Cardiology Intensive Board Review, 3 ed.

Pharmacology

Alexander Kantorovich • Michael A. Militello • Jodie M. Fink

QUESTIONS

Pharmacokinetics and Pharmacodynamics

1.P. M. is admitted to the coronary intensive care unit (ICU) with atrial fibrillation (AFib) and rapid ventricular rate. After controlling the ventricular rate with metoprolol, it is decided to initiate procainamide by intravenous (IV) infusion. P. M. weighs 80 kg. How much of a loading dose would be required to target a level of 8 μg/L? The average steady-state volume of distribution (Vd) for procainamide is 2 L/kg. The bioavailability of the IV formulation is 100%, whereas the oral (PO) form is only 83%.

a.1,000 mg

b.1,300 mg

c.1,500 mg

d.1,700 mg

2.L. M. has been receiving digoxin 0.25 mg PO tablets daily. Her serum drug level is 1.8 ng/mL. She is no longer able to take PO medications and needs to receive digoxin IV. By what percentage do you need to decrease the dose to maintain the current digoxin level?

a.10%

b.25%

c.40%

d.50%

3.What two pharmacokinetic parameters alter the half-life of medications?

a.Loading dose and clearance

b.Absorption and clearance

c.Vd and clearance

d.Absorption and Vd

4.What is the relationship between drug concentration and pharmacologic effect known as?

a.Pharmacokinetics

b.Pharmacogenetics

c.Pharmacology

d.Pharmacodynamics

5.Each line in Figure 5.1 represents a β-blocker in development. Which β-blocker is the most potent?

a.A

b.B

c.C

d.Potency cannot be determined from the above graph

Figure 5.1 • Relationship between drug concentration and effect.

6.Ethanol alters the metabolism of warfarin. Two types of ethanol abuse are chronic ethanol abuse and binge ethanol drinking. How do these types of ethanol use alter warfarin metabolism? Chronic ethanol use _____ and binge ethanol drinking _____.

a.decreases warfarin metabolism, increases warfarin metabolism

b.decreases warfarin metabolism, decreases warfarin metabolism

c.increases warfarin metabolism, decreases warfarin metabolism

d.increases warfarin metabolism, increases warfarin metabolism

7.Which of the following drugs can significantly increase digoxin concentrations?

a.Amiodarone

b.Metoprolol

c.Simvastatin

d.Fenofibrate

Angiotensin-Converting Enzyme (ACE) Inhibitors

8.Which of the following statements is true with regard to ACE inhibitors?

a.Mortality benefit in heart failure (HF) patients is a class effect with ACE inhibitors, and all are Food and Drug Administration (FDA) approved for this indication.

b.ACE inhibitor dose is negligible in HF with regard to mortality benefit.

c.Sodium depletion is an important factor in the development of renal insufficiency associated with ACE inhibitors.

d.ACE inhibitor–associated potassium retention is related to the increase in feedback that leads to aldosterone release.

β-Blockers

9.Match the properties with the associated β-blocking agents.

1. Pindolol i. α-Blockade

2. Propranolol ii. Intrinsic sympathomimetic activity (ISA)

3. Labetalol iii. Membrane-stabilizing activity

4. Bisoprolol iv. β1-Selectivity

a.(1) iv; (2) ii; (3) iii; (4) i

b.(1) iii; (2) i; (3) ii; (4) iv

c.(1) ii; (2) iii; (3) i; (4) iv

d.(1) ii; (2) iv; (3) iii; (4) i

Calcium Channel Blockers (CCBs)

10.By which of the following mechanisms do diltiazem and verapamil slow ventricular rate in patients with AFib?

a.They decrease the conduction velocity within the atrioventricular (AV) node.

b.They decrease the refractory period of nodal tissue.

c.They stimulate vagal tone.

d.They prolong the refractory period of atrial tissue.

