Geriatrics Cardio

Clinical Geriatrics · Week 3

High-Yield Practice Exam

Geriatric Cardiology — The Aging Cardiovascular System — clinical vignettes

50 vignette-style questions  |  Choose the single best answer  |  Answer key and rationales begin after Question 50

Name: ______________________________     Date: ____________     Score: ______ / 50

1.  A 79-year-old with HTN, OSA, and diabetes is found to have new AFib during a clinic visit. HR is 88, BP 132/78. He is asymptomatic and has no signs of HF. Which factor best determines whether he can be managed as an outpatient?

A.  His age alone; all patients over 75 with AF must be admitted

B.  Hemodynamic stability, absence of RVR, and symptom severity

C.  His CHA2DS2-VASc score

D.  Whether he has OSA

E.  The duration of his diabetes

2.  A 76-year-old man with exertional chest pressure for 3 weeks walks without difficulty. Resting ECG is normal and interpretable. He has no prior revascularization. What is the most appropriate initial test?

A.  Pharmacologic nuclear stress test

B.  Coronary angiography

C.  Standard exercise ECG (treadmill) stress test

D.  Exercise echocardiography because of age

E.  Coronary artery calcium score

3.  A 77-year-old with a prior lacunar stroke and well-controlled diabetes asks about her BP target. She is functional and has a good life expectancy. Which target is most appropriate per the lecture?

A.  <150/90, because older adults should have higher targets

B.  <160/100, to avoid falls

C.  <140/90, the only goal ever used after age 65

D.  An intensive goal near 120/80 may benefit her because of her high stroke risk

E.  No target; treat symptoms only

4.  An 82-year-old starting antihypertensive therapy has HTN only (no HF, CKD, or CAD). Which is an appropriate geriatric INITIAL dose per the lecture's common-meds table?

A.  Amlodipine 20 mg daily

B.  Metoprolol tartrate 200 mg BID

C.  Hydrochlorothiazide 100 mg daily

D.  Lisinopril 80 mg daily

E.  Amlodipine 2.5–5 mg daily

5.  A 78-year-old woman stands up after dinner and feels lightheaded. BP drops from 148/80 seated to 118/70 standing, and her HR rises only 4 bpm. Which age-related change most directly explains the weak compensation?

A.  Increased plasma renin activity

B.  Increased alpha-receptor responsiveness

C.  Decreased arterial stiffness

D.  Enhanced endothelial nitric oxide response

E.  Decreased baroreceptor sensitivity, so a larger BP change is needed to trigger a compensatory heart rate response

6.  A 72-year-old with long-standing HTN and diabetes has an echo showing concentric LVH and diastolic dysfunction. He has never had dyspnea, edema, or fatigue. What is his ACC/AHA heart failure stage?

A.  Stage A

B.  Stage C

C.  Stage D

D.  Stage B

E.  NYHA class IV

7.  A 76-year-old has sudden vertigo, vomiting, nystagmus, gait ataxia, and diplopia. Which vascular territory is most likely involved?

A.  Anterior cerebral artery

B.  Middle cerebral artery

C.  Ophthalmic artery

D.  Posterior circulation (vertebrobasilar)

E.  Lenticulostriate branches of the MCA

8.  A 78-year-old asymptomatic woman has a carotid bruit found on exam. Ultrasound shows 40% left ICA stenosis. What is the best management?

A.  Carotid endarterectomy

B.  Medical management: aspirin, statin, smoking cessation, and tight BP control

C.  Carotid stenting

D.  Warfarin

E.  No treatment needed

9.  A 76-year-old man with nonvalvular AFib has a CHA2DS2-VASc of 4. Creatinine clearance is 62 mL/min. He has no mechanical valve and no mitral stenosis. Which is the preferred stroke-prevention therapy?

A.  Warfarin with INR goal 2.5–3.5

B.  Aspirin 81 mg alone

C.  No anticoagulation, because he is over 75

D.  Dual antiplatelet therapy with aspirin and clopidogrel

E.  A DOAC such as apixaban 5 mg BID

10.  An 81-year-old woman's stroke symptoms began 2 hours ago. Noncontrast CT shows no hemorrhage. BP is 172/94. Her history includes a hip replacement 4 months ago, and she has no other contraindications. What is the best treatment?

A.  Withhold thrombolysis because she is over 80

B.  IV alteplase now

C.  Withhold thrombolysis because of her hip replacement

D.  Aspirin only and observe

E.  Wait for MRI before deciding

11.  A 78-year-old with HFrEF is on sacubitril-valsartan and carvedilol. You are considering adding spironolactone. Creatinine is 2.8 mg/dL and K is 5.3 mEq/L. What is the best decision?

A.  Start spironolactone 25 mg daily

B.  Avoid spironolactone because Cr is >2.5 and K is >5.0

C.  Start spironolactone 50 mg twice daily

D.  Substitute eplerenone at full dose

E.  Add potassium chloride supplementation

12.  A 71-year-old man has a 3.4 cm infrarenal AAA found on screening ultrasound. He is asymptomatic. What is the appropriate surveillance interval?

A.  Repeat ultrasound every 3 years

B.  Repeat ultrasound every 6 months

C.  Repeat ultrasound every 12 months

D.  Immediate vascular surgery referral

E.  No further imaging needed

13.  A 74-year-old man's AAA measured 4.2 cm six months ago and 4.8 cm today. He is asymptomatic. What is the best next step?

A.  Repeat ultrasound in 12 months

B.  Repeat ultrasound in 3 years

C.  Start a beta-blocker and observe only

D.  Vascular surgery referral because of rapid growth

E.  Advise him to avoid all exercise

14.  An 83-year-old on amlodipine, HCTZ, and lisinopril has BP of 158/90. Labs are normal. She keeps her pill bottles in a drawer, and her pharmacy fill history shows gaps. What is the most common cause of her resistant HTN?

A.  Primary hyperaldosteronism

B.  Renal artery stenosis

C.  Poor adherence to the medication regimen

D.  Pheochromocytoma

E.  White coat hypertension

15.  An 81-year-old healthy man has a routine visit. BP is 162/68 on repeat readings. He has no symptoms. Which age-related change best explains his BP pattern?

