AAFP Board Review
A 52 yo man presents with 45 minutes of squeezing substernal chest pressure radiating
to his left arm. EKG from a physical two months ago was normal. This is his current
EKG: His history and EKG are most consistent with which one of the following? -
Answers -C. Non-ST segment elevation - Acute Coronary Syndrome
EKG: ST segment depression (not elevation) in inferior and lateral precordial leads
(NSTE-ACS or NSTEMI)
A 72 yo man with NSTE-ACS (NSTEMI) presents to your rural emergency room with
onset of pain two hours ago. What is an appropriate immediate intervention? - Answers
-Oral Chewable aspirin (162-325 mg)
Ischemia-guided strategy: (lower risk patients, preference for low intervention)
1. Aspirin (non-enteric coated, chewable) 2. P2Y12 inhibitor (clopidogrel, ticagrelor) 3.
Anticoagulation (heparin)
Early invasive strategy: (higher risk patients)
Aspirin (non-enteric coated, chewable)
P2Y12 inhibitor (clopidogrel, ticagrelor)
Anticoagulation (heparin)
Consider Glycoprotein IIb/IIIa receptor blockers [Tirofiban (Aggrastat), Eptifibatide
(Integrilin), Abciximab (ReoPro)] before invasive treatment
A 55 yo male is a former smoker with type 2 diabetes mellitus, hypertension, and
hyperlipidemia. He had an ST-elevation myocardial infarction 2 years ago treated with a
drug-eluting stent. He is currently asymptomatic with unremarkable physical exam, Hgb
A1c of 6.8%, blood pressure 130/78 mm Hg and heart rate 65 beats/min. His
medications include metformin 2000 mg daily; metoprolol succinate 25 mg daily;
losartan/hydrochlorothiazide 50 mg/12.5 mg daily; rosuvastatin 20 mg daily; clopidogrel
75 mg daily; and aspirin 81 mg daily.
He would like to reduce the number of medications he is taking. You agree and explain
that guidelines recommend that he may stop taking which of the following? - Answers -
Clopidogrel
A 52 yo man has an acute myocardial infarction for which he had cardiac catheterization
and percutaneous coronary intervention with placement of two drug-eluting stents. Echo
shows an EF of 35%.
He is started on numerous medications at discharge. Which one of the following
medications is more useful for symptom control than for improving mortality for this
patient? - Answers -Nitroglycerin
ACE-inhibitors, ß-blockers, statins, and ASA improve survival post MI.
Dual anti-platelet therapy for at least a year if stents or grafts placed.
,Nitrates, calcium-channel blockers, and digoxin may improve symptoms but do not
affect survival.
A 45 yo man complains of acute, sharp chest pain relieved by leaning forward. On
examination, you hear a pericardial friction rub. The EKG shows diffuse ST elevation.
Which of the following is the most appropriate treatment - Answers -NSAIDs
Pericarditis
Common cause of chest pain in young adults, usually viral or idiopathic cause.
Relieved is typically by sitting forward.
Pain is due to inflammation.
Treatment is NSAIDs (such as indomethacin or high-dose
aspirin (2-4 g/day)
Selecting Statin Intensity
Individuals with clinical ASCVD
High-intensity or maximally tolerated statin. Goal: lower LDL by ≥50%
Primary elevations of LDL >190 mg/dL (usually familial)
High-intensity statin
40-75 yrs with diabetes and LDL ≥70 mg/dl Moderate or high-intensity statin. Goal:
lower LDL by ≥50%
40-75 yrs without clinical ASCVD or diabetes and LDL ≥70, and estimated 10-year
ASCVD risk of ≥7.5%Moderate intensity statin if a discussion of options favors statins -
Answers -High-intensity Statins (>50% LDL-C reduction) Atorvastatin 40-80 mg
Rosuvastatin 20 mg
Moderate-intensity Statins (30% to <50% LDL-C reduction)
Atorvastatin 10-20 mg Rosuvastatin 5-10 mg Simvastatin 20-40 mg Pravastatin 40-80
mg Lovastatin 40 mg Fluvastatin 40 mg bid
An 86 yo woman presents with shortness of breath and a nonproductive cough. She is
slightly tachypneic and tachycardic but temperature and BP are normal. Normal cardiac
exam but bilateral crackles on lung exam and bilateral fluffy infiltrates on CXR. A CBC,
metabolic panel, and troponin are normal. Her EKG shows sinus tachycardia. Which of
the following tests would be best to determine whether she should be treated for
pneumonia, heart failure, or both? - Answers -BNP and procalcitonin levels
•BNP (brain natriuretic peptide) is secreted from the ventricles in response to ventricular
volume expansion and pressure overload.
