DeepSeek NAPLEX Questions (Cardiovascular Conditions)

A 58-year-old male arrives for a lipid panel after eating breakfast 2 hours prior. Which value will be MOST affected by non-fasting status?
A) Total cholesterol (TC)
B) HDL cholesterol
C) LDL cholesterol (calculated)
D) Triglycerides (TG)

Solution: D) Triglycerides (TG)
Rationale: TGs are significantly elevated postprandially (2-9x higher), which can lead to falsely low LDL calculations. TC and HDL remain relatively stable (ACC/AHA Lipid Guidelines 2018).

A patient's lipid panel shows: TC = 210 mg/dL, HDL = 40 mg/dL, TG = 450 mg/dL. Which action is appropriate?
A) Calculate LDL using Friedewald equation
B) Report LDL as "cannot be calculated"
C) Use a direct LDL measurement
D) Repeat the test after a 24-hour fast

Solution: C) Use a direct LDL measurement
Rationale: The Friedewald equation (LDL = TC - HDL - TG/5) is invalid when TG >400 mg/dL. Direct LDL measurement or advanced lipid testing (e.g., NMR) is needed (JACC 2020).

Which scenario would make the Friedewald equation unreliable for LDL estimation?
A) HDL = 60 mg/dL
B) TG = 500 mg/dL
C) TC = 300 mg/dL
D) Non-fasting sample with TG = 180 mg/dL

Solution: B) TG = 500 mg/dL
Rationale: The Friedewald equation becomes inaccurate when TG >400 mg/dL due to very-low-density lipoprotein (VLDL) variability (Clin Chem 2019).

A non-fasting lipid panel shows: TC = 190 mg/dL, HDL = 50 mg/dL, TG = 600 mg/dL. The calculated LDL is 80 mg/dL. What is the best interpretation?
A) LDL is accurate; initiate statin therapy
B) LDL is falsely low; repeat after 12-hour fast
C) LDL is falsely high; the patient has familial hypercholesterolemia
D) Use the result as-is; fasting does not affect LDL

Solution: B) LDL is falsely low; repeat after 12-hour fast
Rationale: Elevated TG from non-fasting status artificially lowers Friedewald-calculated LDL. Repeat testing after fasting (AHA Scientific Statement 2021).

According to recent guidelines, in which patient can a non-fasting lipid panel be acceptable?
A) Initial cardiovascular risk assessment
B) Monitoring statin therapy in diabetes
C) Diagnosis of familial hyperchylomicronemia
D) Evaluation for metabolic syndrome

Solution: A) Initial cardiovascular risk assessment
Rationale: The 2018 ACC/AHA guidelines permit non-fasting panels for initial screening, but fasting is preferred for TG >200 mg/dL or hypertriglyceridemia history.

A 45-year-old kidney transplant patient on tacrolimus develops new-onset hyperlipidemia. Which lipid parameter is MOST likely elevated?
A) HDL only
B) LDL only
C) Both LDL and triglycerides
D) Triglycerides only

Solution: C) Both LDL and triglycerides
Rationale: Calcineurin inhibitors (tacrolimus, cyclosporine) increase both LDL and triglycerides by altering lipid metabolism (Am J Transplant 2019).

A patient starting olanzapine for bipolar disorder should be monitored for which lipid abnormality?
A) Isolated HDL elevation
B) LDL and triglyceride elevation
C) Triglyceride reduction
D) No lipid changes expected

Solution: B) LDL and triglyceride elevation
Rationale: Atypical antipsychotics (e.g., olanzapine, quetiapine) commonly cause mixed dyslipidemia (LDL↑ & TG↑) via metabolic effects (APA Guidelines 2020).

An HIV patient on darunavir/ritonavir develops severe hypertriglyceridemia (TG >1000 mg/dL). Which intervention is MOST appropriate?
A) Switch to dolutegravir
B) Add fenofibrate
C) Initiate cholestyramine
D) Discontinue all ART

Solution: A) Switch to dolutegravir
Rationale: Protease inhibitors (especially with ritonavir) significantly raise TG/LDL. Integrase inhibitors (dolutegravir) are lipid-neutral (DHHS HIV Guidelines 2023).

Which statement about fish oil supplements is CORRECT?
A) All formulations lower both LDL and TG
B) Vascepa lowers TG without increasing LDL
C) Lovaza reduces LDL more than TG
D) They are contraindicated in statin users

Solution: B) Vascepa lowers TG without increasing LDL
Rationale: icosapent ethyl (Vascepa) is purified EPA that lowers TG without raising LDL, unlike mixed EPA/DHA products (REDUCE-IT Trial 2018).

A patient on parenteral nutrition with 20% lipid emulsion develops TG = 850 mg/dL. What is the BEST action?
A) Switch to 10% lipid emulsion
B) Add ezetimibe
C) Continue current regimen
D) Discontinue all lipids

Solution: A) Switch to 10% lipid emulsion
Rationale: IV lipid emulsions (especially 20%) can cause severe hypertriglyceridemia. Reduce dose or switch to lower concentration (ASPEN Guidelines 2022).

A patient with newly elevated LDL and TG has TSH = 12 mIU/L. Which intervention should be prioritized?
A) Start atorvastatin
B) Initiate levothyroxine
C) Prescribe fenofibrate
D) Recommend weight loss

Solution: B) Initiate levothyroxine
Rationale: Hypothyroidism causes elevated LDL/TG. Treating the underlying condition (vs. direct lipid therapy) is first-line (AACE Thyroid Guidelines 2021).