A.  Increased plasma renin activity driving vasoconstriction

B.  Increased beta-adrenergic responsiveness increasing cardiac output

C.  Increased number of SA node pacemaker cells

D.  Increased arterial stiffness with earlier reflected pulse waves raising systolic pressure and widening the pulse pressure

E.  Increased vessel elasticity buffering diastolic pressure

16.  An 85-year-old with AFib (CHA2DS2-VASc 6) has had two major GI bleeds on apixaban despite a full GI workup. She has a reasonable life expectancy and quality of life. What is the most appropriate stroke-prevention option?

A.  Switch to dual antiplatelet therapy indefinitely

B.  Restart full-dose warfarin with a higher INR goal

C.  Left atrial appendage closure device (e.g., Watchman)

D.  No stroke prevention because of age

E.  Rate control alone will prevent stroke

17.  An 80-year-old presents with 2 days of dyspnea. History includes COPD. Exam is limited by wheezing. BNP is normal. Echo is pending. What is the most accurate interpretation?

A.  A normal BNP confirms diastolic heart failure

B.  BNP is not useful in patients over 75

C.  A normal BNP indicates decompensated HF with low output

D.  He needs IV furosemide based on the BNP

E.  A normal BNP essentially rules out heart failure as the cause of dyspnea

18.  A 72-year-old woman has one office BP of 138/86. She has no diabetes, CKD, or known ASCVD. What is the best next step?

A.  Start chlorthalidone today

B.  Confirm with repeated measurements over several visits and/or home or ambulatory monitoring before diagnosing HTN

C.  Start lisinopril and amlodipine in combination

D.  Order a renal artery duplex ultrasound

E.  Reassure her that BP up to 150/90 is normal for her age

19.  An 84-year-old man asks his provider to calculate his 10-year ASCVD risk with the pooled cohort equations to decide about a statin. What is the key limitation?

A.  The calculator overestimates risk only in women

B.  The ASCVD risk estimator is not validated for patients older than 80, so decisions rely on shared decision-making and life expectancy

C.  The calculator requires a coronary calcium score

D.  Statins are contraindicated after age 75

E.  The calculator applies only to diabetic patients

20.  A 75-year-old with HFrEF can walk around the house comfortably but gets short of breath walking from her car to the pharmacy counter. She is comfortable at rest. What is her NYHA functional class?

A.  Class III

B.  Class I

C.  Class II

D.  Class IV

E.  Stage B

21.  An 80-year-old woman has 40 minutes of substernal pressure. ECG shows 3 mm ST elevation in II, III, and aVF. The nearest PCI-capable center can achieve door-to-balloon in 75 minutes. What is the preferred reperfusion strategy?

A.  Fibrinolytics within 30 minutes, since she is over 75

B.  Primary PCI within 90 minutes of first medical contact

C.  Medical management only because of age

D.  Stress test once she is pain-free

E.  Wait 12 hours and reassess

22.  A 78-year-old woman has new nonvalvular AFib. She has HTN and diabetes and no other conditions. What is her CHA2DS2-VASc score?

A.  3

B.  4

C.  5

D.  6

E.  2

23.  An 84-year-old woman has recurrent dizzy spells and one syncopal episode. A Holter shows sinus bradycardia averaging 38 bpm with a 4.2-second sinus pause during a symptomatic episode. TSH and medications are unremarkable. What is the best management?

A.  Permanent pacemaker placement

B.  Start metoprolol

C.  Start digoxin

D.  Reassurance; bradycardia is normal with aging

E.  Atropine as long-term therapy

24.  A 74-year-old woman with a mechanical mitral valve develops AFib. Which anticoagulant must be used?

A.  Warfarin

B.  Apixaban

C.  Rivaroxaban

D.  Dabigatran

E.  Aspirin alone

25.  A 79-year-old man is being evaluated for newly confirmed HTN. Besides CBC, CMP, lipids, TSH, UA, and ECG, which bedside exam element does the geriatric workup specifically always include?

A.  Ankle–brachial index

B.  Tilt-table testing

C.  Orthostatic vital signs

D.  Carotid sinus massage

E.  24-hour urine metanephrines

26.  A 75-year-old with an acute ischemic stroke is a candidate for IV alteplase. Per the lecture, which is the ONLY lab result required before giving thrombolysis (unless she is on anticoagulation)?

A.  Troponin

B.  Lipid panel

C.  Hemoglobin A1c

D.  Complete metabolic panel

E.  Fingerstick glucose

27.  A 79-year-old man has sudden left-sided weakness and facial droop. He was last known well 90 minutes ago. What is the FIRST imaging study?

A.  MRI brain with gadolinium

B.  Carotid duplex ultrasound

C.  Transthoracic echocardiogram

D.  Noncontrast CT of the head

E.  Conventional cerebral angiography

28.  A 76-year-old with HFrEF (EF 30%) is euvolemic on furosemide. Which medication combination provides MORTALITY benefit and should form the core of his regimen?

A.  Furosemide + digoxin + amlodipine

B.  Furosemide dose escalation alone

C.  Diltiazem + hydralazine

D.  ACEI/ARB/ARNI + an evidence-based beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) + an MRA

E.  Aspirin + clopidogrel

29.  A 72-year-old woman had a TIA yesterday with transient left hand weakness. She is now asymptomatic. She has HTN and diabetes. Which describes the recommended workup?

A.  Outpatient follow-up in 3 months with a lipid panel

B.  EEG and lumbar puncture

C.  Neuroimaging within 24 hours (MRI preferred), vessel imaging (carotid ultrasound, MRA, or CTA), ECG/echo, and long-term rhythm monitoring

D.  CT head only; no further workup if normal

E.  Reassurance, since symptoms resolved

30.  An 86-year-old nursing home resident is admitted with urosepsis and a BP of 82/50. Troponin rises then falls. ECG shows diffuse ST depression without ST elevation. She had no chest pain. What is the most likely mechanism of her troponin elevation?

A.  Type 1 MI from acute plaque rupture

B.  STEMI equivalent requiring emergent cath

C.  Laboratory error

D.  Type 2 MI from oxygen supply–demand mismatch caused by sepsis and hypotension

E.  Acute pericarditis

31.  A 74-year-old has ischemic cardiomyopathy with an EF of 28% despite 3 months of optimal medical therapy. ECG shows LBBB with a QRS of 162 ms. NYHA class III. What is the most appropriate device therapy?

