Ischemic heart disease – angina MCQs With Answer

Introduction:

Ischemic heart disease (IHD) and angina are central topics for B. Pharm students studying cardiovascular pharmacology and therapeutics. This concise guide emphasizes pathophysiology, classification (stable, unstable, Prinzmetal), diagnostic clues, and detailed pharmacology of antianginal drugs such as nitrates, beta‑blockers, calcium channel blockers, ranolazine, antiplatelets, statins and ACE inhibitors. Understanding mechanisms, clinical indications, dosing principles, adverse effects and drug interactions is essential for safe medication management and rational therapy selection in coronary artery disease. Clear knowledge of ECG changes, biomarkers and reperfusion strategies enhances clinical reasoning. Now let’s test your knowledge with 50 MCQs on this topic.

Q1. What is the primary pathophysiological mechanism of stable angina?

• Coronary artery vasospasm without atherosclerosis
• Fixed atherosclerotic coronary stenosis causing myocardial demand-supply mismatch
• Acute coronary thrombosis with plaque rupture
• Primary myocarditis leading to reduced coronary perfusion

Correct Answer: Fixed atherosclerotic coronary stenosis causing myocardial demand-supply mismatch

Q2. Which ECG change is most typical during exercise-induced myocardial ischemia?

• New persistent ST elevation in multiple leads
• ST-segment depression in leads corresponding to ischemic territory
• Peaked T waves in all leads
• Complete heart block

Correct Answer: ST-segment depression in leads corresponding to ischemic territory

Q3. Which clinical feature differentiates unstable angina from non-ST elevation myocardial infarction (NSTEMI)?

• Unstable angina presents only with ST-elevation on ECG
• NSTEMI always presents with chest pain at rest
• Unstable angina has no rise in cardiac biomarkers while NSTEMI shows elevated troponin
• Unstable angina is always caused by coronary vasospasm

Correct Answer: Unstable angina has no rise in cardiac biomarkers while NSTEMI shows elevated troponin

Q4. What is the main mechanism of action of organic nitrates like nitroglycerin in relieving angina?

• Blockade of β1 receptors reducing heart rate
• Inhibition of L-type calcium channels decreasing afterload
• Release of nitric oxide causing venodilation and reduced preload
• Inhibition of HMG-CoA reductase lowering cholesterol

Correct Answer: Release of nitric oxide causing venodilation and reduced preload

Q5. Which statement about sublingual nitroglycerin is correct?

• Onset is typically 1–3 minutes and it is used for acute angina relief
• It is given sublingually to prevent first-pass hepatic metabolism but has onset of 1–2 hours
• Sublingual nitroglycerin should be taken continuously to avoid angina recurrence
• It is contraindicated in angina due to atherosclerotic stenosis

Correct Answer: Onset is typically 1–3 minutes and it is used for acute angina relief

Q6. Continuous use of nitrates leads to tolerance. What is the primary strategy to prevent nitrate tolerance?

• Increase dose continuously over time
• Use combined ACE inhibitor therapy
• Provide a daily nitrate-free interval of 8–12 hours
• Administer nitrates only at night

Correct Answer: Provide a daily nitrate-free interval of 8–12 hours

Q7. Which antianginal drug acts mainly by decreasing myocardial oxygen demand through reduction of heart rate and contractility?

• Amyl nitrite
• Beta-blockers such as metoprolol
• Ranolazine
• Amlodipine

Correct Answer: Beta-blockers such as metoprolol

Q8. In vasospastic (Prinzmetal) angina, which class of drugs is considered first-line therapy?

• Long-acting nitrates and calcium channel blockers
• Non-selective beta-blockers alone
• High-dose statin monotherapy
• ACE inhibitors

Correct Answer: Long-acting nitrates and calcium channel blockers

Q9. Which combination is absolutely contraindicated due to risk of severe hypotension?

