Ischemic Heart Disease/Chronic Stable Angina

1. Which of the following may be precipitated by exertion or emotional stress and relieved by rest?

Chronic Stable Angina

Unstable Angina

NSTEMI

STEMI

Chronic stable angina is the correct answer in this case because it is the only one of the options which may be relieved by rest.

Explanation

Chronic stable angina is the correct answer in this case because it is the only one of the options which may be relieved by rest.

2. Which of the following does NOT contribute to myocardial oxygen supply?

Contractility

Coronary blood flow

Oxygen availability

Oxygen extraction

The pathophysiology of IHD is due to a disruption in the balance of myocardial oxygen supply and demand. The supply side consists of coronary blood flow, oxygen availability, and oxygen extraction. The demand side consists of heart rate, contractility, and wall tension.

Explanation

The pathophysiology of IHD is due to a disruption in the balance of myocardial oxygen supply and demand. The supply side consists of coronary blood flow, oxygen availability, and oxygen extraction. The demand side consists of heart rate, contractility, and wall tension.

3. Which of the following would be the goal heart rate when titrating the dose of a beta blocker?

50 bpm

60 bpm

65 bpm

70 bpm

Beta blockers are titrated in order to achieve a heart rate of 55-60 bpm. However, the caveat here is that in some cases, adverse effects may cause the target to be changed for individual patients. An example of this could be symptomatic hypotension. Remember from A&P that cardiac output (CO)= Heart rate (HR) x Stroke volume (SV). Furthermore, Blood pressure (BP)= CO x vascular resistance.

Therefore, since CO affects BP and HR affects CO...by lowering HR we are essentially lowering BP and this may become problematic for some patients.

Explanation

Beta blockers are titrated in order to achieve a heart rate of 55-60 bpm. However, the caveat here is that in some cases, adverse effects may cause the target to be changed for individual patients. An example of this could be symptomatic hypotension. Remember from A&P that cardiac output (CO)= Heart rate (HR) x Stroke volume (SV). Furthermore, Blood pressure (BP)= CO x vascular resistance.

Therefore, since CO affects BP and HR affects CO...by lowering HR we are essentially lowering BP and this may become problematic for some patients.

4. In which instance may clopidogrel indicated for treatment of IHD?

Aspirin is contraindicated

The patient has had a previous MI

The patient has symptomatic peripheral artery disease (PAD)

All of the above are instances in which clopidogrel is indicated

Clopidogrel is indicated for monotherapy in patients who cannot take aspirin.

In addition to this, dual therapy with ASA and clopidogrel may be used in patients who are at "high risk" (previous MI, previous ischemic stroke, or symptomatic PAD).

Explanation

Clopidogrel is indicated for monotherapy in patients who cannot take aspirin.

In addition to this, dual therapy with ASA and clopidogrel may be used in patients who are at "high risk" (previous MI, previous ischemic stroke, or symptomatic PAD).

5. Which of the following is a relative contraindication to beta-blocker therapy?

Acute decompensated heart failure

Bronchospastic disease

Preexisting high-degree AV block

Severe bradycardia

Bronchospastic disease is the only relative contraindication to beta-blockers listed here. All other options are examples of absolute contraindications to beta-blocker therapy.

Explanation

Bronchospastic disease is the only relative contraindication to beta-blockers listed here. All other options are examples of absolute contraindications to beta-blocker therapy.

6. Which beta blocker has NOT been proven to prevent MI/mortality?

Bisoprolol

Carvedilol

Metoprolol succinate

Metoprolol tartrate

Remember, metoprolol SUCCINATE (the extended release form of the drug), NOT metoprolol TARTRATE (the immediate release form of the drug) has been shown to prevent MI/mortality in studies.

Explanation

Remember, metoprolol SUCCINATE (the extended release form of the drug), NOT metoprolol TARTRATE (the immediate release form of the drug) has been shown to prevent MI/mortality in studies.

7. According to the Focused 2014 update, if revascularization is indicated (patient has diabetes and multivessel CAD), which of the following is true?

CABG is preferred in most cases to PCI

PCI is preferred in most cases to CABG

Both CABG and PCI have equal efficacy

From slide 41 of your handout:

CABG is generally recommended in preference to PCI to improve survival in patients with diabetes mellitus and multivessel CAD for which revascularization is likely to improve survival (3-vessel CAD or complex 2-vessel CAD involving the proximal LAD), particularly if a LIMA graft can be anastomosed to the LAD artery, provided the patient is a good candidate for surgery (Level of Evidence: B)

Explanation

From slide 41 of your handout:

CABG is generally recommended in preference to PCI to improve survival in patients with diabetes mellitus and multivessel CAD for which revascularization is likely to improve survival (3-vessel CAD or complex 2-vessel CAD involving the proximal LAD), particularly if a LIMA graft can be anastomosed to the LAD artery, provided the patient is a good candidate for surgery (Level of Evidence: B)

8. Which of the following is the MAJOR reason for the "dose free" intervals in long acting nitrates?

Bradycardia

Dyspepsia

Tachycardia

Tachyphylaxis

Tachyphylaxis is the correct answer. Remember that this means there is an acute decrease in response to the drug.

Explanation

Tachyphylaxis is the correct answer. Remember that this means there is an acute decrease in response to the drug.