A.  Single-chamber pacemaker only

B.  Implantable loop recorder

C.  Cardiac resynchronization therapy with defibrillator (CRT-D)

D.  No device; he is too old

E.  Left atrial appendage occlusion

32.  An 84-year-old has a resting HR of 52. Exercise testing shows a blunted peak HR. Echo shows LVH with preserved EF and impaired relaxation. Which set of normal aging changes is most consistent with this?

A.  Fewer SA node pacemaker cells, reduced beta-adrenergic responsiveness, and increased myocardial stiffness

B.  Increased sympathetic receptor sensitivity and reduced LV wall thickness

C.  Increased pacemaker cells with enhanced chronotropic reserve

D.  Decreased myocardial stiffness with improved early diastolic filling

E.  Decreased atrial size from reduced atrial filling

33.  An 83-year-old man is brought in after 3 falls this month and new intermittent confusion. Pulse is irregularly irregular at 118. ECG shows no discernible P waves and narrow QRS complexes at irregular intervals. Which initial labs are most appropriate for this new diagnosis?

A.  Blood cultures and lumbar puncture

B.  Serum ammonia and lipase

C.  CBC, CMP, and TSH

D.  D-dimer only

E.  Urine drug screen only

34.  A 74-year-old had a minor ischemic stroke (NIHSS 2) 10 hours ago. She did not receive thrombolysis. ECG is in sinus rhythm. What is the best antithrombotic plan for secondary prevention?

A.  Dual antiplatelet therapy (aspirin + clopidogrel) started within 24 hours, continued for about 21 days, then single antiplatelet

B.  Warfarin indefinitely

C.  Apixaban 5 mg BID

D.  No antithrombotic for 2 weeks

E.  Lifelong aspirin + clopidogrel

35.  A 68-year-old man who smoked 1 ppd for 30 years and quit 10 years ago comes for a wellness visit. He has no symptoms. Per USPSTF, which AAA screening recommendation applies?

A.  Annual abdominal CT

B.  No screening (Grade D)

C.  Selective screening only if he has a family history (Grade C)

D.  Insufficient evidence (Grade I)

E.  One-time abdominal ultrasound (Grade B)

36.  A 70-year-old smoker with recurrent episodes of transient right monocular vision loss ('window shade') has a carotid ultrasound showing 80% stenosis of the right internal carotid artery. He is otherwise fit, with a life expectancy greater than 5 years. What is the most appropriate management?

A.  Medical management alone because he is over 65

B.  Repeat carotid ultrasound in 1 year

C.  Carotid endarterectomy plus aspirin, statin, BP control, and smoking cessation

D.  Warfarin anticoagulation

E.  Carotid stenting as the preferred first choice in all patients

37.  An 80-year-old needs drug therapy for confirmed stage 2 HTN. She has no HF, CAD, or arrhythmia. Which is the most appropriate initial approach?

A.  A first-line agent (thiazide, ACEI, ARB, or CCB) started at a low dose and titrated slowly

B.  Metoprolol at full dose as monotherapy

C.  Clonidine as first-line therapy

D.  Maximum doses of two agents at once to reach goal quickly

E.  Hydralazine monotherapy

38.  An 80-year-old man has new AFib with RVR at 132 bpm and mild palpitations. BP is 138/84. He has COPD and no HF. EF is normal. Which is the most appropriate initial rate-control agent?

A.  Amiodarone

B.  Flecainide

C.  Immediate synchronized cardioversion

D.  Adenosine

E.  Diltiazem

39.  A 78-year-old has acute aphasia and right hemiplegia. CTA shows occlusion of the proximal left middle cerebral artery (M1 segment). Symptoms began 3 hours ago, and she received IV alteplase. Which additional intervention is indicated?

A.  Carotid endarterectomy today

B.  Heparin drip

C.  Decompressive craniectomy immediately

D.  Mechanical thrombectomy

E.  No further treatment needed

40.  A 70-year-old retired welder who smokes 1 ppd and had a CABG 10 years ago has episodes of 'a window shade coming down' over his right eye that resolve in minutes. Fundoscopy is normal. What is the best initial imaging test?

A.  MRI of the orbits

B.  Carotid duplex ultrasound

C.  Temporal artery biopsy

D.  Transthoracic echocardiogram only

E.  CT head without contrast only

41.  An 81-year-old woman with severe knee osteoarthritis has typical exertional angina. She cannot walk on a treadmill. Resting ECG shows LBBB. What is the best stress test?

A.  Pharmacologic stress with myocardial perfusion imaging (e.g., regadenoson MPI)

B.  Standard treadmill exercise ECG

C.  Exercise echocardiography

D.  Holter monitor

E.  Repeat resting ECG in 6 months

42.  A 79-year-old with HFrEF started carvedilol 2 weeks ago. Which set of adverse effects is most important to monitor?

A.  Hypotension, bradycardia, and worsening bronchospasm or decompensation

B.  Hyperkalemia and gynecomastia

C.  Hypomagnesemia and ototoxicity

D.  Angioedema and dry cough

E.  Hyperglycemia and gout

43.  A 74-year-old with no diabetes or CKD has confirmed BP averaging 134/82. She is motivated and has no ASCVD. Per the lecture, what is the most appropriate initial management?

A.  Start hydrochlorothiazide 25 mg and lisinopril 10 mg

B.  Lifestyle trial for about 6 months: sodium <2.4 g/day, DASH diet, weight loss, and 30 minutes of daily activity

C.  Start metoprolol tartrate 50 mg BID

D.  No intervention, because treatment provides no benefit after age 70

E.  Start spironolactone 25 mg daily

44.  An 81-year-old has 3 weeks of orthopnea and ankle swelling. On exam, what is the best bedside assessment of her volume status?

A.  Degree of pedal edema

B.  Skin turgor

C.  Capillary refill

D.  Presence of a murmur

E.  Jugular venous pressure (JVP)

45.  A 77-year-old man is hemodynamically stable with symptomatic AFib. He can't say when it started; it has been 'at least a week.' He is not anticoagulated. He and his cardiologist want rhythm control with cardioversion. What is required first?

A.  Immediate cardioversion, since he is symptomatic

B.  Therapeutic anticoagulation for 4 weeks before cardioversion, OR a TEE to exclude left atrial thrombus

C.  Cardioversion without anticoagulation if his CHA2DS2-VASc is low

D.  Catheter ablation as the first step

E.  A pharmacologic stress test

46.  A 79-year-old woman has 2 months of worsening shortness of breath when walking to her mailbox, which resolves with rest. She denies chest pain. Exam and CXR are unremarkable. What is the most likely explanation?