• Sublingual nitroglycerin and aspirin
• Nitrate therapy and phosphodiesterase-5 inhibitors (e.g., sildenafil)
• Beta-blocker and calcium channel blocker (diltiazem) combination
• Statin and aspirin combination

Correct Answer: Nitrate therapy and phosphodiesterase-5 inhibitors (e.g., sildenafil)

Q10. Ranolazine relieves angina by which primary mechanism?

• Blocking β1 receptors to reduce heart rate
• Inhibiting late inward sodium current to reduce diastolic wall tension
• Opening ATP-sensitive potassium channels to vasodilate coronary arteries
• Increasing cAMP in cardiomyocytes to enhance contractility

Correct Answer: Inhibiting late inward sodium current to reduce diastolic wall tension

Q11. Which adverse effect is most commonly associated with long-acting nitrates?

• Bradycardia and hyperkalemia
• Reflex tachycardia and headache
• QT prolongation and torsades de pointes
• Dry cough and angioedema

Correct Answer: Reflex tachycardia and headache

Q12. Which antianginal is contraindicated in acute decompensated heart failure with reduced ejection fraction due to negative inotropic effects?

• Amlodipine
• Verapamil
• Nitroglycerin
• Ranolazine

Correct Answer: Verapamil

Q13. In the initial pharmacologic management of suspected acute coronary syndrome, which medication should be given immediately unless contraindicated?

• High-dose statin only
• Oral anticoagulant without aspirin
• Aspirin chewable 150–325 mg
• Long-acting nitrate patch

Correct Answer: Aspirin chewable 150–325 mg

Q14. Which lab biomarker is most sensitive and specific for myocardial necrosis?

• AST (aspartate aminotransferase)
• Troponin I or T
• CK-BB isoenzyme
• Myoglobin only

Correct Answer: Troponin I or T

Q15. Which antihypertensive class provides mortality benefit post-myocardial infarction and is commonly used in ischemic heart disease?

• Hydralazine
• ACE inhibitors such as enalapril
• Direct vasodilators only
• Alpha-1 blockers exclusively

Correct Answer: ACE inhibitors such as enalapril

Q16. Which lipid-lowering therapy is most important for secondary prevention in ischemic heart disease?

• Bile acid sequestrants
• High-intensity statin therapy
• Omega-3 fatty acids only
• Fibrates alone

Correct Answer: High-intensity statin therapy

Q17. Which statement about beta-blocker use in angina is correct?

• Nonselective beta-blockers are preferred in asthma patients
• Beta-blockers reduce mortality in patients with prior myocardial infarction
• They increase myocardial oxygen demand by increasing contractility
• Beta-blockers are first-line for Prinzmetal angina

Correct Answer: Beta-blockers reduce mortality in patients with prior myocardial infarction

Q18. A patient with stable angina is intolerant to beta-blockers. Which drug class is a good alternative to control angina and heart rate?

• Long-acting nitrates for heart rate control
• Calcium channel blockers, especially non-dihydropyridines like diltiazem or verapamil
• Statins for immediate angina relief
• ACE inhibitors to increase heart rate

Correct Answer: Calcium channel blockers, especially non-dihydropyridines like diltiazem or verapamil

Q19. Which finding is most characteristic of Prinzmetal (variant) angina?

• Chest pain precipitated by exertion and relieved by rest only
• Transient ST-segment elevation during chest pain at rest
• Persistent ST depression between episodes
• Elevation of troponin in all episodes

Correct Answer: Transient ST-segment elevation during chest pain at rest

Q20. Which antiplatelet regimen is typically used after percutaneous coronary intervention (PCI) with stent placement?

• Aspirin monotherapy indefinitely with no P2Y12 inhibitor
• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (e.g., clopidogrel) for a recommended duration
• Warfarin alone for 1 year
• Heparin subcutaneous therapy for 6 months

Correct Answer: Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (e.g., clopidogrel) for a recommended duration

Q21. Why are dihydropyridine calcium channel blockers like amlodipine often combined with beta-blockers in angina?