A schizophrenia patient on clozapine has LDL 190 mg/dL and TG 400 mg/dL. Which monitoring schedule aligns with guidelines?
A) Lipid panel every 3 months
B) No routine monitoring needed
C) Annual HbA1c only
D) Check only if symptoms occur

Solution: A) Lipid panel every 3 months
Rationale: Atypical antipsychotics require quarterly lipid monitoring for first year, then annually (Monitoring Guidelines for SGAs 2019).

A hypertensive patient on chlorothiazide develops new-onset dyslipidemia. Which pattern is MOST expected?
A) Isolated LDL elevation
B) Isolated TG elevation
C) Combined LDL/TG elevation
D) HDL reduction only

Solution: B) Isolated TG elevation
Rationale: Thiazide diuretics (e.g., chlorothiazide) primarily increase triglycerides, with minimal effect on LDL (ACC/AHA Hypertension Guidelines 2022).

A patient with nephrotic syndrome (albumin 1.8 g/dL) has severe hyperlipidemia. Which mechanism explains this finding?
A) Increased hepatic lipoprotein synthesis
B) Enhanced LDL receptor activity
C) Thyroid dysfunction
D) Vitamin D deficiency

Solution: A) Increased hepatic lipoprotein synthesis
Rationale: Nephrotic syndrome causes compensatory ↑ hepatic lipoprotein production due to urinary protein loss (KDIGO 2021 Guidelines).

A patient with alcohol use disorder (AUD) has TG = 1200 mg/dL. Which intervention is MOST urgent?
A) Immediate alcohol cessation
B) Initiation of icosapent ethyl
C) Apheresis referral
D) Statin therapy

Solution: A) Immediate alcohol cessation
Rationale: AUD causes marked TG elevation via ↑ VLDL production. Abstinence is first-line (AHA Scientific Statement 2023).

A patient with HbA1c 9.8% has LDL 160 mg/dL and TG 350 mg/dL. Which drug addresses BOTH abnormalities?
A) Fenofibrate
B) Atorvastatin
C) Niacin
D) Colesevelam

Solution: B) Atorvastatin
Rationale: Statins reduce LDL (primary effect) and modestly lower TG (~15-30%) in diabetes (ADA Standards of Care 2024).

A patient with BMI 42 has LDL 130 mg/dL and TG 400 mg/dL. Which nonpharmacologic strategy is MOST effective for TG reduction?
A) Mediterranean diet
B) Weight loss ≥5%
C) Smoking cessation
D) Alcohol moderation

Solution: B) Weight loss ≥5%
Rationale: Even modest weight loss (5-10%) significantly lowers TG in obesity (ACC/AHA Lifestyle Guidelines 2023).

A 2-pack-per-day smoker quits tobacco. Which lipid improvement is MOST expected at 3-month follow-up?
A) HDL increase by 10-15%
B) LDL decrease by 30%
C) TG reduction to <150 mg/dL
D) No significant change

Solution: A) HDL increase by 10-15%
Rationale: Smoking cessation raises HDL (primary benefit) with minimal LDL/TG effects (Circulation 2021).

A 68-year-old male with history of MI and LDL 110 mg/dL presents for lipid management. Which statin intensity is MOST appropriate?
A) Low-intensity (e.g., pravastatin 10 mg)
B) Moderate-intensity (e.g., atorvastatin 20 mg)
C) High-intensity (e.g., atorvastatin 40-80 mg)
D) No statin needed

Solution: C) High-intensity (e.g., atorvastatin 40-80 mg)
Rationale: Patients with clinical ASCVD (e.g., MI) require high-intensity statins regardless of baseline LDL (ACC/AHA Guideline 2018).

A 45-year-old female with LDL 210 mg/dL (no other risk factors) should be started on:
A) Rosuvastatin 5 mg daily
B) Atorvastatin 80 mg daily
C) Ezetimibe 10 mg daily
D) No therapy unless LDL > 250 mg/dL

Solution: B) Atorvastatin 80 mg daily
Rationale: LDL ≥190 mg/dL warrants high-intensity statin without risk calculation (ACC/AHA 2018).

A 55-year-old diabetic (HbA1c 7.8%) with hypertension and LDL 85 mg/dL should receive:
A) High-intensity statin
B) Moderate-intensity statin
C) Statin only if LDL > 100 mg/dL
D) Fibrate therapy

Solution: A) High-intensity statin
Rationale: Diabetics aged 40-75 with multiple ASCVD risk factors require high-intensity statins regardless of LDL (ADA Standards 2023).

A 60-year-old male (nonsmoker, HDL 50 mg/dL, BP 130/85 mmHg, LDL 145 mg/dL) has 10-year ASCVD risk of 18%. Which statin intensity is recommended?
A) High-intensity
B) Moderate-intensity
C) Low-intensity
D) No statin

Solution: B) Moderate-intensity
Rationale: For primary prevention with 10-year risk 7.5-19.9%, moderate-intensity statins are recommended (ACC/AHA 2018).

An 80-year-old female (LDL 115 mg/dL, no ASCVD) with 10-year risk of 22% should be prescribed:
A) Atorvastatin 80 mg
B) Rosuvastatin 20 mg
C) Pravastatin 40 mg
D) No statin

Solution: C) Pravastatin 40 mg
Rationale: For patients >75 years without ASCVD, moderate-intensity statins are preferred over high-intensity due to limited evidence (ACC Expert Consensus 2022).

Which factor would justify moderate-intensity statin in a patient with 10-year ASCVD risk of 15%?
A) Family history of premature CAD
B) HDL 55 mg/dL
C) BMI 28 kg/m²
D) Age 65 years

Solution: A) Family history of premature CAD
Rationale: Risk-enhancing factors (e.g., family history) support statin use when risk is borderline (7.5-19.9%) (ACC/AHA 2018).

