Cardiovascular Pharmacotherapy

Case Studies
Hypertension
HTN – Case # 1
A 50-year-old African American man has had an average blood pressure of
136/78 mm Hg and heart rate of 72 beats/minute over the past two visits.
He is a smoker but has no other relevant medical history. His TC is 240
mg/dL and HDL is 32 mg/dL. Which one of the following is best to
recommend to manage this patient’s blood pressure?
A. Lifestyle modifications only
B. Lifestyle modifications plus chlorthalidone 25 mg daily
C. Lifestyle modifications plus HCTZ 12.5 mg and lisinopril 20 mg daily
D. Lifestyle modifications plus atenolol 50 mg daily

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HTN – Case # 2
A patient with hypertension and lower-extremity edema is
being treated with amlodipine 10 mg once daily. Her blood
pressure in the clinic today is 152/90 mm Hg and heart rate is
68 beats/minute. Which one of the following is best to
recommend for this patient’s amlodipine-induced lower-
extremity edema?
A. Decrease amlodipine to 5 mg daily.
B. Discontinue amlodipine.
C. Add furosemide 20 mg daily.
D. Add lisinopril 10 mg daily.

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HTN – Case # 3
3. A 78-year-old woman with an average clinic blood pressure of 142/82 mm Hg is
referred to your clinic. Her antihypertensive regimen includes telmisartan 40 mg
daily. The patient is somewhat resistant to adding medications because of concern
that more medications will worsen her daytime fatigue. She undergoes ambulatory
blood pressure monitoring (ABPM) for further evaluation before medication is
added, with average daytime blood pressure 144/80 mm Hg and average nighttime
blood pressure 140/78 mm Hg. Which one of the following best assesses this
patient’s blood pressure?
A. White-coat hypertension

B. Masked hypertension

C. Non-dipping blood pressure pattern, consistent with sleep-disordered breathing

D. Sporadic hypertension, consistent with pheochromocytoma

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HTN – Case # 4
4. A patient calls your clinic, worried because his blood pressure was 192/98 mm Hg
on his home blood pressure monitor. He repeated it to confirm and had a similar
result. He denies feeling any symptoms and denies missing any of his regular
antihypertensives. The patient takes chlorthalidone 25 mg daily and amlodipine 5
mg daily. In addition to arranging for prompt outpatient follow up, which one of the
following is best to recommend for this patient?
A. Increase amlodipine to 10 mg daily.
B. Go to the ED for evaluation of hypertensive emergency.
C. Initiate clonidine 0.1 mg every hour until blood pressure is normalized.
D. Take one extra dose of chlorthalidone 25 mg today only.

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HTN – Case # 5
5. A 55-year-old woman has a new diagnosis of hypertension. Her average blood
pressure on her ABPM was 158/92 mm Hg. She has implemented dietary changes,
but her blood pressure remains elevated. You are consulted to initiate hypertension
treatment. Her other medical history is significant for allergic rhinitis and
hypothyroidism. Her laboratory values are all within normal limits. Which one of the
following is best to recommend initiating in this patient?

A. Metoprolol succinate 50 mg daily

B. Chlorthalidone 25 mg plus lisinopril 10 mg daily
C. Hydrochlorothiazide 25 mg daily
D. Metoprolol succinate 50 mg plus chlorthalidone 25 mg daily

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HTN – Case # 6
H.G. is a 61-year-old man with heart failure with reduced ejection fraction, dyslipidemia,
diabetes, and hypertension. His home blood pressure readings have recently increased to 152–
168/72–84 mm Hg over the past 7–10 days. Six months ago, his home and clinic average blood
pressure reading was 128/70 mm Hg. H.G. takes carvedilol 25 mg twice daily, lisinopril 40 mg
daily, and torsemide 50 mg daily. He denies missing doses of his medication, which is
confirmed by assessing his refill history. He admits recently eating out for several days and not
watching his dietary sodium intake. H.G. also admits feeling short of breath and having more
lower-extremity edema. His weight in the clinic today is 70 kg, a 10-kg increase from his last
visit. His blood pressure in the clinic is 156/86 mm Hg; his laboratory values are all within
normal limits.

Which one of the following best assesses H.G.’s blood pressure?

