in AM, hydrochlorothiazide 12.5 mg daily in AM, and amlodipine 10 mg daily at bedtime. He is found to have controlled awake averages but his nocturnal values are elevated at 134/82 mm Hg. All laboratory results are within normal limits. Which of the following would be a reasonable change to his antihypertensive regimen?

A. Change amlodipine to nifedipine 30 mg twice daily
B. Replace hydrochlorothiazide with chlorthalidone 25 mg daily
C. Add spironolactone 50 mg daily
D. Add losartan 25 mg daily

Answer 12

Answer: B

Option A: Incorrect. Changing amlodipine to nifedipine would be unlikely to change overall blood pressure control at this point.

Option B: Correct. Switching hydrochlorothiazide to chlorthalidone would be reasonable to improve BP control especially nocturnal BP control given its longer effective half-life and data supporting a more consistent 24-hour BP lowering effect compared to hydrochlorothiazide.

Option C: Incorrect. Spironolactone administered daily is not the best option to address nocturnal hypertension.

Option D: Incorrect. Patient is already taking an ACE inhibitor.

Question 13

A 54-year-old white man was brought to the emergency department an hour after ingesting 1500 mg lisinopril and 120 mg amlodipine. Initial vital signs showed significant hypotension of 72/36 mm Hg and tachycardia of 130 beats/min. Other physical examinations and laboratory tests were unremarkable. Toxicology screen was negative for alcohol, other usual licit and illicit substances. He has a history of hypertension and depression with poor adherence to medications. Which of the following statements is correct?

A. Supportive care such as fluid resuscitation and vasopressin administration should be considered only after the comprehensive toxicology report has returned to the medical team.
B. High dose insulin with glucose and calcium gluconate are appropriate treatments for this patient.
C. The consequences from antihypertensive agents overdose are usually mild; therefore, watchful waiting is an appropriate approach for this patient.
D. The toxicities of ACE-Is are generally more severe than CCBs.

Answer 13

Answer: B

Option A: Incorrect. Supportive care should be given to any symptomatic patients as soon as possible.

Option B: Correct. High dose insulin with glucose and calcium gluconate are appropriate treatments for CCB toxicity.

Option C: Incorrect. This patient was hemodynamically unstable, as noted by profound hypotension and tachycardia. Interventions should be taken immediately to maintain hemodynamic stability.

Option D: Incorrect. CCBs generally have more profound toxicities than ACE-Is.

Question 14

A 32-year-old woman is 20 weeks pregnant and has a history of gestational diabetes. She presents with an average BP of 154/96 mm Hg and a heart rate of 60 beats/min. Her laboratory results are remarkable for proteinuria, elevated serum uric acid, and low potassium. Which of the following presents the most appropriate course of action?

A. Closely monitor her BP and provide supportive care
B. Start losartan 50 mg daily while monitoring BP
C. Start methyldopa 250 mg every 6 hours while monitoring BP
D. Start labetalol 100 mg every 12 hours while monitoring BP

Answer 14

Answer: C

Option A: Incorrect. Treatment is indicated.

Option B: Incorrect. Losartan and other angiotensin receptor blockers are contraindicated in pregnancy.

Option C: Correct. Methyldopa is a first-line agent in pregnancy and is the best answer choice.

Option D: Incorrect. With an average heart rate of 60 beats/min, initiation of labetalol may result in bradycardia and result in patient harm.

Question 15

A 56-year-old black woman is currently on verapamil ER 360 mg once daily. She has a past medical history of hypertension and paroxysmal atrial fibrillation. Today, her office BP readings are 137/97 mm Hg and 144/96 mm Hg with a heart rate of 60 beats/min. Which of the following is the most appropriate intervention?

A. Add amlodipine 5 mg daily
B. Increase verapamil ER to 360 mg twice daily
C. Add chlorthalidone 12.5 mg daily
D. Add valsartan 80 mg daily

Answer 15

Answer: D

Option A: Incorrect. Patient is already receiving a calcium channel blocker in verapamil.

Option B: Incorrect. Verapamil ER 360 mg twice daily is above the usual dose and could result in bradycardia with current heart rate.