A candidate for high-intensity statin develops rhabdomyolysis on atorvastatin. Which alternative is MOST appropriate?
A) Rosuvastatin 40 mg
B) Pravastatin 40 mg + ezetimibe
C) Gemfibrozil monotherapy
D) Alirocumab

Solution: B) Pravastatin 40 mg + ezetimibe
Rationale: For statin intolerance, moderate-intensity statin + nonstatin (ezetimibe) is recommended (ACC Expert Decision Pathway 2022).

Which statin dose is pharmacodynamically equivalent to atorvastatin 10 mg for moderate-intensity therapy?
A) Rosuvastatin 20 mg
B) Simvastatin 20 mg
C) Pitavastatin 4 mg
D) Lovastatin 20 mg

Solution: B) Simvastatin 20 mg
Rationale: Atorvastatin 10 mg ≈ Rosuvastatin 5 mg ≈ Simvastatin 20 mg ≈ Pravastatin 40 mg for moderate-intensity LDL reduction (ACC/AHA Guideline 2018).

A patient on rosuvastatin 20 mg daily needs to switch to atorvastatin due to insurance coverage. What is the equivalent high-intensity dose?
A) Atorvastatin 10 mg
B) Atorvastatin 40 mg
C) Atorvastatin 80 mg
D) No equivalent dose exists

Solution: B) Atorvastatin 40 mg
Rationale: Rosuvastatin 20 mg ≈ Atorvastatin 40 mg for high-intensity therapy (both achieve ~50% LDL reduction).

Which statin has the highest potency per milligram based on the equivalent doses listed?
A) Lovastatin
B) Simvastatin
C) Rosuvastatin
D) Pravastatin

Solution: C) Rosuvastatin
Rationale: Rosuvastatin 5 mg ≈ Atorvastatin 10 mg, making it ~2x more potent mg-for-mg (Pharmacotherapy 2021).

A 75-year-old male (CrCl 25 mL/min) requires moderate-intensity statin therapy. Which is the SAFEST choice?
A) Simvastatin 20 mg
B) Lovastatin 40 mg
C) Pravastatin 40 mg
D) Fluvastatin 80 mg

Solution: C) Pravastatin 40 mg
Rationale: Pravastatin is preferred in renal impairment (minimal renal excretion). Avoid simvastatin/lovastatin in CKD due to myopathy risk (KDIGO 2021).

A patient on simvastatin 20 mg develops new muscle pain. Which lab test is MOST critical?
A) Serum creatinine
B) ALT/AST
C) CPK
D) TSH

Solution: C) CPK
Rationale: CPK monitors for statin-induced myopathy. Simvastatin has higher myopathy risk than other statins (FDA Labeling).

Which medication is CONTRAINDICATED with simvastatin 20 mg?
A) Amlodipine
B) Gemfibrozil
C) Metformin
D) Levothyroxine

Solution: B) Gemfibrozil
Rationale: Gemfibrozil + simvastatin increases myopathy risk by inhibiting CYP3A4 and glucuronidation (maximum simvastatin dose = 10 mg with gemfibrozil).

What does the mnemonic "Pharmacists Rock At Saving Lives and Preventing Fatty deposits" help remember?
A) Statin dosing frequencies
B) Statin potency ranking
C) Statin adverse effects
D) Statin contraindications

Solution: B) Statin potency ranking
Rationale: The mnemonic orders statins from highest to lowest potency: Pitavastatin → Rosuvastatin → Atorvastatin → Simvastatin → Lovastatin → Pravastatin → Fluvastatin.

Which statin dose carries the highest risk of myopathy and should generally be avoided?
A) Atorvastatin 40 mg daily
B) Rosuvastatin 20 mg daily
C) Simvastatin 80 mg daily
D) Pravastatin 80 mg daily

Solution: C) Simvastatin 80 mg daily
Rationale: Simvastatin 80 mg/day is contraindicated due to high myopathy risk (FDA Boxed Warning). Max dose = 40 mg/day.

A patient on simvastatin 20 mg develops hypertriglyceridemia. Which medication is contraindicated?
A) Icosapent ethyl
B) Fenofibrate
C) Gemfibrozil
D) Ezetimibe

Solution: C) Gemfibrozil
Rationale: Gemfibrozil + statins increase myopathy risk (2-5x higher than fenofibrate). Maximum simvastatin dose = 10 mg if gemfibrozil must be used (ACC Lipid Guidelines 2023).

A patient reports new muscle pain after 3 weeks of atorvastatin 40 mg. What is the FIRST action?
A) Switch to rosuvastatin
B) Check CPK and hold statin
C) Add coenzyme Q10
D) Reduce dose by 50%

Solution: B) Check CPK and hold statin
Rationale: Initial steps: (1) Hold statin, (2) Check CPK to rule out rhabdomyolysis (>10x ULN), (3) Investigate other causes (e.g., hypothyroidism) (NLA Muscle Safety Task Force 2022).

After resolving statin-related myalgia, when should re-challenge be attempted?
A) Immediately with a different statin
B) After 2-4 weeks with the same statin
C) Only after 6 months
D) Never attempt re-challenge

Solution: B) After 2-4 weeks with the same statin
Rationale: Most patients tolerate re-challenge after 2-4 weeks, often at the same or reduced dose (ACC Expert Consensus 2022).

A patient fails two statin trials due to myalgia. Which is the BEST next option?
A) Fluvastatin XL 80 mg at bedtime
B) Lovastatin 40 mg with grapefruit juice
C) Simvastatin 40 mg + gemfibrozil
D) Atorvastatin 80 mg daily

Solution: A) Fluvastatin XL 80 mg at bedtime
Rationale: Fluvastatin (non-CYP3A4 metabolized) has lower myalgia risk. Avoid lovastatin/simvastatin with strong CYP3A4 inhibitors (grapefruit, gemfibrozil) (AHA Scientific Statement 2023).

