Acute cardio

Question 1

1. 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 1

1. 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).

Question 2

2. 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 2

2. 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.

Question 3

3. 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. Tirofiban.
   B. Bivalirudin.
   C. Enoxaparin.
   D. Tenecteplase

Answer 3

3. 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.

Question 4

4. 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 200 mg of oral metoprolol succinate at
   discharge.
   D. Give no β-blocker at this time.

Answer 4

4. 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 has several 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 marginal blood
   pressure at this time. Answer D is correct; however,
   before discharge, this patient should be reevaluated for
   the initiation of low-dose β-blocker therapy.

Question 5

5. 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 5

5. 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 Triton-TIMI 38 comparing
   the effectiveness of prasugrel and clopidogrel showed the
   superiority of prasugrel, especially for patients presenting
   with a STEMI (Answer B is correct).

Question 6

6. 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 6

6. 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,

Question 7

7. 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 7

7. 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%.

Question 8

8. 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
   hours.

Answer 8

8. 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).

Question 9

9. 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 9

9. 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).

Question 10

10. 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 10

10. 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).

Question 11

Patient Cases
1. A 66-year-old woman (weight 70 kg) with a history of MI, hypertension, hyperlipidemia, and diabetes mellitus
presents with sudden-onset diaphoresis, nausea, vomiting, and dyspnea, followed by a bandlike upper
chest pain (8/10) radiating to her left arm. She had felt well until 1 month ago, when she noticed her typical
angina was occurring with less exertion. Her ECG reveals ST-segment depression in leads II, III, and aVF and
hyperdynamic T waves and positive cardiac enzymes. Blood pressure is 150/90 mm Hg, and all laboratory
results are normal; SCr is 1.2 mg/dL. Home medications are aspirin 81 mg/day, simvastatin 40 mg every night,
metoprolol 50 mg twice daily, and metformin 1 g twice daily. Which regimen is best for this patient?
A. Aspirin 325 mg, ticagrelor 180 mg one dose, and UFH 60-unit/kg bolus; then 12 units/kg/hour titrated
to 50–70 seconds with an early invasive approach.
B. Aspirin 325 mg and enoxaparin 70 mg subcutaneously twice daily with an early invasive approach.
C. An ischemia-guided strategy with tirofiban 25 mcg/kg; then 0.15 mg/kg/minute plus enoxaparin 80 mg
subcutaneously twice daily, aspirin 325 mg/day, and clopidogrel 300 mg one dose; then 75 mg once daily.
D. An ischemia-guided strategy with aspirin 325 mg and ticagrelor 180 mg one dose; plus UFH 70-unit/kg
bolus; then 15 units/kg/hour.

Answer 11

1. Answer: A
   This patient’s atypical symptoms, ST-segment depression
   on ECG, and positive biomarkers for myocardial
   necrosis suggest NSTE-ACS. She has at least three risk
   factors for CAD, a history of CAD (prior MI), and positive
   troponins, which place her at high risk of future
   events. In such high-risk patients, an early invasive
   strategy (as in Answers A and B) is used to determine
   whether occluded or partly occluded arteries exist,
   which ones can be intervened on, and whether to make
   an intervention. An ischemia-guided approach, also
   called “medical management,” as in Answers C and D,
   would not be preferred because of this patient’s risk category
   (i.e., positive troponins). Dual antiplatelet therapy
   (aspirin plus a P2Y12 inhibitor) is indicated for an
   early invasive strategy in managing an NSTE-ACS. In
   patients undergoing PCI, clopidogrel, prasugrel, or ticagrelor
   is appropriate (Answer A is correct). After an initial
   bolus of 60 units/kg and an infusion of 12 units/kg/
   hour (Answer A is correct; Answer D is incorrect), UFH
   can be titrated to an aPTT of 50–70 seconds. Aspirin
   alone without a P2Y12 agent, as in Answer B, would
   not provide adequate antiplatelet therapy. Furthermore,
   enoxaparin would need to be dosed with a 30-mg intravenous
   bolus before initiating twice-daily subcutaneous
   dosing because this patient has positive troponins.
   Glycoprotein IIb/IIIa inhibitors, as in Answer C, can be
   useful in high-risk patients, typically those with positive
   troponins; however, their benefit has been shown
   mainly when UFH, not low-molecular-weight heparin,
   is given as the anticoagulant.

Question 12

Patient Cases (Cont’d)
2. A 45-year-old patient underwent an elective percutaneous transluminal coronary angioplasty and drug-eluting
stent placement in the right coronary artery. Which best represents the minimum time DAPT should be continued?
A. 1 month.
B. 3 months.
C. 6 months.
D. 12 months.

Answer 12

2. Answer: C
   Of importance, this patient case occurs in the context of
   elective stent placement, not after ACS. In the non-ACS
   setting, the duration of DAPT is determined by the type
   of stent placed (bare metal stent vs. drug-eluting stent).
   After elective drug-eluting stent placement, DAPT is
   recommended for at least 6 months because the risk of
   in-stent thrombosis is highest during this time (Answer
   C is correct). The recommendation is for at least 1
   month after bare metal stent placement because endothelialization
   of the stent usually occurs early, typically
   within 1 month after stenting (Answer A is incorrect).
   Bleeding risk may be a reason to consider earlier termination
   (after at least 1 month) of DAPT after bare
   metal stent placement. Although European guidelines consider 3 months of DAPT after drug-eluting stent
   placement appropriate, the recommended minimum
   according to the U.S. guidelines is 6 months (Answer
   B is incorrect). Twelve months of therapy is recommended
   after ACS (Answer D is incorrect).

Question 13

3. A 52-year-old man (weight 100 kg) with a history of hypertension and hypertriglyceridemia presents at a major
   university teaching hospital with a cardiac catheterization laboratory. He has had 3 hours of crushing 10/10
   substernal chest pain radiating to both arms that began while he was eating his lunch (seated), which is accompanied
   by nausea, diaphoresis, and shortness of breath. He has never before had chest pain of this character or
   intensity. He usually can walk several miles without difficulty and smokes 1.5 packs/day of cigarettes. Home
   medications are lisinopril 2.5 mg/day and aspirin 81 mg daily. Current vital signs include heart rate 68 beats/
   minute and blood pressure 178/94 mm Hg. His ECG reveals a 3-mm ST-segment elevation in leads V2–V4, I,
   and aVL. Serum chemistry values are within normal limits. The first set of cardiac markers shows positive
   troponins, 0.8 mcg/L (normal defined as less than 0.1 mcg/L). Which regimen is best for this patient’s STEMI?
   A. Reperfusion with primary PCI and stenting of occluded artery, together with tirofaban 25 mcg/kg; then
   0.15 mg/kg/minute, clopidogrel 300 mg one dose, and aspirin 325 mg one dose.
   B. Reperfusion with a reteplase 10-unit bolus twice, 30 minutes apart, plus a UFH 60-unit/kg bolus and a
   12-unit/kg/hour infusion, clopidogrel, and aspirin.
   C. Reperfusion with tenecteplase 25-mg intravenous push one dose, enoxaparin 30-mg intravenous bolus
   plus 100 mg subcutaneously twice daily, aspirin 325 mg one dose, ticagrelor 180 mg one dose, and bivalirudin
   0.75 mg/kg followed by 1.75 mg/kg/hour.
   D. Reperfusion with primary PCI with stenting, prasugrel 60 mg one dose, aspirin 325 mg one dose, and
   bivalirudin 0.75 mg/kg followed by 1.75 mg/kg/hour.

Answer 13

3. Answer: D
   Because the patient presents to a hospital that can do a
   primary PCI with stent implantation, this is the preferred
   reperfusion strategy (Answers B and C are incorrect).
   Answer A is incorrect because an anticoagulant agent
   must be administered in addition to antiplatelet therapy.
   Reperfusion with fibrinolytic therapy (Answers B and
   C) would only be considered if PCI were expected to be
   delayed by more than 120 minutes. In addition, Answer
   C is incorrect because bivalirudin has not been studied
   with lytic therapy. Answer D – reperfusion with primary
   PCI, DAPT with aspirin and prasugrel, and dosing of
   bivalirudin as an anticoagulant strategy – is correct.

Question 14

4. A 76-year-old male smoker (weight 61 kg) has a history of hypertension, benign prostatic hypertrophy, and
   lower back pain. Three weeks ago, he began to have substernal chest pain with exertion (together with dyspnea),
   which radiated to both arms and was associated with nausea and diaphoresis. These episodes have
   increased in frequency to four or five times daily; they are relieved with rest. He has never had an ECG. Today,
   he awoke with 7/10 chest pain and went to the ED of a rural community hospital 2 hours later. He was acutely
   dyspneic and had ongoing pain. Home medications are aspirin 81 mg/day for 2 months, doxazosin 2 mg/day,
   and ibuprofen 800 mg three times daily. Vital signs include heart rate 42 beats/minute (sinus bradycardia) and
   blood pressure 104/48 mm Hg. Laboratory results include blood urea nitrogen (BUN) 45 mg/dL, SCr 2.5 mg/
   dL, and troponin 1.5 ng/L (normal value less than 0.1 ng/L). His ECG reveals a 3-mm ST-segment elevation.
   Aspirin, ticagrelor, and sublingual nitroglycerin were given in the ED. The nearest hospital with a catheterization
   laboratory facility is 2½ hours away. Which regimen is best?
   A. Give alteplase 15 units intravenously plus enoxaparin 30-mg intravenous bolus.
   B. Use an ischemia-guided treatment strategy with UFH 4000-unit intravenous bolus, followed by 800 units
   intravenously per hour.
   C. Give tenecteplase 35 mg intravenously plus UFH 4000-unit intravenous bolus followed by 800 units intravenously
   per hour.
   D. Transfer the patient to a facility for primary PCI.

