Ischemic Heart Disease
QUESTION 1:
INCORRECT (You answered A; the correct answer is C)
Presentation
SB is a 65-year-old man who arrives at the general medicine clinic with a 1-week history of nausea, agitation,
tremors, and increased number of angina attacks associated with palpitations. The history of the present illness is
that SB has been treated in a smoking cessation clinic and had his last cigarette 1 month ago. SB recently was
treated with colchicine 1 week ago for an acute attack of gout.
The past medical history includes angina for 5 years. The condition has been stable with isosorbide dinitrate, but
SB lately reports chest pain with exertion. He has had hypertension for 10 years that is controlled with
hydrochlorothiazide and has had COPD for 3 years that is stable with theophylline and albuterol prn through an
inhaler.
SB has smoked one pack of cigarettes per day for 30 years and uses alcohol occasionally. His mother has COPD,
and his father has CAD and gout.
Meds
Hydrochlorothiazide 50 mg po qd
KCl 20 mEq po qd
Isosorbide dinitrate 30 mg po tid
Theophylline SR 300 mg po bid
Albuterol inhaler 2 puffs q4h prn
Nitroglycerin .4 mg SL prn for chest pain
EC aspirin 325 mg po qd
NKDA
Physical examination
GEN: Well-developed man in mild distress
BP: 155/95, HR: 100, RR: 16, T: 37.5°C
Ht: 177.8 cm, Wt: 70 kg
HEENT: Mild AV nicking
COR: S1, S2, no S3, sinus tachycardia
CHEST: Barrel chest, increased accessory muscle use
ABD: Soft, nontender
GU: WNL
RECT: Heme negative
EXT: MTP of left toe erythematous, tender, warm to touch 1 week ago, now WNL
NEURO: A/O x 3
labs
Na: 139
K: 4.6
Cl: 96
BUN: 19
WBC: 9.5
Hgb: 13.5
SCr: 1.2
Total chol: 245
Ca:8.1
PO4: 3.2
HCO3: 27
Mg: 1.8
Plts: 253,000
Hct: 40
Gluc: 110
WBC differential: WNL
Theophylline: 21
Urinalysis: WNL
Chest x-ray: Clear
EKG: Sinus tachycardia, occasional PVCs
In 6 months, SB is found to have a peptic ulcer likely caused by aspirin. Which of the following is the most
appropriate choice to replace aspirin in SB's antiischemia drug regimen?
A. Enoxaparin 30 mg sq bid
B. Dipyridamole 50 mg po qid
C. Clopidogrel 75 mg po qid
D. Warfarin 5 mg po qd
E. Amlodipine 5 mg po qd
QUESTION 2:
INCORRECT (You answered D; the correct answer is B)
A 62-year-old man presents with substernal chest discomfort that usually lasts for 2 to 10 minutes that is
pressure-like and radiates up to his jaw and down the left arm and is brought on by walking four blocks or by
arguments with his wife over money. Past medical history (PMH) includes hypercholesterolemia (total cholesterol
[TC], 320 mg/dL; low-density lipoprotein [LDL], 252 mg/dL; triglyceride [TG], 180 mg/dL; and high-density
lipoprotein [HDL], 32 mg/dL), smoking two packs per day for 30 years, benign prostatic hypertrophy (BPH), and
hypertension (HTN) (blood pressure [BP], 156/92 mm Hg). Resting electrocardiogram (ECG) is normal. He
currently takes terazosin 2 mg at bedtime. Which one of the following classes of drugs should be used first to
prevent recurrent episodes of chest pain for chronic therapy?
A. Calcium channel blocker
B. Warfarin
C.
-blocker
D. Nitrates (long acting)
E. Dipyridamole
QUESTION 3:
INCORRECT (You answered E; the correct answer is C)
In chronic stable angina, if a patient cannot tolerate a
-blocker (bronchospasm/asthma), then the patient can be
switched to:
A.
-agonist
B. Hydralazine
C. Calcium channel blocker
D. Dipyridamole
E. ACEI
QUESTION 4:
INCORRECT (You answered C; the correct answer is B)
Short-acting nifedipine is an excellent choice for the treatment of chronic angina because it has a rapid onset of
activity and can acutely lower blood pressure.
A. The statement is correct, and the reason is correct
B. The statement is false, and the reason is correct
C. The statement is correct, and the reason is false
D. The statement is false, and the reason is false
QUESTION 5:
INCORRECT (You answered D; the correct answer is C)
Which category of drug therapy should be avoided in patients with vasospastic or Prinzmetal's angina?