Which non-statin therapy is preferred if a patient cannot tolerate any statin after two attempts?
A) Colesevelam
B) Ezetimibe
C) Niacin
D) Evolocumab

Solution: D) Evolocumab
Rationale: PCSK9 inhibitors (e.g., evolocumab) are preferred over ezetimibe for high-risk patients after statin intolerance (ACC Pathway 2023).

Which OTC product increases myopathy risk when taken with statins?
A) Calcium carbonate
B) St. John's wort
C) Coenzyme Q10
D) Diphenhydramine

Solution: B) St. John's wort
Rationale: St. John's wort induces CYP3A4, reducing statin efficacy but may paradoxically increase toxicity with fluctuating levels (FDA Drug Interactions Table 2023).

A patient taking simvastatin 40 mg daily is prescribed clarithromycin for pneumonia. What is the MOST appropriate action?
A) Continue both medications
B) Discontinue simvastatin temporarily
C) Switch to pravastatin
D) Reduce simvastatin to 20 mg

Solution: B) Discontinue simvastatin temporarily
Rationale: Strong CYP3A4 inhibitors (e.g., clarithromycin) increase simvastatin toxicity risk. Discontinue simvastatin or switch to non-CYP3A4 metabolized statin (e.g., pravastatin) (FDA Drug Interactions 2023).

A 72-year-old male (CrCl 25 mL/min) requires statin therapy. Which statin requires dose reduction in this patient?
A) Atorvastatin 10 mg
B) Rosuvastatin 40 mg
C) Fluvastatin XL 80 mg
D) Pitavastatin 2 mg

Solution: B) Rosuvastatin 40 mg
Rationale: Rosuvastatin >5 mg requires dose adjustment when CrCl <30 mL/min. Max dose = 5 mg daily (KDIGO 2021 Guidelines).

A 30-year-old female on atorvastatin discovers she is 6 weeks pregnant. What is the BEST action?
A) Continue atorvastatin
B) Switch to pravastatin
C) Discontinue statin
D) Reduce dose by 50%

Solution: C) Discontinue statin
Rationale: Statins are contraindicated in pregnancy (FDA Category X). Discontinue immediately and consider alternative lipid management (ACOG Practice Bulletin 2022).

A patient on rosuvastatin develops jaundice and fatigue after 3 months. Which lab test is MOST critical?
A) CPK
B) ALT/AST
C) Serum creatinine
D) TSH

Solution: B) ALT/AST
Rationale: Statins may cause hepatotoxicity (rare). Check LFTs for symptoms like jaundice, though routine monitoring is no longer recommended (ACC/AHA 2018 Update).

A 55-year-old Asian patient requires statin therapy. Which statin should be initiated at half the usual starting dose?
A) Lovastatin
B) Rosuvastatin
C) Pravastatin
D) Fluvastatin

Solution: B) Rosuvastatin
Rationale: Asian patients have ~2x higher rosuvastatin exposure. Start at 5 mg instead of 10 mg (FDA Crestor Labeling).

Which combination is CONTRAINDICATED due to myopathy risk?
A) Atorvastatin + ezetimibe
B) Simvastatin + gemfibrozil
C) Rosuvastatin + alirocumab
D) Pravastatin + fenofibrate

Solution: B) Simvastatin + gemfibrozil
Rationale: Gemfibrozil increases statin plasma levels. Maximum simvastatin dose = 10 mg if combined (ACC Lipid Guidelines 2023).

Which statin MUST be taken with the evening meal for optimal efficacy?
A) Atorvastatin
B) Lovastatin IR
C) Rosuvastatin
D) Pitavastatin

Solution: B) Lovastatin IR
Rationale: Lovastatin immediate-release absorption increases ~50% with food. Other statins can be taken anytime (except fluvastatin IR at bedtime) (Lexicomp 2023).

A patient on simvastatin 20 mg develops myalgia (CPK = 350 U/L). What is the NEXT step?
A) Switch to atorvastatin 80 mg
B) Discontinue statin permanently
C) Hold statin, recheck CPK in 1 week
D) Add coenzyme Q10

Solution: C) Hold statin, recheck CPK in 1 week
Rationale: For myalgia with CPK <10x ULN, hold statin and re-evaluate. May rechallenge after symptoms resolve (NLA Muscle Safety 2022).

A patient asks how ezetimibe works to lower cholesterol. Which response is correct?
A) "It inhibits HMG-CoA reductase in the liver."
B) "It blocks cholesterol absorption in the small intestine."
C) "It increases bile acid excretion in feces."
D) "It activates LDL receptors in peripheral tissues."

Solution: B) "It blocks cholesterol absorption in the small intestine."
Rationale: Ezetimibe inhibits NPC1L1 transporter in the jejunum, reducing dietary and biliary cholesterol absorption (FDA Labeling).

In which patient is ezetimibe monotherapy MOST appropriate?
A) A 45-year-old with LDL 190 mg/dL and no ASCVD
B) A 60-year-old with statin intolerance and LDL 110 mg/dL
C) A 70-year-old post-MI with LDL 70 mg/dL on high-intensity statin
D) A 50-year-old with TG 500 mg/dL and HDL 30 mg/dL

Solution: B) A 60-year-old with statin intolerance and LDL 110 mg/dL
Rationale: Ezetimibe monotherapy is reserved for statin-intolerant patients or those needing additional LDL lowering (~18% reduction) (ACC/AHA Guideline 2018).

