Cardiology HY 4

A 62-year-old male (weight 100 kg) presents to a rural emergency department (ED) with acute STEMI and has been treated with aspirin 324 mg once by mouth. His symptoms started about 6 hours ago and are getting worse. Fibrinolytic therapy with tenecteplase has been identified as the initial reperfusion strategy for this patient after ruling out known contraindications and since there is no cardiac cath lab available in the geographic area. Which of the following is the best next decision in the care for this patient?

• No anticoagulation for 24 hours posts tenecteplase

• Initiate heparin IV 4000 units bolus, followed by 1000 units/hour

• Initiate heparin IV 80 units/kg bolus, followed by 18 units/kg/hour

• Initiate bivalirudin IV 0.75 mg/kg bolus, followed by 1.75 mg/kg/hour

Answer explanation

Fibrinolytic management of STEMI is indicated for STEMI when it has been 12 hours since symptom onset, ECG changes of at least 1mm ST-segment elevation in two or more contiguous leads (*see note below), and door-to-needle time is above 120 minutes (in patients needing to be transferred to get PCI). Among these patients, anticoagulants (heparin, low-molecular-weight heparin, or fondaparinux) must be administered for at least 48 hours. In this clinical scenario, the appropriate dosing for MODE: TEST SCORE: 75.00 LAB REFERENCE (/APP/LAB-REFERENCE/LAB-REFERENCE.PDF) HOME (/APP/QBANK/REVIEW/COMPLETE)   QUESTION: 11 OF 20 CATEGORY: CARDIAC  MYOCARDIAL INFARCTION heparin is 60 units/kg (maximum 4000 units) IV bolus followed by an infusion of 12 units/kg/hour (maximum 1000 units/hour). The American College of Cardiology, American Heart Association, European Society of Cardiology, and the World Heart Federation committee established the following ECG criteria for ST-elevation myocardial infarction (STEMI): New ST-segment elevation at the J point in 2 contiguous leads with the cutoff point as greater than 0.1 mV in all leads other than V2 or V3. In leads V2-V3, the cutoff point is: Greater than 0.2 mV (or 2 mm) in men older than 40 years old Greater than 0.25 mV (2.5 mm) in men younger than 40 years old, or Greater than 0.15 mV (or 1.5 mm) in women If patients have known pre-existing left-bundle branch block, then Sgarbossa's criteria should be used, which include: ST-segment elevation of 1 mm or more that is concordant with (in the same direction as) the QRS complex. ST-segment depression of 1 mm or more in lead V1, V2, or V3. ST-segment elevation of 5 mm or more that is discordant with (in the opposite direction) the QRS complex

Heparin dosing of IV 80 units/kg bolus followed by 18 units/kg/hour is the proper dosing for venous thromboembolism (pulmonary embolus or deep vein thrombosis). Bivalirudin is an adjunct to primary coronary intervention (PCI) and should not be used for initial management with the fibrinolytic strategy of STEMI therapy. High-Yield Core Concept: Fibrinolytic therapy of STEMI should be initiated when the patient's onset of symptoms are within 12 hours of presentation, no contraindications exist, and the goal of 120 minutes to PCI cannot be achieved due to needing to transfer the patient. This should also be given with anticoagulant therapy, including heparin with a dosing strategy of 60 units/kg (maximum 4000 units) IV bolus followed by an infusion of 12 units/kg/hour (1000 units/hour). High-Yield Fast Facts: In addition to anticoagulant initiation post fibrinolytics for STEMI, dual antiplatelet therapy should be initiated consisting of aspirin plus either clopidogrel, ticagrelor, or prasugrel

Contraindications to fibrinolysis therapy for STEMI include any prior hemorrhagic stroke, ischemic stroke within 3 months, intracranial neoplasm, intracranial AV malformation, active internal hemorrhage, aortic dissection, head trauma within the past 3 months, intracranial or intraspinal surgery within 2 months, and blood pressure above 185/110 mmHg unresponsive to emergent therapy

JZ is a 60-year-old man who has been in atrial fibrillation for the last ten days. JZ's past medical history includes hypertension and diabetes mellitus. This is JZ's first episode of atrial fibrillation. His echocardiogram from one month ago shows a normal ejection fraction of 60% and no left ventricular hypertrophy or ventricular dysfunction. JZ complains of occasional palpitations that occur mostly while he is active (walking his dog and doing yard work). His current heart rate is 120 bpm, and his blood pressure is 140/85 mmHg. Current medications include lisinopril 10 mg PO once daily for his hypertension and glipizide 5 mg PO once daily for his diabetes. What is JZ's CHADS2 Score?