A.  Normal deconditioning of aging requiring no workup

B.  Anxiety disorder

C.  Gastroesophageal reflux disease

D.  Normal age-related pulmonary decline

E.  Dyspnea on exertion as an anginal equivalent from coronary heart disease

47.  A 73-year-old asks what she can do to lower her stroke risk the most. She has HTN, hyperlipidemia, OSA, and a sedentary lifestyle, and her father had a stroke. Which risk factor is the most significant AND modifiable?

A.  Age

B.  Family history

C.  Sedentary lifestyle

D.  Hypertension

E.  Sex

48.  A 79-year-old woman has AFib with RVR at 165 bpm, BP 76/44, confusion, and cool, clammy skin. What is the next step?

A.  Anticoagulate for 4 weeks, then cardiovert

B.  TEE before any intervention

C.  Immediate synchronized electrical cardioversion

D.  Oral metoprolol and recheck in 1 hour

E.  Start apixaban and discharge

49.  An 82-year-old man with stable angina has been optimized on medical therapy. Stress testing shows moderate ischemia. Echo shows an EF of 50%. His symptoms are now well controlled. Which statement is most accurate?

A.  Continue medical management; with EF >35%, there is no all-cause mortality difference between optimized medical therapy and an initial invasive approach

B.  Urgent cardiac catheterization is required because of his age

C.  CABG is indicated for all patients over 80 with ischemia

D.  Stop his statin because of his age

E.  PCI is required to improve survival

50.  A 77-year-old with stable angina takes aspirin 81 mg and atorvastatin. He still gets chest pain with moderate exertion. HR is 82, BP 138/78. What is the best next medication to add?

A.  Clopidogrel in addition to aspirin

B.  Warfarin

C.  Hydrochlorothiazide

D.  Immediate PCI before any anti-anginal trial

E.  A beta-blocker, such as metoprolol

Answer Key

Coverage: Arrhythmia / AFib 10  •  CAD / ACS 8  •  Hypertension 7  •  Aging Physiology 3  •  Heart Failure 8  •  Stroke / TIA 8  • Carotid & AAA 6

Answers & Clinical Rationales

1.  Answer: B. Hemodynamic stability, absence of RVR, and symptom severity   [Arrhythmia / AFib]

Rationale: From the lecture case, the inpatient vs. outpatient decision depends on stability, RVR, and symptoms. A stable, rate-controlled, asymptomatic patient can be managed outpatient: start anticoagulation per CHA2DS2-VASc, get an echo, check TSH, and address risk factors (HTN, OSA, DM, obesity, alcohol).

Why not the others: Age alone doesn't mandate admission. CHA2DS2-VASc guides anticoagulation, not the setting of care. OSA and DM duration are risk factors to treat, not disposition criteria.

2.  Answer: C. Standard exercise ECG (treadmill) stress test   [CAD / ACS]

Rationale: Per the algorithm, if the patient can exercise and the resting ECG is interpretable, a standard exercise ECG is first-line (for low-to-intermediate likelihood). Use pharmacologic stress (MPI or echo) if he cannot exercise. Use imaging with exercise (MPI or echo) if the resting ECG is uninterpretable (LBBB, LVH with strain, paced rhythm, digoxin).

Why not the others: Pharmacologic stress is for patients who can't exercise. Angiography is not initial for stable symptoms. Age alone doesn't require imaging. CAC doesn't evaluate symptoms.

3.  Answer: D. An intensive goal near 120/80 may benefit her because of her high stroke risk   [Hypertension]

Rationale: Goal is 130/80 for most older adults. An intensive goal of 120/80 may benefit those at higher stroke risk. Goals should come from a patient-informed discussion, especially with heavy comorbidity or limited life expectancy. HTN is the most significant modifiable stroke risk factor.

Why not the others: Higher targets such as 150/90 or 160/100 are not what the lecture teaches for a functional patient at high stroke risk. Symptom-only treatment ignores the stroke risk.

4.  Answer: E. Amlodipine 2.5–5 mg daily   [Hypertension]

Rationale: Initial doses: amlodipine 2.5–5 mg qd; HCTZ 12.5–25 mg qd; lisinopril 10 mg qd for HTN (2.5–5 mg for HFrEF); losartan 50 mg (25 mg HFrEF); carvedilol 6.25 mg BID HTN (3.125 mg BID HFrEF); spironolactone 25 mg (12.5–25 mg HFrEF); apixaban 5 mg BID; rivaroxaban 20 mg qd; aspirin 81–325 mg; clopidogrel 75 mg.

Why not the others: The other doses are well above typical starting doses (several exceed the maximum dose) and would risk hypotension, falls, and electrolyte disturbances.

5.  Answer: E. Decreased baroreceptor sensitivity, so a larger BP change is needed to trigger a compensatory heart rate response   [Aging Physiology]

Rationale: Aging blunts baroreceptor sensitivity and lowers alpha- and beta-receptor responsiveness. A bigger BP change is needed before HR rises, which predisposes to orthostatic and postprandial hypotension and more BP variability. This is why orthostatic vitals belong in every geriatric HTN workup.

Why not the others: Renin falls with age. Alpha responsiveness falls. Arteries get stiffer. The endothelial NO response is reduced (endothelial dysfunction).

6.  Answer: D. Stage B   [Heart Failure]

Rationale: Stage A: high risk (HTN, obesity, CAD) WITHOUT structural disease. Stage B: structural disease (systolic or diastolic dysfunction, LVH, valvular disease) WITHOUT signs or symptoms. Stage C: structural disease with prior or current symptoms. Stage D: refractory HF. NYHA classes I–IV grade symptoms; class IV means symptoms at rest.

Why not the others: Stage A has no structural disease. C requires symptoms. D is refractory. NYHA IV means symptoms at rest.

7.  Answer: D. Posterior circulation (vertebrobasilar)   [Stroke / TIA]

Rationale: Posterior circulation (basilar, AICA, PICA, PCA) causes the 'V's': vomiting, visual change, vertigo, plus nystagmus, nausea, coma, ataxia, and crossed or contralateral findings. Anterior circulation (ACA/MCA) causes contralateral weakness or sensory deficits, aphasia, and contralateral homonymous hemianopsia.

Why not the others: ACA and MCA strokes give contralateral motor and sensory deficits. Ophthalmic causes monocular vision loss. Lenticulostriate causes lacunar pure motor or sensory deficits.

