BCPS Quiz Bank – CV Part 1 of 2

Answer – management of smoking cessation, hypertension, and dyslipidemia is very important to reduce the risk of an ACS event.

Answer – the TIMI risk calculation is used in unstable angina and NSTEMI.  The determination as to whether to do early invasive strategies (such as PCI) is dependent upon this risk stratification.

Answer – Prasugrel has a boxed warning in elderly patients who are over 75 years of age.

Answer – Platelet lifespan is a bit variable from person to person, but 7-10 days is a good estimate to be the average.  Aspirin irreversibly inhibits the function of platelets, so new ones need to be made to begin to have normal aggregation again.

Answer – ACE inhibitors and ARBs would be the most likely culprits for causing symptoms of suspected angioedema.

Answer – Having a nitrate-free period is the best way to manage the risk of tolerance.  None of the others suggested above have proven efficacy.

Answer – The low pulse would be of highest concern.  His asthma is very well controlled.  It should be monitored, but it would not likely prevent you from using a beta-blocker.  Dropping the pulse further into the 40’s would be risky in this patient and would likely prevent you from using the metoprolol.

Answer – Clopidogrel is used in combination with aspirin following stenting. This is called dual antiplatelet therapy.  Barring a contraindication or problems with bleed risk, this combination is typically used for at least 6-12 months and may be used longer in certain situation.

Answer – Clopidogrel is activated to its pharmacologically active metabolite by CYP2C19.  This is called an example of a prodrug.

Answer – Ticagrelor’s antiplatelet effects can be inhibited by the action of aspirin, and more specifically at doses higher than 100 mg per day.

Answer – Rosuvastatin 20 mg daily would have the greatest potency and be considered a high-intensity statin.

Answer – Of the listed medications, hydrochlorothiazide would have the least potential to improve mortality.  ACE inhibitors, statins, beta-blockers, and likely dual antiplatelet therapy would be indicated and appropriate in an attempt to reduce cardiovascular mortality.

Answer – Elevation in cardiac biomarkers, being on chronic aspirin (or aspirin at least in the last 7 days), and age >65 would all be risk factors in the TIMI scoring assessment.  A patient of Hispanic origin would not be part of the risk calculation.

Answer –  Propofol is not indicated as part of acute management in ACS. Aspirin, nitroglycerin, and oxygen would all be important in a patient with possible ACS.

Answer – Clopidogrel is the alternative antiplatelet agent that patients who cannot tolerate aspirin should take.

Answer – digoxin is cleared by the kidney and this would be the most logical reason as to why the concentration is elevated. None of the other reasons would have a significant clinical impact on digoxin.

Answer – Bradycardia would be least likely to be associated with atrial fibrillation as we will use agents to slow down the heart rate (i.e. rate control with Beta-blockers, Non-DHP CCB’s, or digoxin).

Answer – With a suppressed TSH, this may indicate oversupplementation of thyroid hormone. The most likely symptom of the ones listed is tachycardia.

Answer – A cardioselective beta-blocker would be the best choice for initial management of Afib where rate control is desired.

Answer – in the Chads2Vasc scoring, depression would not be a risk factor in the assessment of whether anticoagulation is indicated.

Answer – Beta-blockers, particularly non-selective beta-blockers like propranolol can blunt some of the effects of hypoglycemia which may make it more difficult to recognize some of the symptoms of hypoglycemia. Sweating is typically unaffected by the beta-blocker.

Answer – Amiodarone has a very LONG half-life, can impact breathing by causing pulmonary fibrosis, and thyroid function should be monitored as it can alter functioning.

Answer – 0.2 would be considered subtherapeutic and may be indicative of underdosing, or inadequate adherence. 2.0 is at the upper end of normal and this would be a higher than usual appropriate target concentration. 3.7 is definitely a toxic level. The best answer would be 0.8 ng/mL.

Answer – Amiodarone is considered a class 3 antiarrhythmic that prolongs phase 3 of the cardiac action potential; it inhibits potassium and sodium channels as part of its mechanism of action.

Answer – 1 minute would be too quick to likely see a decent effect from the drug. 8+ minutes would be too long of a time interval. Guidelines suggest 3-5 minute intervals for administration.

Answer – epinephrine given in ACLS is 1 mg. In an allergic reaction type situation (using an EpiPen or another device), the adult dose is 0.3 mg while the pediatric dose is 0.15 mg.

Answer – Epinephrine has beta AGONIST and alpha agonist activity.

Answer – Adenosine will slow down the heart rate by slowing conduction through the AV node. It will also help restore sinus rhythm in supraventricular tachycardia.

Answer – Atropine can be used in significant bradycardia to stimulate the heart rate and get it to a normal resting heart rate. Indicated in symptomatic patients with a heart rate less than 50 bpm.