11.Which of the following CCBs is indicated in patients presenting with a subarachnoid hemorrhage?

a.Verapamil

b.Diltiazem

c.Isradipine

d.Nimodipine

Diuretics

12.Which of the following loop diuretics is a not a sulfonamide and can, therefore, be given to a patient with a sulfonamide allergy?

a.Ethacrynic acid

b.Bumetanide

c.Torsemide

d.Furosemide

13.True or False: Conivaptan is indicated for the treatment of hyponatremia for patients with underlying HF.

a.True

b.False

Inotropic Agents

14.How does digoxin improve myocardial contractility?

a.Inhibition of the Na+/K+-adenosine triphosphatase

b.Inhibition of the breakdown of cyclic adenosine monophosphate (cAMP)

c.Increases intracellular K+, leading to the opening of calcium channels

d.Directly stimulates calcium release from the sarcoplasmic reticulum

15.F. F. is a 75-year-old man with a history of HF and AFib and was initiated on amiodarone and warfarin. He has been treated for many years with captopril, furosemide, potassium, amlodipine, and digoxin. After 3 days in the hospital, the patient was sent home. One week after discharge, he developed nausea, vomiting, confusion, and symptomatic ventricular tachycardia (VT). His serum digoxin concentration was 3.9 ng/mL and serum potassium level was 5.8 mmol/L. The rhythm was treated with lidocaine, and the patient is now having episodes of nonsustained VT with a blood pressure (BP) of 80/40 mmHg during each episode. What should be your next course of action?

a.Discontinue the amiodarone and digoxin and observe.

b.Discontinue the digoxin and administer digoxin-specific antibodies.

c.Decrease the dose of digoxin.

d.Discontinue digoxin and observe.

16.N. M. is a 75-year-old woman with a long-standing history of HF secondary to viral cardiomyopathy. She presents to the outpatient clinic for routine follow-up. On examination, she was short of breath and reported increasing orthopnea. She was admitted to the ICU for right heart catheterization. Initial readings show a cardiac index of 1.8 L/min/m2, elevated pulmonary capillary wedge pressure (25 mmHg), and high pulmonary pressures (72/45 mmHg). Her initial BP was 105/55 mmHg, and she had a heart rate of 105 beats per minute (bpm). Home medications include captopril, spironolactone, metoprolol XL, and furosemide. Which of the following inotropic agents would be most appropriate?

a.Dopamine

b.Dobutamine

c.Milrinone

d.Isoproterenol

Anticoagulation

17.Which of the following statements is true regarding vitamin K administration?

a.Subcutaneously administered vitamin K exhibits the same bioavailability as oral or IV vitamin K

b.IV vitamin K is superior at lowering the INR than oral vitamin K at similar doses

c.IV vitamin K works faster to lower the INR than oral vitamin K at similar doses

d.Rates of anaphylaxis are similar between oral and IV administration of vitamin K

18.Which of the following agents bind only to factor Xa?

a.Enoxaparin

b.Fondaparinux

c.Bivalirudin

d.Unfractionated heparin (UFH)

19.A. F. is a 52-year-old man with a history of AFib, transient ischemic attacks, hypertension (HTN), and rheumatic heart disease. The recommendations from the Sixth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy suggest that this patient be initiated on _____ for antithrombotic therapy because of AFib.

a.aspirin, 81 mg daily

b.aspirin, 325 mg daily

c.warfarin, with a target goal international normalized ratio (INR) of 2.5

d.warfarin, with a target goal INR of 3.5

20.The patient above is going to be electively cardioverted. What is the timing of PO anticoagulant therapy?

a.Warfarin with a target INR of 3.5 for 4 weeks before cardioversion and continued for 6 weeks after cardioversion

b.Warfarin with a target INR of 3.5 for 3 weeks before cardioversion and continued for 6 weeks after cardioversion

c.Warfarin with a target INR of 2.5 for 3 weeks before cardioversion and continued for 4 weeks after cardioversion

d.Warfarin with a target INR of 2.5 for 6 weeks before cardioversion and continued for 6 weeks after cardioversion