8.  Answer: B. Medical management: aspirin, statin, smoking cessation, and tight BP control   [Carotid & AAA]

Rationale: Asymptomatic stenosis <50%: medical management (aspirin + statin + risk factor control, smoking cessation, BP <120/80). Asymptomatic 70–90%: consider surgical intervention. Routine screening of asymptomatic people is generally NOT beneficial. Prevalence of moderate–severe asymptomatic stenosis is about 7.5% in people over 80, with about 1% annual stroke risk.

Why not the others: CEA and stenting aren't indicated for asymptomatic <50% stenosis. Warfarin has no role. 'No treatment' ignores atherosclerotic risk reduction.

9.  Answer: E. A DOAC such as apixaban 5 mg BID   [Arrhythmia / AFib]

Rationale: Nonvalvular AFib → DOACs (apixaban, rivaroxaban, dabigatran). Apixaban's usual dose is 5 mg BID. Reduce to 2.5 mg BID if he meets 2 of: age ≥80, weight ≤60 kg, Cr ≥1.5. Adjust anticoagulant dosing for renal function, hepatic function, age, and weight. Age itself is a REASON to anticoagulate, not a reason to withhold.

Why not the others: Warfarin is reserved for valvular AF, and INR 2.5–3.5 is the mechanical mitral valve goal. Aspirin and DAPT are inferior for AF stroke prevention.

10.  Answer: B. IV alteplase now   [Stroke / TIA]

Rationale: IV alteplase is first-line if there are no contraindications; earlier is better (best <3 hours, within 4.5 hours). Age alone is NOT a contraindication; the lecture stresses that tPA and thrombectomy work in older adults. Contraindications: intracranial, subarachnoid, or internal bleeding; stroke, intracranial or intraspinal surgery, or serious head trauma within 3 months; intracranial neoplasm, aneurysm, or AVM; bleeding diathesis; severe uncontrolled HTN (>185/110 is the usual threshold, and 172/94 is acceptable).

Why not the others: Age isn't exclusionary. Hip surgery isn't an intracranial or intraspinal procedure, and it was more than 3 months ago. Aspirin alone or waiting for an MRI forfeits treatment time.

11.  Answer: B. Avoid spironolactone because Cr is >2.5 and K is >5.0   [Heart Failure]

Rationale: MRAs (spironolactone, eplerenone) give a mortality benefit in reduced EF but should be AVOIDED if Cr >2.5 or K >5.0 because of hyperkalemia and worsening renal function. Monitor for hypotension, hyperkalemia, renal decline, and gynecomastia (spironolactone).

Why not the others: Starting any MRA or giving K risks life-threatening hyperkalemia. Eplerenone shares the hyperkalemia risk.

12.  Answer: A. Repeat ultrasound every 3 years   [Carotid & AAA]

Rationale: AAA is defined as ≥3 cm. Surveillance: 3.0–3.9 cm every 3 years; 4.0–4.9 cm every 12 months; 5.0–5.4 cm every 6 months (ultrasound or CT). Management: smoking cessation (the biggest modifiable factor, since more than 95% have smoked), treating HTN, DM, and lipids, and lifestyle changes. Vascular referral for >4.0 cm or rapid growth.

Why not the others: 6- and 12-month intervals are for larger aneurysms. 3.4 cm doesn't meet referral criteria. An AAA does require surveillance.

13.  Answer: D. Vascular surgery referral because of rapid growth   [Carotid & AAA]

Rationale: Rapid growth is ≥0.5 cm in 6 months; he grew 0.6 cm. Refer to vascular surgery for >4.0 cm OR rapid growth. Exercise and its transient BP rise are NOT a predictor of rupture, so he doesn't need to avoid activity.

Why not the others: Routine surveillance ignores rapid expansion. Beta-blockers don't meaningfully slow growth. Avoiding exercise isn't recommended.

14.  Answer: C. Poor adherence to the medication regimen   [Hypertension]

Rationale: The lecture states that the #1 cause of resistant HTN is poor medication adherence, especially with polypharmacy, cost, cognitive impairment, and side effects. Always assess adherence (pill counts, fill history, home BP) before working up secondary causes.

Why not the others: Hyperaldosteronism and renal artery stenosis are secondary causes to consider AFTER adherence. Pheochromocytoma is rare. White coat HTN wouldn't explain the refill gaps.

15.  Answer: D. Increased arterial stiffness with earlier reflected pulse waves raising systolic pressure and widening the pulse pressure   [Aging Physiology]

Rationale: Isolated systolic HTN with a wide pulse pressure is the classic aging pattern. Arterial stiffening raises pulse wave velocity, so reflected waves come back early, during systole instead of diastole. That raises SBP and lowers DBP. The result is more aortic impedance, more LV afterload, LV wall thickening, and diastolic dysfunction.

Why not the others: Renin activity falls with age. Beta-receptor responsiveness decreases. Pacemaker cells are lost. Vessel elasticity falls.

16.  Answer: C. Left atrial appendage closure device (e.g., Watchman)   [Arrhythmia / AFib]

Rationale: LAA closure is for patients NOT suitable for long-term oral anticoagulation who have a reasonable life expectancy and quality of life. HAS-BLED estimates bleeding risk (HTN, abnormal renal/liver function, stroke, bleeding, labile INR, elderly >65, drugs/alcohol).

Why not the others: DAPT still bleeds and is less effective. A higher INR increases bleeding. Age isn't a reason to withhold. Rate control doesn't reduce stroke risk.

17.  Answer: E. A normal BNP essentially rules out heart failure as the cause of dyspnea   [Heart Failure]

Rationale: The lecture: if BNP is normal, HF is essentially ruled out (high negative predictive value). Workup also includes CXR (cardiomegaly, cephalization, Kerley B lines, effusions), ECG, CMP, CBC, and echo (systolic and diastolic function, valves). BNP runs higher with age and renal failure and lower with obesity.

Why not the others: A normal BNP doesn't confirm HF of any type. BNP remains useful in older adults. There's no basis to diurese.

18.  Answer: B. Confirm with repeated measurements over several visits and/or home or ambulatory monitoring before diagnosing HTN   [Hypertension]

Rationale: HTN is defined the same in older adults (stage 1 starts at 130/80). The diagnosis should be verified with multiple measurements; the text suggests up to 9 readings over 3 visits, and home or ambulatory readings are useful. BP variability is greater in older adults, so one reading is not enough.