• 0

• 1

• 2

• 3

Answer explanation

CHADS2 = Congestive heart failure, Hypertension, Age > 75, Diabetes and Stroke, or Transient Ischemic Attach (TIA). The score range is 0 to 6. Congestive heart failure, Hypertension, Age > 75, and Diabetes are each worth one point. MODE: TEST SCORE: 75.00 LAB REFERENCE (/APP/LAB-REFERENCE/LAB-REFERENCE.PDF) HOME (/APP/QBANK/REVIEW/COMPLETE)   QUESTION: 13 OF 20 CATEGORY: CARDIOVASCULAR Stroke or TIA is worth 2 points. CHADS2 score helps identify a patient's risk of having a stroke with chronic atrial fibrillation of any type over the next one year.

A 65-year-old African American woman with a history of hypertension, diabetes type 2, and heart failure with reduced ejection fraction (HFrEF) presents to the medication management clinic for follow up. She was recently discharged from the local hospital after a congestive heart failure exacerbation. She is currently stable and reports that she had no symptoms while resting in the waiting room. She did experience symptoms of shortness of breath and fatigue when she had to bathe and get dressed this morning prior to coming to her appointment. Her labs are within normal limits. Which best describes her New York Heart Association (NYHA) functional classification?

• NYHA class I

• NYHA Class II

• NYHA Class III

• NYHA Class IV

Answer explanation

The third answer choice is correct because NYHA class III describes patients with cardiac disease resulting in marked limitation of physical activity. In this class, patients are comfortable at rest, and less than ordinary or minimal exertion causes fatigue or dyspnea. For this patient, bathing and getting dressed resulted in shortness of breath and fatigue. MODE: TEST SCORE: 75.00 LAB REFERENCE (/APP/LAB-REFERENCE/LAB-REFERENCE.PDF) HOME (/APP/QBANK/REVIEW/COMPLETE)   QUESTION: 12 OF 20 CATEGORY: CARDIOLOGY The first answer choice is incorrect because this class describes patients with cardiac disease but without limitation of physical activity. Ordinary physical activity does not cause fatigue, palpitations, dyspnea, or angina. The second answer choice is incorrect because this describes patients with cardiac disease who are comfortable at rest, but ordinary physical activity results in symptoms. Examples of ordinary physical activity would be climbing upstairs rapidly, walking uphill for a short distance, and walking about two blocks. The fourth answer choice is incorrect because this describes someone who has the inability to carry on any physical activity without discomfort. Anginal symptoms are also present at rest. This patient did not have symptoms at rest and therefore, would not fall into this category.

The NYHA classification is the most widely used classification based on functional status. It is important to note heart failure is a progressive disease requiring ongoing assessment. Patients often move from one functional class to another based on their symptom control. High-Yield Fast Fact(s): In contrast to the NYHA functional classification, in the ACC/AHA stages of heart failure classification, patients cannot move backward to prior stages. For example, in the ACC/AHA classification, once symptoms develop, stage C heart failure is present, stage B (presence of structural heart disease without symptoms) will never be achieved again.

Which angiotensin receptor blocker (ARB) is not indicated for pediatric hypertension?

• Losartan

• Olmesartan

• Telmisartan

• Valsartan

Answer explanation

Cozaar (losartan), Benicar (olmesartan), and Diovan (valsartan) have indications for use in the pediatric population. Micardis (telmisartan) does not have an indication for use in the pediatric population.

A 68-year-old White female reports to the clinic for dyslipidemia management. She has a past medical history of known coronary artery disease status post coronary stent, diabetes mellitus, hypertension, and obesity. Current medications include aspirin 81 mg daily, candesartan 16 mg daily, metformin 1000 mg twice a day, and a multivitamin. She smokes one PPD but does not drink alcohol or do any drugs. Her most recent fasting lipid panel results are as follows: TChol = 243, HDL = 56, LDL = 139, TG = 240, Glucose = 115. Her 10-yr CVD risk is estimated to be 11%. Which of the following statements is most correct?