A patient on atorvastatin 40 mg has LDL 85 mg/dL (goal <70 mg/dL for ASCVD). Which add-on therapy is preferred?
A) Fenofibrate
B) Ezetimibe
C) Niacin
D) Gemfibrozil

Solution: B) Ezetimibe
Rationale: Ezetimibe is first-line adjunct to statins for additional LDL reduction (IMPROVE-IT Trial). Fibrates/niacin target TG/HDL, not LDL.

Which patient should avoid ezetimibe?
A) A 65-year-old with moderate hepatic impairment
B) A 40-year-old with statin-induced myalgia
C) A 30-year-old with celiac disease
D) A 55-year-old on cyclosporine post-transplant

Solution: D) A 55-year-old on cyclosporine post-transplant
Rationale: Ezetimibe + cyclosporine increases ezetimibe levels 12-fold (contraindicated per FDA). Hepatic impairment requires no dose adjustment.

For which pediatric population is ezetimibe FDA-approved?
A) Children ≥10 years with familial hypercholesterolemia (FH)
B) Infants with homozygous FH
C) Adolescents with type 2 diabetes
D) Neonates with biliary atresia

Solution: A) Children ≥10 years with familial hypercholesterolemia (FH)
Rationale: Ezetimibe is approved for heterozygous FH in children ≥10 years as adjunct to diet/statin (FDA Labeling).

A patient starts ezetimibe + simvastatin. Which lab test is MOST important to monitor?
A) CPK
B) Serum creatinine
C) Fasting glucose
D) INR

Solution: A) CPK
Rationale: Ezetimibe + statins may increase myopathy risk (though lower than with fibrates). Monitor CPK for muscle symptoms (NLA Recommendations 2022).

Which lipid parameter is LEAST affected by ezetimibe?
A) LDL-C
B) Non-HDL-C
C) Triglycerides
D) Apolipoprotein B

Solution: C) Triglycerides
Rationale: Ezetimibe lowers LDL (~18%) and non-HDL-C but has minimal effect on TG (~5% reduction) (JACC Lipid Guidelines 2023).

According to value-based guidelines, when should ezetimibe be considered before PCSK9 inhibitors?
A) For all patients with ASCVD
B) Only if LDL remains ≥70 mg/dL on maximum-tolerated statin
C) As first-line therapy for diabetes
D) For isolated hypertriglyceridemia

Solution: B) Only if LDL remains ≥70 mg/dL on maximum-tolerated statin
Rationale: Ezetimibe is cost-effective as step 2 therapy after statins, before PCSK9 inhibitors (ACC Value Statement 2021).

How do PCSK9 monoclonal antibodies lower LDL cholesterol?
A) By inhibiting cholesterol absorption in the gut
B) By preventing degradation of LDL receptors in the liver
C) By increasing bile acid excretion
D) By blocking HMG-CoA reductase

Solution: B) By preventing degradation of LDL receptors in the liver
Rationale: PCSK9 inhibitors bind to PCSK9, preventing it from degrading LDL receptors, thereby increasing LDL clearance from circulation (NEJM 2015).

Which patient is the BEST candidate for a PCSK9 inhibitor?
A) A 50-year-old with LDL 160 mg/dL and no ASCVD
B) A 65-year-old with ASCVD and LDL 85 mg/dL on high-intensity statin
C) A 45-year-old with heterozygous FH and LDL 220 mg/dL despite max-tolerated statin + ezetimibe
D) A 70-year-old with TG 500 mg/dL and HDL 30 mg/dL

Solution: C) A 45-year-old with heterozygous FH and LDL 220 mg/dL despite max-tolerated statin + ezetimibe
Rationale: PCSK9 inhibitors are indicated for ASCVD or FH patients needing additional LDL lowering despite maximally tolerated statin/ezetimibe (ACC/AHA Guideline 2018).

A patient is prescribed alirocumab 150 mg SC every 2 weeks. Which administration instruction is correct?
A) Inject into the deltoid after warming to body temperature
B) Administer as a single 150 mg injection in the abdomen
C) Divide into two 75 mg injections at separate sites
D) Must be given IV over 30 minutes

Solution: B) Administer as a single 150 mg injection in the abdomen
Rationale: Alirocumab 150 mg is given as one injection (abdomen, thigh, or upper arm). The 300 mg monthly dose requires two 150 mg injections (FDA Labeling).

A patient prefers monthly dosing for evolocumab. Which regimen is appropriate?
A) 140 mg SC once monthly
B) 420 mg as three separate 140 mg injections
C) 420 mg as a single injection
D) 140 mg IV monthly

Solution: C) 420 mg as a single injection
Rationale: Evolocumab monthly dosing is 420 mg as one injection (prefilled syringe or Pushtronex autoinjector). The 3-injection option is outdated (FDA Labeling 2023).

A patient leaves evolocumab at room temperature for 35 days. What should they do?
A) Continue using it
B) Discard and obtain a new pen
C) Refrigerate immediately
D) Freeze for future use

Solution: B) Discard and obtain a new pen
Rationale: PCSK9 inhibitors are stable at room temperature for ≤30 days. Beyond this, discard due to stability concerns (FDA Labeling).

A patient reports redness and itching at the evolocumab injection site. What is the BEST advice?
A) Discontinue permanently
B) Apply ice and rotate injection sites
C) Switch to oral statin therapy
D) Administer IV instead

Solution: B) Apply ice and rotate injection sites
Rationale: Injection site reactions (redness, itching) are common but mild. Rotate sites (abdomen, thigh, arm) and use cold compresses (NLA Recommendations 2022).

When should LDL be checked after initiating alirocumab?
A) Immediately after the first dose
B) At 4-8 weeks
C) Every 6 months
D) Only if symptoms occur

Solution: B) At 4-8 weeks
Rationale: Check LDL at 4-8 weeks to assess response (expected ~60% reduction). Adjust therapy if goals are unmet (ACC Expert Consensus 2023).

