28: chronic stable Angina& Low-Risk Unstable Angina

Question 1

1. Angina is produced by an imbalance between myocardial oxygen supply (MOS) and demand (MOD) in the myocardium. Which of the following drugs help to correct this imbalance by increasing MOS?
2. Calcium channel blockers
3. Beta blockers
4. Angiotensin-converting-enzyme (ACE) inhibitors
5. Aspirin

Answer 1

3. Angiotensin-converting-enzyme (ACE) inhibitors

Question 2

2. Not all chest pain is caused by myocardial ischemia. Noncardiac causes of chest pain include:
3. Pulmonary embolism
4. Pneumonia
5. Gastroesophageal reflux
6. All of the above

Answer 2

4. All of the above

Question 3

3. The New York Heart Association and the Canadian Cardiovascular Society have described grading criteria for levels of angina. Angina that occurs with unusually strenuous activity or on walking or climbing stair after meals is class:
4. I
5. II
6. III
7. IV

Answer 3

2. II

Question 4

4. Patients at high risk for developing significant coronary heart disease are those with:
5. LDL values between 100 and 130
6. Systolic blood pressure between 120 and 130
7. Class III angina
8. Obesity

Answer 4

3. Class III angina

Question 5

5. To reduce mortality, all patients with angina, regardless of class, should be on:
6. Aspirin 81 to 325 mg/d
7. Nitroglycerin sublingually for chest pain
8. ACE inhibitors or angiotensin receptor blockers
9. Digoxin

Answer 5

1. Aspirin 81 to 325 mg/d

Question 6

6. Patients who have angina, regardless of class, who are also diabetic, should be on:
7. Nitrates
8. Beta blockers
9. ACE inhibitors
10. Calcium channel blockers

Answer 6

3. ACE inhibitors

Question 7

7. Management of all types and grades of angina includes the use of lifestyle modification to reduce risk factors. Which of these modifications are appropriate for which reason? Both the modification and the reason for it must be true for the answer to be correct.
8. Lose at least 10 pounds of body weight. Excessive weight increases cardiac workload.
9. Reduce sodium intake to no more than 2,400 mg of sodium. Sodium increases blood volume and cardiac workload.
10. Increase potassium intake to at least 100 mEq/d. The heart needs higher levels of potassium to improve contractility and oxygen supply.
11. Intake a moderate amount of alcohol. Moderate intake has been shown by research to improve cardiac function.

Answer 7

2. Reduce sodium intake to no more than 2,400 mg of sodium. Sodium increases blood volume and cardiac workload.

Question 8

8. Nitrates are especially helpful for patients with angina who also have:
9. Heart failure
10. Hypertension
11. Both 1 and 2
12. Neither 1 nor 2

Answer 8

3. Both 1 and 2

Question 9

9. Beta blockers are especially helpful for patients with exertional angina who also have:
10. Arrhythmias
11. Hypothyroidism
12. Hyperlipidemia
13. Atherosclerosis

Answer 9

1. Arrhythmias

Question 10

10. Rapid-acting nitrates are important for all angina patients. Which of the following are true statements about their use?
11. These drugs are useful for immediate symptom relief when the patient is certain it is angina.
12. The dose is one sublingual tablet or spray every 5 minutes until the chest pain goes away.
13. Take one nitroglycerine tablet or spray at the first sign of angina; repeat every 5 minutes for no more than two doses. If chest pain is still not relieved, call 911.
14. All of the above

Answer 10

3. Take one nitroglycerine tablet or spray at the first sign of angina; repeat every 5 minutes for no more than two doses. If chest pain is still not relieved, call 911.

Question 11

11. Isosorbide dinitrate is a long-acting nitrate given twice daily. The schedule for administration is 7 a.m. and 2 p.m. because:
12. Long-acting forms have a higher risk for toxicity.
13. Orthostatic hypotension is a common adverse effect.
14. It must be taken with milk or food.
15. Nitrate tolerance can develop.

Answer 11

4. Nitrate tolerance can develop.

Question 12

12. Combinations of a long-acting nitrate and a beta blocker are especially effective in treating angina because:
13. Nitrates increase MOS and beta blockers increase MOD.
14. Their additive effects permit lower doses of both drugs and their adverse reactions cancel each other out.
15. They address the pathology of patients with exertional angina who have fixed atherosclerotic coronary heart disease.
16. All of the above

Answer 12

2. Their additive effects permit lower doses of both drugs and their adverse reactions cancel each other out.

Question 13

13. Drug choices to treat angina in older adults differ from those of younger adults only in:
14. Consideration of risk factors for diseases associated with and increased in aging
15. The placement of drug therapy as a treatment choice before lifestyle changes are tried
16. The need for at least three drugs in the treatment regimen because of the complexity of angina in the older adult
17. Those with higher risk for silent myocardial infarction

Answer 13

1. Consideration of risk factors for diseases associated with and increased in aging

Question 14

14. Which of the following drugs has been associated with increased risk for myocardial infarction in women?
15. Aspirin
16. Beta blockers
17. Estrogen replacement
18. Lipid-lowering agents

Answer 14

3. Estrogen replacement

Question 15

15. Cost of antianginal drug therapy should be considered in drug selection because of all of the following EXCEPT:
16. Patients often require multiple drugs
17. A large number of angina patients are older adults on fixed incomes
18. Generic formulations may be cheaper but are rarely bioequivalent
19. Lack of drug selectivity may result in increased adverse reactions

Answer 15

3. Generic formulations may be cheaper but are rarely bioequivalent

Question 16

16. Situations that suggest referral to a specialist is appropriate include:
17. When chronic stable angina becomes unpredictable in its characteristics and precipitating factors
18. When a post-myocardial infarction patient develops new-onset angina
19. When standard therapy is not successful in improving exercise tolerance or reducing the incidence of angina
20. All of the above

Answer 16

4. All of the above

Question 17

17. The rationale for prescribing calcium blockers for angina can be based on the need for:
18. Increased inotropic effect in the heart
19. Increasing peripheral perfusion
20. Keeping heart rates high enough to ensure perfusion of coronary arteries
21. Help with rate control

Answer 17

4. Help with rate control

Question 18

18. Medications are typically started for angina patients when:
19. The first permanent EKG changes occur
20. The start of class I or II symptoms
21. The events trigger a trip to the emergency department
22. When troponin levels become altered

Answer 18

2. The start of class I or II symptoms

Question 19

19. The most common cause of angina is:
20. Vasospasm of the coronary arteries
21. Atherosclerosis
22. Platelet aggregation
23. Low systemic oxygen

Answer 19

2. Atherosclerosis

Question 20

20. Ranolazine is used in angina patients to:
21. Dilate plaque-filled arteries
22. Inhibit platelet aggregation
23. Restrict late sodium flow in the myocytes
24. Induce vasoconstriction in the periphery to open coronary vessels

Answer 20

3. Restrict late sodium flow in the myocytes

Question 21

21. When is aspirin (ASA) used in angina patients?
22. All angina patients should be taking ASA unless it is contraindicated for allergy or other medical reasons.
23. ASA should only be used in men.
24. ASA has no role in angina, but is useful in MI prevention.
25. The impact of ASA is best at the time of an angina attack.

Answer 21

1. All angina patients should be taking ASA unless it is contraindicated for allergy or other medical reasons.