• They both primarily increase heart rate and have additive effects
• Dihydropyridines cause reflex tachycardia which beta-blockers blunt, improving antianginal effect
• Combination prevents nitrate tolerance
• They synergistically inhibit platelet aggregation

Correct Answer: Dihydropyridines cause reflex tachycardia which beta-blockers blunt, improving antianginal effect

Q22. Which drug reduces myocardial oxygen consumption primarily by venodilation rather than arteriolar dilation?

• Nitroglycerin
• Amlodipine
• Hydralazine
• Verapamil

Correct Answer: Nitroglycerin

Q23. In a patient with stable angina and conduction disturbances (e.g., AV block), which antianginal agent should be used cautiously or avoided?

• Long-acting nitrates
• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem)
• Dihydropyridine calcium channel blockers (amlodipine)
• Ranolazine

Correct Answer: Non-dihydropyridine calcium channel blockers (verapamil, diltiazem)

Q24. Which physiological effect of nitrates most directly reduces myocardial oxygen demand?

• Increased coronary artery plaque stability
• Decreased preload through venodilation and reduced left ventricular wall stress
• Increased systemic vascular resistance
• Direct inotropic stimulation of the heart

Correct Answer: Decreased preload through venodilation and reduced left ventricular wall stress

Q25. Which statement about aspirin in ischemic heart disease is true?

• Aspirin reversibly inhibits platelet function for about 2 hours
• Aspirin irreversibly inhibits cyclooxygenase and reduces thromboxane A2 formation
• Aspirin is contraindicated in all angina patients
• Aspirin primarily acts by reducing LDL cholesterol

Correct Answer: Aspirin irreversibly inhibits cyclooxygenase and reduces thromboxane A2 formation

Q26. Which antihyperlipidemic effect of statins is most relevant to preventing ischemic heart events?

• Direct vasodilation of coronary arteries
• Lowering LDL cholesterol and stabilizing atherosclerotic plaques
• Increasing triglyceride synthesis
• Blocking dietary cholesterol absorption

Correct Answer: Lowering LDL cholesterol and stabilizing atherosclerotic plaques

Q27. Which of the following is a common side effect of beta-blockers that may limit their use in some angina patients?

• Bronchospasm in patients with reactive airway disease when using nonselective agents
• Hyperkalemia due to aldosterone antagonism
• Severe headache similar to nitrates
• QT prolongation more than ranolazine

Correct Answer: Bronchospasm in patients with reactive airway disease when using nonselective agents

Q28. Which stress test modality is preferred for a patient who cannot exercise but requires ischemia evaluation?

• Standard exercise ECG test regardless of ability
• Pharmacologic stress imaging with agents such as dobutamine or vasodilator radionuclide perfusion imaging
• 24-hour Holter monitoring only
• Carotid duplex ultrasound

Correct Answer: Pharmacologic stress imaging with agents such as dobutamine or vasodilator radionuclide perfusion imaging

Q29. Which pharmacologic property of ranolazine requires monitoring when combined with other drugs?

• It causes severe hypotension with nitrates
• It prolongs the QT interval and may interact with other QT‑prolonging drugs
• It causes irreversible platelet inhibition
• It induces strong CYP3A4 enzyme induction lowering other drug levels

Correct Answer: It prolongs the QT interval and may interact with other QT‑prolonging drugs

Q30. Which feature best distinguishes stable angina from unstable angina clinically?

• Stable angina occurs unpredictably at rest with progressively increasing frequency
• Stable angina has reproducible exertional chest pain with predictable threshold and relief by rest or nitroglycerin
• Stable angina always shows elevated troponin
• Stable angina presents with ST-segment elevation at rest

Correct Answer: Stable angina has reproducible exertional chest pain with predictable threshold and relief by rest or nitroglycerin

Q31. Which medication reduces the risk of recurrent ischemic events by inhibiting platelet P2Y12 receptors?

