MCQ Quiz: Ischemic Heart Disease

Ischemic Heart Disease (IHD), also known as coronary artery disease, remains a leading cause of morbidity and mortality globally. It results from an imbalance between myocardial oxygen supply and demand, most commonly due to atherosclerotic plaque accumulation in the coronary arteries. For PharmD students, a comprehensive understanding of IHD, encompassing its pathophysiology, risk factors, clinical presentation, diagnostic approaches, and multifaceted management strategies (including pharmacological and non-pharmacological interventions), is crucial for providing optimal patient care. This MCQ quiz will test your knowledge of the key aspects of Ischemic Heart Disease, focusing on its underlying principles and therapeutic management.

1. The primary underlying cause of most cases of Ischemic Heart Disease (IHD) is:

• A. Coronary artery vasospasm
• B. Atherosclerosis of the coronary arteries
• C. Valvular heart disease
• D. Congenital heart defects

Answer: B. Atherosclerosis of the coronary arteries

2. The imbalance in Ischemic Heart Disease refers to a mismatch between:

• A. Oxygen supply and carbon dioxide removal in the lungs
• B. Myocardial oxygen supply and myocardial oxygen demand
• C. Blood glucose supply and myocardial energy demand
• D. Atrial and ventricular contraction rates

Answer: B. Myocardial oxygen supply and myocardial oxygen demand

3. Which of the following is a major determinant of myocardial oxygen demand?

• A. Diastolic blood pressure
• B. Heart rate, myocardial contractility, and wall tension
• C. Coronary blood flow
• D. Hemoglobin concentration

Answer: B. Heart rate, myocardial contractility, and wall tension

4. Organic nitrates, like nitroglycerin, primarily alleviate angina by:

• A. Increasing myocardial contractility
• B. Causing direct coronary artery vasoconstriction
• C. Reducing myocardial oxygen demand through venodilation (reducing preload) and some arteriodilation (reducing afterload)
• D. Blocking beta-adrenergic receptors

Answer: C. Reducing myocardial oxygen demand through venodilation (reducing preload) and some arteriodilation (reducing afterload)

5. The mechanism of action of organic nitrates involves the release of which signaling molecule that activates guanylyl cyclase?

• A. Acetylcholine
• B. Nitric Oxide (NO)
• C. Prostacyclin
• D. Endothelin-1

Answer: B. Nitric Oxide (NO)

6. Beta-blockers are beneficial in stable angina primarily because they:

• A. Increase coronary blood flow by vasodilation
• B. Decrease myocardial oxygen demand by reducing heart rate and contractility
• C. Inhibit platelet aggregation
• D. Directly dissolve atherosclerotic plaques

Answer: B. Decrease myocardial oxygen demand by reducing heart rate and contractility

7. Which class of calcium channel blockers is generally preferred for angina if a CCB is needed in combination with a beta-blocker, due to less risk of excessive bradycardia or heart block?

• A. Non-dihydropyridines (e.g., Verapamil, Diltiazem)
• B. Dihydropyridines (e.g., Amlodipine, Nifedipine)
• C. All CCBs are equally safe with beta-blockers
• D. CCBs are contraindicated with beta-blockers

Answer: B. Dihydropyridines (e.g., Amlodipine, Nifedipine)

8. Aspirin is recommended for most patients with IHD due to its:

• A. Analgesic effects
• B. Anti-inflammatory effects via COX-1 and COX-2 inhibition
• C. Irreversible inhibition of cyclooxygenase-1 (COX-1) in platelets, reducing thromboxane A2 synthesis
• D. Cholesterol-lowering properties

Answer: C. Irreversible inhibition of cyclooxygenase-1 (COX-1) in platelets, reducing thromboxane A2 synthesis

9. Clopidogrel, a P2Y12 inhibitor, requires metabolic activation in the liver primarily by which cytochrome P450 enzyme?

• A. CYP3A4
• B. CYP1A2
• C. CYP2C19
• D. CYP2D6

Answer: C. CYP2C19

10. Ranolazine is an antianginal agent that is thought to work by:

• A. Releasing nitric oxide
• B. Inhibiting the late inward sodium current, reducing intracellular calcium overload and improving myocardial function
• C. Blocking beta-adrenergic receptors
• D. Inhibiting HMG-CoA reductase

Answer: B. Inhibiting the late inward sodium current, reducing intracellular calcium overload and improving myocardial function

11. “Nitrate tolerance” refers to the phenomenon where:

• A. Patients develop an allergy to nitrates.
• B. The vasodilatory effects of nitrates diminish with continuous or frequent exposure.
• C. Nitrates become more potent over time.
• D. Nitrates cause severe headaches that patients cannot tolerate.

Answer: B. The vasodilatory effects of nitrates diminish with continuous or frequent exposure.