21.Heparin must first bind to _____ to exert its anticoagulant activity.

a.antithrombin

b.thrombin

c.factor X

d.protein C

22.J. M. was initiated on heparin and was given a 5,000-unit bolus. Five minutes after the loading dose of heparin, she began to have bloody emesis, and her systolic pressure dropped to 80 mmHg. How much protamine will she require?

a.25 mg

b.50 mg

c.75 mg

d.100 mg

23.Patients who develop heparin-induced thrombocytopenia have an in vitro cross-reactivity with low-molecular-weight heparin (LMWH) by what percent?

a.90% to 100%

b.60% to 70%

c.25% to 45%

d.5% to 10%

24.A patient with a recent history of heparin-associated antibodies presents with new-onset symptomatic AFib and requires anticoagulation. Other significant past medical history includes severe renal failure secondary to long-standing HTN. The patient’s baseline serum creatinine is 4 mg/dL, with an estimated creatinine clearance of 10 mL/min. Which of the following choices is the best initial therapy?

a.Lepirudin, 0.4 mg/kg bolus, then 0.15 mg/kg/h

b.Lepirudin, 0.2 mg/kg bolus, then 0.15 mg/kg/h

c.Argatroban, 2 μg/kg/min

d.Enoxaparin, 1 mg/kg SC daily

Antiplatelet Agents

25.What is the maximum dose of aspirin that can be concomitantly administered with ticagrelor?

a.81 mg

b.100 mg

c.162 mg

d.325 mg

26.All of the following are differences between clopidogrel and ticagrelor except?

a.Time to maximum platelet inhibition after bolus administration

b.Number of metabolic enzyme activations to active drug

c.Irreversible versus reversible effect at the P2Y12 receptor

d.The number of days to discontinue therapy prior to CABG

27.Respiratory diseases should be closely monitored with the use of which of the following antiplatelet agents?

a.Clopidogrel

b.Prasugrel

c.Ticagrelor

d.Eptifibatide

28.Which of the following side effects differentiate ticlopidine from clopidogrel?

a.Diarrhea

b.Rash

c.Neutropenia

d.Thrombotic thrombocytopenic purpura

29.By which of the following mechanisms do clopidogrel and ticlopidine exert their antiplatelet effects?

a.Cyclo-oxygenase inhibitor

b.Glycoprotein IIb/IIIa inhibitor

c.Adenosine diphosphate (ADP) inhibitor

d.Direct thrombin inhibitor

30.Which of the following glycoprotein IIb/IIIa inhibitors has the highest incidence of severe thrombocytopenia?

a.Tirofiban

b.Abciximab

c.Eptifibatide

d.The incidence is not different between the different agents

31.Which of the following glycoprotein IIb/IIIa inhibitors has the shortest half-life but the longest duration of therapy?

a.Tirofiban

b.Eptifibatide

c.Abciximab

d.Lamifiban

Antiarrhythmic Agents

32.Dronedarone use is contraindicated in which patient population?

a.Post-acute myocardial infarction

b.Severe renal impairment

c.NYHA class IV heart failure

d.1st degree AV block

33.Y.K is a 65-year-old male with symptomatic paroxysmal atrial fibrillation and heart failure recently admitted to the hospital for decompensation. The decision has been made to restore sinus rhythm and utilize antiarrhythmic therapy for rhythm control. Which of the following antiarrythmic agents is most appropraite to use in this patient for rhythm control?

a.Dofetalide

b.Dronedarone

c.Flecanide

d.Quinidine

34.Which of the following agents is effective for converting AFib to sinus rhythm and for maintaining sinus rhythm after it is restored?