9. Ranolazine would be prescribed as a substitute if initial treatment with which agent failed?

ACE inhibitors

Beta-blockers

Calcium channel blockers

Nitrates

Ranolazine is used as a substitute for beta-blockers. This is used in the course of therapy if beta-blockers are contraindicated, ineffective, or cause too many adverse effects. Remember that in some cases if there is no contraindication or overwhelming adverse effects of beta-blockers, ranolazine may be used in addition to the beta-blocker therapy if monotherapy is ineffective.

Explanation

Ranolazine is used as a substitute for beta-blockers. This is used in the course of therapy if beta-blockers are contraindicated, ineffective, or cause too many adverse effects. Remember that in some cases if there is no contraindication or overwhelming adverse effects of beta-blockers, ranolazine may be used in addition to the beta-blocker therapy if monotherapy is ineffective.

10. Which of the following INCORRECTLY describes an NSTEMI?

New onset

Occlusive thrombus

Occuring at rest

ST segment depression

NSTEMI has NON-occlusive thrombus. This, along with the ST segment depression (vs. elevation) are the major differences between an NSTEMI and STEMI.

Explanation

NSTEMI has NON-occlusive thrombus. This, along with the ST segment depression (vs. elevation) are the major differences between an NSTEMI and STEMI.

11. Which of the following are risk factors for IHD? (Check all that apply)

Dyslipidemia

Family history of CVD

Family history of DM

Hypertension

Obesity

Physical inactivity

Smoking

All of the above are correct except for family history of diabetes. While diabetes itself is a risk factor for IHD, this is due to pathophysiology of the disease. Therefore, someone with a family history of the disease would not be at an increased risk of IHD unless they had developed diabetes themselves.

Explanation

All of the above are correct except for family history of diabetes. While diabetes itself is a risk factor for IHD, this is due to pathophysiology of the disease. Therefore, someone with a family history of the disease would not be at an increased risk of IHD unless they had developed diabetes themselves.

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12. Which class of medications and/or medication are associated with a decrease in anginal symptoms? (Check all that apply)

ACEI/ARB

Aspirin

Beta blockers

Calcium channel blockers

Nitrates

Beta blockers, calcium channel blockers and nitrates all decrease symptoms of angina. Ranolazine also decreases symptoms. Of note, beta blockers are the only agents listed that decrease both mortality AND symptoms.

Explanation

Beta blockers, calcium channel blockers and nitrates all decrease symptoms of angina. Ranolazine also decreases symptoms. Of note, beta blockers are the only agents listed that decrease both mortality AND symptoms.

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13. Which PDE5 inhibitor requires at least 48 hours separation between it and nitrate dosing to avoid an increased risk of hypotension?

Sildenafil (Viagra (R))

Tadalafil (Cialis (R))

Vardenafil (Levitra (R))

All PDE5 inhibitors require only 24 hours separation

Due to the longer elimination half life of tadalafil (15-35 hours), the recommended interval of separation of this drug is longer than that of sildenafil and vardenafil.

Explanation

Due to the longer elimination half life of tadalafil (15-35 hours), the recommended interval of separation of this drug is longer than that of sildenafil and vardenafil.

14. A diabetic patient presents to your clinic with HTN and IHD, due to compelling indications, which medication(s) should the patient receive? (Check all that apply)

ACE inhibitor

Beta-blocker

Calcium Channel Blocker

Diuretic

As mentioned in question 6, beta blockers provide both a decrease in mortality and symptoms and provides a rationale for use with HTN and IHD because it also helps to treat HTN. In patients with DM and HTN, ACEi are used to provide a nephroprotective effect. In addition to that, ACEi provide a decrease in mortality associated with IHD and help to treat HTN.

Explanation

As mentioned in question 6, beta blockers provide both a decrease in mortality and symptoms and provides a rationale for use with HTN and IHD because it also helps to treat HTN. In patients with DM and HTN, ACEi are used to provide a nephroprotective effect. In addition to that, ACEi provide a decrease in mortality associated with IHD and help to treat HTN.

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15. Which class of medications and/or medication are associated with a decrease in mortality? (Check all that apply)

ACEI/ARB

Aspirin

Beta blockers

Calcium channel blockers

Nitrates

ACEI/ARBs, Aspirin, and beta blockers have all been shown to decrease mortality in studies. Other agents that have been shown to have this same effect are clopidogrel and statins.

Explanation

ACEI/ARBs, Aspirin, and beta blockers have all been shown to decrease mortality in studies. Other agents that have been shown to have this same effect are clopidogrel and statins.

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16. Which DDI may be a cause for concern and therefore, should be addressed with the physician? (Check all that apply)

Simvastatin 10mg and amlodipine

Simvastatin 20mg and amlodipine

Simvastatin 40mg and amlodipine

Simvastatin 10mg and diltiazem

Simvastatin 20mg and diltiazem

Simvastatin 40mg and diltiazem

Concomitant use of simvastatin no greater than 20mg is recommended with amlodipine. Concomitant use of simvastatin no greater than 10mg is recommended with non-dihydropyridine calcium channel blockers. Using more than this amount can increase the risk of rhabdomyolysis and other muscle toxicities.

Explanation

Concomitant use of simvastatin no greater than 20mg is recommended with amlodipine. Concomitant use of simvastatin no greater than 10mg is recommended with non-dihydropyridine calcium channel blockers. Using more than this amount can increase the risk of rhabdomyolysis and other muscle toxicities.

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