Option C: Incorrect. According to the 2017 ACC/AHA guidelines while thiazides are generally recommended in black adults for the treatment of hypertension, the recommendations for ARB therapy to prevent atrial fibrillation reoccurrence makes option D a better choice for this patient with paroxysmal atrial fibrillation.

Option D: Correct. ARBs are recommended by the ACC/AHA 2017 Hypertension Guideline to decrease atrial fibrillation reoccurrences.

Question 16

Which of the following findings, when increased, indicates elevated cardiac filling pressures (or volume overload) in a patient with heart failure?
A. LVH
B. Potassium
C. LVEF
D. BNP

Answer 16

Answer: D
Option A: Incorrect. LVH is a marker of hypertrophy, but is not specific to volume status.

Option B: Incorrect. Potassium level is not indicative of volume.

Option C: Incorrect. LVEF provides information about the heart’s contractile function after completion of diastole.

Option D: Correct. B-type natriuretic peptide is released by the ventricles in response to chamber wall stretch and increased filling pressures that accompany volume retention.

Question 17

What is the most common etiology of heart failure?
A. Ischemic
B. Idiopathic, unknown cause
C. Viral cardiomyopathy
D. Drug-induced

Answer 17

Answer: A
Option A: Correct. Ischemic etiology, resulting from coronary artery disease, is the most common cause of HFrEF, occurring in up to 2/3 of cases.

Option B: Incorrect. Idiopathic cardiomyopathy, while common, is not as frequent as ischemic etiology.

Options C and D: Incorrect. Viral and drug induced cardiomyopathy are rare causes of heart failure.

Question 18

What is the medical term for the symptom of “patient awakens with a feeling of breathlessness not relieved by sitting up”?
A. Orthopnea
B. Hepatojugular reflex
C. Paroxysmal nocturnal dyspnea
D. Pulmonary congestion

Answer 18

Answer: C
Option A: Incorrect. Orthopnea refers to shortness of breath with a recumbent position that subsides when sitting up.

Option B: Incorrect. Hepatojugular reflex refers to eliciting jugular venous distension upon pressing on the liver.

Option C: Correct. PND does not typically subside with sitting up.

Option D: Incorrect. Pulmonary congestion is a general term referring to excess volume in the lungs.

Question 19

Which of the following is true regarding ACE inhibitors in heart failure?
A. May cause hypotension and hypokalemia
B. Should be avoided in the setting of mild renal dysfunction
C. Indicated in patients with LVEF less than 40% (0.4)
D. Are less likely to cause angioedema compared to angiotensin receptor blockers

Answer 19

Answer: C
Option A: Incorrect. ACE inhibitors cause hyperkalemia.

Option B: Incorrect. ACE inhibitors are still appropriate for use in the setting of renal dysfunction. Renal function should be watched closely after initiation for signs of deterioration.

Option C: Correct. ACE inhibitors are indicated in the setting of heart failure with reduced ejection fraction.

Option D: Incorrect. ACE inhibitors are more likely to cause angioedema compared with ARBs.

Question 20

A 74-year-old Caucasian male with HFrEF is currently on enalapril, carvedilol, furosemide, and digoxin. His provider would like to initiate a mineralocorticoid receptor antagonist today. What baseline labs are required prior to starting this medication?
A. Potassium
B. Magnesium
C. Sodium
D. Glucose

Answer 20

Answer: A
Option A: Correct. Monitoring of potassium is crucially important when initiating a mineralocorticoid receptor antagonist to identify hyperkalemia.

Options B, C, and D: Incorrect. Magnesium, sodium, and glucose are not likely to change much with mineralocorticoid receptor antagonist therapy and are less important to monitor.

Question 21

A 66-year-old woman presents to clinic for heart failure follow-up. She is classified as NYHA FC II. Her blood pressure is 144/82 mm Hg, and most recent EF is 26% (0.26). Her current medication regimen includes lisinopril 20 mg daily, carvedilol 25 mg BID, digoxin 0.125 mg daily, and furosemide 20 mg BID. Which of the following would be the best choice to add at this time?
A. Metolazone
B. Hydralazine and isosorbide dinitrate
C. Spironolactone
D. Hydrochlorothiazide

Answer 21

Answer: C
Option A: Incorrect. Metolazone is incorrect as there is not an indication in this case of volume retention that is not responsive to furosemide.