• Needs LDL reduction of > 50%. Initiate rosuvastatin

• Needs LDL reduction of at least 30%. Initiate fenofibrate

• LDL goal < 130 mg/dL. Initiate pravastatin

• LDL goal < 130 mg/dL. Initiate ezetimibe

Answer explanation

This patient has a history of diabetes, known CAD already with a coronary stent, and a ten-yr risk > 7.5%, which would make her a candidate for high-intensity statin therapy, which means she should have a reduction in LDL-c by at least 50%. As such, only atorvastatin and rosuvastatin will provide an adequate lowering of the LDL-c by > 50% from baseline. MODE: TEST SCORE: 75.00 LAB REFERENCE (/APP/LAB-REFERENCE/LAB-REFERENCE.PDF) HOME (/APP/QBANK/REVIEW/COMPLETE)   QUESTION: 15 OF 20 CATEGORY: HYPERLIPIDEMIA Statin therapy, in this case, rosuvastatin, would be the most appropriate choice given it targets LDL. Fenofibrate, while it has a small LDL reduction component, is prescribed primarily for TG lowering and not appropriate for initial therapy, especially given the strength of data supporting statin use in secondary CAD prevention. Ezetimibe usually only causes a reduction in LDL-c by 20-23% and would be insufficient

High-Yield Core Concept: Patients at high risk for future ASCVD events include (but are not limited to): Patients over > 65 years of age Heterozygous familial hypercholesterolemia History of coronary artery bypass surgery or PCI (i.e., have established CAD) Diabetes mellitus Hypertension CKD with eGFR of 15 - 59 mL/min/1.73 m2 Current smoking LDL > 100 mg/dL History of heart failure The patient, in this case is not only needing secondary prevention against CVD but has several of these high-risk features. High-Yield Fast Fact: Statins and ezetimibe both lead to the upregulation of LDL receptors in the liver that can extract LDL-c out of the circulation

A 76-year-old White male with chronic stable angina is referred for medical management. He is currently not taking any medications for angina. After interviewing and evaluating the patient, you elect to start pharmacologic therapy to improve overall myocardial oxygen demand (MVO ). Which of the following medications would be most appropriate to improve MVO by decreasing heart rate and contractility?

• Amlodipine

• Atenolol

• Fosinopril

• Isosorbide mononitrate

Answer explanation

Management of angina is essentially about maximizing oxygen delivery (supply) and minimizing oxygen utilization (demand). The three key components of oxygen demand are heart rate, contractility, and intramyocardial wall tension. Of the options given above, prescribing a beta-blocker is the only one that would affect oxygen utilization (or decrease MVO2) by acting on the beta-1 receptor in the heart leading to a decrease in heart rate and contractility. Amlodipine, a dihydropyridine calcium channel blocker, improves angina by decreasing systemic vascular resistance (blood pressure) and vasodilation of coronary arteries. Fosinopril, an ACE inhibitor, primarily improves angina through its blood pressureMODE: TEST SCORE: 75.00 LAB REFERENCE (/APP/LAB-REFERENCE/LAB-REFERENCE.PDF) HOME (/APP/QBANK/REVIEW/COMPLETE)   QUESTION: 16 OF 20 CATEGORY: CARDIOVASCULAR DRUGS  ANTIHYPERTENSIVES 2 2 lowering (i.e., afterload) properties. Isosorbide mononitrate, a nitrate, indirectly reduces myocardial wall tension through venodilation both systemically and within the coronary circulation.

A 68-year-old African-American male with a past medical history significant for type 2 diabetes mellitus, hypertension, gout, and allergic rhinitis reports for routine follow up. He denies any complaints and states that he is compliant with his medication therapy. Current medications include allopurinol 300 mg daily, atenolol 25 mg daily, glipizide 5 mg twice a day, and loratadine 10 mg daily. Labs: Chemistry within normal limits; A1c of 7.2%. Vitals in clinic today: BP 134/74 HR 48

Based on the above information, what is this patient's blood pressure goal, and what therapeutic recommendation would be most appropriate at this time?

• Goal < 130/80; increase atenolol to 50 mg daily

• Goal < 130/80; discontinue atenolol and start fosinopril 10 mg daily

• Goal < 140/95; discontinue atenolol and start fosinopril 10 mg daily

• Goal < 150/90; continue current therapy

Answer explanation

While the guidelines have changed over the years, this patient's ideal BP goal is to be < 130/80. This patient is bradycardic per his home blood pressure log and clinic vitals, presumably due to the atenolol therapy. At this time, due to the compelling indication, type 2 diabetes, an ACE inhibitor would be preferred for hypertension treatment. So, given these two facts, the most appropriate option would be to stop the atenolol and start an ACE inhibitor (fosinopril in this case, but any ACE inhibitor would be appropriate).