Answer 14

4. Answer: C
   Unlike the patient in case 3, this patient presents with a
   STEMI to a rural community hospital where the nearest
   hospital with catheterization laboratory facilities is
   more than 120 minutes away (i.e., lytics are indicated).
   He presents within the window for fibrinolytic therapy
   consideration (less than 6 hours after chest pain
   onset) and has no obvious contraindications. Because
   he is still having ischemic chest pain and ST-segment
   elevation, he should benefit from reperfusion therapy.
   He is experiencing bradycardia, which could indicate
   an occlusion above the area perfusing his sinoatrial or
   atrioventricular nodes. Enoxaparin is a treatment option
   for anticoagulant therapy given in conjunction with
   fibrinolytics, but the patient is at higher risk of bleeding
   from impaired enoxaparin clearance and needs a
   dosage adjustment. Furthermore, he is older than 75,
   beyond the age at which the intravenous bolus should be
   given, and the alteplase dosing is incomplete (Answer
   A is incorrect). Simply treating this patient conservatively
   with UFH alone in the setting of ongoing chest
   pain, shortness of breath, and pulmonary edema is not
   optimal (Answer B is incorrect). Diagnostic catheterization
   and possible PCI to determine whether an artery
   can be reperfused may be desirable but is complicated
   because the patient’s SCr is elevated (2.5 mg/dL), and
   he is in a rural hospital, where he cannot be assessed quickly enough (within 90–120 minutes) (Answer D
   is incorrect). Because of the shorter half-life and ease
   of administration of tenecteplase, tenecteplase may be
   preferable to alteplase. Clearance of UFH with tenecteplase
   is not as altered as with enoxaparin, and it would
   be a more appropriate therapy than enoxaparin in combination
   with a thrombolytic (Answer C is correct).

Question 15

Patient Case
Questions 5–7 pertain to the following case.
A 72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal
AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day.
5. Which regimen is best for treating his ADHF?
A. Carvedilol 25 mg twice daily.
B. Sodium nitroprusside 0.1 mcg/kg/min IV.
C. Furosemide 120 mg intravenously twice daily.
D. Milrinone 0.5 mcg/kg/minute.

Answer 15

5. Answer: C
   This patient, who has ADHF, is receiving a β-blocker.
   Although long-term β-blockers can improve HF symptoms
   and reduce mortality, they can also worsen symptoms
   in the short term. It is recommended to keep
   the maintenance β-blocker therapy at the same or at a
   slightly lower dose compared with the outpatient therapy
   in patients with ADHF; increasing the β-blocker
   dose before reaching euvolemia might acutely worsen
   his clinical picture (Answer A is incorrect). In patients
   admitted with volume overload without substantial signs
   of reduced CO, it is reasonable to try intravenous loop
   diuretics initially (Answer C is correct). As gut edema
   increases, oral loop diuretics (notably furosemide)
   become less effective because of decreased absorption.
   Sodium nitroprusside could be useful if signs and
   symptoms of hypoperfusion were present. Because this
   patient presents mainly with warm and wet symptoms,
   diuretics would be first-line (Answer B is incorrect).
   Milrinone is an inotropic drug. Because of their adverse
   effects, inotropes are recommended in cold and wet
   exacerbations only after vasodilatory medications have
   failed (Answer D is incorrect).

Question 16

6. After being initiated on intravenous loop diuretics with only minimal urinary output, the patient is transferred
   to the coronary care unit for further management of diuretic-refractory decompensated HF. His Sao2 is now
   87% on a 4-L nasal cannula, and an arterial blood gas is being obtained. His blood pressure is 110/75 mm
   Hg and heart rate is 75 beats/minute. The patient’s SCr and K+ concentrations have begun to rise and are now
   2.7 mg/dL and 5.4 mmol/L, respectively. In addition to a one-time dose of intravenous chlorothiazide, which
   regimen is most appropriate for this patient?
   A. Nitroglycerin 20 mcg/minute.
   B. Sodium nitroprusside 0.3 mg/kg/minute.
   C. Dobutamine 5 mcg/kg/minute.
   D. Milrinone 0.5 mcg/kg/minute.

Answer 16

6. Answer: A
   Intravenous vasodilators such as nitroglycerin (Answer
   A) and sodium nitroprusside (Answer B) are reasonable
   if intravenous diuretics fail and the patient progresses
   to acute pulmonary edema. Both agents rapidly cause
   venous vasodilation and reduce pulmonary filling
   pressures, which can relieve acute shortness of breath.
   Answer A, nitroglycerin, is optimal for this patient,
   given his declining renal function and the concern
   for increased risk of thiocyanate toxicity with sodium
   nitroprusside in this setting (Answer B is incorrect).
   Dobutamine is typically used in states of low CO
   decompensation and is counteracted by concomitant
   β-blocker therapy, making it a poor choice in patients
   receiving β-blockers (Answer C is incorrect). Although
   milrinone is a more acceptable inotropic agent in a
   patient receiving β-blockers, the dosing strategy is inappropriate as an initial dose (Answer D is incorrect).
   Finally, inotropes are generally reserved for patients
   when other therapies have failed.

Question 17

7. The patient initially responds with 2 L of urinary output overnight, and his weight decreases by 1 kg the next
   day. However, by day 5, his urinary output has diminished again, and his SCr has risen to 4.3 mg/dL. He was
   drowsy and confused this morning during rounds. His extremities are cool and cyanotic, blood pressure is
   89/58 mm Hg, and heart rate is 98 beats/minute. It is believed that he is no longer responding to his current
   regimen. A Swan-Ganz catheter is placed to determine further management. Hemodynamic values are cardiac
   index 1.5 L/minute/m2, SVR 2650 dynes/second/cm5, and PCWP 30 mm Hg. Which regimen is most appropriate
   for his current symptoms?
   A. Milrinone 0.2 mcg/kg/minute.
   B. Dobutamine 10 mcg/kg/minute.
   C. Sodium nitroprusside 0.1 mcg/kg/minute.
   D. Phenylephrine 20 mcg/minute.

Answer 17

7. Answer: A
   Signs of a decreased CO state in HF (e.g., increased
   SCr, decreased mental status, cool extremities) suggest
   a cold and wet state, and adjunctive therapy is
   indicated. Positive inotropic agents such as milrinone
   will increase CO to maintain perfusion to vital organs.
   Milrinone will also vasodilate the peripheral vessels
   to unload the heart (lower SVR). Although dobutamine
   would be a potential choice in this patient, it is
   not recommended in patients receiving β-blockers, and
   the initial starting dose is too aggressive (Answer B is
   incorrect). Although this patient has low blood pressure,
   his elevated SVR suggests that he will tolerate
   the vasodilatory effects of milrinone as long as it is
   appropriately renally adjusted for worsening renal dysfunction
   (Answer A is correct). Nitroprusside would be
   relatively contraindicated in patients with an SBP less
   than 100 mm Hg and is absolutely contraindicated in
   patients with an SBP less than 90 mm Hg (Answer C is
   incorrect). Phenylephrine has no positive beta effects;
   therefore, it will not augment contractility. In addition,
   it will cause vasoconstriction through alpha stimulation,
   which will further increase SVR and probably
   worsen CO (Answer D is incorrect). Vasoconstrictors
   are reserved for patients in cardiogenic shock.

Question 18

Patient Cases
Questions 8 and 9 pertain to the following case.
A 68-year-old man is admitted after an episode of syncope, with a presyncopal syndrome of seeing black spots
and dizziness before passing out. Telemetry monitor showed sustained VT for 45 seconds. His medical history
includes HF NYHA class III, LVEF 30%, two MIs, hypertension for 20 years, LV hypertrophy, DM, and diabetic
nephropathy. His medications include lisinopril 5 mg/day, furosemide 20 mg twice daily, metoprolol 25 mg twice
daily, digoxin 0.125 mg/day, glipizide 5 mg/day, atorvastatin 40 mg, and aspirin 81 mg/day. His blood pressure is
120/75 mm Hg, with heart rate 80 beats/minute, BUN 30 mg/dL, and SCr 2.2 mg/dL.
8. Which is the best therapy to initiate for conversion of his sustained VT?
A. Amiodarone 150 mg intravenously for 10 minutes, then 1 mg/minute for 6 hours, then 0.5 mg/minute.
B. Sotalol 80 mg twice daily titrated to QTc of about 450 milliseconds.
C. Dofetilide 500 mcg twice daily titrated to QTc of about 450 milliseconds.
D. Procainamide 20 mg/minute, with a maximum of 17 mg/kg.

Answer 18

8. Answer: A
   Treatment options for sustained VT depend on concomitant
   disease states, particularly LVEF (40% cutoff). In
   a patient with LV dysfunction, class I agents such as
   procainamide are contraindicated (Answer D is incorrect).
   In a patient whose CrCl is less than 60 mL/minute,
   sotalol requires a considerable dose reduction to avoid
   an excess risk of torsades de pointes. Sotalol is not an
   effective cardioversion drug but is more useful for preventing
   future episodes of arrhythmias (maintaining
   sinus rhythm) once sinus rhythm is achieved (Answer
   B is incorrect). Dofetilide is indicated only for AF, not
   for ventricular arrhythmias; similarly, cardioversion
   rates with dofetilide are low (Answer C is incorrect).
   Amiodarone is first-line therapy for sustained VT in
   patients with severe renal insufficiency, HF, and SHD
   (Answer A is correct).