• Warfarin
• Clopidogrel
• Low-dose aspirin only
• Heparin

Correct Answer: Clopidogrel

Q32. In a patient with angina and concomitant diabetes mellitus, which agent class provides both cardiovascular and renal protective effects post-MI?

• Dihydropyridine calcium channel blockers only
• ACE inhibitors
• Short-acting nitrates exclusively
• Antiarrhythmic class III drugs

Correct Answer: ACE inhibitors

Q33. Which coronary intervention is most appropriate for a patient with left main coronary artery significant stenosis?

• Medical therapy only
• Coronary artery bypass grafting (CABG)
• Long-term nitrate patch without revascularization
• Percutaneous transluminal angioplasty without stenting always

Correct Answer: Coronary artery bypass grafting (CABG)

Q34. Which effect explains why nitrates may improve subendocardial perfusion in ischemia?

• Marked increase in myocardial contractility
• Reduction in left ventricular end-diastolic pressure and wall tension
• Systemic vasoconstriction directing blood to the heart
• Permanent dilation of epicardial coronary arteries only

Correct Answer: Reduction in left ventricular end-diastolic pressure and wall tension

Q35. Which of the following is an angina equivalent symptom more common in diabetics?

• Severe pleuritic chest pain
• Silent ischemia or atypical dyspnea and fatigue without chest pain
• Classic crushing substernal pain only on exertion
• Severe left shoulder dislocation

Correct Answer: Silent ischemia or atypical dyspnea and fatigue without chest pain

Q36. Which pharmacokinetic characteristic is important when choosing nitrate formulation for acute angina relief?

• High oral bioavailability with delayed onset
• Rapid onset of action such as sublingual or spray administration
• Extended duration of action only matters for acute relief
• Minimal first-pass effect to prolong half-life

Correct Answer: Rapid onset of action such as sublingual or spray administration

Q37. Which antianginal drug is most appropriate for a patient with bradycardia and hypotension where further HR reduction is undesirable?

• Non-dihydropyridine calcium channel blocker (verapamil)
• Beta-blocker (metoprolol)
• Ranolazine, because it has minimal effects on heart rate and blood pressure
• High-dose IV nitroprusside

Correct Answer: Ranolazine, because it has minimal effects on heart rate and blood pressure

Q38. Which mechanism contributes to coronary plaque rupture and acute coronary syndromes?

• Excessive collagen deposition making plaques stable
• Inflammation and thinning of the fibrous cap overlying a lipid-rich necrotic core
• Excessive HDL leading to plaque instability
• Marked vasodilation of coronary microcirculation

Correct Answer: Inflammation and thinning of the fibrous cap overlying a lipid-rich necrotic core

Q39. For long-term secondary prevention after myocardial infarction, which combination is commonly recommended unless contraindicated?

• High-intensity statin, beta-blocker, ACE inhibitor, and low-dose aspirin
• Only long-acting nitrates and no antiplatelet therapy
• Warfarin only without antiplatelet therapy
• Short-course antibiotics and high-dose NSAIDs

Correct Answer: High-intensity statin, beta-blocker, ACE inhibitor, and low-dose aspirin

Q40. Which adverse interaction must be considered when combining verapamil with a beta-blocker?

• Marked hypertension due to additive pressor effects
• Additive negative chronotropic and inotropic effects increasing risk of bradycardia and heart block
• Complete prevention of nitrate tolerance
• Enhanced antiplatelet effect causing thrombocytosis

Correct Answer: Additive negative chronotropic and inotropic effects increasing risk of bradycardia and heart block

Q41. Which clinical scenario is most consistent with microvascular angina (syndrome X)?