A. Treatment-resistant hypertension
B. Pseudo-resistant hypertension
C. White-coat hypertension
D. Masked hypertension 

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HTN – Case # 7
H.G. is a 61-year-old man with heart failure with reduced ejection fraction, dyslipidemia,
diabetes, and hypertension. His home blood pressure readings have recently increased to 152–
168/72–84 mm Hg over the past 7–10 days. Six months ago, his home and clinic average blood
pressure reading was 128/70 mm Hg. H.G. takes carvedilol 25 mg twice daily, lisinopril 40 mg
daily, and torsemide 50 mg daily. He denies missing doses of his medication, which is
confirmed by assessing his refill history. He admits recently eating out for several days and not
watching his dietary sodium intake. H.G. also admits feeling short of breath and having more
lower-extremity edema. His weight in the clinic today is 70 kg, a 10-kg increase from his last
visit. His blood pressure in the clinic is 156/86 mm Hg; his laboratory values are all within
normal limits.
Which one of the following is best to recommend for H.G.’s recent uncontrolled BP?
A. Increase carvedilol to 50 mg twice daily.
B. Add clonidine 0.1-mg/hour patch; change once weekly.
C. Add hydrochlorothiazide 25 mg daily.
D. Increase torsemide to 100 mg daily for 3–5 days.
HTN – Case # 8
8. A 78-year-old woman is seen for a hypertension follow-up. She takes
hydrochlorothiazide 25 mg daily, lisinopril 20 mg daily, and nifedipine XL 30 mg
daily. Her home and clinic blood pressure readings have been 142–154/64–72 mm
Hg. Pertinent laboratory values from today are Na 128 mEq/L and K 4.9 mEq/L.
Physical examination reveals 1+ bilateral lower-extremity edema. Which one of the
following is best to recommend regarding this patient’s hypertension regimen?
A. Discontinue hydrochlorothiazide and replace with chlorthalidone 25 mg daily.
B. Discontinue hydrochlorothiazide and replace with torsemide 5 mg daily.
C. Discontinue nifedipine and replace with diltiazem CD 120 mg daily.
D. Increase lisinopril to 40 mg daily.
HTN – Case # 9
9. A 59-year-old man with labile hypertension is seen in your clinic. He takes
amlodipine 10 mg daily and chlorthalidone 25 mg every morning. He reports having
blood pressure elevations starting at 4 p.m. that last until 10 p.m. The patient keeps
excellent home blood pressure records; his average blood pressure during this time
is 160/90 mm Hg, and his blood pressure during the morning and early afternoon is
118–126/62–70 mm Hg. Which one of the following is best to recommend to
manage this patient’s blood pressure elevation during this limited time?

A. Start lisinopril 10 mg at 3 p.m.

B. Start lisinopril 10 mg in the morning.
C. Start captopril 12.5 mg at 3 p.m.
D. Start captopril 12.5 mg in the morning.
HTN – Case # 10
10. A physician is caring for a frail 75-year-old woman with hypertension. The
patient’s blood pressure is 145– 150/70–78 mm Hg on amlodipine 10 mg daily and
hydrochlorothiazide 25 mg daily. The physician asks your opinion on whether he
should target the blood pressure goal suggested by the 2017 ACC/AHA hypertension
guidelines or the goal suggested by the AAFP guidelines. Which one of the following
is best to recommend for this patient?
A. Evidence shows that reducing SBP to lower than 150 mm Hg in patients 75 and older
increases the risk of falls.
B. Evidence shows that reducing SBP to lower than 150 mm Hg in patients 75 and older
decreases the quality of life.
C. Evidence shows that reducing SBP to lower than 130 mm Hg in patients 75 and older
improves CV outcomes.
D. Evidence shows that reducing SBP to lower than 130 mm Hg in patients 75 and older
increases the risk of falls.
HTN – Case # 11
11. A 53-year-old man with a history of hypertension, dyslipidemia, and type 2
diabetes is discharged from the hospital 2 weeks after an acute MI. His home drugs
include aspirin 81 mg daily, prasugrel 10 mg daily, and atorvastatin 40 mg daily.
During his hospitalization, the patient’s blood pressure was low; his blood pressure
medications were discontinued and were not resumed on discharge. Today, his
blood pressure is 146/80 mm Hg and heart rate is 52 beats/minute. Which one of
the following is best to initiate in this patient today?
A. Lisinopril 10 mg daily
B. Chlorthalidone 25 mg daily
C. Amlodipine 5 mg daily
D. Metoprolol succinate 50 mg daily
HTN – Case # 12
12. A 73-year-old woman has difficult-to-treat hypertension. Her current regimen
includes lisinopril 40 mg daily, chlorthalidone 25 mg daily, and amlodipine 10 mg
daily. She also takes mirabegron 50 daily, rosuvastatin 10 mg daily, and loratadine
10 mg daily. Her blood pressure has been 150–155/75–78 mm Hg and heart rate 58–
60 beats/minute during the past three visits, which did not improve with the last
medication adjustment. Pertinent laboratory values today are Na 136 mEq/L, K 4.7
mEq/L, and SCr 1.4 mg/dL. Which one of the following is best to recommend for this
patient’s hypertension?
A. Discontinue mirabegron.
B. Add doxazosin 4 mg daily.
C. Increase chlorthalidone to 50 mg daily.
D. Add carvedilol 12.5 mg twice daily.
 
