Rob Final

Adam, a 72-year-old man, has been admitted to the hospital due to HF decomposition. He reports progressively increased dyspnea when walking, increased bilateral lower extremity swelling (3=), a 13-kg weight gain in the past 3 weeks, and dietary non-adherence. Adam has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), and hyperlipidemia. Despite these condition, the patient seems to be well perfused and stable. Pertinent laboratory values include BNP 23000 pg/ml (0-50 pg/ml), K+ 4.9 mEq/K, BUN 32 mg/dl, Scr 2 mg/dl, blood pressure 108/62 mmHg, and heart rate 82 beats/min. Current medications on admission include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day. After receiving an initial infusion of Furosemide 80 mg IV once, Adam became lethargic with altered mental status, and her blood pressure dropped to 80/76, with PCWP of 13 mmHg. What is the best approach for managing Adam’s condition?

A. Initiate Nitroglycerin 0.5 mcg/kg/min

B. Initiate Nestiride 2 mcg/kg bolus; then 0.01 mcg/kg/min

C. Initiate Furosemide 120 mg intravenously twice daily

D. Initiate 1 L of IV 0.9% NaCl

D. Initiate 1 L of IV 0.9% NaCl

In an ICU setting, a 52-year-old woman is admitted with dilated nonischemic cardiomyopathy, heart failure, and biventricular dysfunction (LVEF 25%) and moderate mitral regurgitation. She complains of progressive fatigue. Her heart rate is 95, and her BP is 185/100 (MAP=128). Her baseline creatinine has risen from 0.9 to 2.1. During evaluation, her pulmonary capillary wedge pressure is 19, cardiac Index 1.4, and systemic vascular resistance is 3025 dynes/second/cm (800-1200 dynes/second/cm5). Her home medication includes Rampril 5 mg PO daily, Carvedilol 3.125 mg PO BID, Spironolactone 200 mg PO daily, and Furosemide 80 mg PO daily. What is the appropriate step to take in this situation?

A. Continue furosemide, then initiate IV nesiritde

B. Discontinue furosemide only, then initiate IV milrinone

C. Discontinue carvedilol and furosemide only, then initiate IV dobutamine

D. Continue furosemide, then initiate IV nitroprusside

E. Switch to fursemide 80 mgIV BID and then increase the dose of

A. Continue furosemide, then initiate IV nesiritde

CS is a 55-year-old man with a history of dyslipidemia and ischemic heart disease who had a myocardial infarction 3 months ago. His EF is 40%. His current medications are aspirin 81 mg PO once daily, metoprolol XL 100 mg PO daily, atorvastatin 40 mg PO at daily, and sublingual nitroglycerin as needed. He continues to experience occasional symptoms of angina at rest and has increased taking sublingual Nitro up to 5 or 6 times a week. His blood pressure is 155/95 mm Hg, and his pulse is 110 beats/min.

What is the most appropriate pharmacologic intervention?

A. Add amiodarone

B. Add diltiazem

C. Switch metoprolol to carvedilol

D. Add isosorbide mononitrate

E. Add IV Nitroglycerin Infusion

B. Add diltiazem

A 53 year old Asian American male is admitted to the ER. Upon the patient’s admission into the hospital on day 2 his EKG shows Atrial Fibrillation.

Which of the medication’s below could be used to manage his Atrial Fib, with the least proarrthymic affect on this patient’s unstable heart condition with a QT interval of 450.

A. Procainamide

B. Flecainide

C. Quinidine

D. Lopressor

E. Norvasc

D. Lopressor

In the ER, A 46 year old Hispanic male, DT continues to experience chest pain on exertion while he has been working this week and SOB. The following results are obtained: Fasting lipid profile: total cholesterol 216 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c- 8.5, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, BP= 165/98, HR= 84 Troponin 2.3 and CK MB are positive. EKG= ST-segment depression

A. NSTEMI

B. STEMI

C. Stable Angina

D. Unstable Angina

E. Variant Angina

A. NSTEMI

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct= 40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CK MB negative EKG= ST-segment elevation

Which antianginal medication below would be recommended to manage reducing DT's chest pain and ischemic angina based on his history diagnosis of hypertension and other labs obtained thus far?