A. Calcium channel blocker
B. Aspirin
C.
-blocker
D. Nitrates (long acting)
E. Epoprostenol
QUESTION 6:
INCORRECT (You answered C; the correct answer is B)
A 62-year-old man presents with substernal chest discomfort that usually lasts for 2 to 10 minutes that is
pressure-like and radiates up to his jaw and down the left arm and is brought on by walking four blocks or by
arguments with his wife over money. Past medical history (PMH) includes hypercholesterolemia (total cholesterol
[TC], 320 mg/dL; low-density lipoprotein [LDL], 252 mg/dL; triglyceride [TG], 180 mg/dL; and high-density
lipoprotein [HDL], 32 mg/dL), smoking two packs per day for 30 years, benign prostatic hypertrophy (BPH), and
hypertension (HTN) (blood pressure [BP], 156/92 mm Hg). Resting electrocardiogram (ECG) is normal. He
currently takes terazosin 2 mg at bedtime. The most likely diagnosis is:
A. NSTEMI
B. Exertional angina
C. STEMI
D. Pulmonary embolism
E. Psychosis with conversion reaction
QUESTION 7:
CORRECT (You correctly answered D)
Antioxidant vitamins such as vitamin E and vitamin C should routinely be given to patients with angina because
their use will delay the growth of atherosclerotic lesions and reduce cardiovascular events such as myocardial
infarction (MI) and stroke.
A. The statement is correct, and the reason is correct
B. The statement is false, and the reason is correct
C. The statement is correct, and the reason is false
D. The statement is false, and the reason is false
QUESTION 8:
CORRECT (You correctly answered B)
Verapamil should be effective in the treatment of chronic angina because it:
A.
heart rate,
B.
heart rate,
C.
heart rate,
contractility,
SBP
D.
heart rate,
contractility,
SBP
QUESTION 9:
contractility,
SBP
contractility,
SBP
INCORRECT (You answered B; the correct answer is A)
The principal determinant of myocardial oxygen demand is:
A. Heart rate
B. Contractility
C. Left ventricular wall tension
D. Pulmonary vascular resistance
QUESTION 10:
INCORRECT (You answered D; the correct answer is E)
Which of the following is most likely NOT a cause of myocardial reperfusion injury?
A. cellular pH fluctuations.
B. damage to the sarcolemma.
C. generation of toxic oxygen radicals.
D. Ca2+ overload.
E. inhibition of the electron transport chain.
QUESTION 11:
INCORRECT (You answered B; the correct answer is A)
Clopidogrel 75 mg/day should be used along with aspirin following primary coronary intervention with balloon
angioplasty and stent placement for up to 1 year because the combination of antiplatelet agents reduces MI,
stroke, or death compared to aspirin alone.
A. The statement is correct, and the reason is correct
B. The statement is false, and the reason is correct
C. The statement is correct, and the reason is false
D. The statement is false, and the reason is false
QUESTION 12:
INCORRECT (You answered C; the correct answer is A)
A 62-year-old man presents with substernal chest discomfort that usually lasts for 2 to 10 minutes that is
pressure-like and radiates up to his jaw and down the left arm and is brought on by walking four blocks or by
arguments with his wife over money. Past medical history (PMH) includes hypercholesterolemia (total cholesterol
[TC], 320 mg/dL; low-density lipoprotein [LDL], 252 mg/dL; triglyceride [TG], 180 mg/dL; and high-density
lipoprotein [HDL], 32 mg/dL), smoking two packs per day for 30 years, benign prostatic hypertrophy (BPH), and
hypertension (HTN) (blood pressure [BP], 156/92 mm Hg). Resting electrocardiogram (ECG) is normal. He
currently takes terazosin 2 mg at bedtime. Which of the following medications could be given acutely to the
patient to relieve his chest discomfort?
A. Sublingual nitroglycerin
B. Dipyridamole
C. Acetaminophen
D. Sildenafil
E. Alteplase
QUESTION 13:
INCORRECT (You answered A; the correct answer is E)
Which of the following risk factors for CAD should be treated vigorously in patients with angina?
A. Dyslipidemia
B. Hypertension
C. Smoking cessation
D. Diabetes
E. All of the above
QUESTION 14:
INCORRECT (You answered B; the correct answer is A)
Aspirin should routinely be prescribed to patients with chronic angina because aspirin has been shown to reduce
myocardial infarction and other vascular events in patients with known coronary artery disease (CAD).
A. The statement is correct, and the reason is correct
B. The statement is false, and the reason is correct
C. The statement is correct, and the reason is false
D. The statement is false, and the reason is false