HTN – Case # 13
13. A 50-year-old woman was recently given a diagnosis of hypertension caused by
her prednisone therapy for rheumatoid arthritis. She takes prednisone 40 mg daily;
she has not yet been initiated on an antihypertensive. Her blood pressure is 148–
156/80–85 mm Hg and heart rates are 62–70 beats/minute. On physical
examination, she has 2+ pitting edema bilaterally. Pertinent laboratory values today
are Na 140 mEq/L, K 3.4 mEq/L, and SCr 1.0 mg/dL. Which one of the following is
best to recommend for this patient’s hypertension?
A. Chlorthalidone 25 mg daily
B. Metoprolol succinate 100 mg daily
C. Amlodipine 10 mg daily
D. Spironolactone 25 mg daily 
HTN – Case # 14
14. A 44-year-old man with hypertension takes chlorthalidone 25 mg daily.
His blood pressure in the clinic today is 128/70 mm Hg and heart rate is 76
beats/minute. His laboratory values are within normal limits. However, he
has concerns of new-onset erectile dysfunction. Which one of the following
is best to recommend for this adverse effect in this patient?
A. Change to telmisartan 40 mg daily.
B. Change to doxazosin 2 mg daily.
C. Change to metoprolol succinate 100 mg daily.
D. Change to isosorbide mononitrate ER 30 mg daily.
 
HTN – Case # 14
15. A 55-year-old woman takes hydrochlorothiazide 25 mg daily and
amlodipine 10 mg daily. She presents for a follow-up of her hypertension.
Her blood pressure readings have been 146–152/70–75 mm Hg. Pertinent
laboratory values include Na 140 mEq/L, K 4.8 mEq/L, and SCr 0.9 mg/dL.
Which one of the following is best to recommend for this patient’s
hypertension?
A. Add lisinopril 40 mg daily.
B. Add spironolactone 25 mg daily.
C. Change from hydrochlorothiazide to furosemide 40 mg daily.
D. Change from hydrochlorothiazide to chlorthalidone 25 mg daily.
 