A. Cardizem

B. Clonidine

C. HCTZ

D. Ranexa

E. Nifedipine Extended Release

E. Nifedipine Extended Release

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CK MB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages. During the procedure, he is placed on several IV antiplatelet agents to prevent clotting. He is kept in the hospital for a few days after his procedure. On day 5 his platelet count is 120, Hb= 13, HCT= 39, RBC= 4.8.

What abnormality may DT be experiencing to cause his platelets to decline?

A. Hemolytic Anemia

B. Aplastic Anemia

C. Thrombocytopenia

D. Neutropenia

E. Vitamin K deficiency

C. Thrombocytopenia

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct= 40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CK MB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages. During the procedure, he is placed on an IV antiplatelet agent to prevent clotting. He is evaluated for oral anticoagulation therapy.

Which of the agents listed below inhibit the Vitamin K epoxide reductase thus inhibiting Vitamin K clot formation?

A. Aspirin

B. Enoxaparin

C. Brillanta

D. Coumadin

E. Arixtra

D. Coumadin

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CK MB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages.

Which of the following antihyperlipidemic agents helps to prevent coronary artery disease through the prevention of bile acid reabsorption from the GI tract? (Select all that apply)

A. Crestor

B. Cholestyramine

C. Zetia

D. Colestipol

E. Simvastatin

F. Tricor

B. Cholestyramine

D. Colestipol

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CK MB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages. After a success procedure DT is evaluated for Lipid management using Niacin therapy. Which of DT's new diagnosed disease states may be aggravated by Niacin treatment?

A. Hypertension

B. Diabetes

C. Low HDL

D. Anemia

E. photosensitivity

B. Diabetes

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CKMB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages. During the procedure, he is placed on an IV antiplatelet agent to prevent clotting. Which of the agents listed below inhibit platelet aggregation through the inhibition of the G2b3a receptor complex. (Select all that apply)

A. Abciximab

B. Tirofiban

C. Eptifibatide

D. Ticagrelor

E. Bivalirudin

A. Abciximab

B. Tirofiban

C. Eptifibatide

To prevent the formation of DVT or Pulmonary Embolisms in a patient post cardioversion, which of the medications below should be started which has the shortest onset of action, is parenteral, and quickly reaches steady state anticoagulation for the patient’s protection?

A. Apixaban

B. Unfractionated Heparin

C. Altepase

D. Arixtra

E. Angiomax

B. Unfractionated Heparin

A 46-year-old woman complains of the abrupt onset of her chest pounding. She is diagnosed with Bigeminy PVCs. Which of the following Class I agent listed below is the most effective agent for converting Ventricular tachycardia to normal sinus rhythm?

A. Lidocaine

B. Digoxin

C. Amiodarone

D. Flecainide

E. Adenosine

A. Lidocaine

A 53 year old Asian American male is admitted to the ER from Psychiatric facility. He has a past medical history of Schizophrenia with Bipolar Manic Depression. His past medical history is also positive for Hypertension, Diabetes, and Sleep Apnea. Upon the patient’s admission into the hospital on day 2 his EKG shows Atrial Fibrillation with an atrial rate of 150 bpm. The pt has a normal ECHO cardiogram with an EF of 45%. The pts current medication list include DiovanHCT 80/12.5 daily, JanuvaMet 1000/25 daily,Adderall 10 mg Daily, Seroquel 400 mg BID, Haldol 1-2 mg po q6h as needed. Which of the medication’s below could be used for initial management of his Atrial Fib, with the least proarrthymic affect on this patient’s unstable heart condition with a QTc interval of 450. (Select All That Apply)

A. Amiodarone 150 mg Bolus followed by 1 mg/minute continuous infusion

B. Diltiazem 25 mg Bolus followed by 5-10 mg/hr continuous infusion

C. Digoxin 500 mcg bolus followed by 0.125 mg po daily to a level of 1-2

D. Esmolol 100 mcg/kg/min continuous infusion followed by Lopressor 50 mg PO BID

E. Ibutilide 1 mg IV over 10 minutes repeated times 1 more dose if needed

B. Diltiazem 25 mg Bolus followed by 5-10 mg/hr continuous infusion

D. Esmolol 100 mcg/kg/min continuous infusion followed by Lopressor 50 mg PO BID

In the ER, A 46 year old Hispanic male, DT continues to experience chest pain on exertion while he has been working this week and SOB. The following results are obtained: Fasting lipid profile: total cholesterol 216 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c- 8.5, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, BP= 165/98, HR= 84 Troponin and CK MB are negative. EKG= ST-segment elevation