Question 19

9. The patient presents to the ED 3 months after amiodarone maintenance initiation (he refused ICD placement)
   after a syncopal episode, during which he lost consciousness for 30 seconds, according to witnesses. He also
   has rapid heart rate episodes during which he feels dizzy and lightheaded. He feels very warm all the time (he
   wears shorts, even though it is winter), cannot sleep, and has lost 3 kg in weight. He received a diagnosis of
   hyperthyroidism caused by amiodarone therapy. On telemetry, he has runs of nonsustained VT. Which best
   predicts the duration of amiodarone-associated hyperthyroidism in this patient?
   A. 12 hours.
   B. 1 month.
   C. 6 months.
   D. 18 months.

Answer 19

9. Answer: C
   With the prolonged half-life of amiodarone and extensive
   fat tissue volume of distribution, hyperthyroid
   adverse effects would be expected to last for 3–5 halflives
   of the drug, which is 5–8 months (Answer C is
   correct; Answer A is incorrect). Although therapeutic
   concentrations may decrease substantially by then,
   1 month is too soon for the effects to subside (Answer
   B is incorrect). Although some iodine and amiodarone
   molecules will probably remain absorbed in fat stores
   for years, if not for life, therapeutic concentrations
   should not exist for longer than what is predicted by the
   half-life (Answer D is incorrect).

Question 20

10. A 64-year-old woman presents to the ED with the chief concern of palpitations. Her medical history includes
    hypertension controlled with a diuretic and an inferior-wall MI 6 months ago. She is pale and diaphoretic but
    can respond to commands. The patient’s laboratory values are within normal limits. Her vital signs include
    blood pressure 95/70 mm Hg and heart rate 145 beats/minute; telemetry shows sustained VT. Despite chronic
    use of β-blocker therapy, the patient has developed sustained VT that is successfully terminated with lidocaine.
    Subsequent electrophysiologic testing reveals inducible VT, and sotalol 80 mg orally twice daily is prescribed.
    Two hours after the second dose, the patient’s QTc is 520 milliseconds. Which regimen change would
    be most appropriate for this patient?
    A. Continue sotalol at 80 mg orally twice daily.
    B. Increase sotalol to 120 mg orally twice daily.
    C. Discontinue sotalol and initiate dofetilide 125 mcg orally twice daily.
    D. Discontinue sotalol and initiate amiodarone 400 mg orally three times daily.

Answer 20

10. Answer: D
    This patient is having QT prolongation with sotalol,
    placing her at an elevated risk of developing lifethreatening
    torsades de pointes. Sotalol should be discontinued
    immediately (Answers A and B are incorrect).
    Given the QT prolongation that occurred with
    sotalol, the same will probably occur with dofetilide
    (Answer C is incorrect). Amiodarone is associated with
    minimal risk of torsades de pointes and therefore would
    be an appropriate alternative agent to prevent ventricular
    arrhythmias (Answer D is correct).

Question 21

Patient Cases
11. A 68-year-old man with a history of stage 5 chronic kidney disease receiving hemodialysis, hypertension,
CAD post-MI, HFrEF, and gastroesophageal reflux disease presents with acute-onset shortness of breath and
chest pain. After his recent dialysis, he was nonadherent to medical therapy for 2 days and noticed he had
gained 2 kg in 24 hours. His baseline orthopnea worsened to sleeping sitting up in a chair for the 2 nights
before admission. He admits smoking cocaine within the past 24 hours and developed acute-onset chest tightness
with diaphoresis and nausea, and his pain was 7/10. He went to the ED, where his blood pressure was
250/120 mm Hg. He had crackles halfway up his lungs on examination, and chest radiography detected bilateral
fluffy infiltrates with prominent vessel cephalization. His ECG revealed sinus tachycardia, heart rate 122
beats/minute, and ST-segment depressions in leads 2, 3, and aVF. He was admitted for a hypertensive emergency.
Laboratory results are as follows: BUN 48 mg/dL, SCr 11.4 mg/dL, BNP 2350 pg/mL, troponin T 1.5
ng/L (less than 0.1 mcg/L), creatine kinase 227 units/L, and creatine kinase-MB 22 units/L. Which medication
is best for this patient’s hypertensive emergency?
A. Intravenous nitroglycerin 5 mcg/minute titrated to a 25% reduction in MAP.
B. Labetalol 2 mcg/minute titrated to a 50% reduction in MAP.
C. Sodium nitroprusside 0.25 mcg/kg/minute titrated to a 25% reduction in MAP.
D. Clonidine 0.1 mg orally every 2 hours as needed for a 50% reduction in MAP.

Answer 21

11. Answer: A
    Hypertensive emergency should be treated immediately
    by no more than a 25% reduction in MAP over
    the first hour, followed by a further reduction to a blood
    pressure of 160/100 mm Hg over the next 2–6 hours.
    The patient’s comorbidities guide the optimal therapy.
    His dialysis and SCr of 11.4 mg/dL are contraindications
    to sodium nitroprusside (Answer C is incorrect)
    because of possible thiocyanate toxicity. Labetalol
    (and β-blockers in general) is controversial in patients
    who have taken cocaine, but its nonselective nature
    makes it an option; however, this patient appears to
    have decompensated HF, and a reduction of 50% initially
    is too rapid a decrease in blood pressure for safety
    (Answer B is incorrect). Clonidine is not appropriate
    for a hypertensive emergency because its oral form is
    difficult to titrate and can lead to precipitous drops in
    blood pressure beyond the goal 25% reduction and possibly
    stroke or worsening MI (Answer D is incorrect).
    Nitroglycerin is optimal, considering the patient’s lack
    of contraindications to this therapy and his evolving
    MI and symptoms of HF (Answer A is correct).

Question 22

12. A 56-year-old white woman with a long history of hypertension because of nonadherence and recently diagnosed
    HF (EF 35%) presents to the local ED with blood pressure 210/120 mm Hg and heart rate 105 beats/
    minute. She states that she felt a little lightheaded but that she now feels okay. She ran out of her blood pressure
    medications (including hydrochlorothiazide, carvedilol, and lisinopril) 3 days ago. Her current laboratory values
    are within normal limits. Which medication is best for this patient?
    A. Sodium nitroprusside 0.25 mcg/kg/minute titrated to a 25% reduction in MAP.
    B. Labetalol 80 mg intravenously; repeat until blood pressure is less than 120/80 mm Hg.
    C. Resumption of home medications; refer for follow-up within 2 days.
    D. Resumption of home medications; initiate amlodipine 10 mg daily; refer for follow-up in 1 week.

Answer 22

12. Answer: C
    In an asymptomatic hypertensive crisis (without acute
    target-organ damage), giving intravenous medications,
    as in Answers A and B, and admitting the patient to
    the hospital are unnecessary (Answers A and B are
    incorrect). This patient is likely presenting because
    of recent nonadherence. Resuming her home medications
    (Answer C is correct) at this time would be most
    appropriate, with a close follow-up to ensure that her
    prescribed regimen is working. Adding a fourth agent
    (Answer D is incorrect) at this time is unnecessary,
    considering that her disease could be controlled on her
    current drug regimen if she were adherent. Follow-up
    should occur within the first few days, rather than waiting
    1 week.

Question 23

Questions 1 and 2 pertain to the following case.
G.G. is a 56-year-old white man with type 2 diabetes. He
is a nonsmoker and is concerned about his risk of coronary
heart disease (CHD). His vital signs include blood pressure
(BP) 152/98 mm Hg (average home blood pressure 150/92
mm Hg), heart rate 70 beats/minute, and body mass index
(BMI) 26.5 kg/m2. His fasting laboratory test results today
include serum creatinine (SCr) 0.8 mg/dL, total cholesterol
(TC) 188 mg/dL, low-density lipoprotein cholesterol
(LDL) 130 mg/dL, high-density lipoprotein cholesterol
(HDL) 30 mg/dL, and triglycerides (TG) 90 mg/dL, and his urine albumin/creatinine ratio is 86.5 mg/g (previously 68 mg/g). The patient’s 10-year atherosclerotic cardiovascular
disease (ASCVD) risk is 21%.
1. Which is most appropriate to recommend for this patient’s BP control at today’s visit?

A. Amlodipine 5 mg/day.
B. Lisinopril 10 mg/day.
C. Hydrochlorothiazide 12.5 mg/day plus amlodipine
5 mg/day.
D. Chlorthalidone 12.5 mg/day plus lisinopril 10 mg/day.

Answer 23

1. Answer: D
   The patient’s blood pressure is above his goal of less than
   140/90 mm Hg (according to the ADA; can consider less
   than 130/80 mm Hg because the 10-year ASCVD risk is
   greater than 15%) and less than 130/80 mm Hg (according
   to the ACC/AHA); thus, antihypertensive therapy should
   be initiated. The patient has stage 2 HTN according to the
   ACC/AHA guidelines; patients in this stage should be initiated
   on two medications of different classes, particularly
   if their blood pressure is more than 20/10 mm Hg above
   goal; Answers A and B are incorrect because they only
   recommend monotherapy. According to the 2021 ADA
   standards, treatment of HTN should include drug classes
   shown to reduce CV events in patients with diabetes (ACE
   inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine
   CCBs), with the specific use of ACE inhibitors or
   ARBs if the patient has albuminuria or CAD. The ACC/
   AHA guidelines recommend ACE inhibitors and ARBs as
   first-line treatment for patients with diabetes in the presence
   of albuminuria, making Answer D correct. Calcium
   channel blockers and thiazide diuretics are also recommended
   as first-line agents. Answer D is correct because
   it includes both a thiazide diuretic, which improved CV
   outcomes in the ALLHAT trial, and an ACE inhibitor for
   renal protection. Answer C is incorrect because it does
   not include an ACE inhibitor or an ARB, one of which is
   needed because the patient has albuminuria.