HTN – Case # 15
7. T.J. is a 45-year-old African American woman presenting for routine follow-up of
her DM2. She has no other medical history. Her blood pressure today (average of 2
readings) is 138/88 mm Hg. Her HR is 77 beats/minute. Her BP at her last visit was
136/85 mm Hg. Her current medications include glyburide 5 mg daily. Her labs include
Na 140 mEq/L, K 4.0 mEq/L, Cl 102 mEq/L, bicarbonate 28 mEq/L, blood urea
nitrogen 14 mg/dL, SCr 0.8 mg/dL, and 24-hour urine albumin 16 mg/24 hours. What
is the best approach for managing her HTN?
A. Begin diet and lifestyle modifications only
B. Begin lifestyle modifications and add amlodipine 5 mg daily
C. Begin lifestyle modifications and add lisinopril 2.5 mg daily
D. Begin lifestyle modifications and add lisinopril 2.5 mg daily plus HCTZ 12.5 mg daily
HTN – Case # 16
R.P. is an 69-year-old African American man with a history of HTN and gout. His
medications include allopurinol 300 mg/day, amlodipine 10 mg/day, and aspirin 81
mg/day. His vital signs include BP 145/85 mm Hg and HR 82 beats/minute. His
laboratory values are normal and his 10-year ASCVD risk is 22.4%. Which is the best
therapy for R.P.?
A. Add HCTZ 25 mg/day to achieve a systolic BP (SBP) goal of less than 130 mm Hg.
B. Add lisinopril 40 mg/day and titrate to achieve an SBP goal of < 140.
C. Add atenolol 50 mg/day to achieve an SBP < 130 mm Hg.
D. Make no changes to his current medications because his SBP is at goal.
HTN – Case # 17
A.M. is a 32-year-old woman with type 1 DM and HTN. Her current medication
regimen is as follows: ramipril 10 mg/day, chlorthalidone 25 mg/day, amlodipine 10
mg/day, ethinyl estradiol 20 mcg/norethindrone 1 mg (for the past 2 years), and insulin
as directed. Her vital signs today include BP 145/83 mm Hg, repeated BP 145/81 mm
Hg; HR 82 beats/minute; height 66 inches; weight 70 kg. A.M. would prefer not to take
any more drugs, if possible.
Which option is the best clinical plan for A.M.?
A. No change in therapy is currently warranted.
B. Advise weight loss and recheck her BP in 3 months.
C. Change chlorthalidone to hydrochlorothiazide.
D. Discuss changing her contraceptive method.
HTN – Case # 18
A.M. is a 32-year-old woman with type 1 DM and HTN. Her current medication
regimen is as follows: ramipril 10 mg/day, chlorthalidone 25 mg/day, amlodipine 10
mg/day, ethinyl estradiol 20 mcg/norethindrone 1 mg (for the past 2 years), and insulin
as directed. Her vital signs today include BP 145/83 mm Hg, repeated BP 145/81 mm
Hg; HR 82 beats/minute; height 66 inches; weight 70 kg. A.M. would prefer not to take
any more drugs, if possible.
A.M. and her husband have decided they are ready to have children. What is the best
medication option for A.M.?
A. No change in therapy is warranted.
B. Discontinue ramipril and replace with labetalol.
C. Increase chlorthalidone to 50 mg/day.
D. Discontinue all antihypertensive therapy.
Heart Failure
 Heart Failure

CHF – Case # 1
L.S. is a 48-year-old woman with alcohol-induced cardiomyopathy. Her most recent LVEF is 20%; her daily
activities are limited by dyspnea and fatigue (NYHA class III). Her medications include lisinopril 40 mg daily,
furosemide 40 mg twice daily, carvedilol 12.5 mg twice daily, spironolactone 25 mg/day, and digoxin 0.125
mg/day. She has been stable on these doses for the past month. Her most recent laboratory results include
sodium (Na) 140 mEq/L, potassium (K) 4.0 mEq/L, chloride 105 mEq/L, bicarbonate 26 mEq/L, blood urea
nitrogen 12 mg/dL, SCr 0.8 mg/dL, glucose 98 mg/dL, calcium 9.0 mg/dL, phosphorus 2.8 mg/dL, magnesium
2.0 mEq/L, and digoxin 0.7 ng/mL. She weighs 69 kg, and her vital signs include BP 112/70 mm Hg and HR 68
beats/minute. She has normal breath sounds and no pedal edema. What is the best approach for maximizing the
management of her HF?

A. Increase carvedilol to 25 mg twice daily.

B. Increase lisinopril to 80 mg/day.

C. Increase spironolactone to 50 mg/day.

D. Increase digoxin to 0.25 mg/day.

 Heart Failure

CHF – Case # 2
J.T. is a 62-year-old man (height 72 inches, weight 85 kg) with a history of CHD (MI 3 years ago),
HTN, depression, chronic kidney disease (CKD; baseline SCr 2.8 mg/dL), PAD, osteoarthritis,
hypothyroidism, and HF (LVEF of 25%). His medications include aspirin 81 mg/day, simvastatin
40 mg every night, enalapril 5 mg twice daily, metoprolol succinate 50 mg/day, furosemide 80 mg
twice daily, cilostazol 100 mg twice daily, acetaminophen 650 mg four times daily, sertraline 100
mg/day, and levothyroxine 0.1 mg/day. His vital signs include BP 120/70 mm Hg and HR 72
beats/minute. Pertinent laboratory results include K 4.1 mEq/L, SCr 2.8 mg/dL, and a thyroid-
stimulating hormone of 2.6 mIU/L. His HF is stable and considered NYHA class II. What is the
best approach for maximizing the management of his HF?