Classify this pts cardiac condition

A. NSTEMI

B. STEMI

C. ACS

D. Stable Angina

E. Unstable Angina

F. Variant Angina

D. Stable Angina

John is a , 61 year old white male pt, who was awaken by substernal chest pain this morning and continues to experience chest pain as his wife is taking him to his Drs office. He was previously released from the Rehab hospital 2 weeks ago after recovering from a Stroke 4 weeks ago. His BP is 195/110 on arrival and his HR is 110 bpm. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL=160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct= 40, PLTs= 320 Wt. 100 KG He is given SL Nitro 0.4 mg x 3 doses, 650 mg of Chewable Aspirin, Morphine 2 mg iv q 15 minutes as needed for chest pain, and Hi-Flow Nasal Canula O2 at 5 liters/minute. Exercise treadmill test and 12 Lead EKG: Positive for ischemic angina, Troponin and CK MB are obtained. EKG= ST-segment elevation. Which medications below would be recommended prior to PCI to continue management of John's chest pain and ischemic angina based on his history diagnosis of hypertension, Diabetes, CAD and other labs obtained thus far? (Select all that Apply)

A. T-PA 100 mg by continuous infusion over 1.5 hrs

B. Heparin 8000 unit Bolus & 1800 unit/hr infusion

C. IV Nitroglycerin

D. Metoprolol 5 mg IV up to 15 mg followed by 50 mg po BID

E. Tenectaplase

B. Heparin 8000 unit Bolus & 1800 unit/hr infusion

C. IV Nitroglycerin

D. Metoprolol 5 mg IV up to 15 mg followed by 50 mg po BID

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CKMB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for any blockages. After the procedure, he is placed on an antiplatelet regimen for 6 months. Which of the agents listed below inhibit platelet aggregation through the inhibition of P2Y12 receptor antagonists?

A. Eliquis

B. Abciximab

C. Brillanta

D. KCentra

E. Dabigatran

C. Brillanta

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CKMB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages. After the procedure, he is placed on an oral anticoagulant agent to prevent future clotting events in the coronary arteries. Which of the agents listed below inhibit platelet aggregation through the Direct inhibition of Factor II?

A. Rivaroxaban

B. Apixaban

C. Arixtra

D. Cangrelor

E. Bivalirudin

E. Bivalirudin

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CKMB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages. During the procedure, he is not noted to have any clot formation. Which of the agents listed below have the ability to convert plasminogen to plasmin thus treating pts with STEMI or Acute MI in which clots form in the coronary arteries?

A. Argatroban

B. Bivalirudin

C. Dabigatran

D. Tenectaplase

E. fondaparinux

D. Tenectaplase

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CKMB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages. During the procedure, he is placed on an IV continuous infusion of unfractionated Heparin. Which of the agents listed below can bind to and reverse the effects of Unfractionated Heparin?

A. Warfarin

B. Vitamin K

C. Protamine

D. Packed red blood cells

E. Praxbind

C. Protamine

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CKMB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages. During the procedure, he is placed on IV Heparin, Eptifibatide, Plavix, and Aspirin. He is kept in the hospital for a few days after his procedure. On day 5 his platelet count is 90, Hb= 12, HCT= 36, RBC= 4.8. What significant drug-lab abnormality may DT be experiencing due to the drug complications associated with his PCI?

A. Hemolytic Anemia

B. Aplastic Anemia

C. Thrombocytopenia

D. Neutropenia

E. Vitamin K deficiency

C. Thrombocytopenia

In the ER, a Hispanic, 39 year old male pt, DT continues to experience chest pain on exertion and with an increased heart rate. The following results are obtained: Fasting lipid profile: total cholesterol 246 mg/dL, HDL 27 mg/dL, LDL= 160, triglycerides 150 mg/dL fasting glucose 198 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct=40, PLTs= 320 Exercise treadmill test: Positive for ischemic angina, HR= 80, BP= 165/99, Troponin negative, CKMB negative EKG= ST-segment elevation DT is evaluated in the Heart Cath Lab for a PCI to determine any blockages. During the procedure, he is placed on an IV antiplatelet agent to prevent clotting. Which of the agents listed below inhibit platelet aggregation through the inhibition of the G2b3a receptor complex?