Why not the others: Drugs before confirmation risk overtreatment. Secondary-HTN workup isn't indicated. 150/90 is NOT 'normal' for age; the stage-1 cutoff is still 130/80.

19.  Answer: B. The ASCVD risk estimator is not validated for patients older than 80, so decisions rely on shared decision-making and life expectancy   [CAD / ACS]

Rationale: Risk estimators help in older adults, but the ASCVD calculator does NOT apply to patients over 80. In older adults, statins are 'start low, go slow' to the maximally tolerated dose, and use may depend on life expectancy. Average age of first MI: 66 in men, 72 in women; more than 80% of CHD deaths occur after age 65.

Why not the others: The other statements are false. Statins aren't contraindicated after 75, and the calculator doesn't require CAC or diabetes.

20.  Answer: A. Class III   [Heart Failure]

Rationale: NYHA I: no limitation. II: slight limitation, comfortable at rest, ordinary activity causes symptoms. III: marked limitation, comfortable at rest, LESS than ordinary activity causes symptoms. IV: unable to do any physical activity without discomfort, symptoms at rest. Short walks around the house are fine, but minimal exertion causes symptoms, so class III.

Why not the others: I has no limitation. II involves ordinary activity. IV has symptoms at rest. Stage B is an ACC/AHA stage, not an NYHA class.

21.  Answer: B. Primary PCI within 90 minutes of first medical contact   [CAD / ACS]

Rationale: STEMI: reperfusion within 12 hours of symptom onset. PCI within 90 minutes is preferred. Fibrinolysis (within 30 minutes of arrival) is for when timely PCI isn't available. Age alone is not a contraindication to reperfusion. After STEMI: antiplatelet, statin, beta-blocker, and ACEI.

Why not the others: Lytics are second-line when PCI is available in time, and bleeding risk is higher in older adults. Withholding reperfusion for age is wrong. Stress testing is contraindicated in active STEMI. Delay forfeits myocardium.

22.  Answer: C. 5   [Arrhythmia / AFib]

Rationale: CHA2DS2-VASc: CHF 1, HTN 1, Age ≥75 2, DM 1, Stroke/TIA/thromboembolism 2, Vascular disease 1, Age 65–74 1, Sex category female 1. Her score: age ≥75 (2) + HTN (1) + DM (1) + female (1) = 5. That is roughly 7% annual stroke risk, so anticoagulate.

Why not the others: 3 or 4 misses the 2 points for age ≥75 or the female point. 6 would require another factor (e.g., vascular disease). 2 counts age alone.

23.  Answer: A. Permanent pacemaker placement   [Arrhythmia / AFib]

Rationale: The bradycardia 'rule of 3': pacemaker for HR <30, HR <35 with symptoms, or a pause >3 seconds. She has symptomatic bradycardia plus a 4.2-second pause. Age-related loss of SA node pacemaker cells predisposes to sick sinus syndrome.

Why not the others: Metoprolol and digoxin worsen bradycardia. Symptomatic pauses are not normal aging. Atropine is a temporary acute treatment.

24.  Answer: A. Warfarin   [Arrhythmia / AFib]

Rationale: 'Valvular' AFib means any mechanical valve and/or moderate–severe mitral stenosis. It MUST be treated with warfarin. DOACs are contraindicated with mechanical valves (dabigatran caused excess thrombosis and bleeding in RE-ALIGN).

Why not the others: DOACs are only for nonvalvular AF. Aspirin alone is inadequate.

25.  Answer: C. Orthostatic vital signs   [Hypertension]

Rationale: The geriatric HTN workup is the same as for younger adults, but the text says orthostatic vitals are ALWAYS part of it. Older patients have blunted baroreflexes, and antihypertensives can cause orthostatic hypotension and falls. The workup also includes fundoscopy, thyroid, abdomen, a brief neuro exam, and a medication review (NSAIDs, steroids).

Why not the others: ABI, tilt-table, carotid sinus massage, and metanephrines are not routine HTN workup elements.

26.  Answer: E. Fingerstick glucose   [Stroke / TIA]

Rationale: Glucose is the only lab required before IV alteplase (except in anticoagulated patients, who need coags/INR). Hypoglycemia can mimic stroke. Advanced imaging and other labs (CBC, CMP, INR, troponin, A1c, lipids) shouldn't delay treatment.

Why not the others: Troponin, lipids, A1c, and CMP are part of the workup but shouldn't delay thrombolysis.

27.  Answer: D. Noncontrast CT of the head   [Stroke / TIA]

Rationale: Expedient imaging: noncontrast CT to rule out hemorrhage before thrombolysis. Goal: imaging within 20 minutes of arrival. Every minute of stroke loses about 1.9 million neurons. MRI/MRA is more sensitive but takes longer and shouldn't delay treatment.

Why not the others: MRI, carotid ultrasound, echo, and angiography come later or would delay time-critical decisions.

28.  Answer: D. ACEI/ARB/ARNI + an evidence-based beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) + an MRA   [Heart Failure]

Rationale: HFrEF drugs with mortality benefit: ACEI/ARB/ARNI (lisinopril, losartan, sacubitril-valsartan), beta-blockers (metoprolol, carvedilol, bisoprolol), and MRAs (spironolactone, eplerenone). Loop diuretics relieve symptoms but give NO survival benefit. Start low in older adults, e.g., carvedilol 3.125 mg BID or lisinopril 2.5–5 mg daily.

Why not the others: Loops and digoxin improve symptoms only. Amlodipine is neutral. Diltiazem is harmful in HFrEF. Antiplatelets are not HF therapy.

29.  Answer: C. Neuroimaging within 24 hours (MRI preferred), vessel imaging (carotid ultrasound, MRA, or CTA), ECG/echo, and long-term rhythm monitoring   [Stroke / TIA]

Rationale: TIA workup: neuroimaging within 24 hours (MRI preferred), vessel imaging (intracranial and carotid: MRA or carotid ultrasound), ECG and echo, and long-term rhythm monitoring for paroxysmal AF. Admit high-risk patients for an expedited workup. Stroke risk within 90 days is high.

Why not the others: Delayed follow-up, EEG/LP, CT alone, or reassurance miss treatable causes (carotid stenosis, AF) during the high-risk window.