Question 24

2. Which is best for primary prevention of CHD for this patient?

A. Aspirin 325 mg/day.
B. Atorvastatin 10 mg/day.
C. Aspirin 81 mg/day plus atorvastatin 40 mg/day.
D. Atorvastatin 40 mg/day plus clopidogrel 75 mg/
day.

Answer 24

2. Answer: C
   Using the PCE risk calculator, this patient has an estimated
   10-year ASCVD risk of 21%. Because the patient is 40–75
   years old with diabetes and has an LDL of 70–189 mg/
   dL, at least moderate-intensity statin therapy is indicated.
   However, high-intensity statin therapy can be considered if
   several risk factors exist or in patients 50–75 years of age,
   according to the 2018 AHA/ACC Multisociety cholesterol
   guidelines. Similarly, the ADA guidelines state that highintensity
   statin therapy can be considered in patients with
   diabetes with several ASCVD risk factors; this patient has
   elevated blood pressure, dyslipidemia, and albuminuria
   (Answer B is incorrect). For patients with diabetes, the
   ADA recommends aspirin 75–162 mg for men 50 and older
   who have at least one other risk factor for CHD (Answer
   C is correct). If indicated, aspirin 81 mg can be used for
   primary prevention if the patient is at low risk of bleeding
   (Answer A is incorrect). Clopidogrel is recommended
   for primary prevention only if the patient has an allergy to aspirin (Answer D is incorrect). Once the patient’s lipids
   and blood pressure are better controlled, it may be appropriate
   to discontinue aspirin therapy because the benefits
   of therapy are closely balanced by risks, particularly in
   those with a lower risk of ASCVD.

Question 25

3. J.R. is a 55-year-old Hispanic man (weight 66 kg) with a medical history significant for HTN and a myocardial infarction (MI) 9 months ago, leading to placement of a bare metal stent (BMS). His current medications include aspirin 325 mg/day, clopidogrel 75 mg/day, atorvastatin 40 mg/day, and metoprolol succinate 50 mg/day. His vital signs are BP 145/88 mm Hg and heart rate 52 beats/minute. His laboratory test results show LDL 68 mg/dL (baseline 138 mg/dL) and SCr 1.0 mg/dL. Which is currently best for secondary prevention of CHD? A. Decrease the aspirin dose to 81 mg/day and add lisinopril to 5 mg/day. B. Increase atorvastatin to 80 mg/day and increase metoprolol succinate to 100 mg/day. C. Decrease the aspirin dose to 81 mg/day and increase metoprolol succinate to 100 mg/day. D. Discontinue clopidogrel and increase atorvastatin to 80 mg/day.

Answer 25

3. Answer: A The patient’s heart rate is at less than 60 beats/minute. Therefore, the metoprolol dose should not be increased because of the risk of worsening bradycardia and heart block, making Answers B and C incorrect. Because the patient is taking a high-intensity statin with an adequate response in his LDL (reduction of 50% or more from baseline), his statin dose need not be increased, making Answers B and D incorrect. The patient’s blood pressure is not at goal (goal less than 130/80 mm Hg according to the 2017 AHA/ACC guidelines). An ACE inhibitor guideline is a class I recommendation for secondary prevention in patients with HTN. The aspirin dose after PCI associated with the lowest bleeding risk is 81 mg, making Answer A correct. Clopidogrel is indicated for at least 1 year after PCI in the setting of ACS, making Answer D incorrect.

Question 26

4. D.P. is a 60-year-old patient who is being discharged from the hospital after admission for an ST-segment elevation MI (STEMI). D.P. received a percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) and is at low risk of bleeding. Which is the best recommendation for this patient’s aspirin and P2Y12 inhibitor therapy? A. Aspirin 325 mg indefinitely and ticagrelor for at least 1 year. B. Aspirin 325 mg for 1 month; then aspirin 81 mg indefinitely and clopidogrel for 6 months. C. Aspirin 81 mg indefinitely and clopidogrel for 1 month. D. Aspirin 81 mg indefinitely and prasugrel for at least 1 year.

Answer 26

4. Answer: D Patients who receive a DES should be treated with DAPT with aspirin and a P2Y12 inhibitor for at least 12 months per most recent guidelines. After 12 months, patients should receive aspirin monotherapy indefinitely. The recommended aspirin dose is 81 mg/day. Answer D is correct because it recommends both the appropriate aspirin dose and the appropriate DAPT duration. Answer A is incorrect because of the aspirin dose. Answer B is incorrect because of both the aspirin dose and the DAPT duration. Answer C is incorrect because of the DAPT duration. However, it is important to note that recent literature has demonstrated that a shorter (e.g. 1 to 3 month) duration of DAPT followed by monotherapy with P2Y12 inhibitor therapy may be noninferior to 12 months of DAPT with a lower bleeding risk.

Question 27

5. T.S. is a patient who had an NSTEMI with everolimus DES placement 5 months ago. T.S. is scheduled to undergo radical prostatectomy for prostate cancer. He underwent a noninvasive stress test, with negative findings for myocardial ischemia. His current medications include aspirin 81 mg/day and clopidogrel 75 mg/day. Which is the best recommendation regarding the patient’s dual antiplatelet therapy (DAPT)? A. Discontinue both aspirin and clopidogrel at least 7 days before the procedure. B. Continue clopidogrel, but discontinue aspirin at least 5 days before the procedure. C. Continue aspirin, but discontinue clopidogrel at least 7 days before the procedure. D. Continue aspirin, but discontinue clopidogrel at least 5 days before the procedure.

Answer 27

5. Answer: D Patients who have recently (less than 1 year) undergone DES placement are at higher risk of stent thrombosis after the cessation of P2Y12 inhibitor therapy. Answer D is correct. The 2016 ACC/AHA guideline focused update on the duration of DAPT states that elective noncardiac surgery after DES implantation in patients for whom P2Y12 inhibitor therapy will need to be discontinued can be considered at 3–6 months if the risk of delaying surgery is greater than the risk of stent thrombosis. If P2Y12 inhibitor therapy needs to be held in patients treated with DAPT, the guidelines recommend reinitiating therapy as soon as possible. Continuing aspirin is recommended, if possible. However, Answers A and C are incorrect because the proper timing of clopidogrel discontinuation should be 5 days, not 7 days. Answers A and B are incorrect because aspirin should be continued in the setting of recent ACS.

Question 28

6. G.F. is a 50-year-old African American woman with peripheral arterial disease (PAD). She has been unable to tolerate angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) because of hyperkalemia. Her current medication regimen is amlodipine 10 mg/day, chlorthalidone 12.5 mg/ day, metoprolol succinate 25 mg/day, rosuvastatin 20 mg/day, and aspirin 81 mg/day. Her vital signs today include BP 146/82 mm Hg, repeated BP 148/85 mm Hg; heart rate 78 beats/minute; weight 69 kg (154 lb); and height 64 inches. Her laboratory tests show K 4.9 mEq/L, Na 133 mEq/L, and creatinine clearance (CrCl) 65 mL/minute. Which is the best therapeutic plan for this patient? A. No medication changes are warranted. B. Initiate hydralazine 25 mg three times daily. C. Increase metoprolol succinate to 50 mg/day. D. Increase chlorthalidone to 25 mg/day.

Answer 28

6. Answer: C This patient’s blood pressure must be treated because it is above her blood pressure goal (goal is less than 130/80 mm Hg, according to the 2017 AHA/ACC guidelines) (Answer A is incorrect). Chlorthalidone cannot be increased because the patient’s sodium concentration is slightly low (Answer D is incorrect). Hydralazine would be a third- or fourth-line agent that is typically reserved for patients with resistant HTN and is not currently indicated (Answer B is incorrect). Therefore, increasing the metoprolol dose would be most appropriate at this time (Answer C is correct).

Question 29

Questions 7 and 8 pertain to the following case. A.M. is a 32-year-old woman with type 1 diabetes and HTN. Her current medication regimen is as follows: ramipril 10 mg/day, chlorthalidone 25 mg/day, amlodipine 10 mg/ day, ethinyl estradiol 20 mcg/norethindrone 1 mg (for the past 2 years), and insulin as directed. Her vital signs today include BP 145/83 mm Hg, repeated BP 145/81 mm Hg, heart rate 82 beats/minute, height 66 inches, weight 70 kg (155 pounds), and BMI 24.5 kg/m2. A.M. would prefer not to take any more drugs, if possible. 7. Which is the best clinical plan for A.M.? A. No change in therapy is currently warranted. B. Advise weight loss and recheck her blood pressure in 3 months. C. Change chlorthalidone to hydrochlorothiazide. D. Discuss changing her contraceptive method.

Answer 29

7. Answer: D Oral contraceptives, specifically estrogen, can increase blood pressure, and risk can increase with duration of use. An alternative contraceptive without estrogen would be less likely to contribute to the patient’s HTN, making Answer D correct. Answers A and B are incorrect because the patient’s blood pressure requires better control, but weight loss is unlikely to help because the patient’s BMI is normal. Answer C is incorrect because hydrochlorothiazide is no more potent than chlorthalidone, and chlorthalidone reduced CV events in the ALLHAT trial.