•Release is directly proportional to ventricular dysfunction and correlates with end-
diastolic pressure.
•BNP undergoes partial renal excretion; levels are inversely proportional to creatinine
clearance.
,•Increases in both HFrEF and HFpEF
A 72 yo male has a new diagnosis of hypertensive cardiomyopathy with left ventricular
ejection fraction of 30%. He has dyspnea at rest and with minimal exertion. Which one
of the following drugs will reduce his mortality risk? - Answers -Lisinopril
Physiologic Basis of HF Treatment
Low cardiac output triggers sympathetic neurohormonal activation, which ultimately
results in premature apoptosis of cardiac myocytes. Treatment is directed toward: -
Answers -−Preload reduction: diuretics, nitrates
−Afterload reduction: ACEI, ARB, hydralazine, nitrates
−Sympathetic blockade: ß-blockers
−Aldosterone-antagonist therapy: spironolactone,
eplerenone
A 69 yo woman with hypertension, previous MI, and EF 32% is seen in your office. She
is comfortable at rest but is breathless when walking upstairs. Her current medications
are atorvastatin, lisinopril, metoprolol succinate, furosemide, and aspirin. Her blood
pressure is 132/78. Exam: no murmur, (+) bibasilar rales, trace pretibial edema. EKG 52
beats/min, multifocal PVCs, QRS interval 0.10 sec. Adding which one of the following
would help to decrease both mortality and risk of hospitalization? - Answers -
Spironolactone (Aldactone)
−Reduce mortality and improve ejection fraction −Appropriate if GFR >30mL/min and
K+<5 mEq/dL −Avoid concomitant NSAIDs and COX-2 inhibitors −Spironolactone (but
not eplerenone) can cause breast
tenderness and gynecomastia
- decreases severity of OSA
Hydralazine Plus Isosorbide Dinitrate (BiDil) - Answers -•Vasodilator in HFrEF•Reduces
mortality rates and improves quality-of-
life measures and symptoms•Use when diuretics, β-blockers, and an ACEI (or
ARB) do not control symptoms or are not
tolerated•Particularly effective in African-Americans with
NYHA class III or IV heart failure
62 yo man with hypertension and heart failure reports dyspnea on exertion. Current
medications are enalapril 10 mg bid, carvedilol 12.5 mg bid, spironolactone 25 mg daily,
and furosemide 20 mg daily. On exam, blood pressure is 128/82 and pulse 62. An
Echocardiogram shows ejection fraction of 35% and BNP level is 250 pg/mL.
, Current American Heart Association guidelines recommend which of the following to
further reduce morbidity and mortality? - Answers -Stop enalapril and start
sacubitril/valsartan (Entresto) 49/51 mg twice
daily
In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or
ARB, replacement by an ARNI is recommended to further reduce morbidity and
mortality. (Class I)
A 70 yo man has a history of a myocardial infarction and now has heart failure with an
EF of 30%. EKG with sinus rhythm. Which one of the following medications that he is
currently taking is potentially harmful and should be discontinued? - Answers -Diltiazem
(Cardizem)
Drugs to Avoid in HFrEF
•Calcium channel blockers−Verapamil, diltiazem have potent negative inotropic effect
and are associated with worsening heart failure and increased risk of adverse
cardiovascular events. −May use amlodipine for BP lowering, but can cause leg edema
•Most antiarrhythmic drugs
•NSAIDs
•Thiazolidinediones (cause water retention)
−Pioglitazone (Actos) −Rosiglitazone (Avandia)
Advanced Heart Failure Care - Answers -•Implantable cardioverter defibrillator (ICD) to
reduce risk of sudden death due to ventricular tachyarrhythmias
−For patients with LVEF ≤35%, NYHA class II or III symptoms on meds, and life
expectancy > one year
•Cardiac resynchronization therapy (CRT) (Biventricular pacing) −For patients with
LVEF ≤35%, NYHA class II, III, or IV symptoms on meds, QRS duration ≥150 ms, and
life expectancy > one year
•Left ventricular assist devices (LVAD) as a "bridge" to recovery or transplant or other
decisions
−For patients with anticipated 1-year survival of <50%
•Heart transplantation
HFpEF Treatment
In appropriately selected patients with HFpEF
• EF ≥45%
• elevated BNP levels or HF admission within 1 year
• estimated glomerular filtration rate >30 mL/min
A 52 yo man presents with 45 minutes of squeezing substernal chest pressure radiating
to his left arm. EKG from a physical two months ago was normal. This is his current
EKG: His history and EKG are most consistent with which one of the following? -
Answers -C. Non-ST segment elevation - Acute Coronary Syndrome
EKG: ST segment depression (not elevation) in inferior and lateral precordial leads
(NSTE-ACS or NSTEMI)
A 72 yo man with NSTE-ACS (NSTEMI) presents to your rural emergency room with
onset of pain two hours ago. What is an appropriate immediate intervention? - Answers
-Oral Chewable aspirin (162-325 mg)
Ischemia-guided strategy: (lower risk patients, preference for low intervention)