a.Digoxin

b.Amiodarone

c.Diltiazem

d.Propranolol

35.M. G., a 50-year-old man, collapsed at home after shoveling his sidewalk. His son initiated cardiopulmonary resuscitation immediately, and an emergency medical service was called. When the squad arrived, it was determined that M. G. was in ventricular fibrillation (VF), and he was cardioverted with 200, 300, and 360 J. Epinephrine was given, and M. G. was shocked again. M. G. was still in VF. It was decided to initiate antiarrhythmic therapy. Choose the most appropriate agent from the list below.

a.Lidocaine

b.Amiodarone

c.Procainamide

d.Bretylium

Acute Coronary Syndromes

36.G. M. is a 45-year-old man presenting with a non-ST-segment-elevation myocardial infarction (MI). His creatinine clearance is estimated to be 30 mL/min. You would like to initiate eptifibatide. Which of the following doses would be the best choice?

a.Loading dose of 180 μg/kg and a maintenance of 2 μg/kg/min

b.Loading dose of 90 μg/kg/min and a maintenance dose of 2 μg/kg/min

c.Loading dose of 180 μg/kg and a maintenance dose of 1 µg/kg/min

d.Loading dose of 90 µg/kg/min and a maintenance dose of 1 µg/kg/min

37.M. M. is a 39-year-old man with an inferior wall non-ST-segment-elevation MI. He has a history of poorly controlled HTN and diabetes mellitus (DM). You initiate aspirin, clopidogrel, and atorvastatin. His baseline serum creatinine is 3.4 mg/dL and you estimate his creatinine clearance to be 25 mL/min. What dose of enoxaparin would you choose?

a.1 mg/kg every 12 hours

b.1 mg/kg daily

c.Enoxaparin is not indicated at this time

d.Fondaparinux is safer to use in M. M.

38.B. B. is a 77-year-old man who presents with typical chest pain and pressure. He has ST elevations in lead V2–4. He is 80 kg with a serum creatinine of 0.7 mg/dL with an estimated creatinine clearance of 75 mL/min. You initiate aspirin, clopidogrel, metoprolol, and atorvastatin. You want to initiate enoxaparin and reteplase. What is the enoxaparin dose for this patient?

a.Loading dose of 30 mg IV once followed immediately by 1 mg/kg every 12 hours

b.Loading dose of 30 mg IV once followed by 0.75 mg/kg every 12 hours

c.1 mg/kg daily

d.0.75 mg/kg every 12 hours

39.Which of the following is not a risk factor for intracranial hemorrhage in patients receiving fibrinolytic therapy in the treatment of ST-segment-elevation MI?

a.HTN

b.Body weight

c.Age

d.Time to presentation

40.R. M. is a 65-year-old man presenting to the emergency department (ED) with an ST-segment-elevation MI. It is decided to initiate thrombolytic therapy to induce reperfusion. The patient weighs 72 kg. What is the most effective dose of alteplase for this patient?

a.0.9 mg/kg, with a maximum of 90 mg

b.15 mg bolus; then 54 mg over 30 minutes; then 36 mg over 60 minutes

c.15 mg bolus; then 50 mg over 30 minutes; then 35 mg over 60 minutes

d.60 mg over 1 hour; then 20 mg per hour for 2 hours

Hyperlipidemia

41.M. R. is a 74-year-old man with a history of hypercholesterolemia treated with simvastatin. Two months ago he had a permanent pacemaker placed for sick sinus syndrome. He now presents with a 1-month history of fever, chills, and unexplained weight loss. On physical examination he has a new tricuspid regurgitation murmur. A transesophageal echocardiogram confirms your suspicion of endocarditis. Which of the following antibiotics increases the risk of rhabdomyolysis when given with simvastatin?

a.Ceftriaxone

b.Vancomycin

c.Daptomycin

d.Linezolid

42.Put the following regimens in order according to their low-density lipoprotein (LDL)-lowering ability.