Which of the following monitoring parameters are NOT indicated for Amiodarone?

• An electrocardiogram yearly

• Lipase every six months

• Thyroid function tests every six months

• Chest radiograph yearly

Answer explanation

The second answer option is correct because you do not have to monitor pancreatic function in patients taking amiodarone. An electrocardiogram is performed to monitor for QT prolongation. Thyroid function tests are performed to monitor for hyperthyroidism or hypothyroidism. A chest x-ray is performed to monitor for pulmonary toxicity. The above monitoring parameters vary in frequency based on the development of symptoms or at least done annually while on chronic amiodarone therapy and as part of routine outpatient medical management.

You are reviewing the management of angina and recall that decreasing myocardial oxygen demand (MVO ) is critically important for minimizing angina episodes. Assuming all of the following interventions are appropriate for a given patient, which of the following would you predict would improve angina by decreasing MVO ?

• Infusing 2 units of packed red blood cells

• Performing a CABG

• Providing home oxygen therapy

• Prescribing a beta-blocker

Answer explanation

Management of angina is essentially about maximizing oxygen delivery (supply) and minimizing oxygen utilization (demand). The three key components of oxygen demand are heart rate, contractility, and intramyocardial wall tension. Of the options given above, prescribing a beta-blocker is the only one that would affect oxygen utilization (or decrease MVO2) by acting on the beta-1 receptor in the heart leading to a decrease in heart rate (negative chronotropic effect) and contractility (negative inotropic effect). The other options would target improving the amount of oxygen delivered to the myocardium (supply). For a more in-depth review, you are referred to a medical physiology and/or pharmacology textbook. MODE: TEST SCORE: 75.00 LAB REFERENCE (/APP/LAB-REFERENCE/LAB-REFERENCE.PDF) HOME (/APP/QBANK/REVIEW/COMPLETE)   QUESTION: 19 OF 20 CATEGORY: CARDIOLOGY 2 2 References: Antman EM, Selwyn AP, Loscalzo J. Chapter 243. Ischemic Heart Disease. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. Talbert RL. Chapter 23. Ischemic Heart Disease. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011.

A 74-year-old White male with refractory angina is currently receiving maximally tolerated traditional antianginal therapy of an ACE inhibitor, beta-blocker, calcium channel blocker, and isosorbide dinitrate. Vital signs include a blood pressure of 112/68 and a heart rate of 56. Despite this therapy, the patient continues to experience 2-3 angina episodes per day. Unfortunately, he is no longer a candidate for cardiac revascularization. He is requesting further angina relief, so you elect to start ranolazine. Which of the following most accurately describe the proposed mechanism of action of ranolazine in angina management?

• Decreases catecholamine activity by blocking adrenergic receptors on the heart

• Inhibits the late sodium current in myocytes decreasing diastolic wall tension

• Reduces preload and dilates the large epicardial coronary arteries

• Blocks the conversion of angiotensin I to angiotensin II

Answer explanation

Ranolazine is a novel antianginal medication that does not affect hemodynamics (blood pressure or heart rate) in order to produce a reduction in angina. Instead, ranolazine inhibits the late sodium current in myocytes. Normally in ischemic myocytes, these late sodium channels cause an increase in intracellular sodium, which further results in an increase in intracellular calcium. Intracellular calcium overload directly increases diastolic wall tension MODE: TEST SCORE: 75.00 LAB REFERENCE (/APP/LAB-REFERENCE/LAB-REFERENCE.PDF) HOME (/APP/QBANK/REVIEW/COMPLETE)   QUESTION: 20 OF 20 CATEGORY: CARDIOVASCULAR DRUGS  ANTIANGINALS and perpetuates myocardial ischemia. Therefore, by blocking this late sodium current (or channel), you have a net reduction in intracellular calcium leading to decreased diastolic wall tension (or increased relaxation) and a decrease in angina. The other options describe mechanisms of beta-blockers (decreasing catecholamine activity), nitrates (reducing preload), and ACE inhibitors (angiotensin I to angiotensin II). References: Talbert RL. Chapter 23. Ischemic Heart Disease. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. Greene RS, Rangel RM, Edwards KL, Chastain LM, Brouse SD, Alvarez CA, Collins LA, Brilakis ES, Banerjee S. Ranolazine for the treatment of refractory angina in a veterans population. Cardiovasc Revasc Med. 2012 Mar;13(2):141.e1-5. Ranexa Prescribing Information. Gilead Sciences, Inc. December 2011.