30.  Answer: D. Type 2 MI from oxygen supply–demand mismatch caused by sepsis and hypotension   [CAD / ACS]

Rationale: Type 2 MI is an imbalance between myocardial O2 supply and demand, often from an acute illness or a flare of a chronic condition. Causes: sepsis, acute blood loss, anemia, pneumonia, PE, COPD, CHF, dysrhythmias, and hypertensive urgency. Treat the underlying cause. Note that NSTEMI is more common than STEMI in older adults.

Why not the others: Plaque rupture is type 1 MI. No ST elevation means it is not a STEMI equivalent. Pericarditis causes diffuse ST ELEVATION with PR depression.

31.  Answer: C. Cardiac resynchronization therapy with defibrillator (CRT-D)   [Heart Failure]

Rationale: ICD: prevents sudden death from VT/VF in EF <35%. CRT: improves cardiac output in cardiomyopathy with EF <35% and QRS >150 ms. He meets both. Non-drug care: sodium <3 g/day, relative fluid restriction, exercise and cardiac rehab once stable.

Why not the others: A pacemaker alone doesn't resynchronize or defibrillate. A loop recorder is diagnostic. Age alone isn't a contraindication. LAAO is for AF stroke prevention.

32.  Answer: A. Fewer SA node pacemaker cells, reduced beta-adrenergic responsiveness, and increased myocardial stiffness   [Aging Physiology]

Rationale: Normal aging: fewer pacemaker cells (bradycardia, sick sinus), less response to sympathetic stimulation (blunted max HR), myocyte hypertrophy, myocardial stiffness, and atrial fibrosis. Early diastolic filling falls, so the atrial kick matters more. The left atrium enlarges, and that substrate predisposes to AFib.

Why not the others: Receptor sensitivity falls and wall thickness rises. Pacemaker cells decline. Myocardial stiffness rises and early filling falls. Atrial size increases.

33.  Answer: C. CBC, CMP, and TSH   [Arrhythmia / AFib]

Rationale: AFib is the most common arrhythmia (about 12% of people over 75). Older adults may present atypically with falls, delirium, or syncope, as well as fatigue, palpitations, and dyspnea. ECG: irregularly irregular with no P waves. Workup: CBC, CMP (electrolytes, renal function for DOAC dosing), TSH (hyperthyroidism), and echo.

Why not the others: The other options don't address reversible causes of AFib (thyroid, electrolytes) or anticoagulation planning.

34.  Answer: A. Dual antiplatelet therapy (aspirin + clopidogrel) started within 24 hours, continued for about 21 days, then single antiplatelet   [Stroke / TIA]

Rationale: For minor stroke or high-risk TIA, DAPT has shown benefit when started within the first 24 hours and continued for 21 days, then a single antiplatelet. Other secondary prevention: BP control (the most important modifiable risk factor), a statin, and anticoagulation ONLY if AF is found.

Why not the others: Anticoagulants are for AF or cardioembolic causes. Withholding treatment increases early recurrence. Long-term DAPT raises bleeding without added benefit.

35.  Answer: E. One-time abdominal ultrasound (Grade B)   [Carotid & AAA]

Rationale: USPSTF AAA: Men 65–75 who have EVER smoked: one-time ultrasound (B). Men 65–75 who never smoked: selectively offer (C). Women who never smoked and have no family history: recommend against (D). Women 65–75 who ever smoked or have a family history: insufficient evidence (I). Ultrasound is sensitive and specific; CT gives more detail and is used for pre-op planning.

Why not the others: Annual CT is not the screening test. D applies to never-smoking women. C applies to never-smoking men. I applies to women who ever smoked.

36.  Answer: C. Carotid endarterectomy plus aspirin, statin, BP control, and smoking cessation   [Carotid & AAA]

Rationale: He is SYMPTOMATIC (amaurosis fugax) with high-grade ipsilateral stenosis, so revascularization is indicated along with best medical therapy. CEA is the gold standard and preferred for high-grade stenosis; stenting (CAS) is reserved for patients with reasons to avoid CEA (hostile neck anatomy, prior radiation, significant cardiac disease). CAS carries higher stroke risk; CEA carries higher post-op MI risk. Intervention requires a life expectancy over 5 years.

Why not the others: Medical therapy alone is undertreatment for symptomatic high-grade disease. Surveillance delays needed care. Warfarin isn't indicated for carotid atherosclerosis. Stenting isn't preferred first-line.

37.  Answer: A. A first-line agent (thiazide, ACEI, ARB, or CCB) started at a low dose and titrated slowly   [Hypertension]

Rationale: First-line agents are thiazides (HCTZ, chlorthalidone), ACEI, ARB, and CCBs (amlodipine). In older adults, 'start low, go slow' (e.g., amlodipine 2.5–5 mg, HCTZ 12.5 mg) because of side effects such as dizziness, hypotension, fatigue, imbalance, and electrolyte disturbance. Beta-blockers are reserved for compelling indications.

Why not the others: Beta-blockers aren't first-line without a compelling indication. Clonidine is on the Beers list (CNS effects, rebound). Aggressive dual max dosing causes hypotension and falls. Hydralazine is not first-line.

38.  Answer: E. Diltiazem   [Arrhythmia / AFib]

Rationale: Stable AF rate control: beta-blockers (carvedilol, metoprolol) or non-dihydropyridine CCBs (diltiazem, verapamil). With COPD, a CCB avoids possible bronchospasm (the deck notes BB caution in lung disease). Rhythm agents are amiodarone, flecainide, propafenone, and sotalol. All may need geriatric dose adjustment.

Why not the others: Amiodarone and flecainide are rhythm-control drugs; flecainide is avoided in structural heart disease. He's stable, so no immediate cardioversion. Adenosine doesn't control AF rate.

39.  Answer: D. Mechanical thrombectomy   [Stroke / TIA]

Rationale: Mechanical thrombectomy is for large vessel occlusion: terminal ICA or M1 (the proximal MCA, extending from the end of the ICA). Eligible patients get IV alteplase AND transfer for thrombectomy. Patients outside the window or with wake-up stroke may still qualify based on CT/MR perfusion mismatch.

Why not the others: CEA isn't done acutely during an LVO. A heparin drip isn't indicated after tPA. Craniectomy is for malignant edema. Doing nothing withholds proven therapy.