1. Aspirin (non-enteric coated, chewable) 2. P2Y12 inhibitor (clopidogrel, ticagrelor) 3.
Anticoagulation (heparin)
Early invasive strategy: (higher risk patients)
Aspirin (non-enteric coated, chewable)
P2Y12 inhibitor (clopidogrel, ticagrelor)
Anticoagulation (heparin)
Consider Glycoprotein IIb/IIIa receptor blockers [Tirofiban (Aggrastat), Eptifibatide
(Integrilin), Abciximab (ReoPro)] before invasive treatment
A 55 yo male is a former smoker with type 2 diabetes mellitus, hypertension, and
hyperlipidemia. He had an ST-elevation myocardial infarction 2 years ago treated with a
drug-eluting stent. He is currently asymptomatic with unremarkable physical exam, Hgb
A1c of 6.8%, blood pressure 130/78 mm Hg and heart rate 65 beats/min. His
medications include metformin 2000 mg daily; metoprolol succinate 25 mg daily;
losartan/hydrochlorothiazide 50 mg/12.5 mg daily; rosuvastatin 20 mg daily; clopidogrel
75 mg daily; and aspirin 81 mg daily.
He would like to reduce the number of medications he is taking. You agree and explain
that guidelines recommend that he may stop taking which of the following? - Answers -
Clopidogrel
A 52 yo man has an acute myocardial infarction for which he had cardiac catheterization
and percutaneous coronary intervention with placement of two drug-eluting stents. Echo
shows an EF of 35%.
He is started on numerous medications at discharge. Which one of the following
medications is more useful for symptom control than for improving mortality for this
patient? - Answers -Nitroglycerin
ACE-inhibitors, ß-blockers, statins, and ASA improve survival post MI.
Dual anti-platelet therapy for at least a year if stents or grafts placed.
,Nitrates, calcium-channel blockers, and digoxin may improve symptoms but do not
affect survival.
A 45 yo man complains of acute, sharp chest pain relieved by leaning forward. On
examination, you hear a pericardial friction rub. The EKG shows diffuse ST elevation.
Which of the following is the most appropriate treatment - Answers -NSAIDs
Pericarditis
Common cause of chest pain in young adults, usually viral or idiopathic cause.
Relieved is typically by sitting forward.
Pain is due to inflammation.
Treatment is NSAIDs (such as indomethacin or high-dose
aspirin (2-4 g/day)
Selecting Statin Intensity
Individuals with clinical ASCVD
High-intensity or maximally tolerated statin. Goal: lower LDL by ≥50%
Primary elevations of LDL >190 mg/dL (usually familial)
High-intensity statin
40-75 yrs with diabetes and LDL ≥70 mg/dl Moderate or high-intensity statin. Goal:
lower LDL by ≥50%
40-75 yrs without clinical ASCVD or diabetes and LDL ≥70, and estimated 10-year
ASCVD risk of ≥7.5%Moderate intensity statin if a discussion of options favors statins -
Answers -High-intensity Statins (>50% LDL-C reduction) Atorvastatin 40-80 mg
Rosuvastatin 20 mg
Moderate-intensity Statins (30% to <50% LDL-C reduction)
Atorvastatin 10-20 mg Rosuvastatin 5-10 mg Simvastatin 20-40 mg Pravastatin 40-80
mg Lovastatin 40 mg Fluvastatin 40 mg bid
An 86 yo woman presents with shortness of breath and a nonproductive cough. She is
slightly tachypneic and tachycardic but temperature and BP are normal. Normal cardiac
exam but bilateral crackles on lung exam and bilateral fluffy infiltrates on CXR. A CBC,
metabolic panel, and troponin are normal. Her EKG shows sinus tachycardia. Which of
the following tests would be best to determine whether she should be treated for
pneumonia, heart failure, or both? - Answers -BNP and procalcitonin levels
•BNP (brain natriuretic peptide) is secreted from the ventricles in response to ventricular
volume expansion and pressure overload.
