CLINICAL THERAPEUTICS IV CARDIOVASCULAR MODULE EXAM 2 (DYSLIPIDEMIA, ACUTE MI, CORONARY ARTERY DISEASE) FALL 2010

NAME

HONOR PLEDGE (SIGNATURE)

Questions 1 2 refer to the following case ME is 62 YO semi-retired construction worker with a 9-year history of CAD presenting to the cardiology clinic today. He describes a 2-week history of chest pain that occurs 3-4 times per day with even the minor activity (showering, getting dressed, walking to the mailbox). Most of these episodes have resolved with rest, but he has used his sublingual NTG on three occasions the last week. He denies any symptoms at rest, but is worried about a recurrent AMI. He is enrolled in Medicare D, but remains concerned about the mounting cost of his medications. His current medications include lisinopril 10 mg PO Qday, metoprolol 50 PO BID, simvastatin 40 mg PO Qday, and NTG 0.4 mg SL PRN. In clinic today, his BP is 146/76 mmHg (average of 3 measurements) and HR is 68 bpm. Labs reveal eGFR >60 mL/min. 1. How would you classify MEs angina according to Candandian Cardiovascular Society Classification? a. Class I b. Class II c. Class III d. Class IV 2. Which of the following prescriptions should ME receive today? a. Amlodipine 5 mg PO QDay b. Nitroglycerin 0.4 mg SL 30 min prior to minor activity c. Ranolazine ER 500 mg PO BID d. Isosorbide mononitrate 60 mg PO Qday 3. Which of the following classes of medications produces the most profound reduction in arterial vascular resistance (afterload)? a. Beta-blockers b. Dihydropyridine (DHP) calcium channel-blockers c. Long-acting nitrates d. Ranolazine

Question 4 5 refer to the following case BF is 47 YO female brought to the ED yesterday evening by ambulance following an episode of crushing substernal chest pain from her local gymnasium. Earlier this week she began a self-directed weight-loss program and noted the onset severe shortness of breath, chest pain, and diaphoresis after approximately 5 minutes on the elliptical machine. She immediately called for help and the gymnasium staff promptly called 911. The chest pain resolved en route to the ED following administration of 3 doses of SL nitroglycerin in the ambulance. BF has now completed an extensive 12-hour cardiac work-up to rule-out AMI (including ECG, troponins) and is now preparing for discharge following a 12-hour observation in the ED. Her resting BP in the ED this morning is 144/88 mmHg (HR = 80 bpm). Her medications prior to admission are amlodipine 10 mg PO Qday and aspirin 81 mg PO Qday. 4. Which of the following recommendations should you make regarding BFs regimen? I. Discontinue amlodipine II. Add metoprolol 12.5 mg PO BID III. Add nitroglycerin 0.4 mg SL PRN a. II only b. III only c. II and III d. I, II, and III 5. BF returns to clinic 4 weeks later and reports that she feels much better. Two times during the last month she has experienced mild angina toward the end of her 30-minutes aerobics course. Both episodes resolved promptly with rest and she has experienced no other anginal episodes. How would you classify BFs angina according to Candandian Cardiovascular Society Classification? a. Class I b. Class II c. Class III d. Class IV 6. GM is a 65 year old male who presented to the Emergency Department complaining of chest pain. Upon evaluation by the healthcare provider, he is found to have ST segment elevation MI. What of the following most appropriately describes the pathogenesis of this patients condition? a. A blocked coronary artery b. Chest pain and diaphoresis c. Acute plaque rupture and thrombosis d. ST segment elevation 7. BB is being evaluated for risk factors for his coronary artery disease. His healthcare provider decides to place BB on daily aspirin therapy. Which of the following most accurately describes the mechanism of action of aspirin? a. Inhibits arachidonic acid formation b. Inhibits Adenosine Diphosphate activity c. Inhibits thromboxane A2 formation d. Inhibits Glycoprotein IIb/IIIa receptor

