A 58-year-old with hypertension AND type 2 diabetes has BP 158/96 on two visits. No antihypertensive yet. What is the MOST appropriate first-line medication?
A. Metoprolol
B. Lisinopril (ACE inhibitor)
C. Amlodipine
D. Hydrochlorothiazide
Correct: B. Lisinopril. In HTN + DM, ACE inhibitors (or ARBs) are first-line due to renoprotective effects - reduce proteinuria and slow CKD progression. If ACE-I not tolerated (cough), switch to ARB (losartan). JNC 8 and ADA guidelines support this choice.
Question 2
A 70-year-old with HFrEF (EF 35%) has worsening dyspnea, orthopnea, +2 pitting edema. Which medication REDUCES MORTALITY in HFrEF?
A. Furosemide
B. Digoxin
C. Carvedilol (beta-blocker)
D. Amlodipine
Correct: C. Carvedilol. Mortality-reducing meds in HFrEF: ACE-I/ARB, beta-blockers (carvedilol, metoprolol succinate, bisoprolol), aldosterone antagonists (spironolactone), ARNI (sacubitril/valsartan), SGLT2 inhibitors. Furosemide relieves symptoms only. Digoxin reduces hospitalizations but NOT mortality.
Question 3
A 62-year-old has crushing substernal chest pain radiating to left arm, diaphoresis, nausea x 45 min. ECG shows ST elevation in leads II, III, aVF. Diagnosis?
A. Anterior STEMI
B. Unstable angina
C. Inferior STEMI
D. NSTEMI
Correct: C. Inferior STEMI. ST elevation in II, III, aVF = inferior wall MI (RCA territory). Anterior STEMI: V1-V4 (LAD). Lateral: I, aVL, V5-V6. Management: activate cath lab, aspirin + P2Y12 inhibitor, heparin, primary PCI within 90 minutes. NSTEMI has NO ST elevation.
Question 4
A 72-year-old woman with HTN has irregularly irregular HR 88. ECG: no P waves, irregular ventricular rhythm. No contraindications to anticoagulation. Best next step?
A. Aspirin only
B. Rate control with metoprolol only
C. Calculate CHA2DS2-VASc score and initiate anticoagulation
D. Immediate cardioversion
Correct: C. CHA2DS2-VASc then anticoagulation. This is atrial fibrillation. CHA2DS2-VASc: CHF, HTN, age 65-74, DM, vascular disease, female (1 pt each); age 75+, prior stroke (2 pts). Score 2+ in men or 3+ in women: anticoagulate (DOACs preferred over warfarin). Aspirin alone is no longer recommended for AF stroke prevention.
Question 5
Patient on HCTZ for HTN has K+ 3.1 mEq/L on labs (normal 3.5-5.0). Most appropriate next step?
A. Stop HCTZ and switch antihypertensives
B. Add spironolactone immediately
C. Potassium supplementation + dietary counseling; continue HCTZ
D. No action; expected side effect
Correct: C. Thiazides cause hypokalemia (increase urinary K+ excretion). K+ 3.1 is mildly low. First: oral K+ supplement + dietary counseling (bananas, greens). No need to stop HCTZ for mild hypokalemia. Consider adding ACE-I or spironolactone if severely low. Always recheck after supplementation.
Question 6
A 55-year-old with established CAD (prior MI) has LDL 88 mg/dL on high-intensity statin. What is the ACC/AHA LDL goal for secondary prevention ASCVD?
A. LDL < 130 mg/dL
B. LDL < 100 mg/dL
C. LDL < 70 mg/dL
D. LDL < 55 mg/dL
Correct: C. LDL <70 mg/dL for very high-risk ASCVD (established CAD, prior MI, stroke). This patient at 88 is not at goal. Next step: add ezetimibe, then PCSK9 inhibitor if still not at goal. Some guidelines now suggest <55 for very-high-risk patients.
Question 7
A 66-year-old with HTN, DM, HFrEF (EF 30%) develops persistent dry cough on lisinopril. Best alternative?
A. Amlodipine
B. Metoprolol succinate
C. Losartan (ARB)
D. Hydrochlorothiazide
Correct: C. Losartan (ARB). ACE-I-induced cough = bradykinin accumulation (~15% of patients). ARBs block angiotensin II receptor; NO bradykinin buildup, no cough. Same mortality benefit in HFrEF and renoprotection in DM. Do NOT combine ACE-I + ARB.
Question 8
A healthy 45-year-old has BP 148/92 on three occasions. Exercises regularly, non-smoker, no DM/CKD/ASCVD. First-line management?
A. Start lisinopril immediately
B. Refer to cardiology
C. Lifestyle modification for 3-6 months before medication
D. 24-hour ABPM only
Correct: C. Lifestyle modification first. Stage 1 HTN (130-139/80-89) in LOW-RISK patients (no ASCVD, DM, CKD, or 10-year risk <10%): lifestyle modification x 3-6 months before medication. DASH diet, sodium <2.3g/day, exercise 150 min/week, weight loss, alcohol reduction.
Question 9
ECG shows narrow-complex tachycardia 175 bpm, no P waves, BP 110/70, stable. FIRST-LINE acute treatment?
A. Synchronized cardioversion
B. IV amiodarone
C. Vagal maneuvers, then IV adenosine 6mg
D. IV metoprolol
Correct: C. Vagal maneuvers then adenosine. SVT (likely AVNRT). Stable SVT algorithm: (1) Vagal maneuvers (Valsalva, carotid massage), (2) IV adenosine 6mg rapid push - transiently blocks AV node to break re-entry. If no response: 12mg adenosine. Cardioversion for UNSTABLE SVT only.
Question 10
Patient with stable angina on nitrates is prescribed sildenafil by another provider for ED. Primary concern?
A. Increased MI risk
B. QT prolongation
C. Severe life-threatening hypotension
D. Hyperkalemia
Correct: C. Severe hypotension. Nitrates + PDE5 inhibitors (sildenafil, tadalafil, vardenafil) = ABSOLUTE CONTRAINDICATION. Both are vasodilators; combined effect causes life-threatening hypotension. A critical high-yield drug interaction for boards. If patient needs both angina treatment and ED treatment, switch nitrate to beta-blocker or CCB.