A. Angiomax

B. Tirofiban

C. Argatroban

D. Ticagrelor

E. Bivalirudin

B. Tirofiban

A 47-year-old patient (weight 78 kg) with a history of stable ischemic heart disease (SIHD) presents with substernal chest pressure. His electrocardiogram (ECG) shows ST-segment depression. His initial troponin (cTn) is elevated. The patient undergoes percutaneous coronary intervention (PCI) with two drug-eluting stents. According to practice guidelines, in addition to aspirin 81 mg daily, which P2Y12 inhibitor regimen is most appropriate for this patient at discharge?

A. Clopidogrel 75 mg daily for 6 months

B. Prasugrel 10 mg daily for 1 year

C. Ticagrelor 60 mg twice daily for 1 year

D. Ticagrelor 90 mg twice daily for 6 months

B. Prasugrel 10 mg daily for 1 year

A 72-year-old African American patient presents with chest pain after a

recent drug-eluting stent placement 3 months ago and is treated for ST-

segment elevation myocardial infarction (STEMI) due to in-stent

thrombosis with successful PCI. The patient reports compliance with his

dual antiplatelet therapy, which consisted of clopidogrel 75 mg daily and

aspirin 81 mg daily. He also takes ranitidine for indigestion-related

symptoms. Which of the following best describes a rationale for

clopidogrel’s reduced activity in this patient?

A. Presence of CYP3A4 polymorphism

B. Presence of CYP2C19 polymorphism

C. Drug interaction with ranitidine

D. Improper clopidogrel dose

B. Presence of CYP2C19 polymorphism

A 55-year-old African American patient with hypertension (HTN) but no history of coronary artery disease presents to the ED for one episode of back pain accompanied by nausea and vomiting which resolved after one dose of sublingual nitroglycerin. Social history is unremarkable. Home medications include chlorthalidone 25 mg daily and amlodipine 5 mg daily. ECG shows some ST-segment depression. Laboratory values are within normal limits and her estimated creatinine clearance (CrCl) is 67 mL/min (1.12 mL/s). cTn is undetectable. Weight = 80 Kg. Based on the patient’s Thrombolysis in Myocardial Infarction (TIMI) risk score, which is the most appropriate strategy for this patient?

A. Early invasive approach

B. Fibrinolytic therapy

C. Ischemia-guided approach

D. Primary PCI

C. Ischemia-guided approach

A patient with a past medical history significant for diabetes mellitus

(DM) is hospitalized for STEMI, has PCI performed, and is now being

prepared for discharge. Estimated CrCl is 50 mL/min (0.83 mL/s), and

LDL-C is 79 mg/dL (2.05 mmol/L). Pertinent laboratory data include

sodium 134 mEq/L (mmol/L), potassium 3.4 mEq/L (mmol/L), and

creatinine 1.5 mg/dL (133 μmol/L). Blood pressure is 115/80 mm Hg

and heart rate is 78 beats per minute. Current medications include

aspirin 81 mg daily, atorvastatin 80 mg daily, metoprolol succinate 50

mg daily, lisinopril 10 mg daily, and ticagrelor 90 mg twice daily.

Echocardiogram reveals a left ventricular ejection fraction (LVEF) of

25% (0.25). Which guideline-directed medical therapy would be best to

add to this patient’s regimen?

A. Alirocumab 75 mg SC every 2 weeks

B. Diltiazem extended-release 180 mg daily

C. Losartan 25 mg daily

D. Spironolactone 25 mg daily

D. Spironolactone 25 mg daily

A 57-year-old patient (weight 92 kg) with a history of SIHD presents with

a 4-hour history of substernal chest pressure. The ECG shows 3 mm

ST-segment elevation in leads V2–V4. The initial cTn is 5.2 ng/mL

(mcg/L), SCr 1.1 mg/dL (97 μmol/L), and potassium 3.7 mEq/L

(mmol/L). The nearest hospital with catheterization laboratory facilities is

2.5 hours away by ambulance. Blood pressure is 210/85 mm Hg at

present. Which of the following is the most appropriate reperfusion

strategy for this patient?

A. Blood pressure must be lowered before fibrinolytic therapy is

considered.

B. Primary PCI is preferred over fibrinolytic therapy in this patient.

C. Tenecteplase 50 mg IVP once.

D. Reteplase 10 units IVP once.

A. Blood pressure must be lowered before fibrinolytic therapy is

considered.