• Chest pain with obstructive epicardial coronary artery disease on angiography
• Typical exertional chest pain, normal coronary angiography, and evidence of ischemia on stress testing due to small-vessel dysfunction
• Chest pain only due to pulmonary embolism
• Chest pain that responds only to antibiotics

Correct Answer: Typical exertional chest pain, normal coronary angiography, and evidence of ischemia on stress testing due to small-vessel dysfunction

Q42. Which antianginal medication class has the advantage of reducing afterload by arterial vasodilation?

• Organic nitrates only affect preload
• Dihydropyridine calcium channel blockers such as amlodipine
• Pure beta-blockers have strong vasodilatory afterload reduction
• Ranolazine primarily reduces afterload

Correct Answer: Dihydropyridine calcium channel blockers such as amlodipine

Q43. In acute chest pain evaluation, which triage acronym historically guided immediate measures but has evolved in practice?

• MONA: Morphine, Oxygen, Nitrates, Aspirin
• SOAP: Subjective, Objective, Assessment, Plan
• ABCDE: Airway, Breathing, Circulation, Disability, Exposure
• FAST: Face, Arms, Speech, Time

Correct Answer: MONA: Morphine, Oxygen, Nitrates, Aspirin

Q44. Which medication should be avoided or used with caution in patients with hypertrophic obstructive cardiomyopathy presenting with angina?

• Beta-blockers are contraindicated
• Diuretics and vasodilators that reduce preload and may worsen outflow obstruction
• Verapamil is always the best choice without caution
• Isosorbide dinitrate is first-line without monitoring

Correct Answer: Diuretics and vasodilators that reduce preload and may worsen outflow obstruction

Q45. Which factor is the strongest modifiable risk factor for development of ischemic heart disease?

• Age
• Smoking
• Family history of early CAD
• Male sex

Correct Answer: Smoking

Q46. Which statement about sublingual versus transdermal nitrates is correct regarding pharmacodynamics?

• Transdermal nitrates have faster onset than sublingual
• Sublingual nitrates produce rapid onset for acute relief while transdermal provide sustained prophylaxis
• Sublingual nitrates are used only for chronic prevention
• Transdermal nitrates avoid tolerance without requiring nitrate-free intervals

Correct Answer: Sublingual nitrates produce rapid onset for acute relief while transdermal provide sustained prophylaxis

Q47. Which laboratory abnormality is most commonly used to confirm myocardial infarction rather than stable angina?

• Elevated troponin levels indicating myocardial necrosis
• Decreased LDL cholesterol acutely
• Elevated hemoglobin concentration
• Positive D-dimer only

Correct Answer: Elevated troponin levels indicating myocardial necrosis

Q48. Which patient characteristic makes beta-blockers less suitable for angina management?

• History of well-controlled hypertension without respiratory disease
• Active severe asthma or COPD with frequent bronchospasm when using nonselective agents
• History of myocardial infarction
• Young patient with exercise-induced angina

Correct Answer: Active severe asthma or COPD with frequent bronchospasm when using nonselective agents

Q49. Which statement regarding aspirin dosing in secondary prevention of ischemic heart disease is most appropriate?

• Low-dose aspirin (75–100 mg daily) is often effective for long-term secondary prevention
• Aspirin should be avoided entirely after MI
• Only very high-dose aspirin (>1000 mg daily) is effective
• Aspirin is replaced by statins for antiplatelet effect

Correct Answer: Low-dose aspirin (75–100 mg daily) is often effective for long-term secondary prevention

Q50. When teaching a patient about nitroglycerin use for angina, which instruction is most important?

• Take nitroglycerin tablets three times daily at fixed intervals to prevent attacks without any nitrate-free period
• Place sublingual nitroglycerin under the tongue at onset of chest pain and repeat every 5 minutes up to three doses, seek emergency care if pain persists
• Always combine nitroglycerin with sildenafil to enhance effect
• Crush and swallow sublingual nitroglycerin tablets for faster action

Correct Answer: Place sublingual nitroglycerin under the tongue at onset of chest pain and repeat every 5 minutes up to three doses, seek emergency care if pain persists

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