Which lipid parameter is LEAST affected by PCSK9 inhibitors?
A) LDL-C
B) Non-HDL-C
C) Triglycerides
D) Apolipoprotein B

Solution: C) Triglycerides
Rationale: PCSK9 inhibitors lower LDL (~60%), non-HDL (~35%), and apoB (~50%) but have minimal effect on TG (~5-10% reduction) (FOURIER Trial 2017).

According to value-based guidelines, PCSK9 inhibitors should be used after:
A) Statin monotherapy
B) Statin + ezetimibe
C) Niacin therapy
D) Bile acid sequestrants

Solution: B) Statin + ezetimibe
Rationale: PCSK9 inhibitors are cost-effective only after maximally tolerated statin + ezetimibe in high-risk patients (ACC Value Statement 2021).

How do bile acid sequestrants primarily lower LDL cholesterol?
A) By inhibiting cholesterol synthesis in the liver
B) By blocking intestinal bile acid reabsorption
C) By increasing LDL receptor expression
D) By promoting biliary cholesterol excretion

Solution: B) By blocking intestinal bile acid reabsorption
Rationale: These drugs bind bile acids in the intestine, interrupting enterohepatic circulation and forcing the liver to use cholesterol to synthesize new bile acids (ACC/AHA Guideline 2018).

Which patient should avoid colesevelam?
A) A 60-year-old with LDL 190 mg/dL and TG 600 mg/dL
B) A 45-year-old with type 2 diabetes (A1C 7.5%)
C) A 70-year-old with ASCVD on statin therapy
D) A 50-year-old with heterozygous FH

Solution: A) A 60-year-old with LDL 190 mg/dL and TG 600 mg/dL
Rationale: Bile acid sequestrants are contraindicated when TG >500 mg/dL due to risk of worsening hypertriglyceridemia (FDA Labeling).

A patient takes levothyroxine 100 mcg daily and cholestyramine 4 g BID. What is the BEST administration advice?
A) Take both medications together with breakfast
B) Space cholestyramine ≥4 hours after levothyroxine
C) Crush and mix both medications in applesauce
D) Switch to colesevelam to avoid interactions

Solution: B) Space cholestyramine ≥4 hours after levothyroxine
Rationale: Bile acid sequestrants bind to levothyroxine (and warfarin, digoxin). Administer other drugs 1 hour before or 4-6 hours after (Lexicomp 2023).

How should a patient prepare colesevelam granules?
A) Mix with 2 oz of carbonated beverage
B) Sprinkle dry granules on applesauce
C) Stir into 8 oz of water or juice
D) Take tablets whole with milk

Solution: C) Stir into 8 oz of water or juice
Rationale: Colesevelam packets must be mixed with 8 oz liquid. Avoid carbonated drinks (can cause clumping) (FDA Labeling).

A patient reports severe constipation on cholestyramine 8 g/day. What is the BEST initial action?
A) Discontinue permanently
B) Add docusate sodium
C) Switch to colestipol
D) Reduce dose to 4 g/day

Solution: D) Reduce dose to 4 g/day
Rationale: Constipation is dose-dependent. First-line is dose reduction ± psyllium. Colestipol has similar GI effects (NLA Recommendations 2022).

Which bile acid sequestrant is safest in pregnancy?
A) Cholestyramine
B) Colestipol
C) Colesevelam
D) All are equally safe

Solution: C) Colesevelam
Rationale: Colesevelam is preferred in pregnancy (minimal systemic absorption). Monitor vitamin K status (ACOG Practice Bulletin 2022).

Which lab test is MOST important for a patient starting cholestyramine long-term?
A) Serum calcium
B) INR
C) CPK
D) ALT/AST

Solution: B) INR
Rationale: Bile acid sequestrants can cause vitamin K deficiency, increasing bleeding risk. Monitor INR in patients on warfarin (ACC Expert Consensus 2023).

Which lipid change is LEAST likely with bile acid sequestrants?
A) LDL reduction (15-30%)
B) HDL increase (3-5%)
C) Triglyceride reduction (20-30%)
D) Non-HDL reduction (10-20%)

Solution: C) Triglyceride reduction (20-30%)
Rationale: These drugs may increase TG by 5-20%. Avoid in hypertriglyceridemia (JACC Lipid Guidelines 2023).

Which bile acid sequestrant has an FDA-approved indication for type 2 diabetes?
A) Cholestyramine
B) Colestipol
C) Colesevelam
D) All of the above

Solution: C) Colesevelam
Rationale: Colesevelam lowers A1C by ~0.5% via unclear mechanisms (possibly GLP-1 effects) (ADA Standards 2023).

How do fibrates primarily lower triglyceride levels?
A) By inhibiting VLDL synthesis in the liver
B) By increasing lipoprotein lipase activity via apoC-II
C) By blocking intestinal cholesterol absorption
D) By promoting bile acid excretion

Solution: B) By increasing lipoprotein lipase activity via apoC-II
Rationale: Fibrates activate PPARα → ↑ apoC-II → enhances lipoprotein lipase → breaks down VLDL/TG (ACC Lipid Guidelines 2023).

Which patient should NOT receive gemfibrozil?
A) A 55-year-old with TG 600 mg/dL on simvastatin
B) A 60-year-old with CrCl 25 mL/min and TG 400 mg/dL
C) A 45-year-old with primary biliary cirrhosis
D) A 50-year-old with diabetes and HDL 30 mg/dL

Solution: C) A 45-year-old with primary biliary cirrhosis
Rationale: Fibrates are contraindicated in severe liver disease (including PBC) and severe renal impairment (CrCl <30 for fenofibrate) (FDA Labeling).