•Release is directly proportional to ventricular dysfunction and correlates with end-
diastolic pressure.
•BNP undergoes partial renal excretion; levels are inversely proportional to creatinine
clearance.
,•Increases in both HFrEF and HFpEF
A 72 yo male has a new diagnosis of hypertensive cardiomyopathy with left ventricular
ejection fraction of 30%. He has dyspnea at rest and with minimal exertion. Which one
of the following drugs will reduce his mortality risk? - Answers -Lisinopril
Physiologic Basis of HF Treatment
Low cardiac output triggers sympathetic neurohormonal activation, which ultimately
results in premature apoptosis of cardiac myocytes. Treatment is directed toward: -
Answers -−Preload reduction: diuretics, nitrates
−Afterload reduction: ACEI, ARB, hydralazine, nitrates
−Sympathetic blockade: ß-blockers
−Aldosterone-antagonist therapy: spironolactone,
eplerenone
A 69 yo woman with hypertension, previous MI, and EF 32% is seen in your office. She
is comfortable at rest but is breathless when walking upstairs. Her current medications
are atorvastatin, lisinopril, metoprolol succinate, furosemide, and aspirin. Her blood
pressure is 132/78. Exam: no murmur, (+) bibasilar rales, trace pretibial edema. EKG 52
beats/min, multifocal PVCs, QRS interval 0.10 sec. Adding which one of the following
would help to decrease both mortality and risk of hospitalization? - Answers -
Spironolactone (Aldactone)
−Reduce mortality and improve ejection fraction −Appropriate if GFR >30mL/min and
K+<5 mEq/dL −Avoid concomitant NSAIDs and COX-2 inhibitors −Spironolactone (but
not eplerenone) can cause breast
tenderness and gynecomastia
- decreases severity of OSA
Hydralazine Plus Isosorbide Dinitrate (BiDil) - Answers -•Vasodilator in HFrEF•Reduces
mortality rates and improves quality-of-
life measures and symptoms•Use when diuretics, β-blockers, and an ACEI (or
ARB) do not control symptoms or are not
tolerated•Particularly effective in African-Americans with
NYHA class III or IV heart failure
62 yo man with hypertension and heart failure reports dyspnea on exertion. Current
medications are enalapril 10 mg bid, carvedilol 12.5 mg bid, spironolactone 25 mg daily,
and furosemide 20 mg daily. On exam, blood pressure is 128/82 and pulse 62. An
Echocardiogram shows ejection fraction of 35% and BNP level is 250 pg/mL.
, Current American Heart Association guidelines recommend which of the following to
further reduce morbidity and mortality? - Answers -Stop enalapril and start
sacubitril/valsartan (Entresto) 49/51 mg twice
daily
In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or
ARB, replacement by an ARNI is recommended to further reduce morbidity and
mortality. (Class I)
A 70 yo man has a history of a myocardial infarction and now has heart failure with an
EF of 30%. EKG with sinus rhythm. Which one of the following medications that he is
currently taking is potentially harmful and should be discontinued? - Answers -Diltiazem
(Cardizem)
Drugs to Avoid in HFrEF
•Calcium channel blockers−Verapamil, diltiazem have potent negative inotropic effect
and are associated with worsening heart failure and increased risk of adverse
cardiovascular events. −May use amlodipine for BP lowering, but can cause leg edema
•Most antiarrhythmic drugs
•NSAIDs
•Thiazolidinediones (cause water retention)
−Pioglitazone (Actos) −Rosiglitazone (Avandia)
Advanced Heart Failure Care - Answers -•Implantable cardioverter defibrillator (ICD) to
reduce risk of sudden death due to ventricular tachyarrhythmias
−For patients with LVEF ≤35%, NYHA class II or III symptoms on meds, and life
expectancy > one year
•Cardiac resynchronization therapy (CRT) (Biventricular pacing) −For patients with
LVEF ≤35%, NYHA class II, III, or IV symptoms on meds, QRS duration ≥150 ms, and
life expectancy > one year
•Left ventricular assist devices (LVAD) as a "bridge" to recovery or transplant or other
decisions
−For patients with anticipated 1-year survival of <50%
•Heart transplantation
HFpEF Treatment
In appropriately selected patients with HFpEF
• EF ≥45%
• elevated BNP levels or HF admission within 1 year
• estimated glomerular filtration rate >30 mL/min