Atorvastatin, 10 mg daily (A)

Cholestyramine, 8 g daily (C)

Pravastatin, 20 mg daily (P)

Gemfibrozil, 600 mg twice daily (G)

a.A > P > C > G

b.P > A > G > C

c.A > P > G > C

d.A > C > P > G

43.D. L. is a 76-year-old white man with a past medical history significant for DM type 2 and HTN. Chronic AFib was recently diagnosed with coronary artery disease (CAD) and hypercholesterolemia and he was initiated on gemfibrozil 600 mg twice daily and atorvastatin 40 mg daily. His other medications include glyburide, metoprolol, furosemide, levothyroxine, insulin, and aspirin. Two weeks later, he began to experience pain in his right calf, with pain and stiffness throughout his back, buttocks, and thigh. After another week, he was admitted to the hospital with similar heightened symptoms. On admission, his blood urea nitrogen was elevated, and the urinalysis showed orange, cloudy urine; protein, greater than 300; glucose, greater than 1,000; ketones, 2+; hemoglobin, 3+; red blood cell count, 6 to 10; and myoglobin, 1,367. Which of the following statements is true?

a.The patient is experiencing rhabdomyolysis secondary to the drug interaction of atorvastatin and glyburide.

b.Forced diuresis with urine alkalinization and discontinuation of gemfibrozil and atorvastatin are indicated for this patient.

c.Atorvastatin is contraindicated in a patient with DM type 2 and HTN.

d.If nicotinic acid, rather than gemfibrozil, had been used for hypercholes- terolemia, this reaction would have been prevented.

Hypertension

44.N. H. is a 57-year-old man status post MI with a BP of 150/88 mmHg and a heart rate of 87 bpm. He is currently on aspirin, clopidogrel, atorvastatin, and lisinopril. Which agent would be the most appropriate addition for treatment of his HTN?

a.Hydrochlorothiazide

b.Metoprolol

c.Clonidine

d.Losartan

45.B. T. is a 56-year-old woman with long-standing HTN that is difficult to control. She is currently being treated with amlodipine 10 mg daily, lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, and clonidine 0.4 mg three times daily. She presented to the emergency room, and her initial BP was 200/110 mmHg. She states she had run out of one of her medications. Which one of her medications would most likely be implicated in causing hypertensive urgency?

a.Amlodipine

b.Lisinopril

c.Hydrochlorothiazide

d.Clonidine

46.C. P. is a 46-year-old white man admitted with worsening headache, and nausea and vomiting over 48 hours. The patient is status post single-lung transplant secondary to α1-antitrypsin deficiency. His immunosuppression regimen includes cyclosporine, prednisone, and azathioprine. As a result of the cyclosporine, he has HTN and renal dysfunction (baseline serum creatinine, 1.9 mg/dL). His BP is controlled with clonidine 0.2 mg twice daily and metoprolol tartrate 25 mg twice daily. Two months ago, he was changed to metoprolol from amlodipine because of peripheral edema. The patient was in his usual state of health until approximately 1 week ago, when he experienced diarrhea, which has since resolved. On admission, his BP was 208/110 mmHg and his serum creatinine was 3.8 mg/dL. What is the most appropriate regimen to control this patient’s BP?

a.Change back to amlodipine 10 mg daily

b.Initiate nitroprusside drip and give IV fluids

c.Add captopril to the regimen and titrate to effect

d.Give sublingual nifedipine

Heart Failure

47.R. W. is a 60-year-old woman with HF (left ventricular ejection fraction <30%) who has HTN with a BP of 152/90 mmHg. Her potassium is 4.0 mg/dL and serum creatinine is stable at 1.5 mg/dL. She is currently on digoxin and furosemide. Which regimen is most appropriate to initiate in this patient?

a.Hydralazine 25 mg four times daily

b.Metoprolol tartrate 12.5 mg twice daily

c.Valsartan 20 mg twice daily

d.Lisinopril 5 mg daily

48.A. V. is a 49-year-old woman with a history of HF presenting to the ED for the second time in a month with acutely decompensated HF. She has dyspnea at rest and 3+ edema in her lower extremities. Her serum creatinine is 1.8 mg/dL and BP is 90/60 mmHg. Her home regimen includes enalapril 20 mg twice daily, carvedilol 3.125 mg twice daily, and furosemide 40 mg PO daily. Which of the following is most appropriate for this patient?

a.Admit her to the hospital for IV furosemide therapy and hemodynamic monitoring.

b.Admit her to the hospital for diuresis with nesiritide.

c.Initiate an infusion of nesiritide in the ED and reassess in 4 hours.

d.Schedule intermittent outpatient infusions of nesiritide.