Option B: Incorrect. Hydralazine and isosorbide dinitrate would be reasonable to add in the setting HFrEF in an African American patient who is otherwise optimized on guideline-directed medical therapy.

Option C: Correct. Spironolactone is the best choice in a patient with symptomatic HFrEF with LVEF less than or equal to 35% (0.35).

Option D: Incorrect. Hydrochlorothiazide is incorrect as loop diuretics are preferred for treatment of volume retention in heart failure and addition of this particular thiazide diuretic, which does not have potent diuretic effects, would more likely result in adverse effects such as hypokalemia and renal dysfunction.

Question 22

A 68-year-old female returns to clinic after having a follow-up echocardiogram for evaluation of cardiac structure and function on optimal heart failure medications to assess next steps. Her echo reveals an LVEF of 30% to 35% (0.30-0.35), which is only marginally improved compared to her baseline echocardiogram of 25% to 30% (0.25-0.30). She is NYHA FC II by symptoms today. Her current cardiac medications include enalapril 10 mg twice daily, carvedilol 25 mg twice daily, digoxin 0.125 mg once daily, and spironolactone 25 mg once daily. She is euvolemic. Vitals: BP 122/74 mm Hg, P 58, weight 82 kg (180 lb; dry weight). What is the MOST appropriate treatment plan for the patient at this point?
A. Increase carvedilol to 50 mg twice daily
B. Switch enalapril to sacubitril/valsartan
C. Add candesartan
D. Increase digoxin to 0.25 mg daily

Answer 22

Answer: B
Option A: Incorrect. The patient’s pulse is already below 60 beats/min.

Option B: Correct. Switching to sacubitril/valsartan is correct based on the latest treatment guidelines for heart failure, which recommend switching to an angiotensin receptor neprilysin inhibitor in the setting of symptomatic HFrEF in a patient currently tolerating an ACE inhibitor or ARB.

Option C: Incorrect. It is not generally recommended to add an ARB to an ACE inhibitor due to increased risk for hyperkalemia and renal dysfunction.

Option D: Incorrect. Digoxin dose should be limited to 0.125 mg daily to minimize risk for toxicity from this medication.

Question 23

Which of the following diuretic combinations is used for the purpose of reducing congestion in the setting of diuretic resistance?
A. Hydrochlorothiazide and spironolactone
B. Spironolactone and torsemide
C. Furosemide and spironolactone
D. Furosemide and metolazone

Answer 23

Answer: D
Options A, B, and C: Incorrect. Hydrochlorothiazide and spironolactone are not strong diuretics in the setting of diuretic resistance.

Option D: Correct. Metolazone is added when volume retention does not respond to loop diuretics.

Question 24

Which of the following statements is most appropriate for patient counseling on nonpharmacologic management of heart failure?
A. Supervised exercise is recommended including aerobic activity and weight lifting
B. Contact health care provider if weight increases by more than 5 lb (2.3 kg) in a day or 10 lb (4.5 kg) in a week
C. Lower dietary sodium intake to no more than 2 g/day
D. Maintain alcohol intake to no more than 2 drinks per day if diagnosed with alcohol-induced cardiomyopathy

Answer 24

Answer: C
Option A: Incorrect. Heavy weight lifting is not recommended in patients with heart failure due to potential for SNS activation.

Option B: Incorrect. Patients should contact their provider when weight increases by 3 lb (1.4 kg) in a single day or 5 lb (2.3 kg) in a week.

Option C: Correct.

Option D: Incorrect. Alcohol should be avoided in the setting of alcohol-induced cardiomyopathy.

Question 25

A 68-year-old African American woman with HFrEF is admitted to the hospital for new onset acute decompensated heart failure. Her current medications include felodipine 2.5 mg daily and atorvastatin 20 mg daily. BP is 88/50 mm Hg, pulse 102 beats/min. Hemodynamic readings include a PCWP of 16 mm Hg (2.1 kPa) and a CI of 1.8 L/min/m2 (0.030 L/s/m2).
Which of the following is the most appropriate treatment plan for this patient?
A. Fluids, inotropes
B. Diuretics, vasodilators
C. Fluids, inotropes, vasodilators
D. Diuretics, fluids, inotropes

Answer 25

11. Answer: A
    Option A: Correct. Fluids and inotropes are appropriate in a patient who exhibits low perfusion (low CI) and dehydration (low urine output).