40.  Answer: B. Carotid duplex ultrasound   [Carotid & AAA]

Rationale: Amaurosis fugax (transient monocular blindness) is a TIA of the ophthalmic artery, usually from an ipsilateral carotid embolus. Best initial test: carotid ultrasound (accurate, reliable, operator dependent). CTA must include angiography; MRA without contrast if contrast is contraindicated. Carotid disease risk factors: smoking, AGE, male sex. Note that diplopia is not typical of carotid disease.

Why not the others: Orbit MRI and temporal artery biopsy don't evaluate carotid stenosis (consider GCA only with headache, jaw claudication, or high ESR). Echo alone and noncontrast CT miss the carotid source.

41.  Answer: A. Pharmacologic stress with myocardial perfusion imaging (e.g., regadenoson MPI)   [CAD / ACS]

Rationale: Unable to exercise → pharmacologic stress (vasodilator MPI, dobutamine echo, or CMR). LBBB also makes the ECG uninterpretable for ischemia, so imaging is required either way.

Why not the others: She can't exercise, so treadmill and exercise echo are out. A Holter doesn't provoke ischemia. Waiting is inappropriate.

42.  Answer: A. Hypotension, bradycardia, and worsening bronchospasm or decompensation   [Heart Failure]

Rationale: CHF med monitoring: Beta-blocker: hypotension, bradycardia; caution in lung disease and acute decompensated HF. ACEI/ARB/ARNI: hypotension, decreased renal function (benefit outweighs a mild GFR drop), hyperkalemia. MRA: hypotension, hyperkalemia/renal function, gynecomastia. Loops: electrolytes (check BMP, Mg), hypotension; OK in reduced kidney function.

Why not the others: Hyperkalemia and gynecomastia point to an MRA. Hypomagnesemia and ototoxicity point to loop diuretics. Angioedema and cough point to ACEIs. Hyperglycemia and gout point to thiazides.

43.  Answer: B. Lifestyle trial for about 6 months: sodium <2.4 g/day, DASH diet, weight loss, and 30 minutes of daily activity   [Hypertension]

Rationale: For SBP 130–139 without diabetes, the lecture recommends a lifestyle trial of about 6 months before drugs. Non-drug measures: weight loss, 30 minutes of activity a day, sodium <2.4 g, DASH diet, potassium supplementation, and limiting alcohol. Treatment still benefits older adults: a 10/5 drop lowers MI by about 25%, stroke by about 40%, and CHF by about 50%.

Why not the others: Dual therapy is premature. Beta-blockers aren't first-line for uncomplicated HTN. Treatment does help after 70. Spironolactone is for resistant HTN.

44.  Answer: E. Jugular venous pressure (JVP)   [Heart Failure]

Rationale: The lecture: elevated JVP is the best assessment of volume status. HF exam: S3 gallop, ± murmur, rales, edema. Pedal edema in older adults is confounded by venous insufficiency, CCBs, and immobility.

Why not the others: Edema is nonspecific. Skin turgor is unreliable in older adults. Capillary refill reflects perfusion. A murmur doesn't assess volume.

45.  Answer: B. Therapeutic anticoagulation for 4 weeks before cardioversion, OR a TEE to exclude left atrial thrombus   [Arrhythmia / AFib]

Rationale: Timing: immediate if unstable. If AF has lasted <48 hours, cardioversion can proceed. Otherwise (48 hours or more, or unknown), anticoagulate for 4 weeks first, or use a TEE to rule out LA/LAA thrombus. Continue anticoagulation for at least 4 weeks after cardioversion.

Why not the others: He's stable with unknown duration, so immediate cardioversion risks embolic stroke. A low score doesn't remove the pericardioversion thrombus risk. Ablation is for persistent symptomatic AF despite other therapies.

46.  Answer: E. Dyspnea on exertion as an anginal equivalent from coronary heart disease   [CAD / ACS]

Rationale: DOE is the most common INITIAL presentation of CAD in older adults. Anginal equivalents include dyspnea, epigastric pain, fatigue, confusion, and malaise. Older patients have an impaired 'ischemia warning system': on treadmill testing, patients over 70 took more than twice as long to report angina after ECG-documented ischemia. If symptoms fit a supply/demand mismatch with no better explanation, work up CHD.

Why not the others: Attributing exertional dyspnea to aging, anxiety, GERD, or lung decline misses ischemia.

47.  Answer: D. Hypertension   [Stroke / TIA]

Rationale: Stroke risk factors: age, HTN, HLD, AFib, OSA, tobacco/alcohol, sedentary lifestyle. HTN is the most significant and modifiable risk factor; BP is the single most important treatable risk factor for stroke. Lowering BP by 10/5 reduces stroke by about 40%. About 80% of strokes are ischemic: ⅔ thrombotic, ⅓ embolic (AF, valvular disease, PFO).

Why not the others: Age, family history, and sex are not modifiable. A sedentary lifestyle matters, but HTN is the most significant modifiable factor.

48.  Answer: C. Immediate synchronized electrical cardioversion   [Arrhythmia / AFib]

Rationale: Hemodynamic compromise → IMMEDIATE cardioversion, regardless of AF duration or anticoagulation status. Start anticoagulation alongside if possible, but don't delay.

Why not the others: The 4-week anticoagulation and TEE pathways are for STABLE patients with AF of 48 hours or more (or unknown duration). Oral meds and discharge are inappropriate in shock.

49.  Answer: A. Continue medical management; with EF >35%, there is no all-cause mortality difference between optimized medical therapy and an initial invasive approach   [CAD / ACS]

Rationale: It is safer to defer cath for initial medical management in stable ischemic heart disease. With EF >35%, optimized medical therapy and an initial invasive approach have the same all-cause mortality. Consider cath for high risk of severe CAD or symptoms refractory to maximal therapy. Cath improves survival in multivessel disease with EF <35%.

Why not the others: Age is not an indication for cath or CABG. Statins can continue (start low, go slow; consider life expectancy). PCI in stable disease treats symptoms but doesn't improve survival.

50.  Answer: E. A beta-blocker, such as metoprolol   [CAD / ACS]

Rationale: Asymptomatic SIHD: antiplatelet (aspirin 81 or clopidogrel 75) plus a statin. Symptomatic: add anti-anginals (beta-blocker, CCB, nitrates, ranolazine). PCI is for symptoms that persist despite medical therapy. Refer everyone to cardiac rehab. His HR and BP leave room for a beta-blocker.

Why not the others:DAPT isn't indicated in stable angina without a recent ACS or stent. Warfarin has no role. A thiazide isn't anti-anginal. PCI comes after medical failur