A. Discontinue metoprolol and begin carvedilol 12.5 mg twice daily.

B. Increase enalapril to 10 mg twice daily.
C. Add spironolactone 25 mg/day.
D. Add digoxin 0.125 mg/day.
 Heart Failure

CHF – Case # 3
Which drug that J.T. (from Patient Case 2) is currently taking would be best to
discontinue because of his HFrEF?
A. Acetaminophen.
B. Sertraline.
C. Cilostazol.
D. Levothyroxine.
 Heart Failure

CHF – Case # 4
Questions 4–8 pertain to the following case.
K.S. is a 76-year-old woman with obesity who presents with mild exertional dyspnea, which she noticed
recently while walking around her neighborhood. She becomes SOB when walking fast or on hills but still
walks about ¼ mile per day. She also admits having limited orthopnea and paroxysmal nocturnal
dyspnea. She has had mild edema in the evenings for many years. She denies angina, palpitations, or
syncope. She is a nonsmoker. She has a history of HTN, myocardial infarction (MI) 2 years ago,
depression, gastroesophageal reflex disease, and hyper­lipidemia. Her medications consist of metoprolol
succinate 150 mg daily, lisinopril 10 mg daily, furosemide 20 mg daily, aspirin 81 mg daily, sertraline 50
mg daily, omeprazole 20 mg daily, and simvastatin 20 mg at bedtime. Her vital signs today include blood
pressure 178/85 mm Hg and heart rate 62 beats/minute. Her physical examination is positive for jugular
venous pulsation (JVP), S3 present; trace edema in both extremities; and lungs with slight crackles.
Laboratory findings show SCr 2.5 mg/dL and K 4.5 mEq/L. Her electrocardiogram (ECG) reveals nor­
mal sinus rhythm (NSR).

Given K.S.’s clinical presentation, which symptom has the greatest sensitivity to detect HF?
A. Shortness of breath.
B. Paroxysmal nocturnal dyspnea.
C. Orthopnea.
D. Edema.
 Heart Failure

CHF – Case # 13
Because of L.S.’s many hospitalizations, she is enrolled in the
CardioMEMS program. Which would be best to recommend regarding
anticoagulation for this patient?
A. Add warfarin 5 mg daily (titrate to an INR of 2–3).
B. Add aspirin 81 mg/day.
C. Add both clopidogrel 75 mg/day and aspirin 81 mg/day.
D. Add clopidogrel 75 mg/day.
 Heart Failure

CHF – Case # 14
D.F. is an 84-year-old woman with a medical history significant for type 2 DM (diet
controlled), osteoporo­sis, hypercholesterolemia, and HTN who presents to the clinic with a 1-
year history of dyspnea on exertion, which has worsened over the past month. Her
medications are lisinopril 20 mg daily, alendronate 70 mg once weekly, calcium/vitamin D
500 ng/125 international units three times daily, simvastatin 20 mg daily, and aspirin 81 mg
daily. Vital signs include blood pressure 120/80 mm Hg and heart rate 80 beats/minute.
Physical examination reveals lungs: + rales/rhonchi; cardiac: JVP elevated to 7 cm with a
large V wave, S3 present; and extremities: 2+ edema to knee bilaterally. Laboratory values
are as follows: SCr 1.2 mg/dL, K 4.7 mEq/L, and BNP 856 pg/mL. An ECHO reveals an
LVEF of 66%, mild tricuspid regurgitation, mild mitral regurgitation, and global
hypokinesis. An ECG reveals LV hypertrophy. Which is the most appropriate ther­apeutic
recommendation for D.F.’s HF at this time?
A. Add furosemide.
B. Add hydrochlorothiazide.
C. Add spironolactone.
D. Add isosorbide mononitrate.
 Heart Failure