Which combination is absolutely contraindicated?
A) Fenofibrate + atorvastatin
B) Gemfibrozil + repaglinide
C) Fenofibrate + ezetimibe
D) Gemfibrozil + rosuvastatin

Solution: B) Gemfibrozil + repaglinide
Rationale: Gemfibrozil inhibits CYP2C8 → ↑ repaglinide levels (risk of severe hypoglycemia). Fenofibrate is safer with statins/antidiabetics (Clin Pharmacol Ther 2022).

A 70-year-old (CrCl 45 mL/min) needs fenofibrate for TG 500 mg/dL. Which action is correct?
A) Use standard dose (145 mg daily)
B) Reduce dose by 50%
C) Switch to gemfibrozil
D) Avoid all fibrates

Solution: B) Reduce dose by 50%
Rationale: Fenofibrate requires dose reduction when CrCl 31-80 mL/min. Gemfibrozil doesn’t require adjustment but has higher myopathy risk (KDIGO 2021).

A patient on fenofibrate + rosuvastatin develops muscle pain. Which lab is MOST critical?
A) ALT/AST
B) CPK
C) Serum creatinine
D) TSH

Solution: B) CPK
Rationale: Fibrate + statin increases myopathy risk. Check CPK if symptoms occur (NLA Muscle Safety Recommendations 2022).

How should gemfibrozil be administered?
A) With the evening meal
B) 30 minutes before breakfast and dinner
C) At bedtime with a snack
D) On an empty stomach

Solution: B) 30 minutes before breakfast and dinner
Rationale: Gemfibrozil must be taken 30 min before meals for optimal absorption (FDA Labeling). Fenofibrate is taken with food.

A patient with TG 800 mg/dL starts fenofibrate. Which lipid change is MOST likely?
A) LDL decreases by 30%
B) HDL decreases by 10%
C) TG decreases by 45%
D) Non-HDL increases by 20%

Solution: C) TG decreases by 45%
Rationale: Fibrates lower TG by 20-50% and may increase HDL by 10-15%. LDL may rise if baseline TG is very high (JACC Lipid Guidelines 2023).

Which fibrate is preferred in a patient with CrCl 25 mL/min?
A) Fenofibrate (micronized)
B) Gemfibrozil
C) Fenofibric acid
D) Neither should be used

Solution: B) Gemfibrozil
Rationale: Gemfibrozil doesn’t require renal dosing (unlike fenofibrate). Monitor for myopathy (KDIGO 2021).

Which drug combination is absolutely contraindicated due to severe myopathy risk?
A) Fenofibrate + atorvastatin
B) Gemfibrozil + simvastatin
C) Fenofibric acid + rosuvastatin
D) Gemfibrozil + colchicine

Solution: B) Gemfibrozil + simvastatin
Rationale: Gemfibrozil inhibits CYP3A4 and UGT1A1 → ↑ simvastatin levels (3-5x). Absolute contraindication due to extreme rhabdomyolysis risk (FDA Labeling 2023).

A patient on repaglinide 2 mg TID is prescribed gemfibrozil. What is the MOST appropriate action?
A) Continue both medications
B) Discontinue repaglinide
C) Switch to fenofibrate
D) Reduce repaglinide dose by 75%

Solution: C) Switch to fenofibrate
Rationale: Gemfibrozil inhibits CYP2C8 → ↑ repaglinide AUC by 8-fold (severe hypoglycemia risk). Fenofibrate is safer (Diabetes Care 2022).

A 68-year-old on fenofibrate and colchicine for gout develops thigh pain. Which lab is MOST urgent?
A) ALT/AST
B) CPK
C) Serum creatinine
D) INR

Solution: B) CPK
Rationale: Fibrate + colchicine increases myopathy risk. Check CPK immediately (if >10x ULN, discontinue both) (ACR Guidelines 2023).

A patient stabilized on warfarin (INR 2.3) starts fenofibrate. What monitoring is required?
A) No additional monitoring
B) INR weekly for 1 month
C) Daily fingerstick glucose
D) Serum magnesium

Solution: B) INR weekly for 1 month
Rationale: Fibrates displace warfarin from albumin → ↑ free warfarin levels. Monitor INR closely (may need 10-30% warfarin dose reduction) (CHEST Guidelines 2021).

A patient with TG 600 mg/dL needs lipid therapy but takes simvastatin 40 mg. Which is the safest fibrate option?
A) Gemfibrozil 600 mg BID
B) Fenofibrate 145 mg daily
C) Fenofibric acid 105 mg daily
D) Colesevelam 3.75 g daily

Solution: B) Fenofibrate 145 mg daily
Rationale: Fenofibrate has lower myopathy risk with statins vs. gemfibrozil. Max simvastatin dose = 20 mg if combined (ACC Lipid Guidelines 2023).

A patient on glipizide 10 mg daily starts gemfibrozil. Which symptom warrants immediate attention?
A) Constipation
B) Dizziness and diaphoresis
C) Muscle cramps
D) Headache

Solution: B) Dizziness and diaphoresis
Rationale: Gemfibrozil ↑ sulfonylurea effects → hypoglycemia. Fenofibrate is preferred (ADA Standards 2023).

Why is gemfibrozil contraindicated with ezetimibe?
A) ↑ Risk of cholelithiasis
B) Severe hypertriglyceridemia
C) 10-fold increase in ezetimibe levels
D) Hepatotoxicity

Solution: C) 10-fold increase in ezetimibe levels
Rationale: Gemfibrozil inhibits ezetimibe glucuronidation → ↑ ezetimibe AUC by 1200%. Fenofibrate is safe (Clin Pharmacol Ther 2022).