Options B and C: Incorrect. Vasodilators should not be used in patients with low BP who are poorly perfused.

Options D: Incorrect. The patient is not exhibiting signs of volume retention with a PCWP of 16 mm Hg (2.1 kPa).

Question 26

A 68-year-old African American woman with HFrEF is admitted to the hospital for new onset acute decompensated heart failure. Her current medications include felodipine 2.5 mg daily and atorvastatin 20 mg daily. BP is 88/50 mm Hg, pulse 102 beats/min. Hemodynamic readings include a PCWP of 16 mm Hg (2.1 kPa) and a CI of 1.8 L/min/m2 (0.030 L/s/m2).
When the patient is ready to be discharged from the hospital, you are consulted as the pharmacy clinician on the cardiology team about appropriate take-home medications. Her BP is 110/72 mm Hg, HR 86; pertinent labs include sodium 138 mEq/L (mmol/L), potassium 4.2 mEq/L (mmol/L), SCr 4.4 mg/dL (389 μmol/L). Which vasodilator should be added at this time?
A. ACE inhibitor
B. Angiotensin receptor blocker
C. Hydralazine and isosorbide dinitrate
D. Nondihydropyridine calcium channel blocker

Answer 26

Answer: C
Options A and B: Incorrect. The patient’s renal function is too poor to initiate an ACE inhibitor or ARB.

Option C: Correct. Hydralazine and isosorbide dinitrate is the most appropriate vasodilator of choice in the setting of severe renal dysfunction.

Option D: Incorrect. Nondihydropyridine calcium channel blockers are contraindicated in the setting of HFrEF.

Question 27

A 72-year-old man presents to the clinic today with complaints of increasing shortness of breath while dressing and carrying groceries and a 10 lb (4.5 kg) weight gain. A few months prior, he noticed episodes of waking in the middle of the night with shortness of breath, difficulty breathing after walking two flights of stairs, as well as ankle edema. The patient has a history of osteoarthritis × 10 years, hypertension × 4 years, diabetes mellitus × 5 years, dyslipidemia, and is status postmyocardial infarction 2 years ago.
Physical examination reveals the following: BP 148/96 mm Hg, pulse 98 beats/min, Ht: 5′11″ (180 cm), Wt: 189 lb (86 kg; usual = 178 lb [81 kg]), BMI: 26.4 kg/m2
(+) JVD, (−) HJR or hepatomegaly
(+) S3, (+) S4
ECG: regular rate/rhythm, evidence of old infarct
ECHO: EF 33% (0.33)
CXR: Crackles bilaterally and cardiomegaly (enlarged heart)
Labs:
Sodium: 142 mE/L (mmol/L)
Potassium: 3.7 mEq/L (mmol/L)
Magnesium: 1.8 mEq/L (0.90 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 µmol/L)
BNP: 322 pg/mL (ng/L; 93 pmol/L)
Current medications:
Aspirin 81 mg daily
Amlodipine 5 mg daily
Glipizide 10 mg twice daily for diabetes
Simvastatin 20 mg nightly at bedtime
Ibuprofen 600 mg twice daily
Which of the patient’s medications can exacerbate systolic dysfunction heart failure?
A. Ibuprofen
B. Amlodipine
C. Glipizide
D. Simvastatin

Answer 27

Answer: A
Option A: Correct. NSAIDs can worsen fluid retention in patients with heart failure.

Option B: Incorrect. Dihydropyridine calcium channel blockers are safe to use for HFrEF, unlike nondihydropyridine calcium channel blockers.

Options C and D: Incorrect. Neither leads to worsening heart failure.