Answer – Dopamine is a precursor to norepinephrine. Norepinephrine has alpha and beta agonist activity.

Answer – In the NYHA classification system, it is numbered. 1-4. 4 is the worst for a patient.

Answer – Pregabalin which is most often used for nerve pain syndromes, is well known for causing edema and potentially contributing to weight gain.

Answer – Ethacrynic acid does not have a sulfa group and would be the least likely to cause a reaction. Metolazone is actually a thiazide-like diuretic.

Answer – thiazides and thiazide-like diuretics can actually cause elevations in calcium levels. Magnesium and potassium would likely go down in patients who are on this medication.

Answer – Furosemide can promote significant fluid loss through the urine. Dosing too late in the day can force patients to get up a lot during the night while trying to sleep. Breakfast/morning time would be the most appropriate time to initiate the dose.

Answer – thiazide diuretics are well known to potentially increase the concentrations of lithium and this should be monitored (at a minimum) and/or avoided if possible.

Answer – NSAIDs can and do exacerbate edema and CHF symptoms. Caution and avoidance of NSAIDs should be done whenever possible in a patient with CHF.

Answer – Low potassium and/or magnesium can increase the risk of cardiac glycoside toxicity (digoxin). Serum concentrations likely would not change because of this drug interaction and concentrations certainly wouldn’t be less.

Answer – Hyperkalemia is a common potential adverse effect with spironolactone.

Answer – Spironolactone has the potential to cause gynecomastia which can involve breast enlargement (man-boobs) and painful breasts.

Answer – Furosemide’s potential to run off fluid and cause dehydration could leave our patients at risk for acute renal failure.

Answer – Atenolol does not have the evidence to support a compelling indication for use of a beta-blocker in heart failure.

Answer – beta-blockers can mask symptoms of hypoglycemia, exacerbate symptoms of asthma, and cause bradycardia. They would be unlikely to affect BPH.

Answer – Ivabradine causes hyperpolarization and ultimately reduces pacemaker action on the sinus node; this can reduce heart rate further and is a risk with its use.

Answer – Eplerenone is a little more selective in its receptor blockade, so there is potential for it to cause less gynecomastia compared to spironolactone. Cost and clinician experience has historically been a barrier to its use.

Answer – Symptoms can improve with the use of digoxin in CHF, but there has been no proven benefit. It is unlikely to reduce the need for diuretics and would not impact urinary frequency.

Answer – Pioglitazone would have the highest risk of exacerbating CHF and worsening symptoms. This medication should be reassessed in this setting.

Answer – the risk with coadministration of sacubitril/valsartan is the potential for angioedema when used in combination with an ACE.

Answer – Increasing the dose of furosemide makes the most sense. There isn’t any evidence that other loops are better with morbidity or mortality and there is plenty of room to increase. Patients with renal failure may actually require steeper doses. Adding chlorthalidone at this time would not be appropriate as loops are the best at removing fluid. If the dose of furosemide was maximized, then you could consider a thiazide but likely wouldn’t select chlorthalidone with the patient’s renal function. In that situation, metolazone may be more suitable.

Answer – In anaphylaxis, epinephrine is going to be the drug of choice. Norepinephrine is typically the initial vasopressor of choice in septic, cardiogenic and hypovolemic shock.

Answer – Dobutamine and its ability to have beta-1 agonist activity would be the best agent to utilize in this situation.

Answer – stroke volume is likely to decrease on account of phenylephrine. It can be used as an alternative to norepinephrine. It has primarily vasoconstrictive properties as it is an alpha agonist.

Answer – Losartan has some potential uricosuric activity. Chlorthalidone would be more likely to increase uric acid levels.

Answer – It can be utilized in a hypertensive crisis situation and one of the major advantages is that it can help maintain adequate flow to the kidney compared to some other antihypertensives.

Answer – According to the guidelines, anyone with ASCVD (answer C), an LDL >190, or has diabetes with a CVD 10-year risk greater than 7.5% should all receive a high-intensity statin. The only one that doesn’t fit these criteria is B.

Answer – Pravastatin and rosuvastatin are considered hydrophilic statins.  Simvastatin, atorvastatin, and lovastatin are all considered lipophilic statins.

Answer – This is definitely a high-risk patient and an LDL goal of less than 70 would be appropriate. To get that LDL to goal, ezetimibe would be the best option. PCSK9 inhibitors can also be considered but come with significant expense and they are not listed in this question. Rosuvastatin is maxed out and a fibrate would not be appropriate without having very elevated triglycerides.

Answer – All of the above are false. PCSK9 inhibitors (i.e. alirocumab, evolocumab) only come as injectable medications. They can substantially reduce LDL levels in the range of up to 60-70%. Myopathy really isn’t a major concern with these medications compared to statins.

