CCS Treatment Planning & Management 2 — Questions and Answers
Question 1: A patient with HFrEF (EF 30%) is already on optimal doses of ACE inhibitor and beta-blocker. What is the next recommended addition to reduce mortality?
- Add digoxin
- Add spironolactone (MRA) (Correct answer)
- Add amlodipine
- Add hydralazine only
Correct answer: Add spironolactone (MRA)
Mineralocorticoid receptor antagonists (MRAs) like spironolactone or eplerenone are guideline-recommended as a third pillar of HFrEF therapy to further reduce mortality.
Question 2: Which anticoagulant strategy is preferred for a patient with non-valvular atrial fibrillation and a CrCl of 40 mL/min?
- Warfarin with tight INR control
- Apixaban at reduced dose (Correct answer)
- Rivaroxaban standard dose
- Dabigatran 150 mg BID
Correct answer: Apixaban at reduced dose
Apixaban at reduced dose (2.5 mg BID) is preferred in moderate renal impairment because it has the most evidence for safety and efficacy at CrCl 25–49 mL/min.
Question 3: A patient post-STEMI has a residual EF of 28% after 3 months of optimal medical therapy. Which device therapy should be discussed?
- Cardiac resynchronization therapy (CRT) alone
- Implantable cardioverter-defibrillator (ICD) (Correct answer)
- Permanent pacemaker
- Wearable cardioverter-defibrillator only indefinitely
Correct answer: Implantable cardioverter-defibrillator (ICD)
An ICD is indicated for primary prevention of sudden cardiac death when EF remains ≤35% at least 40 days post-MI on optimal medical therapy.
Question 4: Which medication should be avoided in a patient with symptomatic hypotension (SBP 80 mmHg) and acute decompensated heart failure?
- IV furosemide
- IV dobutamine
- Oral ACE inhibitor (Correct answer)
- Low-dose IV nitroglycerin
Correct answer: Oral ACE inhibitor
Oral ACE inhibitors are contraindicated in acute decompensated HF with symptomatic hypotension because they further reduce preload and afterload, worsening perfusion.
Question 5: A patient with stable angina and diabetes has a three-vessel CAD with SYNTAX score of 33. What revascularization strategy does current evidence favor?
- PCI with drug-eluting stents to all vessels
- CABG (Correct answer)
- Medical therapy alone
- Staged PCI over 3 sessions
Correct answer: CABG
High SYNTAX scores (≥33) in three-vessel CAD, especially with diabetes, favor CABG over PCI based on improved survival and lower MACCE rates.
Question 6: Which antihypertensive class is the first-line agent for hypertension in a patient with proteinuric chronic kidney disease?
- Beta-blocker
- Calcium channel blocker
- ACE inhibitor or ARB (Correct answer)
- Thiazide diuretic
Correct answer: ACE inhibitor or ARB
ACE inhibitors or ARBs are first-line in CKD with proteinuria because they reduce intraglomerular pressure and slow progression independent of blood pressure lowering.
Question 7: A patient on warfarin for mechanical mitral valve (INR target 2.5–3.5) needs elective colonoscopy. What is the recommended bridging approach?
- Stop warfarin 5 days before; bridge with therapeutic LMWH (Correct answer)
- Continue warfarin unchanged
- Switch to aspirin perioperatively
- Stop warfarin 2 days before; no bridging needed
Correct answer: Stop warfarin 5 days before; bridge with therapeutic LMWH
Patients with mechanical mitral valves are at high thrombotic risk and require therapeutic LMWH bridging when warfarin is interrupted for procedures.
CCS Treatment Planning & Management 2
A patient with HFrEF (EF 30%) is already on optimal doses of ACE inhibitor and beta-blocker.
What is the next recommended addition to reduce mortality?