Question 30

8. A.M. and her husband have decided that they are ready to have children. Which is best regarding A.M.’s antihypertensive regimen? A. No change in therapy is currently warranted. B. Discontinue ramipril and replace it with labetalol 100 mg twice daily. C. Increase chlorthalidone to 50 mg/day. D. Discontinue all antihypertensive therapy.

Answer 30

8. Answer: B Angiotensin-converting enzyme inhibitor therapy is contraindicated in pregnancy because of teratogenicity, and discontinuing ramipril is the most important next step, making Answer B correct and Answers A and C incorrect. Answer D is incorrect because this patient will require very good blood pressure control during her pregnancy, given that untreated HTN is associated with adverse events in the mother, fetus, and infant.

Question 31

9. A.D. is a 45-year-old woman with chronic kidney disease (CKD) and worsening HTN. Her home BP readings have been in the range of 130–149 mm Hg (systolic) over 70–79 mm Hg (diastolic) for the past month. Her current antihypertensive regimen includes lisinopril 40 mg/day, felodipine 10 mg/day, and carvedilol 25 mg twice daily. Her vital signs today include BP 139/75 mm Hg, repeated BP 138/72 mmHg; heart rate 58 beats/minute; weight 56 kg (125 pounds); and height 62 inches. Her laboratory values are as follows: SCr 1.9 mg/dL (glomerular filtration rate [GFR] 30.1 mL/minute/1.73 m2), K 5.1 mEq/L, Na 145 mEq/L, fasting blood glucose (FBG) 97 mg/ dL, TSH 2.65 mIU/mL, and albumin/creatinine ratio 66 mg/dL. Which is the next best step to better control her BP? A. Add spironolactone 12.5 mg/day. B. Add furosemide 20 mg twice daily. C. Change lisinopril to losartan 100 mg/day. D. Increase carvedilol to 50 mg twice daily.

Answer 31

9. Answer: B This patient’s blood pressure goal is less than 130/80 mm Hg according to the ACC/AHA guidelines, and additional treatment is needed. Loop diuretics (Answer B) work well for patients with renal insufficiency. Answer A is incorrect because this patient’s potassium concentration is above the recommended concentration to initiate spironolactone (greater than 5 mEq/L), and her GFR is too low for therapy to benefit. Answer C is incorrect because changing from lisinopril to losartan would probably not lower blood pressure. Answer D is incorrect because carvedilol for this patient is at the maximum recommended dose.

Question 32

10. B.L. is a 62-year-old white man who has had type 2 diabetes for the past 25 years. He is a moderate alcohol consumer (3 drinks per night, with occasional binges) and is obese (BMI 40.1 kg/m2). In the past year, he had an MI and 5-vessel coronary artery bypass graft (CABG). He has well-controlled HTN (125/70 mm Hg). He currently takes metformin 1000 mg twice daily, liraglutide 1.8 mg subcutaneously once daily, aspirin 81 mg/day, rosuvastatin 10 mg/day, metoprolol 25 mg twice daily, lisinopril 40 mg/day, and nitroglycerin 0.4 mg sublingually as needed. Fasting laboratory test results show TC 148 mg/dL, TG 220 mg/dL, HDL 32 mg/dL, LDL 72 mg/dL, non-HDL 116 mg/dL, SCr 1.3 mg/dL, Na 142 mEq/L, K 4.5 mEq/L, hemoglobin A1C (A1C) 6.8%, and alanine aminotransferase (ALT) 75 IU/L (history of ALT readings of 56–92 IU/L during the past 3 years). His primary care physician asks you about his chronically elevated ALT concentration and about continuing his statin therapy. Which is the best response? A. Decrease rosuvastatin to 5 mg/day. B. Change rosuvastatin to ezetimibe 10 mg/day. C. Continue rosuvastatin 10 mg/day. D. Increase rosuvastatin to 20 mg/day.

Answer 32

10. Answer: D According to the 2018 AHA/ACC Multisociety cholesterol guidelines, 2020 AACE/ACE consensus statement on cholesterol management, and the 2021 ADA standards of care, patients with clinical ASCVD should receive highintensity statin therapy. The only high-intensity statin therapy included in the options for this case is rosuvastatin 20 mg/day mg/day, making Answer D correct. Answer C is incorrect because rosuvastatin 10 mg/day is considered moderate intensity. Answer A is incorrect because a mild, chronic ALT elevation will not be adversely affected by statin therapy, and lowering the dose will not likely improve this. Answer B is incorrect because ezetimibe monotherapy has not reduced morbidity or mortality in clinical trials to date. Additionally, per the 2020 AACE/ ACE consensus statement, this patient would be considered extreme risk due to having ASCVD and diabetes, making the LDL goal <55 mg/dL.

Question 33

11. A.H. is a 45-year-old African American woman with chronic obstructive pulmonary disease and atrial fibrillation for whom metoprolol was changed to verapamil today because of severe lung disease. Today, her BP is 126/78 mm Hg. She has been taking simvastatin 40 mg/day for cholesterol for the past 4 years. Her fasting laboratory test results show TC 196 mg/dL, TG 85 mg/dL, HDL 50 mg/dL, LDL 129 mg/dL, non-HDL 146 mg/dL, SCr 1.3 mg/dL, Na 141 mEq/L, and K 4.0 mEq/L. Her baseline 10-year ASCVD risk score is 20%. Which is best to address her lipid values? A. No change in therapy is currently warranted. B. Change simvastatin to rosuvastatin 20 mg/day. C. Change simvastatin to lovastatin 40 mg twice daily. D. Increase the simvastatin dose to 80 mg/day.

Answer 33

11. Answer: B Answer A is incorrect; a therapy change is needed because simvastatin is metabolized primarily by the CYP3A4 isoenzyme system, and verapamil competes for this same metabolic pathway. Answer C is incorrect; the maximal dose of lovastatin has similar risks. Answer D is incorrect; although the coadministration of simvastatin and verapamil is not contraindicated, the simvastatin dose should be decreased to 10 mg/day to reduce the risk of rhabdomyolysis. Rosuvastatin is metabolized through an alternative pathway and does not interact with verapamil, making Answer B correct. In addition, high-intensity statin therapy is indicated for this patient, according to the 2018 AHA/ ACC Multisociety guidelines, because her baseline 10-year ASCVD risk score is 20%.

Question 34

12. P.T. is a 73-year-old Asian woman with a history of coronary artery disease (CAD; with stent placement 5 years ago). She has adhered to her medication regimen since her stent placement without problems. Her primary care physician checked her CK concentration because of muscle pain that she described as moderate in severity. Her medication regimen has been stable for the past 3 years and includes atorvastatin 40 mg/ day, aspirin 81 mg/day, carvedilol 6.25 mg twice daily, and omeprazole 20 mg as needed. Fasting laboratory test results show TC 135 mg/dL, TG 85 mg/ dL, HDL 50 mg/dL, LDL 68 mg/dL, non-HDL 85 mg/dL, SCr 1.2 mg/dL (CrCl [ideal body weight {IBW}] 32 mL/ minute), Na 141 mEq/L, K 4.0 mEq/L, and CK 503 U/L (normal limits 20–200 U/L). Which is the next best step for P.T.? A. Continue atorvastatin 40 mg/day and continue monitoring patient symptoms. B. Discontinue atorvastatin permanently because the patient is statin intolerant. C. Hold atorvastatin and reassess the patient’s symptoms in 2–4 weeks. D. Lower the atorvastatin dose to 20 mg every evening and continue monitoring patient symptoms.

Answer 34

12. Answer: C This patient has moderate symptoms with a CK elevation less than 10 times the ULN; hence, statin therapy should be held and symptoms reassessed in 2–4 weeks. If symptoms have resolved, the patient can be rechallenged with the same statin at the same dose, the same statin at a lower dose, or a different statin. Answers A and D are incorrect because they continue atorvastatin. Answer B is incorrect because patients are not defined as statin intolerant until they have had symptoms on two or three different statins, preferably those with alternative metabolic pathways, at least one of which was at the lowest dose when the symptoms occurred. Answer C is correct because statin therapy is being held and the patient is being reassessed at an appropriate time.

Question 35

13. J.M. is a 41-year-old African American man who arrives at the clinic for a follow-up. Three months ago, he was told for the first time that his cholesterol concentration was high and that he had to work on his diet and exercise. He is otherwise healthy, does not smoke, and takes no prescription medications. His BP today is 121/68 mm Hg. Fasting laboratory test results today show TC 262 mg/dL (down from 273 mg/dL), TG 145 mg/dL (down from 160 mg/dL), HDL 42 mg/dL (no change), LDL 191 mg/dL (down from 199 mg/dL), non-HDL 220 mg/dL (down from 231 mg/dL), and SCr 1.0 mg/ dL. Which is best for treating his cholesterol, according to the 2018 American Heart Association (AHA)/ American College of Cardiology (ACC) Multisociety treatment guidelines for blood cholesterol? A. Continue to work on diet and exercise; no medications are needed. B. Continue to work on diet and exercise, and initiate atorvastatin 80 mg/day. C. Continue to work on diet and exercise, and initiate lovastatin 20 mg/day. D. Continue to work on diet and exercise, and initiate simvastatin 40 mg every evening.

Answer 35

13. Answer: B Because the patient’s LDL remains greater than 190 mg/ dL, the 2018 ACC/AHA Multisociety cholesterol guidelines recommend a high-intensity statin such as atorvastatin 80 mg/day, making Answer B correct and Answer A incorrect. Answers C and D are incorrect because they recommend initiating moderate- and low-intensity statins, respectively.