Answer – Managing atrial fibrillation by rate control with an agent that can also lower blood pressure would be the best option. A beta-blocker is not listed, so the next likely choice would be a non-dihydropyridine calcium channel blocker. Increasing the ACE inhibitor could be helpful for hypertension (but likely not that much given the patient’s ethnicity). It would not be helpful in managing atrial fibrillation. Hydrochlorothiazide would not have an effect on atrial fibrillation either. Digoxin would likely not be beneficial in managing hypertension.

Answer – Chlorthalidone has a significantly longer half-life than hydrochlorothiazide and because of this, it would be the agent most likely to help with later day hypertension. Carvedilol and metoprolol tartrate need to be dosed twice daily.

Answer – Beta-blockers aren’t generally a first-line agent and there is potential for beta-blockers to impact breathing. The valsartan could elevate the potassium level further than we would like. Alpha-blockers are not appropriate as initial therapy with the exception of a potential compelling indication like BPH (in males) or possibly PTSD (prazosin). Amlodipine would be the best option of the agents listed.

Answer – Oral furosemide bioavailability is approximately 50%. This would mean that we would need about half the IV furosemide to match his previous oral dosing.

Answer – All of the above have been shown to substantially reduce systolic and diastolic blood pressure with the exception of smoking cessation. Smoking cessation can have numerous other cardiovascular and all-cause mortality benefits but doesn’t specifically have a significant blood pressure-lowering effect on its own.

Answer – All of the above are true with the exception of avoidance in isolated systolic hypertension. Fenoldopam can contribute to hypokalemia, tachycardia, and elevations in intraocular pressure.

Answer – The risk for blood clots in the post-op setting is going to be front-loaded. The highest risk time period will be within the first few weeks.

Answer – Erythropoiesis stimulating agents have an associated risk of increasing the likelihood of cardiovascular issues like MI, stroke, or DVT. There is a boxed warning because of this potential risk.

Answer – Thiazide diuretics have the potential to preserve calcium from being removed from the body by the kidney. Indapamide is the most likely medication of the ones listed that would contribute to an elevation in calcium.

Answer – With the use of clonidine, it would be much more likely to cause bradycardia versus tachycardia. This symptom would be inconsistent with its adverse effect profile.

Answer – Use of dual CYP3A4 and P-glycoprotein medications like ritonavir can either make the use of apixaban contraindicated (if already needing a lower dose) or have recommendations to reduce the current dosing. Dosing in DVT/PE treatment is initially higher than it is in atrial fibrillation as we give 10 mg twice daily for 7 days. Gender is not a factor in determining the appropriate dose.

Answer – If enoxaparin needed to be reversed, protamine would be more appropriate. Betrixaban reversal is off-label for andexanet alfa, but there is some evidence to indicate that it will have some benefit. Apixaban and rivaroxaban reversal is an indication for andexanet alfa.

Answer – The only boxed warning that protamine sulfate carries is for the risk of hypersensitivity reactions which could lead to catastrophic cardiovascular complications like hypotension and cardiovascular collapse. Risk is increased by higher, more frequent doses, and rapid administration.

Answer – With the rare risk of hypotension and cardiovascular collapse due to protamine hypersensitivity reactions, having epinephrine available would be appropriate. The other agents would not provide benefit in the event of a protamine reaction.

Answer – Digoxin toxicity will often present with the patient experiencing hyperkalemia. As DigiFab is given, this drop in digoxin concentration could cause an intracellular shift of potassium. Because of this, potassium levels in the blood can drop significantly and corresponding hypokalemia can occur.

Answer – Of the options listed, apixaban is going to have the best evidence in the setting of significant renal dysfunction. Warfarin would be the other appropriate alternative to consider in this setting.

Answer – Atropine is the go-to agent in ACLS with significant bradycardia. If the patient doesn’t seem to be responding to atropine, epinephrine or dopamine may be considered.

Answer – Adenosine has an incredibly short half-life that is measured in seconds. When indicated, repeat doses may be necessary due to the short half-life to convert the rhythm in an ACLS situation.

Answer – Given the risk of cardiovascular risk from the NSAID, the ibuprofen should be the highest priority medication to discontinue.

Answer – A cardioselective beta-blocker is the drug of choice in the setting of STEMI. Metoprolol and atenolol are the two most commonly used agents.

Answer – Alcohol accumulation, methemoglobinemia, and heparin resistance are all potential complications especially as the length of time that nitroglycerin is being given increases. Note that methemoglobinemia can be managed with methylene blue. Neutropenia would not be a likely consequence of prolonged administration of nitroglycerin.

Answer – Tachycardia and bradycardia are both situations where you’d want to avoid the use of nitrates until the heart rate has come back to normal. One of the major risks of giving nitroglycerine in the setting of inappropriate cardiac function is the alteration in perfusion may cause decompensation and inadequate blood flow to critical organs.