CHF – Case # 15
Questions 15–17 pertain to the following case.
C.A. is a 75-year-old woman (height 56 inches, weight 71 kg [156 lb]) who resides in an assisted living. She is referred to
your cardiology clinic for medication therapy management. She is ambulatory, generally alert, and oriented, with no
cognitive impairment. Her medical history is significant for NYHA functional class III HFpEF (LVEF of 55%), HTN,
chronic obstructive pulmonary disease, and osteoarthritis. She takes the following med ­ications: amlodipine 20 mg daily,
furosemide 20 mg daily, fluticasone/salmeterol 45/21 mcg 2 puffs twice daily, albuterol metered dose inhaler as needed, and
acetaminophen 500 mg three times daily as needed. On physical examination, C.A. appears well nourished and groomed.
She is mildly SOB on exertion but in no apparent pain or distress. Evaluation of her lungs reveals diminished breath sounds
in the bases with no adventitious sounds. Abdomen palpation is soft and nontender, with active bowel sounds and no signs of
hepatosplenomegaly. She has 1+ nonpitting chronic edema and vascular changes to lower extremities. Her vital signs
indicate blood pressure 155/85 mm Hg, heart rate 100 beats/minute, and oxygen saturation 94% on 2 L/minute. Her
physical examination is positive for JVP, S3 present; trace edema in both extremities, and lungs with slight crackles.
Laboratory tests show SCr 1.3 mg/dL, K 4.0 mEq/L, and BNP 875 pg/mL. Her CBC is significant for hemoglobin 12 g/dL,
hema­tocrit 23%, and mean corpuscular volume 80 fL/cell. Her iron studies completed before clinic show ferritin 50 ng/ mL
and transferrin saturation (TSAT) 15%. Her vitamin B12 concentration is 310 pg/mL. Her ECG reveals NSR.

Given C.A.’s clinical presentation and laboratory findings, which would be the best recommendation to
improve her QoL?
A. Ferrous sulfate 325 mg orally three times daily with ascorbic acid.
B. Cyanocobalamin 1000 mcg intramuscularly weekly for 4 weeks.
C. Outpatient intravenous iron therapy weekly for 4 weeks.
D. Darbepoetin alfa 0.75 mcg/kg once every 2 weeks.
 Heart Failure

CHF – Case # 16 & 17

Which best depicts C.A.’s blood pressure goal?
A. Less than 130/80 mm Hg.
B. Less than 140/90 mm Hg.
C. Less than 150/90 mm Hg.
D. Less than 140/80 mm Hg.

C.A.’s furosemide dose is increased; however, she needs better control of her
blood pressure. Which would be most appropriate to add to amlodipine?
A. Carvedilol.
B. Bisoprolol.
C. Spironolactone.
D. Metolazone.
 Heart Failure

CHF – Case # 18
R.S., a 58-year-old woman with a history of hypertension (HTN), coronary heart
disease (CHD), myocardial infarction (MI) 4 months ago, and dyslipidemia, presents to
the clinic for a follow-up. She has no worsening signs or symptoms of dyspnea or
edema compared with her baseline. An echocardiogram reveals a left ventricular
ejection fraction (LVEF) of 35%. She is in New York Heart Association (NYHA) class
III. Her medications include aspirin 81 mg/day, metoprolol succinate 150 mg/day, and
atorvastatin 40 mg every night. Her vital signs include blood pressure (BP) 138/80 mm
Hg and heart rate (HR) 58 beats/minute. Her lungs are clear, and laboratory results are
within normal limits. Given her history and physical examination, what is the most
appropriate modification to R.S.’s current drug therapy?
A. Continue current therapy.
B. Initiate digoxin 0.125 mg/day.
C. Initiate spironolactone 25 mg/day.
D. Initiate lisinopril 5 mg/day.
 Heart Failure

CHF – Case # 19
J.O. is a 64-year-old woman with NYHA class II nonischemic dilated cardiomyopathy
(LVEF of 30%). She presents to the heart failure (HF) clinic for a follow-up. She is
euvolemic. Her medications include enalapril 10 mg twice daily, furosemide 40 mg
twice daily, and potassium chloride 20 mEq twice daily. Her vital signs include BP
130/88 mm Hg and HR 78 beats/minute. Her laboratory results are within normal
limits. What is the best way to manage J.O.’s HF?
A. Continue current regimen.
B. Increase enalapril to 20 mg twice daily.
C. Initiate carvedilol 3.125 mg twice daily.
D. Initiate digoxin 0.125 mg/day.
 Heart Failure