Question 36

14. J.T. is a 36-year-old man with heterozygous familial hypercholesterolemia (HeFH) who arrives at the primary care clinic for a follow-up. He currently takes atorvastatin 80 mg/day. He reports adherence to his medication and states that he follows a low-fat diet and exercises 40 minutes/day 4 days/week. Fasting laboratory test results today show TC 275 mg/dL (baseline 320 mg/dL), TG 204 mg/dL (baseline 265 mg/dL), HDL 75 mg/dL (increased from 50 mg/dL), LDL 160 mg/dL (down from 217 mg/dL), and non-HDL 200 mg/dL (down from 270 mg/dL). Which would best treat his cholesterol according to the 2018 AHA/ACC Mutisociety cholestrol guidelines? A. Initiate alirocumab 75 mg subcutaneously every 2 weeks. B. Initiate ezetimibe 10 mg/day. C. Initiate fenofibrate 54 mg/day. D. Initiate colesevelam 3750 mg/day.

Answer 36

14. Answer: B This patient’s disease would be categorized into statin benefit group 2 according to the 2018 AHA/ACC Multisociety cholesterol guidelines because of a baseline LDL of 190 mg/ dL or greater. These patients should take a high-intensity statin to achieve 50% or more LDL lowering. The patient is currently receiving maximum doses of both atorvastatin and has achieved around 26% LDL lowering. The guidelines state that adding ezetimibe is reasonable if the LDL remains 100 mg/dL or greater after patients have received maximally tolerated statin therapy; Answer B is correct. Answer A is incorrect because PCSK9 inhibitors are considered only after patients have received maximally tolerated statin therapy plus ezetimibe and their LDL remains at 100 mg/dL or greater. Fenofibrate is primarily used for TG lowering and can increase LDL values, making Answer C incorrect. Although bile acid sequestrants provide additional LDL lowering, they can also increase TG values and have a relative contraindication with TG concentrations greater than 200 mg/dL, making Answer D incorrect.

Question 37

15. A 65-year-old woman who had a minor ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score of −2) 3 weeks ago presents for a follow-up. Her current medications include aspirin 81 mg/day (taking before the stroke), clopidogrel 75 mg/day, chlorthalidone 25 mg/day, lisinopril 40 mg/ day, and atorvastatin 80 mg/day. The medical resident has requested an evaluation of the patient’s antiplatelet therapy. Which recommendation would best reduce the patient’s risk of recurrent stroke while minimizing the risks of bleeding? A. Continue clopidogrel and aspirin for a total of 90 days and then continue clopidogrel indefinitely. B. Continue both aspirin and clopidogrel indefinitely. C. Discontinue both clopidogrel and aspirin and initiate ticagrelor 90 mg twice daily indefinitely. D. Discontinue clopidogrel and increase aspirin dose to 325 mg/day indefinitely.

Answer 37

15. Answer: A The 2021 AHA/ASA secondary stroke prevention guidelines recommend that, for a minor ischemic stroke (NIHSS score 3 or less) or high-risk TIA (ABCD score 4 or greater), DAPT with aspirin and clopidogrel should be initiated early (ideally within 12–24 hours of symptom onset and at least within 7 days of onset), which can be continued for 21–90 days, followed by SAPT indefinitely (Answer A is correct). Continuing DAPT indefinitely is not recommended because of a higher risk of bleeding (Answer B is incorrect). Ticagrelor has no evidence to support indefinite use for secondary stroke prevention (Answer C is incorrect). There is no evidence that increasing aspirin to 325 mg/day is more effective in secondary stroke prevention, but it does increase bleeding risk (Answer D is incorrect).

Question 38

Patient Case 1. A 59-year-old white male tobacco smoker with no significant medical history presents to the wellness clinic at your hospital for BP, diabetes, and cholesterol screening. The fasting screening tests show BP 140/86 mm Hg, TC 196 mg/dL, LDL 110 mg/dL, HDL 50 mg/dL, TG 80 mg/dL, and FBG 80 mg/dL. He asks whether he should take an aspirin daily to prevent CVD. Which is the best response to his question? A. Yes, a daily aspirin 162 mg will help prevent ASCVD events. B. Yes, a daily aspirin 81 mg will help prevent ASCVD events. C. No, his risk of intracranial bleeding is higher than his risk of an ASCVD event. D. No, his risk of gastrointestinal (GI) bleeding is higher than his risk of an ASCVD event.

Answer 38

1. Answer: B The USPSTF recommends aspirin 81 mg/day for adults age 50–59 years with a 10-year ASCVD risk of 10% or greater, calculated using the ACC/AHA PCE risk calculator (tools. acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/ estimate/). Using this calculator, this patient’s 10-year ASCVD risk is 14.7% (sex male; age 59 years; race white; TC 196 mg/dL; HDL 50 mg/dL; SBP 140 mm Hg; treatment for high blood pressure no; diabetes no; smoker yes). In addition, the 2019 ACC/AHA guideline for primary prevention of CVD states that low-dose aspirin can be considered for adults age 40–70 years at higher ASCVD risk who are not at increased risk of bleeding. Aspirin therapy is recommended in this patient. Answer A is incorrect because the USPSTF recommends low-dose aspirin. Answer B is correct because 81 mg/day of aspirin is the recommended dose for primary prevention. Answers C and D are incorrect because the risk of bleeding does not outweigh the benefit of ASCVD reduction in this patient. However, if the patient’s risk factors (tobacco smoking, hypertension, dyslipidemia) become controlled, his ASCVD risk score will likely decrease; in that instance, aspirin therapy is unlikely to have as much of a benefit, and the risk of bleeding may outweigh the CV benefit.

Question 39

Patient Case 2. M.P., a 52-year-old Asian woman, presents to the clinic to discuss her heartburn symptoms. Her primary care physician has been running late, and she was rushed back to her examination room a few minutes ago. Her BP is 151/84 mm Hg. She has no history of HTN, and the only drug she takes is over-the-counter (OTC) famotidine. Which is the next best action to take? A. Recheck her blood pressure after she has been seated quietly for 5 minutes. B. Initiate hydrochlorothiazide 12.5 mg/day. C. Initiate lisinopril 10 mg/day. D. There is no need for concern with her BP because she does not have HTN

Answer 39

2. Answer: A At least two blood pressure measurements should be made to accurately assess blood pressure. A blood pressure measurement is likely inaccurate if the patient has not been seated quietly for at least 5 minutes (Answer A is correct). Determinations for therapy can be made after accurate blood pressure readings have been obtained (Answers B and C are incorrect). This patient may have undiagnosed HTN (Answer D is incorrect).

Question 40

Patient Case 3. A 50-year-old African American woman with no significant medical history presents to your clinic for her BP assessment. When she participated in a health fair the past week, she was told that her BP was “too high.” Today, her BP is 155/85 mm Hg, with a repeated BP of 150/83 mm Hg. Her HR is 72 beats/minute. She takes vitamin D supplementation daily and acetaminophen as needed. Laboratory test results show SCr 0.9 mg/dL, K 4.0 mEq/L, and Na 141 mEq/L. Her BMI is 26.0 kg/m2. Which is the next best action for her? A. Treat with education on diet and exercise only. B. Treat with education on diet and exercise, and initiate benazepril 10 mg/day. C. Treat with education on diet and exercise, and initiate HCTZ 12.5 mg/day. D. Treat with education on diet and exercise, and initiate HCTZ 12.5 mg/day and amlodipine 5 mg/day.

Answer 40

3. Answer: D This patient meets the criteria for stage 2 HTN according to the 2017 AHA/ACC HTN guidelines. At stage 2, both nonpharmacologic and pharmacologic therapy is recommended (Answer A is incorrect). Thiazide diuretics and CCBs are a recommended first-line therapy in African American patients according to the 2017 AHA guidelines, whereas ACE inhibitors are recommended as subsequent therapy (Answer B is incorrect). However, because the patient is more than 20 mm Hg above her SBP goal, the guidelines recommend two antihypertensive agents (Answer C is incorrect; Answer D is correct).

Question 41

Patient Case 4. A 60-year-old white man with type 2 diabetes is new to your clinic. Today, his BP is 155/78 mm Hg, with a repeated measurement of 151/73 mm Hg. His heart rate is 80 beats/minute. He could not tolerate two different ACE inhibitors because of cough. He currently takes metformin 850 mg three times daily, glipizide 10 mg twice daily, hydrochlorothiazide 25 mg/day, and omeprazole as needed. Laboratory test results are as follows: SCr 1.5 mg/dL (CrCl [IBW] 54 mL/minute), A1C 6.8%, K 4.0 mEq/L, and microalbumin/creatinine 98.2 mg/g. His BMI is 31.6 kg/m2. Which would best address his elevated blood pressure? A. No further treatment is needed. B. Initiate amlodipine 2.5 mg/day. C. Initiate losartan 25 mg/day. D. Initiate metoprolol succinate 25 mg/day.

Answer 41

4. Answer: C Angiotensin receptor blockers are the best replacement medications for ACE inhibitors in this patient because diabetes is a compelling indication for their use, especially in patients with albuminuria. In addition, ARBs have less risk of cough than ACE inhibitors; therefore, they can be used in patients who have cough with an ACE inhibitor (Answer C is correct; Answers B and D are incorrect). Treatment is needed because the patient’s blood pressure is above goal (goal is less than 140/90 mm Hg according to the ADA [may consider less than 130/80 mm Hg if 10-year ASCVD risk score is 15% or greater or if patient has clinical ASCVD] and less than 130/80 mm Hg according to ACC/AHA) (Answer A is incorrect).