49.A patient with New York Heart Association class III HF was hospitalized 2 months ago for an exacerbation of his HF. The patient was discharged on lisinopril, furosemide, and digoxin. His lungs are clear and his vital signs are as follows: BP, 105/56 mmHg; heart rate, 84 bpm; and respiration rate, 18. Which regimen is most appropriate to initiate in this patient?

a.Atenolol 50 mg daily

b.Carvedilol 3.125 mg twice daily

c.Carvedilol 25 mg twice daily

d.Metoprolol tartrate 50 mg twice daily

50.Which β-blockers are recommended for use for patients with HF?

a.Metoprolol tartrate, pindolol, propranolol

b.Carvedilol, metoprolol succinate, bisoprolol

c.Metoprolol succinate, metoprolol tartrate, carvedilol

d.Metoprolol tartrate, carvedilol, bisoprolol

51.Y. J. is a 67-year-old African American man with HF who has been treated with lisinopril 20 mg daily, metoprolol succinate 25 mg daily, furosemide 40 mg twice daily, and spironolactone 12.5 mg daily. Despite his current therapy, he still complains of shortness of breath while conducting usual daily activities. What is the most appropriate change that should be made to his regimen?

a.Increase spironolactone

b.Start hydralazine

c.Initiate isosorbide dinitrate and hydralazine

d.Increase lisinopril

52.Which of the following statements is true?

a.Serum levels are used to guide the selection of the dose of digoxin.

b.Because spironolactone was found to have mortality benefit in the Randomized Aldactone Evaluation Study (RALES), the addition of spironolactone should be considered for all HF patients.

c.The benefit of long-term IV inotropic therapy may outweigh the increased mortality risk in refractory patients unable to be weaned from IV inotropic support.

d.Digoxin exhibits both symptomatic and mortality benefit in patients with HF.

Endocarditis

53.One month ago, a 37-year-old woman with sinus infection responded well to a 14-day course of amoxicillin/clavulanate 875/125 mg twice daily. She is scheduled for a root canal in 1 week. In the past, her dentist had prescribed one dose of clindamycin 600 mg, 1 hour prior to any dental work, for endocarditis prophylaxis because of her history of mitral valve prolapse. Realizing she has not received her prescription, the patient calls the dentist’s office for an antibiotic. What prophylaxis is indicated for this patient?

a.Amoxicillin 2 g PO 1 hour before the procedure

b.Clindamycin 600 mg PO 1 hour before the procedure

c.Azithromycin 500 mg PO 1 hour before the procedure

d.No prophylaxis recommended in this patient

54.S. C. is a 59-year-old woman diagnosed with enterococcal endocarditis. She has no known drug allergies. Which of the following would exhibit standard therapy?

a.Penicillin G, 5 million units IV every 4 hours for 4 to 6 weeks, plus gentamicin, 2.5 mg/kg IV every 8 hours for 4 to 6 weeks

b.Ampicillin, 2 g IV every 4 hours for 4 to 6 weeks, plus gentamicin, 1 mg/kg IV every 8 hours for 4 to 6 weeks

c.Ampicillin, 2 g IV every 4 hours for 4 to 6 weeks, plus gentamicin, 1 mg/kg IV every 8 hours for 3 to 5 days

d.Vancomycin, 30 mg/kg per 24 hours in two equally divided doses for 4 to 6 weeks