RJ is a 68-year-old patient (weight 100 kg) who presents to the hospital

with consistent substernal chest pain rated 8 out 10 for the last 4 hours

that radiates to his left arm and up into his jaw. Past medical history

includes DM, HTN, ischemic stroke, depression, and dyslipidemia. ECG

reveals ST-segment depression and the initial cTn is elevated. All other

laboratory values are within normal limits including renal and liver

function. Blood pressure is 124/74 mm Hg and heart rate is 78 beats per

minute. RJ has received 3 doses of sublingual nitroglycerin with minimal

relief. The plan is for RJ to go to the catheterization laboratory for PCI

and stent placement in the next 12 hours.

7. Which of the following represents the most likely pathophysiologic

mechanism of RJ’s ACS event?

A. Vasospasm

B. Ruptured atherosclerotic plaque

C. Increase in myocardial oxygen demand in the setting of a fixed

decrease in supply

D. Smooth muscle cell proliferation

B. Ruptured atherosclerotic plaque

RJ is a 68-year-old patient (weight 100 kg) who presents to the hospital with consistent substernal chest pain rated 8 out 10 for the last 4 hours that radiates to his left arm and up into his jaw. Past medical history includes DM, HTN, ischemic stroke, depression, and dyslipidemia. ECG reveals ST-segment depression and the initial cTn is elevated. All other laboratory values are within normal limits including renal and liver function. Blood pressure is 124/74 mm Hg and heart rate is 78 beats per minute. RJ has received 3 doses of sublingual nitroglycerin with minimal relief. The plan is for RJ to go to the catheterization laboratory for PCI and stent placement in the next 12 hours. Which of the following represents the most appropriate antiplatelet regimen, in addition to aspirin, for RJ while he is still in the ED before going to PCI?

A. Clopidogrel 300 mg, followed by 75 mg daily

B. Ticagrelor 180 mg, followed by 90 mg twice daily

C. Prasugrel 60 mg, followed by 10 mg daily

D. Eptifibatide 180 mcg/kg IV bolus × 2 given 10 minutes apart, followed by 2 mcg/kg/min IV infusion started after first bolus

B. Ticagrelor 180 mg, followed by 90 mg twice daily

Which of the following represents the most appropriate anticoagulant

regimen to initiate in the ED?

A. Unfractionated heparin 8,000 units IV bolus, then 1,800 units/hr IV

infusion

B. Fondaparinux 5 mg subcutaneously (SC) every 24 hours

C. Bivalirudin 0.10 mg/kg IV bolus, followed by 0.25 mg/kg/hr IV

infusion

D. Enoxaparin 100 mg SC every 12 hours

D. Enoxaparin 100 mg SC every 12 hours

Which of the following substances is central in the clotting cascade as

well as involved in platelet activation and aggregation?

A. Von Willebrand factor

B. Collagen

C. Thrombin

D. Tissue factor

C. Thrombin

A 72-year-old patient presents to the ED with chest tightness that started 8 hours ago. This is the third episode, is associated with diaphoresis and dyspnea, and is refractory to sublingual nitroglycerin. Blood pressure is 114/78 mm Hg, heart rate is 112 bpm, respiratory rate is 26 breaths/min, and oxygen saturation is 89% (0.89) on room air. ECG shows 2-mm ST-segment depression. Bilateral crackles are noted at the bases bilaterally on physical examination. Which of the following acute supportive measures should be avoided in this patient?

A. IV metoprolol

B. IV morphine

C. IV nitroglycerin

D. Oxygen

A. IV metoprolol

A 54-year-old patient presents to the ED complaining of acute-onset

chest pain radiating down his left arm, which started 2 hours ago. He

admits to cocaine ingestion just prior to the onset of symptoms. Blood

pressure is 220/108 mm Hg, heart rate is 108 bpm, and oxygen

saturation is 98% (0.98) on room air. ECG shows 1 mm ST-segment

depression. Laboratory values are pending. Which of the following acute

supporting measures is most appropriate at this time?

A. IV metoprolol

B. IV morphine

C. IV nitroglycerin

D. Oxygen

C. IV nitroglycerin

A patient treated for STEMI complicated by symptomatic heart failure

(LVEF 35% [0.35]) is being started on eplerenone. Baseline serum

creatinine and potassium were within normal limits. When should serum

creatinine and potassium levels be reassessed?