Question 28

A 72-year-old man presents to the clinic today with complaints of increasing shortness of breath while dressing and carrying groceries and a 10 lb (4.5 kg) weight gain. A few months prior, he noticed episodes of waking in the middle of the night with shortness of breath, difficulty breathing after walking two flights of stairs, as well as ankle edema. The patient has a history of osteoarthritis × 10 years, hypertension × 4 years, diabetes mellitus × 5 years, dyslipidemia, and is status postmyocardial infarction 2 years ago.
Physical examination reveals the following: BP 148/96 mm Hg, pulse 98 beats/min, Ht: 5′11″ (180 cm), Wt: 189 lb (86 kg; usual = 178 lb [81 kg]), BMI: 26.4 kg/m2
(+) JVD, (−) HJR or hepatomegaly
(+) S3, (+) S4
ECG: regular rate/rhythm, evidence of old infarct
ECHO: EF 33% (0.33)
CXR: Crackles bilaterally and cardiomegaly (enlarged heart)
Labs:
Sodium: 142 mE/L (mmol/L)
Potassium: 3.7 mEq/L (mmol/L)
Magnesium: 1.8 mEq/L (0.90 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 µmol/L)
BNP: 322 pg/mL (ng/L; 93 pmol/L)
Current medications:
Aspirin 81 mg daily
Amlodipine 5 mg daily
Glipizide 10 mg twice daily for diabetes
Simvastatin 20 mg nightly at bedtime
Ibuprofen 600 mg twice daily
Which of the following is true regarding the patient’s current NYHA functional class and stage of heart failure?
A. Class III, Stage B
B. Class III, Stage C
C. Class II, Stage B
D. Class II, Stage C

Answer 28

Answer: B

Options A and C: Incorrect. The patient is currently experiencing symptoms of heart failure, therefore he is stage C.

Option B: Correct.

Option D: Incorrect. He has shortness of breath with activities of daily living, which constitutes a NYHA functional class III.

Question 29

A 72-year-old man presents to the clinic today with complaints of increasing shortness of breath while dressing and carrying groceries and a 10 lb (4.5 kg) weight gain. A few months prior, he noticed episodes of waking in the middle of the night with shortness of breath, difficulty breathing after walking two flights of stairs, as well as ankle edema. The patient has a history of osteoarthritis × 10 years, hypertension × 4 years, diabetes mellitus × 5 years, dyslipidemia, and is status postmyocardial infarction 2 years ago.
Physical examination reveals the following: BP 148/96 mm Hg, pulse 98 beats/min, Ht: 5′11″ (180 cm), Wt: 189 lb (86 kg; usual = 178 lb [81 kg]), BMI: 26.4 kg/m2
(+) JVD, (−) HJR or hepatomegaly
(+) S3, (+) S4
ECG: regular rate/rhythm, evidence of old infarct
ECHO: EF 33% (0.33)
CXR: Crackles bilaterally and cardiomegaly (enlarged heart)
Labs:
Sodium: 142 mE/L (mmol/L)
Potassium: 3.7 mEq/L (mmol/L)
Magnesium: 1.8 mEq/L (0.90 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 µmol/L)
BNP: 322 pg/mL (ng/L; 93 pmol/L)
Current medications:
Aspirin 81 mg daily
Amlodipine 5 mg daily
Glipizide 10 mg twice daily for diabetes
Simvastatin 20 mg nightly at bedtime
Ibuprofen 600 mg twice daily
Which of the following is the most appropriate acute treatment plan for the patient’s heart failure?
A. Add furosemide and lisinopril, discontinue ibuprofen
B. Increase amlodipine to 10 mg daily, continue ibuprofen
C. Add furosemide, lisinopril, and carvedilol, continue ibuprofen
D. Add hydrochlorothiazide, discontinue amlodipine, discontinue ibuprofen

Answer 29

Answer: A
Option A: Correct. Add a loop diuretic, as well as a RAAS blocker which is indicated in this patient with HFrEF, in addition to discontinuing ibuprofen which may exacerbate heart failure.

Options B and C: Incorrect. It is not advisable to continue ibuprofen, an NSAID that can exacerbate heart failure symptoms by leading to fluid retention.

Option D: Incorrect. Hydrochlorothiazide is inferior to loop diuretics with respect to treating volume retention.