Question 42

Patient Case 5. A 58-year-old Hispanic woman with CAD and type 2 diabetes presents to the clinic with her home BP readings. She is frustrated because her BP is still not at goal. She currently takes HCTZ 25 mg/day, lisinopril 40 mg/day, amlodipine 10 mg/day, and metoprolol tartrate 25 mg twice daily. She tried clonidine but had to discontinue it because of orthostasis. Today, her BP is 148/79 mm Hg, with a repeated measurement of 145/81 mm Hg. Her HR is 58 beats/minute. Laboratory test results today show SCr 1.2 mg/dL (CrCl [adjusted body weight] 51.8 mL/minute), K 4.2 mEq/L, and Na 142 mEq/L. Her BMI is 27.5 kg/m2, and ejection fraction is 45%. Which regimen change, if any, would be best for this patient? A. Initiate spironolactone 12.5 mg/day. B. Discontinue hydrochlorothiazide, and initiate chlorthalidone 25 mg/day. C. Increase metoprolol to 50 mg twice daily. D. No change in her current regimen is warranted.

Answer 42

5. Answer: B This patient has resistant HTN, which is the inability to reach a goal blood pressure with full doses of an appropriate three-drug regimen that includes a diuretic. The 2018 AHA scientific statement for managing resistant HTN recommends substituting an optimally dosed thiazide-like diuretic (chlorthalidone) for the prior diuretic (hydrochlorothiazide) before adding an MRA such as spironolactone (Answer A is incorrect; Answer B is correct). Therapy change is needed because her blood pressure remains above goal (goal is less than 130/80 mm Hg according to the ACC/AHA and ADA guidelines) (Answer D is incorrect). Metoprolol cannot be increased because of her heart rate (Answer C is incorrect).

Question 43

Patient Case 6. A 72-year-old white man is new to your clinic. He has not seen a health care provider for the past 7 years because of financial issues. Today, his BP is 175/100 mm Hg, with a repeated measurement of 169/99 mm Hg. He takes no medications, although he took a drug for his BP “years ago.” He has no symptoms of illness or of feeling bad. Today, laboratory test results are as follows: SCr 1.6 mg/dL (CrCl [adjusted body weight] 56.4 mL/minute), K 4.0 mEq/L, and Na 142 mEq/L. His BMI is 30.2 kg/m2. Which intervention would best treat this patient’s HTN? A. Initiate lisinopril 10 mg/day. B. Initiate HCTZ 12.5 mg/day. C. Initiate lisinopril/HCTZ 10/12.5 mg/day. D. Send him to the emergency department for hypertensive emergency.

Answer 43

6. Answer: C Initiation of a two-drug regimen is required for this patient to control his blood pressure in a reasonable time because he has stage 2 HTN and is more than 20/10 mm Hg above his BP goal of less than 130/80 mm Hg (Answer C is correct; Answers A and B are incorrect). This patient’s blood pressure is not high enough to qualify as a hypertensive emergency (or urgency) (Answer D is incorrect).

Question 44

Patient Case 7. A 62-year-old white man who smokes 1 pack/day presents to your clinic taking no medications. His medical history includes an MI 5 years ago, at which time a stent was placed. The primary care physician will address the patient’s other drug-related problems but would like your help in addressing his cholesterol status. The patient would prefer to lower his cholesterol without medications, if possible. Fasting laboratory results are as follows: TC 187 mg/dL, TG 157 mg/dL, HDL 43 mg/dL, LDL 113 mg/dL, non-HDL 144 mg/dL, SCr 1.0 mg/dL, ALT 25 IU/L, Na 140 mEq/L, and K 4.7 mEq/L. His BMI is 32.5 kg/m2 and BP is 115/65 mm Hg. Which is the best recommendation to treat his cholesterol? A. Diet, exercise, and weight loss only. B. Diet, exercise, weight loss, and simvastatin 40 mg/day. C. Diet, exercise, weight loss, and atorvastatin 80 mg/day. D. Diet, exercise, weight loss, and pravastatin 20 mg/day.

Answer 44

7. Answer: C Per the 2020 AACE/ACE consensus statement for cholesterol management, this patient would be classified as very high risk due to having ASCVD, and his LDL goal is <70 mg/dL. Both the 2018 AHA/ACC Multisociety cholesterol guidelines and the 2020 AACE/ACE consensus statement recommend high-intensity statin therapy due to having CAD and his age less than 75 (Answer C is correct, Answer A is incorrect). Simvastatin 40 mg/day is a moderate-intensity statin (Answer B is incorrect), and pravastatin 20 mg/ day is a low-intensity statin (Answer D is incorrect).

Question 45

Patient Case 8. A 62-year-old woman (height 64 inches, weight 81 kg) with a history of diabetes who underwent a three-vessel CABG 5 years earlier completes her fasting laboratory testing. Medications have been stable since her CABG and include simvastatin 80 mg/day, glipizide 5 mg twice daily, metoprolol SR 25 mg/day, and aspirin 81 mg/ day. During the past year, her renal function had steadily decreased (6 months ago, her SCr was 1.5 mg/dL). Laboratory results are as follows: TC 143 mg/dL, TG 160 mg/dL, HDL 42 mg/dL, LDL 63 mg/dL, non-HDL 101 mg/dL, SCr 2.3 mg/dL, CrCl (IBW) 21.9 mL/minute, ALT 45 IU/L, Na 144 mEq/L, K 4.9 mEq/L, and A1C 7.5%. Which is the best recommendation for this patient? A. Add omega-3 fatty acids, with eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA) at least 1 g/day. B. Add fenofibrate 160 mg/day. C. Continue simvastatin 80 mg/day. D. Change simvastatin to atorvastatin 20 mg/day.

Answer 45

8. Answer: D Because this patient has ASCVD, a high-intensity statin would normally be recommended. However, she also has renal insufficiency. According to the simvastatin package label, patients with a CrCl of less than 30 mL/minute should not take simvastatin 80 mg/day, making Answer C incorrect. However, atorvastatin 20 mg/day would be a safe dose for her, making Answer D correct. Fenofibrate would not be beneficial because her TG concentrations are not greater than 500 mg/dL, and fenofibrate is contraindicated in more severe renal dysfunction, making Answer B incorrect. Adding omega-3 fatty acids would be less beneficial than changing the patient’s regimen to an appropriately dosed statin, making Answer A incorrect.

Question 46

Patient Case 9. A 50-year-old African American woman who does not smoke and has no significant medical history presents for her annual well-woman examination. Her fasting laboratory test results are as follows: TC 157 mg/dL, TG 277 mg/dL, HDL 39 mg/dL, LDL 63 mg/dL, non-HDL 118 mg/dL, SCr 0.9 mg/dL, ALT 20 IU/L, Na 144 mEq/L, K 4.5 mEq/L, and FBG 99 mg/dL. Her BMI is 30.3 kg/m2 and BP is 110/60 mm Hg. Which is best to manage her elevated TG? A. Diet, exercise, and weight loss. B. Fenofibrate 160 mg/day. C. Gemfibrozil 600 mg twice daily. D. Pravastatin 80 mg every evening.

Answer 46

9. Answer: A Because this patient’s TG concentrations are less than 500 mg/dL, lifestyle therapies should be a focus before drug therapy is initiated, making Answers B and C incorrect. She does not require statin therapy because her 10-year ASCVD risk is 1.3%, which is considered low risk per the 2018 AHA/ACC Multisociety cholesterol guidelines; therefore, Answer D is incorrect. Answer A is correct because this patient’s TG concentrations would likely be lowered as a result of weight loss and lifestyle modification.

Question 47

Patient Cases 10. A 52-year-old man with a history of symptomatic atrial fibrillation, dyslipidemia, and hypothyroidism presents to the clinic. For the past month, he has been in atrial fibrillation, with unsuccessful cardioversion. His cardiologist initiated chronic amiodarone therapy today. His medications include simvastatin 40 mg/ day, levothyroxine 137 mcg/day, warfarin as directed, and metoprolol succinate 50 mg/day. Laboratory test results are as follows: TC 131 mg/dL, TG 100 mg/dL, HDL 32 mg/dL, LDL 79 mg/dL, non-HDL 99 mg/dL, SCr 1.1 mg/dL, CrCl 83 mL/ minute, ALT 52 IU/L, Na 142 mEq/L, K 4.8 mEq/L, INR 2.3, and TSH 4.32 mIU/mL. Which is the best treatment recommendation for this patient? A. Discontinue simvastatin because it cannot be used concomitantly with amiodarone. B. Increase simvastatin to 80 mg every evening because the patient’s LDL will increase once amiodarone therapy is begun. C. Lower simvastatin to 20 mg every evening to reduce the risk of a drug-drug interaction. D. Add niacin 500 mg twice daily to increase his HDL.

Answer 47

10. Answer: C This patient’s simvastatin dose should be reduced to decrease the likelihood of a drug interaction with amiodarone (Answer C is correct). He requires statin therapy for lipid control (Answer A is incorrect). Increasing the simvastatin dose would increase the likelihood of an adverse effect because of a drug-drug interaction (Answer B is incorrect). Although niacin could improve his HDL, this is not currently his primary concern. In addition, studies have found no benefit to treating HDL concentrations, and AACE/ACE recommends that low HDL be treated with aggressive lifestyle modifications rather than medications (Answer D is incorrect).