A. 3 days

B. 1 week

C. 2 weeks

D. 1 month

A. 3 days

A patient is treated for NSTEMI. An echocardiogram reveals an LVEF of

20% (0.20). The patient is hemodynamically stable and being

discharged on the following medications: aspirin 81 mg daily, prasugrel

10 mg daily, rosuvastatin 40 mg daily, carvedilol 3.125 mg twice daily,

ramipril 10 mg daily, and spironolactone 25 mg daily. What is the most

appropriate duration of carvedilol therapy for this patient?

A. 6 months

B. 1 year

C. 3 years

D. Indefinitely

D. Indefinitely

EP, a 66-year-old patient, complains of sudden onset tightness in his chest and jaw, shortness of breath, diaphoresis and headache that began 3 hours ago when shoveling snow on the patio. The patient has no known medical problems, takes no medications, and has no known drug allergies. Blood pressure is 194/98 mmHg, heart rate 98 bpm. Electrocardiogram reveals T wave inversion in 2 contiguous leads. Creatinine is 1.1 mg/dL (97 μmol/L; creatinine clearance 77 mL/min [1.28 mL/s]) and cardiac troponin is 4.6 ng/mL (mcg/L; normal <0.02 ng/mL [mcg/L]). Which of the following antithrombotic therapies should be avoided in this patient?

A. Alteplase

B. Aspirin

C. Enoxaparin

D. Ticagrelor

A. Alteplase

A patient presents to the emergency department (ED) with lower back pain, diaphoresis, and nausea and is treated for unstable angina with aspirin 325 mg and intravenous (IV) unfractionated heparin. Which option depicts the most appropriate monitoring of parameters during IV unfractionated heparin administration?

A. Activated partial thromboplastin time (aPTT) every 3 hours until therapeutic

B. aPTT every 6 hours until therapeutic

C. Activated clotting time (ACT) every 12 hours until therapeutic

D. ACT daily until therapeutic

B. aPTT every 6 hours until therapeutic

1. YG is a 67 year old male who presents to the ER with a chief complaint of “My chest is killing me.” The patient reports diaphoresis and chest pain that radiated down his jaw and left arm. The patient states that he didn’t feel well over the last couple of days and therefore he called 911 at the onset of his chest pain. Upon arrival to the ER, EMS reports that they administered aspirin 324 mg PO once and nitroglycerin 0.4 mcg SL x 2 while in route to the ER. Vitals: BP 150/87 HR 99 RR 20 O2 89% Temp 99.1 PMH: DM and HTN Medications: Lisinopril 40 mg PO QD, Metoprolol 25 mg PO QD, Metformin 500 mg PO BID, insulin glargine 40 U ... Humalog 5 U SQ AC Drug allergies: iodine An EKG monitor was placed on the patient and the patient was found to have St elevation of 4.5 mm ... syndrome protocol was initiated on YG. CT angiography was performed and found that YG’s chest pain was caused by high risk lesions.

Which of the following best represents the best choice to use as an antiplatelet in the

management of YG?

A. Apixaban

B. Clopidogrel

C. Prasugrel

D. Cangrelor

D. Cangrelor

An EKG reading or organized, wide QRS complexes that are > 3 mm is indicative of what type of arrythmia?

Ventricular tachycardia

Which of the following electrolytes may increase the risk of digoxin toxicity? SATA

A. Calcium

B. Phoshporous

C. Potassium

D. Magnesium

A. Calcium

B. Phoshporous

D. Magnesium

Which of the following best describes the most appropriate protocol to follow to effectively complete CPR in BJ?

Compressions for 2 minutes > check for a rhythm > deliver a shock if a rhythm is present >

compression for 2 minutes > check for a rhythm > deliver a shock if a rhythm is present >

administer epinephrine every 3-5 minutes > repeat

Which of the following drugs should BJ have been prescribed as home medications to reduce the risk of complications and mortality associated with his chronic disease states? SATA

A. ACEi

B. Beta-blocker

C. CCB

D. Insulin glargine

A. ACEi

B. Beta-blocker

EKG question:

Pulseless electrical activity

P.I. is a 35 year old who presents to the ER unresponsive due to a drug overdose. Due to the patient’s presentation the patient’s current and past history is limited. Upon arrival CPR is initiated in PI and the following vitals were reported: BP 60/40 HR 0 Temp 100.5 RR 14. While performing CPR a defibrillator is placed to check for a rhythm and unfortunately no rhythm is present. After 6 rounds of CPR over 20-25 minutes the patient was successful in achieving ROSC. A targeted temperature management protocol is initiated in PI. Which of the following best represents drugs that may be used to maintain hypothermia or are used to manage complications that may occur as a result of inducing hypothermia? SATA