Question 30

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, atenolol 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 have increased from once monthly to once daily. Blood pressure is 128/64 mm Hg; 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 atenolol to 100 mg PO daily
C. Refer the patient to the hospital
D. Schedule an outpatient coronary angiogram

Answer 30

Answer: C
Option A: Incorrect. Although isosorbide mononitrate would be a reasonable choice to prevent chronic angina symptoms, the patient is experiencing symptoms consistent with ACS and requires referral to the hospital.
Option B: Incorrect. Although increasing atenolol would be a reasonable choice to prevent chronic angina symptoms, the patient is experiencing symptoms consistent with ACS and requires referral to the hospital.
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.
Option D: Incorrect. While it is likely that this patient requires an angiogram, given that the patient is experiencing symptoms consistent with ACS, referral to the hospital with potential for an inpatient angiogram is preferred to scheduling it as an outpatient.

Question 31

A patient is started on ranolazine 500 mg PO twice daily for recurrent angina symptoms. Which of the following should be monitored during ranolazine therapy?
A. Blood pressure and heart rate
B. Creatinine and potassium levels
C. Drug interactions and QT interval
D. Symptoms of angioedema and heart failure

Answer 31

Answer: C
Option A: Incorrect. Ranolazine does not affect blood pressure or heart rate.
Option B: Incorrect. Ranolazine will not affect potassium levels or creatinine.
Option C: Correct. ECG should be obtained to check for significant QT prolongation and drug interaction screen should be performed as ranolazine has significant drug interactions either through additive QT prolongation potential or alterations in drug metabolism or transport (CYP, OCT2, and P-gp).
Option D: Incorrect. Ranolazine does not cause angioedema or symptoms of heart failure.

Question 32

A 75-year-old male with a history of hypertension, dyslipidemia, and SIHD presents to the cardiology office for routine follow-up evaluation. He states that overall he is feeling well. However, he still experiences angina symptoms with walking up a flight of stairs. His current medication regimen includes losartan 25 mg PO daily, rosuvastatin 5 mg PO daily, metoprolol XL 25 mg PO daily, and aspirin 81 mg PO daily. Vital signs in office reveal a blood pressure of 140/64 mm Hg and a heart rate of 96 beats/min. What is the most appropriate pharmacologic intervention to manage the patient’s anginal symptoms?

A. Add amlodipine 5 mg PO daily
B. Add diltiazem ER 180 mg PO daily
C. Increase losartan to 50 mg PO daily
D. Increase metoprolol XL to 50 mg PO daily

Answer 32

Answer: D
Option A: Incorrect. Patient is not optimized on his β-blocker and amlodipine will not decrease heart rate (which is already elevated).
Option B: Incorrect. The combination of β-blockers and nondihydropyridine CCBs should be avoided due to potential for significant bradycardia and conduction disturbances.
Option C: Incorrect. Losartan does not have antianginal effects and will not help control the patient’s symptoms
Option D: Correct. Patient is on a small initial dose of metoprolol with continued angina symptoms. Heart rate is elevated to 96 beats/min. Metoprolol should be increased to further decrease myocardial oxygen demand without having to add additional medications.

Question 33

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 (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 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

Answer 33

Answer: A
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.
Option B: Incorrect. Sublingual NTG has immediate effects and relief of chest pain should occur within minutes. Additionally, if pain persists for 30 minutes after administration ACS should be considered.
Option C: Incorrect. In a patient with established SIHD, calling 9-1-1 prior to administering at least one dose of sublingual nitroglycerin is unnecessary.
Option D: Incorrect. This was an old recommendation. Emergency services should be contacted if no relief after the first dose.

Question 34

Rupture of an atherosclerotic plaque followed by thrombus formation best describes the pathophysiology of which of the following manifestations of ischemic heart disease?
A. Acute coronary syndrome
B. Chronic stable angina
C. Microvascular angina
D. Variant angina

Answer 34

Answer: A
Option A: Correct. ACS typically occurs when an existing atherosclerotic plaque ruptures, stimulating platelet adhesions, activation, aggregation, and thrombus formation.
Option B: Incorrect. Chronic stable angina typically occurs when oxygen demand is increased in patients with decreased oxygen supply due to obstructive atherosclerotic plaques.
Option C: Incorrect. Microvascular disease is thought to be due to disease in smaller coronary vessels causing typical angina in the absence of obstructive CAD of the epicardial arteries.
Option D: Incorrect. Vasospasm occurs in response to an acute narrowing or vasoconstriction of a coronary artery.