Question 48

11.A 76-year-old man with a history of CAD and diabetes completes his fasting laboratory testing. For the past 2 months, he has been treated for a diabetic foot ulcer. While interviewing the patient, you discover that he helped his wife tear down her jewelry display at a convention and had been feeling achy during the past week. Medications include atorvastatin 80 mg/day, niacin 500 mg twice daily, fish oil supplement 1000 mg/ day, metoprolol succinate 25 mg/day, lisinopril 20 mg/day, and aspirin 81 mg/day. Laboratory test results are as follows: TC 148 mg/dL, TG 146 mg/dL, HDL 37 mg/dL, LDL 82 mg/dL, non-HDL 111 mg/dL, CK 1064 U/L, SCr 1.7 mg/ dL, CrCl 37 mL/minute, ALT 36 IU/L, Na 144 mEq/L, and K 5.0 mEq/L. Which is best to address his laboratory test results? A. Discontinue atorvastatin because of his elevated CK. The patient will be unable to take statin therapy in the future. B. Hold atorvastatin because of his elevated CK, and monitor his CK. C. Continue therapy because the elevated CK is likely caused by his diabetic foot ulcer and recent strenuous activity. D. Change his therapy to ezetimibe/simvastatin 10/80 mg/day because his LDL is not at goal.

Answer 48

11. Answer: B Because the patient is symptomatic, statin therapy should be held to ascertain whether his symptoms resolve or his CK improves. Future CK readings will dictate whether statin therapy should be discontinued (Answer B is correct; 11. Answer: B Because the patient is symptomatic, statin therapy should be held to ascertain whether his symptoms resolve or his CK improves. Future CK readings will dictate whether statin therapy should be discontinued (Answer B is correct;

Question 49

Patient Case 12. A 66-year-old man presents to the primary care clinic with a medical history of HTN and an MI first occurrence with coronary stent placement that was 4 mm in diameter 8 months ago. His current medications include aspirin 81 mg/day orally, prasugrel 10 mg/day orally, nitroglycerin 0.4-mg tablets sublingually as needed for chest pain, metoprolol succinate 75 mg/day orally, ramipril 10 mg/day orally, and atorvastatin 20 mg/day orally. The patient denies tobacco and alcohol use. He asks how long he will need to take prasugrel. Which is the best answer? A. If you have a BMS, call your physician because you should be able to discontinue prasugrel now. B. If you have a DES, call your physician because you should be able to discontinue prasugrel now. C. You will need to take prasugrel indefinitely. D. You will need to take prasugrel for at least 1 year after your MI and stent placement.

Answer 49

12. Answer: D After placement of a BMS or a DES for ACS, a P2Y12 inhibitor is indicated for at least 1 year, making Answer D correct and Answers A and B incorrect. Extended DAPT can be considered in patients with a DAPT score of 2 or higher; however, this patient’s current score is 0 or 1, depending on the type of stent placed, making Answer C incorrect.

Question 50

CLINICAL PEARLS OF ACEI/ARB

Answer 50

Clinical Pearls: – Very useful as monotherapy since they do not cause “pseudo” tolerance as with other vasodilator medications. Why? – As monotherapy, ACE inhibitors may be less effective in African Americans due to lower renin release – Confer “renal protective effects” in diabetics by decreasing glomerular filtration pressures

Question 51

ACEI/ARB IN PREGNANCY & DRUG INTERACTIONS

Answer 51

Pregnancy: – Category D – Increased infant mortality has been associated with use in all trimesters and birth defects if used in the first 9 weeks of gestation. § Drug Interactions: – Hyperkalemia is increased if used with a potassium sparing diuretic, aldosterone antagonist, salt-substitutes – Allopurinol, digoxin, lithium, methotrexate medications have ¯ renal excretion (note: digoxin & lithium are narrow therapeutic index drugs) – NSAIDs will ¯ effectiveness of ACEi

Question 52

How Do NSAIDs Decrease the Effectiveness of ACEi & ARBs?

Answer 52

ACEIs and ARBs inhibit efferent renal arteriolar vasoconstriction that lowers glomerular filtration pressure. NSAIDs, by inhibition of prostaglandins and bradykinin, produce vasoconstriction of the afferent renal arteriole and reduce the ability of the kidney to regulate (increase) glomerular blood flow

Question 53

Whats the different mechanism of spirinolactone & eplerenone?

Answer 53

– Competitively binds to the mineralocorticoid receptor in the distal renal tubule to prevent the intracellular gene transcription necessary to upregulate the critical components for Na+ and water reabsorption. – Spironolactone differs mechanistically from eplerenone in that spironolactone also binds and inhibits the glucocorticoid, progesterone and androgen receptors. – This results in a net reduction in plasma volume that can reduce the preload and impact stroke volume.

Question 54

moa of eplerenone

Answer 54

Mechanisms of action: – Have antifibrotic effects that reduce the remodeling process (likely contributing factor in RALES trial) – The presence of a 9,11 epoxide group on eplerenone reduces its affinity for the androgen receptor, thereby allowing more testosterone to maintain the balance of inhibition of breast tissue proliferation. * This is the main reason why eplerenone causes less gynecomastia than spironolactone

Question 55

side effects and clinical considerations

Answer 55

Spironolactone has many uses/indications and least likely to have DDI § Both agents reduce mortality in HF § Eplerenone confers lower risk of gynecomastia but higher risk of DDI via CYP450 3A4 and dose dependent risk of hyperkalemia § Avoid both agents with most salt substitutes & renal failure/impairment Side Effects: – Hyperkalemia (eplerenone may be worse & dose dependent) – Gynecomastia and breast tenderness (worse worse with spironolactone) § Clinical Considerations: – Avoid salt-substitutes – May be first line in hyperaldosteronism (↑Na+ & ↓K+) – In HF risk of hyperkalemia greater as likely on ACE/ARB – NSAIDs can reduce the efficacy – Avoid in renal failure or anuria àrisk of hyperkalemia

Question 56

eplerenone uses & notes

Answer 56

HTN § HF (post MI; NYHA FC II – IV) § Dose: 25 mg daily and titrate up to 50 mg once daily § Major CYP3A4 substrate § Dose dependent risk of hyperkalemia § SE: Gynecomastia (~1%)

Question 57

spironolactone uses & notes

Answer 57

Hypokalemia § HTN § HF (Class III & IV) § Primary Aldosteronism § Cirrhosis (Ascites) § Acne Vulgaris § Hirsutism Dose in HF: 25 mg daily (up to 50 mg daily if tolerated). Doses in cirrhosis can be as high as 100-400 mg/d (give 40 mg lasix for every 100 mg of spironolactone) § Renal dose adjust & use caution § Max diuretic effect 2-3 days; max antihypertensive effect 2-3 wks § SE: Gynecomastia (9%), breast pain 2%) § RALES trial for HF indicatio

Question 58

How do alpha2 agonist work to lower blood pressure?

Answer 58

Mechanism of Action (cont.): – Bind to a2 receptors (inhibitory; Gi linked G-coupled protein receptor) on postsynaptic nerves in the nucleus tractus solitarii (NTS) regions of the medulla oblongata of the brain stem. Their activation mimics the activation of the baroreceptor reflex as seen with an increase in pressure, thus tricking the sympathetic vasomotor center that it needs to decrease. – This creates an reduction in sympathetic outflow and an increase in parasympathetic outflow to the heart, blood vessels, and kidneys. Mechanism of Action (cont.): The net effect of this reduce sympathetic outflow is a: – ¯ CO [because of a reduction in both heart rate and stroke volume (from a relaxation of venous capacitance vessels)] * Affected most in the supine position when sympathetic outflow to the vasculature is already low. – ¯ TPR (or afterload) * Affected most upon standing when the sympathetic outflow to the vasculature increases; why see orthostasis. – ¯ Renin release from the juxtaglomerular cells of the nephron – this is likely to be minimal due to compensatory mechanisms that get activated from the reductions in CO and TPR.

Question 59

Which alpha2 agonist can be used to wean patients off of the ventilator in the ICU?

Answer 59

Dexmedetomidine (Precedex): – Indicated for ICU sedation and procedural sedation – Doesn’t suppress the respiratory drive as much as other agents àaid in weaning from ventilator * Used for up to 24 hrs – Side Effect: * Hypotension but at HIGH doses and rapid infusions can stimulate peripheral alpha 2b receptors and can cause vasoconstriction and HTN

Question 60

Which alpha2 agonist can be used to treat clozapine induced sialorrhea?

Answer 60

§ Clonidine is known to cause dry mucous membranes and especially dry mouth – It used off-label to help treat the effects of clozapine associated drooling

Question 61

Why is a history of medication noncompliance a concern for patients taking clonidine?

Answer 61

§ Clonidine (Catapres): – Immediate release formulation is greatest risk due to shorter half-life compared to other agents – This is the rational for the TTS (transdermal therapeutic system) * Apply to skin every 7 days

Question 62

How do alpha2 agonists worsen depression and erectile dysfunction?

Answer 62

Alpha2 agonistsàpenetrate BBB – Reduces sympathetic tone on all major organs innervated by SNS – Known to WORSEN both depression and erectile dysfunction * Erectile dysfunction is controlled by both parasympathetic and sympathetic nervous system

Question 63

Which abnormal lab test has been associated with the use of one of the alpha2 agonists?

Answer 63

§ Methyldopa (main one): – + Coomb’s test (10-30%) and about 5% may develop hemolytic anemia * May be due to methyldopa altering the Rh antigens in the surface of RBCs resulting in autoimmune activation through a process called, “molecular mimicry”