A. Vecoronium

B. Meperidine

C. Fentanyl

D. Cold saline at 30 mL/h

B. Meperidine

C. Fentanyl

D. Cold saline at 30 mL/h

Which of the following must be administered to YG for the management of ACS? SATA

A. Oxygen 2-3 L/min

B. Isosorbide mononitrate 30 mg PO QD

C. Clopidogrel 300 mg PO once

D. Aspirin 324 mg PO once

E. Morphine 5 mg IV q5-30 minutes PRN chest pain

A. Oxygen 2-3 L/min

E. Morphine 5 mg IV q5-30 minutes PRN chest pain

Which of the following best represents the type of ACS the patient is experiencing?

A. NSTEMI

B. STEMI

C. V-tach

D. Angina

B. STEMI

Which of the following best represents potential treatment options for a patient who presents with NSTEMI and has a calculated TIMI score of 2?

A. Morphine, aspirin, nitroglycerin, oxygen, heparin, B-blocker, clopidogrel, PCI, eptifibatide (optional)

B. Morphine, prasugrel, nitroglycerin, oxygen, bivalirudin, B-blocker, clopidogrel, PCI, and eptifibatide (optional)

C. Morphine, aspirin, nitroglycerin, oxygen, heparin, beta-blocker, clopidogrel

D. Aspirin, nitroglycerin, oxygen, B-blocker, alteplase, morphine, and bivalirudin

C. Morphine, aspirin, nitroglycerin, oxygen, heparin, beta-blocker, clopidogrel

All of the following are symptoms associated with heart failure except:

a. Shortness of breath

b. Fever

c. Fatigue

d. Edema

b. Fever

All of the following represents the most appropriate combination of therapy for the youtumanagement of chronic heart failure except?

a. Hydrochlorothiazide, Valsartan, Carvedilol

b. Hydrochlorothiazide, Valsartan, Metoprolol Succinate

c. Furosemide, Lisinopril, Bisoprolol

d. Furosemide, Lisinopril, Metoprolol Tartrate

d. Furosemide, Lisinopril, Metoprolol Tartrate

A 24 year old female presents to the ER with complaints of severe shortness of breath, dyspnea, and chest pain. She is active and denies tobacco use. Two days prior, she noticed pain and swelling in her left lower extremity. Her past medical history is negative for thrombosis, Her current medications include Tri-Levlen (levonorgestrel/ethinyl estradiol) tabs, folic acid and ibuprofen 600 mg q 8 hrs prn for pain. A duplex ultrasound of the left lower extremity revealed a DVT. The patient's height is 6 feet and weight is 220 lb (100 kg). Which of the following is an appropriate therapy for this patient?

a. Heparin 5000 units SC q 8 hrs

b. Enoxaparin 30 mg SC twice daily

c. Enoxaparin 100 mg SC q 12 hrs

d. Enoxaparin 40 mg once daily

e. Heparin 5000 units SC q 12 hours

c. Enoxaparin 100 mg SC q 12 hrs

Which of the following represents the most appropriate combination of therapy for the management of chronic heart failure (Ejection Fraction > 45%)?

a. Valsartan, Amlodipine, Atenolol

b. Lisinopril, Amlodipine, Metoprolol Tartrate

c. Valsartan, Amlodipine, propranolol

d. Lisinopril, Amlodipine, Bisoprolol

d. Lisinopril, Amlodipine, Bisoprolol

All of the following represents an accurate definition of diastolic heart failure except:

a. Ejection fraction > 60 %

b. Preserved ejection fraction

c. Ejection fraction < 40% SYSTOLIC HF

d. Increased stiffness of the cardiac muscle

c. Ejection fraction < 40% SYSTOLIC HF

Which of the following would be appropriate for reversing a bleed associated with rivaroxaban use?

a. Idarucizumab

b. Vitamin K

c. Andexanet alfa

d. Protamine

c. Andexanet alfa

Which of the following is/are least likely to induce cough and angioedema?

a. Ramipril

b. Valsartan/Sacubitril (ARNI)

c. Lisinopril

d. Valsartan

d. Valsartan

A 47 year old male patient is diagnosed with a lower-extremity DVT. The patient weighs 80 kg. Her past medical history shows presence of DVT and heparin-induced thrombocytopenia. Which of the following medications would you consider recommending (Choose all that applies)?