Question 35

Implementation of an aerobic exercise program targets which of the following treatment goals for patients with stable ischemic heart disease?
A. Alleviate acute symptoms of angina
B. Prevent acute coronary syndrome and death
C. Prevent progression of stable ischemic heart disease
D. Prevent recurrent symptoms of angina

Answer 35

Answer: C
Option A: Incorrect. Sublingual nitroglycerin or rest are directed at acute relief of angina symptoms. In a patient experiencing acute angina symptoms, exercise would likely increase symptoms due to increased oxygen demand.
Option B: Incorrect. There is no evidence to suggest exercise reduces the risk of MACE in patients with SIHD.
Option C: Correct. Exercise and other lifestyle modifications decrease risk factors, prevent progression of disease, and reduce the risk for SIHD-related complications.
Option D: Incorrect. Exercise does not prevent recurrent symptoms of angina.

Question 36

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 500 mg PO 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

Answer 36

Answer: A
Option A: Correct. CCBs are recommended as the initial treatment for patients with variant angina.
Option B: Incorrect. Long-acting nitrates can be added to CCBs in patients with recurrent angina symptoms. However, the nitrate-free interval required with long-acting nitrates limits their use in controlling vasospasm as monotherapy.
Option C: Incorrect. β-Blockers should be avoided in patients with variant angina as they can worsen vasospasm through unopposed α-adrenergic receptor stimulation.
Option D: Incorrect. Ranolazine is not the recommended initial therapy in patients with variant angina.

Question 37

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 daily, carvedilol 25 mg PO twice 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 104/70 mm Hg, and his pulse is 60 beats/min. What is the most appropriate pharmacologic intervention?
A. Add diltiazem
B. Add isosorbide mononitrate
C. Change carvedilol to acebutolol
D. Taper off carvedilol and start nifedipine

Answer 37

Answer: B
Option A: Incorrect. Concomitant use of nondihydropyridine CCBs and β-blockers should be avoided due to risk of significant bradycardia and AV conduction defects. Additionally, this patient’s heart rate is already on the lower end at 60 beats/min.
Option B: Correct. The patient has continued symptoms despite being on an appropriate dose of metoprolol. Long-acting nitrates are appropriate additional therapy for recurrent angina symptoms.
Option C: Incorrect. Changing from carvedilol to a β-blocker with intrinsic sympathomimetic activity (acebutolol) should be avoided.
Option D: Incorrect. Substitution of nifedipine for carvedilol is not recommended as carvedilol effectively lowers heart rate whereas nifedipine may actually increase heart rate due to reflex tachycardia. Dihydropyridine CCBs can be effective adjuncts to β-blockers in patients with recurrent symptoms of angina, but would not be ideal in this patient given the low blood pressure.

Question 38

A 63-year-old woman with a past medical history of dyslipidemia and chronic stable angina is treated with aspirin 81 mg PO once daily, metoprolol XL 200 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 stable ischemic heart disease?
A. Isosorbide dinitrate
B. Ramipril
C. Ranolazine
D. Verapamil

Answer 38

Answer: B
Option A: Incorrect. Addition of long-acting nitrates should only be considered if angina symptoms are poorly controlled.

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.

Option C: Incorrect. Ranolazine can be considered if the patient has recurrent angina symptoms. This patient’s angina is well-controlled.

Option D: Incorrect. Addition of verapamil can be considered if patient has continuing angina symptoms. Additionally, it should be used with caution in patients already on β-blockers.

Question 39

A 59-year-old male has a history of hypertension, dyslipidemia, stable 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, nebivolol 5 mg PO daily, felodipine 5 mg PO daily, and sildenafil 20 mg PO thrice daily. His blood pressure is 102/76 mm Hg and heart rate is 56 beats/min. He continues to experience ischemic symptoms with minimal exertion. What is the most appropriate pharmacological intervention to improve the management of this patient’s ischemic heart disease?
A. Add isosorbide mononitrate
B. Add ranolazine
C. Increase felodipine to 10 mg PO daily
D. Increase nebivolol to 10 mg PO daily

Answer 39

Answer: B
Option A: Incorrect. Concomitant use of long-acting nitrates and PDE-5 inhibitors is contraindicated especially in this patient who is on scheduled sildenafil for treatment of pulmonary hypertension.