8. A patient presents to the ER complaining of chest pressure. An EKG is performed that shows ST segment elevation in leads V4, V5, and V6. What is the most likely coronary artery that is affected? a. LCX b. LAD c. OM1 d. RCA 9. AG is a 55 year old male who presents to the Emergency Department with a chief complaint of chest pain. He is given aspirin, nitroglycerin, metoprolol, oxygen, clopidogrel, and started on a heparin drip in preparation for going to the cardiac catheterization lab. Which of the agents that AG is being treated with will not help reduce his mortality? a. Aspirin b. Beta Blockers c. Nitroglycerin d. Clopidogrel 10. AG is a 72 year old female who is due to undergo cardiac catheterization. Her weight is 57 kg. What is the most appropriate dose of prasugrel for this patients? a. 60 mg load and 10 mg by mouth daily b. 60 mg load and 5 mg by mouth daily c. 30 mg load and 10 mg by mouth daily d. 30 mg load and 5 mg by mouth daily 11. A patient is admitted with an acute myocardial infarction and is taken to the catheterization lab. Upon receiving laboratory results back, it is discovered that the patient has a platelet count of 80,000. Which of the following would be the preferred agent to use in this patient in order to place a coronary stent? a. enoxaparin b. bivalirudin c. abciximab d. eptifibatide 12. Of the following drugs used in the treatment of a patient with a STEMI, which agent is a reversible inhibitor of platelet aggregation? a. Aspirin b. Ticagrelor c. abciximab d. clopidogrel

13. Decreasing the input/absorption rate from an oral dosage form, e.g., nifedipine GITS relative to an IR formulation, has the following (pharmacokinetic) PK consequences for a drug: a. Decreased peak plasma concentrations b. Increased peak-to-trough fluctuation c. Increased apparent half-life (flip-flop) d. a and c are correct e. a, b, and c are correct

14. Which of the following statements is/are correct about basic PK/PD of nitroglycerin (GTN)? a. GTN has active circulating metabolites, 1,2-GDN and 1,3-GDN. b. At the vascular wall, GTN is denitrated enzymatically involving thiol groups, to form nitric oxide (NO). c. NO crosses the plasma membrane and inhibits phosphodiesterase, raising intracellular cGMP and causing smooth muscle relaxation. d. a and b are correct. e. a, b and c are correct. 15. Which of the following statements is correct about transdermal (TDS) GTN? a. Reasonably constant GTN plasma concentrations are sustained for up to 24 hours b. Plasma concentrations of GTN metabolites (1,2-GDN and 1,3-GDN) are much lower than GTN c. After a single dose, the hemodynamic and anti-anginal effects decline despite maintaining constant plasma concentrations d. a and c are correct e. a, b and c are correct 16. The primary hemodynamic basis for calcium channel blockers to relieve angina is increasing coronary blood supply. a. True b. False 17. An angina patient who took Sildenafil (VIAGRA) 3 hours ago now has angina attack. Which of the following drugs should NOT be used? a. Nifedipine b. Nitroglycerin c. Propranolol d. Diltiazem 18. Which of the following anti-anginal drug combinations is the LEAST likely to cause a drug-drug interaction? a. Propranolol and nitroglycerin b. Nitroglycerin and nifedipine c. Propranolol and verapamil d. Propranolol and diltiazem

19. A stable angina patient has been under extensive emotional stress latterly and using a nitroglycerin patch to prevent angina for one week. This treatment is not as effective as before now. Which of the followings would be an appropriate intervention? a. Add amyl nitrite ampoules b. Switch nitroglycerin patch to a long-acting oral nitrate c. Initiate propranolol d. a and b

20. Cholestyramine lowers LDL levels by which of the following mechanisms? a. Inhibition of bile acid absorption b. Inhibition of HMG-CoA reductase c. Inhibition of cholesterol absorption d. Inhibition of lipoprotein lipase e. Inhibition of VLDL release 21. The primary action of which of the following agents is to increase the activity of lipolysis in adipose tissue? a. gemfibrozil (Lopid) b. niacin (Generic) c. cholestyramine (Questran) d. atorvastatin (Lipitor) e. ezetimibe (Zetia) 22. A 48-year-old woman has no major medical illness but a family history of cardiovascular disease. Fasting serum lipid studies show Cholesterol total: 165 mg/dL LDL-cholesterol 130 mg/dL HDL-cholesterol 25 m/dL Triglycerides 230 mg/dL Which of the following agents would be the most appropriate pharmacotherapy for this individual? a. gemfibrozil (Lopid) b. niacin (Generic) c. cholestyramine (Questran) d. atorvastatin (Lipitor) e. ezetimibe (Zetia) 23. Which agent listed below has the highest risk of myopathy (muscular weakness) when used in combination with statins? a. cholestyramine (Questran) b. ezetimibe (Zetia) c. gemfibrozil (Lopid) d. colestipol (Colestid) e. niacin (Generic)

