BCACP Cardiovascular Disease Management 4 — Questions and Answers
Question 1: A patient with non-valvular atrial fibrillation and CrCl of 28 mL/min requires anticoagulation. Which DOAC is preferred and at what dose adjustment?
- Apixaban 2.5 mg BID (if age ≥80, weight ≤60 kg, or SCr ≥1.5 mg/dL—at least 2 criteria met) (Correct answer)
- Rivaroxaban 15 mg daily
- Dabigatran 75 mg BID
- Edoxaban 30 mg daily
Correct answer: Apixaban 2.5 mg BID (if age ≥80, weight ≤60 kg, or SCr ≥1.5 mg/dL—at least 2 criteria met)
Apixaban is preferred in severe CKD and ESRD due to the least renal elimination (~27%), with dose reduction to 2.5 mg BID when at least 2 of 3 criteria are met (age ≥80, weight ≤60 kg, SCr ≥1.5).
Question 2: A 62-year-old male patient with a recent STEMI is discharged on dual antiplatelet therapy (aspirin + ticagrelor). When should aspirin be taken relative to ticagrelor to avoid reduced efficacy?
- Aspirin doses should be limited to ≤100 mg/day; high-dose aspirin blunts ticagrelor's antiplatelet effect (Correct answer)
- Aspirin should be taken at least 4 hours before ticagrelor
- Aspirin should be taken at night while ticagrelor is taken in the morning
- Aspirin and ticagrelor timing has no effect on efficacy
Correct answer: Aspirin doses should be limited to ≤100 mg/day; high-dose aspirin blunts ticagrelor's antiplatelet effect
High-dose aspirin (>100 mg/day) paradoxically attenuates ticagrelor's antiplatelet effect by blocking prostacyclin synthesis; aspirin should be maintained at ≤100 mg/day.
Question 3: A patient with HFrEF, EF 30%, NYHA class II, already on optimal medical therapy including an ACE inhibitor, beta-blocker, and aldosterone antagonist, has an EKG showing LBBB with QRS duration of 158 ms. What additional therapy should be recommended?
- Cardiac resynchronization therapy (CRT) (Correct answer)
- Digoxin
- Hydralazine/isosorbide dinitrate
- Ranolazine
Correct answer: Cardiac resynchronization therapy (CRT)
CRT is indicated in HFrEF patients with EF ≤35%, NYHA class II-IV on optimal medical therapy with LBBB and QRS ≥150 ms, as it improves symptoms, EF, and reduces mortality.
Question 4: A pharmacist reviews a patient's chart and notes that 3 days post-STEMI, the patient's troponin is still elevated. The prescriber asks about starting a statin. What is the correct recommendation?
- Start high-intensity statin immediately regardless of baseline LDL-C (Correct answer)
- Defer statin until troponin normalizes
- Start only if LDL-C is above 190 mg/dL
- Statin therapy is not indicated for troponin-positive events
Correct answer: Start high-intensity statin immediately regardless of baseline LDL-C
High-intensity statin therapy should be initiated as early as possible after ACS regardless of baseline LDL-C levels, as statins provide pleiotropic benefits beyond LDL lowering in this acute setting.
Question 5: A patient taking diltiazem for rate control in atrial fibrillation is started on simvastatin 40 mg. What is the most significant drug interaction concern?
- Diltiazem inhibits CYP3A4, increasing simvastatin exposure and risk of myopathy/rhabdomyolysis (Correct answer)
- Diltiazem induces CYP3A4, reducing simvastatin efficacy
- Diltiazem displaces simvastatin from plasma proteins
- No clinically significant interaction exists
Correct answer: Diltiazem inhibits CYP3A4, increasing simvastatin exposure and risk of myopathy/rhabdomyolysis
Diltiazem is a moderate CYP3A4 inhibitor that increases simvastatin plasma concentrations significantly, raising the risk of myopathy and rhabdomyolysis; dose should be capped or a non-CYP3A4-metabolized statin used.
Question 6: A 70-year-old patient with chronic stable angina is optimally treated with metoprolol succinate and amlodipine but remains symptomatic. What is the most appropriate add-on antianginal therapy?
- Ranolazine
- Long-acting nitrate
- Ivabradine (if HR >70 bpm and sinus rhythm)
- Either ranolazine or a long-acting nitrate are appropriate add-on options (Correct answer)
Correct answer: Either ranolazine or a long-acting nitrate are appropriate add-on options
Both ranolazine and long-acting nitrates are appropriate add-on antianginal agents when patients remain symptomatic on beta-blocker plus calcium channel blocker therapy.
Question 7: Which laboratory finding would be an absolute contraindication to initiating an aldosterone antagonist in a patient with HFrEF?
- Serum potassium ≥5.0 mEq/L or eGFR <30 mL/min (Correct answer)
- Serum sodium <135 mEq/L
- Hemoglobin <10 g/dL
- Total bilirubin >2 mg/dL
Correct answer: Serum potassium ≥5.0 mEq/L or eGFR <30 mL/min
Aldosterone antagonists are contraindicated when serum potassium is ≥5.0 mEq/L due to severe hyperkalemia risk, or when eGFR is <30 mL/min due to impaired potassium excretion.
BCACP Cardiovascular Disease Management 4
A patient with non-valvular atrial fibrillation and CrCl of 28 mL/min requires anticoagulation.
Which DOAC is preferred and at what dose adjustment?