CHF – Case # 20
J.M. is a 65-year-old woman with a history of HTN and poor medication adherence
who presents to her primary care physician with shortness of breath and markedly
decreased exercise tolerance. An echocardiogram reveals an LVEF of 65%, with
diastolic dysfunction. J.M.’s medications include extended-release nifedipine 90
mg/day and hydrochlorothiazide 25 mg/day. Her vital signs include BP 128/78 mm Hg
and HR 98 beats/minute. Her lung fields are clear to auscultation, and there is no
evidence of systemic congestion. Which is the best pharmacologic management for
J.M.?
A. Discontinue extended-release nifedipine and initiate diltiazem 240 mg/day.
B. Discontinue hydrochlorothiazide and initiate furosemide 40 mg twice daily.
C. Initiate digoxin 0.125 mg/day.
D. Add lisinopril 5 mg/day.
Stable IHD
 SIHD

SIHD – Case # 1
A 60-year-old man with stable ischemic heart disease (SIHD), HTN,
hyperlipidemia (HLD), and depression presents with angina on exertion.
His medications include aspirin 81 mg daily, nitroglycerin 0.4 mg
sublingually as needed for chest pain, atorvastatin 20 mg daily,
citalopram 40 mg daily, and chlorthalidone 25 mg daily. His blood
pressure is 158/92 mm Hg and heart rate is 68 beats/minute. Laboratory
values are within normal limits. Which would best treat his angina?
A. Lisinopril 10 mg daily.
B. Ranolazine 500 mg twice daily.
C. Verapamil 120 mg daily
D. Carvedilol 12.5 mg twice daily.
 SIHD

SIHD – Case # 2
A 56-year-old patient had CABG surgery performed for refractory
symptoms of angina despite maximally tolerated medical therapy and
multiple percutaneous coronary interventions. Which of the following
medications should be initiated following CABG surgery and continued
indefinitely to maintain patency of the saphenous vein grafts?  
A. Aspirin
B. Carvedilol
C. Enalapril
D. Nitroglycerin sublingual
 SIHD

SIHD – Case # 3
A 68-year-old male presents with complaints of angina when walking two
flights of stairs. The pain is relieved with rest and only occasionally
requires a dose of SL NTG for relief. His PMH includes a history of MI 3
years ago, HTN, and hyperlipidemia. He quit smoking 3 years ago after
his MI. His home medications include aspirin 81 mg daily, metoprolol 25
mg twice daily, and atorvastatin 80 mg daily. Vital signs: BP is 158/92
mm Hg, HR 82 bpm. Which of the following is most appropriate to treat
this patient's angina?
A. Lisinopril 10 mg daily
B. Ranolazine 1,000 mg twice daily
C. Increase metoprolol to 50 mg twice daily
D. SL NTG 1 tablet as needed for angina
 SIHD

SIHD – Case # 4
A 72-year-old woman with a history of several TIAs, HTN,
and gastroesophageal reflux disease (GERD) while taking
lisinopril, hydrochlorothiazide, and omeprazole presents to
her physician. She finds it difficult to pay for her medications
each month. Which is the best antithrombotic regimen to
prevent stroke in this patient?
A. Warfarin with target international normalized ratio (INR) 2.5.
B. Prasugrel 10 mg daily.
C. Clopidogrel 75 mg daily.
D. Aspirin 81 mg daily.
 SIHD

SIHD – Case # 5
JC is a 79-year-old 150 kg man who recently sustained an ischemic
stroke. During the workup, he was found to have atrial fibrillation.
His blood pressure is 145/90 mm Hg. His serum creatinine is 4.5
mg/dL (398 μmol/L)(creatinine clearance 28 mL/min [0.47 mL/s])
and his BMI is 50 kg/m2. Which of the following oral
anticoagulants is most appropriate for JC?
A.Apixaban 5 mg daily
B.Edoxaban 30 mg daily
C.Dabigatran 150 mg twice daily
D.Warfarin adjusted to a target INR of 2.5
 SIHD

SIHD – Case # 6
RG is a 74-year-old man who is being discharged from the
hospital after a mild stroke. His blood pressure has stabilized
at 156/98 mm Hg and is low-density lipoprotein cholesterol is
110 mg/dL (2.84 mmol/L). On which of the following
regimens should RG be placed?
A.Atorvastatin 40 mg daily
B.Hydrochlorothiazide 25 mg daily plus rosuvastatin 20 mg daily
C.Lisinopril 5 mg daily
D.Lovastatin 40 mg daily plus losartan 50 mg daily
 SIHD