a. Fondaparinux

b. Enoxaparin

c. Agatroban

d. Dalteparin

a. Fondaparinux

c. Agatroban

Which of the following actions would you consider recommending (Select all that applies):

a. Continue lisinopril because it has been shown to improve mortality and morbidity

b. Discontinue Ibuprofen and switch patient to acetaminophen 1000 mg every 6 hours

c. Discontinue potassium and lisinopril, and continue to monitor patient blood pressure

d. Discontinue Ibuprofen and initiate hydrocodone 5 mg, and monitor for pain relief

c. Discontinue potassium and lisinopril, and continue to monitor patient blood pressure

d. Discontinue Ibuprofen and initiate hydrocodone 5 mg, and monitor for pain relief

In a patient with heparin-induced thrombocytopenia, which of the following therapies will be appropriate for treating pulmonary embolism (assuming appropriate doses)?

a. Agatroban

b. Enoxaparin

c. Aspirin

d. Heparin

a. Agatroban

Advantages of LMWH over UFH include all of the following except?

a. Subcutaneous administration

b. Lower incidence of heparin-induced thrombocytopenia

c. Predictable response at lower doses

d. Once or Twice daily dosing

e. No dosage adjustment needed with renal insufficiency

e. No dosage adjustment needed with renal insufficiency

Which of the following statements is true regarding the progression of heart failure?

a. Cardiac output is increased and Frank-Starling law is unaffected

b. Frank-Starling law is unaffected

c. Cardiac-output is decreased and Frank-Starling law is unaffected

d. Cardiac output is reduced and Frank-Starling law is disrupted

d. Cardiac output is reduced and Frank-Starling law is disrupted

A 55 year old female patient undergoing hemodialysis is most likely to experience which of the following complications?

a. MRSA Infection

b. Formation of Clot

c. Pain in the insertion area

d. Congestive heart failure

d. Congestive heart failure

ACE inhibitors can induce cough by doing the following (choose all that apply):

a. Enhancing release of kininase

b. Increase levels of bradykinin

c. Decrease levels of bradykinin

d. Inhibition of kininase

b. Increase levels of bradykinin

d. Inhibition of kininase

How long should enoxaparin be continued in a patient with an acute DVT?

a. At least 4-5 days until the INR is > 2.0 for 24 hours

b. At least 7-10 days until the INR is > 3.0 for 24 hours

c. At least 4-5 days until INR is < 2.0 for 24 hours

d. At least 24 hours until the INR is > 3.0 for 24 hours

a. At least 4-5 days until the INR is > 2.0 for 24 hours

Carvedilol provides an added advantage in the management of heart failure by exerting which of the following:

a. Blockade of increased sympathetic nervous system activity

b. Stimulation of beta-2 receptors

c. Blockade of angiotensin II receptors

d. Increased heart rate and decreased blood pressure

a. Blockade of increased sympathetic nervous system activity

A 24 year old female presents to the ER with complaints of severe shortness of breath, dyspnea, and chest pain. She is active and denies tobacco use. Two days prior, she noticed pain and swelling in her left lower extremity. Her past medical history is negative for thrombosis, Her current medications include Tri-Levlen tabs (levonorgestrel/ethinyl estradiol), folic acid and ibuprofen 600 mg q 8 hrs prn for pain. A duplex ultrasound of the left lower extremity revealed a DVT. Which of the following most likely contributed to the current issue?

a. The use of Tri-Levlen

b. The use of folic acid

c. Immobility

d. The use of ibuprofen

a. The use of Tri-Levlen

All of the following can be used for either the diagnosis of heart failure or its progression except:

a. MRI

b. X-Ray

c. Echocardiogram

d. BNP

a. MRI

You were asked to provide medication education to a patient taking warfarin. Which of the following would you consider (choose all that applies):

a. Eat a consistent amount of vitamin K -rich foods per week

b. Take warfarin with meals and remain standing for 30 mins

c. When in pain consider taking NSAIDs for pain relieve

d. When you change any medication be sure to let your pharmacist/physician know

e. Report any symptoms of bleeding to your physician

a. Eat a consistent amount of vitamin K -rich foods per week

d. When you change any medication be sure to let your pharmacist/physician know

e. Report any symptoms of bleeding to your physician