How does niacin primarily increase HDL cholesterol levels?
A) By inhibiting CETP activity
B) By blocking HDL uptake in the liver via scavenger receptor B-1
C) By stimulating apoA-I synthesis in the intestines
D) By increasing LDL receptor expression

Solution: B) By blocking HDL uptake in the liver via scavenger receptor B-1
Rationale: Niacin prevents hepatic uptake of HDL particles while allowing cholesterol removal ("HDL recycling"), enhancing reverse cholesterol transport (JACC 2023).

Which lipid profile change is LEAST likely with niacin therapy?
A) LDL reduction by 15-25%
B) HDL increase by 20-35%
C) Triglyceride reduction by 20-50%
D) Lipoprotein(a) increase by 10-20%

Solution: D) Lipoprotein(a) increase by 10-20%
Rationale: Niacin lowers Lp(a) by ~20%. The other changes are expected (LDL↓, HDL↑, TG↓) (AHA Scientific Statement 2022).

A patient reports taking "vitamin B3" 50 mg daily for cholesterol management. What counseling is needed?
A) "This is adequate for lipid control."
B) "Therapeutic doses start at 500 mg daily."
C) "Switch to immediate-release niacin for better absorption."
D) "Add a statin to enhance effects."

Solution: B) "Therapeutic doses start at 500 mg daily."
Rationale: Lipid-lowering niacin doses (1-3 g/day) far exceed multivitamin B3 doses (20-50 mg). Immediate-release requires titration to minimize flushing (ACC Lipid Guidelines 2023).

A patient experiences severe flushing with extended-release niacin. Which strategy is MOST effective for prevention?
A) Take on an empty stomach
B) Pretreat with ibuprofen 30 minutes before dosing
C) Avoid all fatty foods
D) Switch to gemfibrozil

Solution: B) Pretreat with ibuprofen 30 minutes before dosing
Rationale: Flushing (prostaglandin-mediated) is reduced by aspirin/NSAIDs 30 min before dosing. Taking with food and avoiding alcohol/hot drinks also helps (NLA Recommendations 2022).

Which patient should avoid niacin therapy?
A) A 60-year-old with chronic gout
B) A 45-year-old with diabetes and HDL 30 mg/dL
C) A 50-year-old with LDL 190 mg/dL
D) A 55-year-old with hypertension

Solution: A) A 60-year-old with chronic gout
Rationale: Niacin increases uric acid (contraindicated in active gout) and may worsen hyperglycemia in diabetes (FDA Labeling).

Which lab test is MOST critical for a patient starting high-dose niacin?
A) CPK
B) Fasting glucose
C) Serum calcium
D) INR

Solution: B) Fasting glucose
Rationale: Niacin can increase blood glucose by 5-10%. Monitor HbA1c in diabetics (ADA Standards 2023).

According to current guidelines, niacin is MOST appropriate for which patient?
A) A patient with ASCVD on max statin + ezetimibe with HDL 35 mg/dL
B) A patient with TG 200 mg/dL and no other risk factors
C) A patient with LDL 70 mg/dL on high-intensity statin
D) A patient with familial hypercholesterolemia

Solution: A) A patient with ASCVD on max statin + ezetimibe with HDL 35 mg/dL
Rationale: Niacin may be considered for residual risk in ASCVD patients with low HDL despite optimal therapy, though evidence is limited (ACC Pathway 2023).

A patient experiences severe flushing with immediate-release (IR) niacin. Which alternative formulation is preferred to minimize this side effect?
A) Niacinamide
B) Extended-release (ER) niacin
C) Flush-free niacin (inositol hexaniacinate)
D) Sustained-release (SR) niacin

Solution: B) Extended-release (ER) niacin
Rationale: ER niacin causes less flushing than IR but carries higher hepatotoxicity risk if crushed/chewed. Flush-free formulations are ineffective for lipid management (ACC Lipid Guidelines 2023).

Which patient should absolutely avoid niacin therapy?
A) A 50-year-old with LDL 190 mg/dL and peptic ulcer disease
B) A 60-year-old with diabetes and HDL 30 mg/dL
C) A 45-year-old with gout and TG 300 mg/dL
D) A 55-year-old with hypertension

Solution: A) A 50-year-old with LDL 190 mg/dL and peptic ulcer disease
Rationale: Niacin is contraindicated in active peptic ulcer disease due to bleeding risk. Gout and diabetes require caution but aren't absolute contraindications (FDA Labeling).

A patient starting ER niacin 500 mg at bedtime reports intolerable flushing. What is the BEST recommendation?
A) Take with grapefruit juice
B) Pretreat with aspirin 325 mg 30 minutes before dosing
C) Switch to IR niacin
D) Discontinue permanently

Solution: B) Pretreat with aspirin 325 mg 30 minutes before dosing
Rationale: Aspirin/NSAIDs block prostaglandin-mediated flushing. Avoid alcohol/hot drinks which exacerbate flushing (NLA Recommendations 2022).

A patient on simvastatin 40 mg starts niacin ER 1 g/day. Which monitoring is MOST critical?
A) INR
B) CPK
C) Serum phosphate
D) Urinalysis

Solution: B) CPK
Rationale: Niacin + statins increase myopathy risk (especially with niacin ≥1 g/day). Monitor for muscle pain/weakness (ACC Expert Consensus 2023).

A patient on niacin develops new-onset diabetes. Which lab change is MOST likely?
A) Fasting glucose 130 mg/dL
B) Uric acid 3.2 mg/dL
C) Phosphorus 1.8 mg/dL
D) Platelets 450,000/mm³

Solution: A) Fasting glucose 130 mg/dL
Rationale: Niacin increases insulin resistance (fasting glucose ↑ by 5-10%). Monitor HbA1c in diabetics (ADA Standards 2023).