SIHD – Case # 6
A 75-year-old patient with SIHD presents with continued angina. His
home medications include aspirin 81 mg daily, allopurinol 100 mg daily,
lisinopril 20 mg daily, carvedilol 25 mg twice daily, rosuvastatin 20 mg
daily, isosorbide mononitrate 60 mg daily, and acetaminophen as needed
for pain. His PMH includes a history of MI, HTN, gout, dyslipidemia, and
arthritis. Vital signs: BP 100/60 mm Hg; HR 62 bpm, weight 90 kg. Labs
are within normal limits. Which of the following is the most
appropriate option to treat this patient's angina?
 
A.Change carvedilol 25 mg twice daily to amlodipine 10 mg daily
B.Increase carvedilol to 50 mg twice daily
C.Change isosorbide mononitrate to a nitroglycerin patch
D.Add ranolazine 500 mg twice daily
 STROKE

AIS – Case # 1
JM is a 77-year-old man who presents to the emergency
department with symptoms of an ischemic stroke. His past
medical history includes hypertension, hypothyroidism,
benign prostatic hypertrophy, and hypercholesterolemia.
What are JM's stroke risk factors?
A. Age, hypertension, and hypercholesterolemia
B. Age, sex, hypertension, hypothyroidism, and hypercholesterolemia
C. Age, sex, hypertension, hypercholesterolemia
D. Sex, hypothyroidism, benign prostatic hypertrophy, and hypercholesterolemia
E. Sex, hypertension, hypercholesterolemia
 STROKE

AIS – Case # 2
BW is an 84-year-old male who presents to the emergency department
with acute ischemic stroke symptoms. His symptoms began 2 hours ago.
His current BP is 176/98 mm Hg and his glucose is 110 mg/dL (6.1
mmol/L). He has had a computed tomography (CT) scan of the head that
shows no bleeding. He is currently taking aspirin 81 mg daily and
lisinopril 10 mg daily. He has no medication allergies. Is BW a candidate
for alteplase?
A. Yes
B. No, his symptoms began too long ago
C. No, he is too old
D. No, he is taking aspirin
 STROKE

AIS – Case # 3
SD is a 65-year-old woman who presents to the emergency department
with acute ischemic stroke symptoms. Her symptoms began 6 hours ago.
Her current BP is 170/96 mm HG and her glucose is 104 mg/dL (5.8
mmol/L). She has had a computed tomography (CT) scan of the head that
shows no bleeding. She is currently taking hydrochlorothiazide 25 mg
daily. She is allergic to aspirin (oral facial edema). Is SD a candidate for
alteplase?
A. Yes
B. No, her symptoms began too long ago
C. No, she is too old
D. No, she is taking hydrochlorothiazide
 STROKE

AIS – Case # 4
ML is a 68-year-old woman who presented with an ischemic
stroke 2 days ago. She received alteplase and her deficits
improved. Prior to the stroke, she was taking no medications.
She is allergic to aspirin (hives and shortness of breath).
Which of the following agents should ML receive to prevent
recurrent strokes?
A. Aspirin
B. Clopidogrel
C. Clopidogrel plus aspirin
D. Extended-release dipyridamole plus aspirin
 STROKE

AIS – Case # 5
MK is a 58-year-old man who has had atrial fibrillation for 5
years. He was maintained on aspirin 325 mg daily. Four days
ago, he sustained an ischemic stroke. What is the best choice
of therapy for MK to prevent recurrent stroke?
A. Aspirin
B. Clopidogrel
C. Extended-release dipyridamole plus aspirin
D. Rivaroxaban
 STROKE

AIS – Case # 6
JM is a 74-year-old man who is being discharged
from the hospital after a mild stroke. His BP has
stabilized at 156/98 mm Hg and is low-density
lipoprotein cholesterol is 110 mg/dL (2.84 mmol/L).
On which of the following regimens should JM be
placed?
A. Atorvastatin 40 mg daily
B. Hydrochlorothiazide 25 mg daily plus rosuvastatin 20 mg daily
C. Lisinopril 5 mg daily
D. Lovastatin 40 mg daily plus losartan 50 mg daily
Thank U