Option B: Correct. Addition of ranolazine is appropriate as the patient’s angina symptoms are poorly controlled. Additionally, blood pressure and heart rate are on the lower end, and addition of ranolazine will not affect blood pressure or heart rate.

Option C: Incorrect. Although the patient’s angina symptoms are poorly controlled on the current regimen, increasing the dose of felodipine may further decrease blood pressure, which is already low.

Option D: Incorrect. Blood pressure and heart rate are already low. Increasing nebivolol will increase the risk of symptomatic bradycardia.

Question 40

A 56-year-old male 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/m2. 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; 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 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

Answer 40

Answer: A
Option A: Correct. The patient has untreated dyslipidemia and stable ischemic heart disease. Therefore, a high-intensity statin like atorvastatin is indicated.

Option B: Incorrect. The patient is already adhering to a satisfactory aerobic exercise program. Further, he has untreated dyslipidemia for which he requires therapy.

Option C: Incorrect. Aspirin doses greater than 162 mg PO daily do not provide additional benefit in patients with stable ischemic heart disease.

Option D: Incorrect. Blood pressure and heart rate are at goal and the patient’s symptoms are well controlled. Therefore, escalation in the carvedilol dose is unnecessary.

Question 41

A 66-year-old female 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

Answer 41

Answer: B
Option A: Incorrect. This would be correct for a patient with stable ischemic heart disease who received a BMS.

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.

Option C: Incorrect. This would be correct if the patient presented with ACS. Alternatively, if the patient had a favorable benefit:risk profile for prolonged DAPT, this would be a consideration in a patient with SIHD who received a DES. The patient’s age and history of peptic ulcer disease presents an unfavorable benefit:risk ratio.

Option D: Incorrect. Indefinite therapy is not indicated. The patient’s age and history of peptic ulcer disease presents an unfavorable benefit:risk ratio for prolonged DAPT following PCI with stent placement.

Question 42

A 53-year-old woman with a history of hypertension and dyslipidemia is diagnosed with microvascular disease. Her blood pressure is 138/90 mm Hg and heart rate is 74 beats/min. Her current medications include aspirin 162 mg PO daily, benazepril 10 mg PO daily, and simvastatin 20 mg PO daily. Which of the following changes to her regimen are recommended to treat her microvascular angina?
A. Add nadolol
B. Add ranolazine
C. Increase benazepril to 20 mg PO daily
D. Increase simvastatin to 40 mg PO daily

Answer 42

Answer: A
Option A: Correct. Similar to patients with SIHD due to obstructive CAD, β-blockers are recommended as the initial therapy to control angina symptoms in patients with microvascular disease.

Option B: Incorrect. In patients with microvascular angina, ranolazine is typically reserved for symptoms refractory to other therapies.

Option C: Incorrect. Increasing benazepril will help with her hypertension; however, ACE inhibitors do not have antianginal effects and will not relieve her symptoms of angina.

Option D: Incorrect. While a dose increase in simvastatin or a change to a high-intensity statin may be warranted, statins do not prevent symptoms of angina.

Question 43

A 62-year-old male 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

Answer 43

Answer: A
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.

Option B: Incorrect. Monotherapy with clopidogrel is only considered for patients with SIHD and allergy or intolerance to aspirin.

Option C: Incorrect. The patient does not complain of any symptoms of angina and blood pressure is at goal. Adding felodipine will not provide additional benefit.

Option D: Incorrect. While ACE inhibitors have been shown to decrease MACE, this patient is already on an ARB (valsartan). Adding an ACE inhibitor would not confer any additional benefit and can increase the risk for adverse reactions (hyperkalemia).

Question 44

A 75-year-old female 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

Answer 44

Answer: A
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.

Option B: Incorrect. Sublingual nitroglycerin is used to relieve acute symptoms not to prevent recurrent symptoms.

Option C: Incorrect. The patient is hypertensive; selection of an antianginal drug that also lowers BP would be preferred. Additionally, ranolazine is costly and is often reserved for patients refractory to other antianginal therapies.

Option D: Incorrect. Although the patient is hypertensive and has HFrEF, because she is also experiencing some mild, acute exacerbation of heart failure, increasing the dose of carvedilol should be delayed until the symptoms of heart failure have been treated.