24. A 47 year old male patient with hypertension on lisinopril 20 mg daily presents to clinic for evaluation of his cholesterol. He reports good medication compliance, works out at the YMCA three times weekly, and follows a low fat diet. He drinks 1 to 2 beers on the weekend but does not smoke. He states that heart disease runs in his family and that his mother died of myocardial infarction at age 61. Based on this presentation, how many risk factors does this patient have? a. One b. Two

c. Three d. Four 25. A 56 year old male with CAD and hypercholesterolemia presents for follow-up on simvastatin 40 mg daily (see fasting lipid profile below). What would be the best recommendation to achieve his LDL goal of therapy? Labs: TC TG HDL LDL ALT hs-CRP 167 140 41 98 20 6 a. b. c. d. Continue simvastatin 40 mg daily Add fenofibrate 145 mg daily Switch to pravastatin 40 mg daily Add ezetimibe 10 mg daily

26. Patients with peripheral vascular disease (PVD) or abdominal aortic aneurysm (AAA) are considered to have the same cardiovascular risk as patients with established coronary artery disease (CAD). Which of the following is also a coronary risk equivalent? a. Asthma b. Diabetes c. Hypothyroidism d. Hyperparathyroidism Questions 28 29 refer to the following case A 62 year old patient with type 2 diabetes returns to clinic after being discharged from the hospital following a myocardial infarction. He is overweight, continues to smoke and has elevated blood pressure. 27. Which of the following represents the most appropriate lipid goal for this patient? a. LDL cholesterol less than 70 mg/dL b. HDL cholesterol less than 30 mg/dL c. LDL cholesterol less than 130 mg/dL d. HDL cholesterol less than 70 mg/dL 28. After taking atorvastatin 40 mg daily for 6 weeks, the patient returns for follow-up (see fasting lipid profile below). Which of the following represents the most appropriate drug therapy change for this patient? Labs: TC TG HDL LDL ALT 190 175 27 128 21 a. b. c. d. Increase atorvastatin to 80 mg daily Add niaspan 500 mg at bedtime Switch to simvastatin 40 mg daily Add gemfibrozil 600 mg twice daily

29. After initiating therapeutic lifestyle changes (TLC), a patient asks what he can implement in addition to exercise to lower his cholesterol. Which of the following is most appropriate for this patient? a. Add 3 grams of red yeast rice twice daily b. Add 5 grams of sustained release niacin daily c. Add 80 mg of ginkgo biloba three times daily d. Add 1 gram of omega 3-fatty acids (fish oil) daily

30. A 68 year old male with atrial fibrillation on warfarin, presents for evaluation of elevated LDL cholesterol. Because of myalgias on atorvastatin and simvastatin, his physician would like to start this patient on colestipol. Which of the following is the best advice concerning this regimen? a. Request that the physician change colestipol to rosuvastatin b. Take colestipol at least 2 hours before, or 6 hours after warfarin c. Take colestipol with levothyroxine in the morning, and warfarin alone at night d. Remind the physician that colestipol is only indicated for patients unable to swallow colesevelam 31. A 42 year old male with hypertension presents to clinic to follow-up on his fasting laboratory values (see labs below). Which of the following represents the most appropriate drug therapy option for this patient? Labs: TC TG HDL LDL ALT 300 683 35 130 21 a. b. c. d. Fenofibrate 145 mg daily Colestipol 10 grams twice daily Atorvastatin 10 mg daily Pitavastatin 1 mg daily

32. Lipoprotein particles are composed of a. apolipoprotein, cholesterol, lipoprotein lipase, cholesteryl esters, and triglycerides b. cholesterol, cholesteryl esters, triglycerides, prostaglandins, and fatty acids c. apolipoprotein, cholesterol, triglycerides, cholesteryl esters, phospholipids d. all of the above 33. Nitrovasodilators blockers: a. enhance the levels of calcium calmodulin complex b. reduce the levels of calcium calmodulin complex c. enhance the levels of cGMP d. reduce the levels of cGMP 34. A direct effect of calcium channel blockers is : a. enhancement in the levels of calcium calmodulin complex b. reduction in the levels of calcium calmodulin complex c. enhancement in the level of cGMP d. reduction in the level of cGMP

35. A structurally newer version of statins is being designed. Which among the following is likely to possess anti-hyperlipidemic activity in vivo?

36. Of the following three fibrates, circle the one that is expected to possess the longest duration of action.

37. Arrange the following anti-anginal molecules in the order of their increasing duration of action. Use 1 for shortest duration, 2 for next best and 3 for longest duration.

O 2NO O 2NO ONO 2

ONO 2

38. Bile Acid Sequestrants (BAS) form an important strategy to reduce high bad cholesterol in blood. For the following potential BAS rank the effectiveness in sequestering bile acids as they pass through the intestine. Use 1 for most effective, 3 for least. {HINT: Analysis should begin with the pKa value of each group present in the three structures.}

39. Calcium channel blockers suffer from the problem of rebound angina because (answer in not more than 3 sentences)

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