12. To prevent nitrate tolerance with long-acting nitrate formulations (e.g., transdermal patches), what strategy is commonly recommended?

• A. Using the lowest effective dose
• B. Administering the nitrate continuously 24 hours a day
• C. Incorporating a daily “nitrate-free” or “low-nitrate” interval of 10-12 hours
• D. Combining nitrates with a diuretic

Answer: C. Incorporating a daily “nitrate-free” or “low-nitrate” interval of 10-12 hours

13. From a medicinal chemistry perspective, organic nitrates like nitroglycerin and isosorbide dinitrate are considered:

• A. Active nitric oxide donors themselves
• B. Prodrugs that require enzymatic bioactivation to release nitric oxide
• C. Direct guanylyl cyclase activators
• D. Inhibitors of phosphodiesterase-5

Answer: B. Prodrugs that require enzymatic bioactivation to release nitric oxide

14. The biotransformation of nitroglycerin to release NO is thought to involve which enzyme system, particularly mitochondrial aldehyde dehydrogenase (ALDH2)?

• A. Cytochrome P450 enzymes
• B. Glutathione S-transferases
• C. Mitochondrial aldehyde dehydrogenase (ALDH2)
• D. Xanthine oxidase

Answer: C. Mitochondrial aldehyde dehydrogenase (ALDH2)

15. Which of the following is a common and often dose-limiting side effect of organic nitrates?

• A. Bradycardia
• B. Hypertension
• C. Headache
• D. Bronchoconstriction

Answer: C. Headache

16. The use of long-acting nitrates is primarily for:

• A. Acute relief of anginal attacks
• B. Prophylaxis against anginal attacks
• C. Lowering LDL cholesterol
• D. Preventing platelet aggregation

Answer: B. Prophylaxis against anginal attacks

17. Sublingual nitroglycerin is administered for acute anginal attacks because this route offers:

• A. Slow, sustained release
• B. Avoidance of first-pass metabolism and rapid onset of action
• C. Direct action on myocardial cells
• D. Minimal side effects

Answer: B. Avoidance of first-pass metabolism and rapid onset of action

18. Which of the following beta-blockers is cardioselective (beta-1 selective)?

• A. Propranolol
• B. Metoprolol
• C. Nadolol
• D. Timolol

Answer: B. Metoprolol

19. In patients with stable IHD and a history of myocardial infarction or heart failure, which class of drugs is generally recommended indefinitely to reduce mortality?

• A. Long-acting nitrates
• B. Beta-blockers (evidence-based)
• C. Dihydropyridine calcium channel blockers as monotherapy
• D. Ranolazine

Answer: B. Beta-blockers (evidence-based)

20. ACE inhibitors or ARBs are recommended in patients with IHD, particularly if they also have:

• A. Only isolated stable angina
• B. Hypertension, diabetes, chronic kidney disease, or left ventricular dysfunction
• C. Severe hyperlipidemia unresponsive to statins
• D. A high risk of nitrate tolerance

Answer: B. Hypertension, diabetes, chronic kidney disease, or left ventricular dysfunction

21. Stable angina pectoris is typically characterized by chest pain or discomfort that is:

• A. Constant and unrelated to exertion
• B. Provoked by exertion or emotional stress and relieved by rest or nitroglycerin
• C. Sharp, stabbing, and localized to one point
• D. Always radiating to the left arm

Answer: B. Provoked by exertion or emotional stress and relieved by rest or nitroglycerin

22. Which of the following is a modifiable risk factor for Ischemic Heart Disease?

• A. Age
• B. Male gender
• C. Family history of premature IHD
• D. Smoking

Answer: D. Smoking

23. The “vulnerable plaque” in atherosclerosis, which is prone to rupture and cause acute coronary syndromes, is typically characterized by:

• A. A thick fibrous cap and small lipid core
• B. A thin fibrous cap, large lipid core, and significant inflammation
• C. Extensive calcification and no inflammation
• D. Being composed primarily of smooth muscle cells

Answer: B. A thin fibrous cap, large lipid core, and significant inflammation

24. Besides lifestyle modifications, what is the cornerstone of pharmacological therapy for all patients with established IHD to reduce ASCVD events and mortality?

• A. Long-acting nitrates
• B. Statin therapy
• C. Calcium channel blockers
• D. Ranolazine

Answer: B. Statin therapy

25. Prinzmetal’s angina (variant angina) is caused by:

• A. Fixed atherosclerotic obstruction
• B. Coronary artery vasospasm
• C. Increased myocardial oxygen demand during exercise
• D. Aortic valve stenosis

Answer: B. Coronary artery vasospasm

26. Which class of drugs is particularly effective for treating Prinzmetal’s angina?

• A. Beta-blockers (may worsen spasm)
• B. Calcium channel blockers and nitrates
• C. Statins
• D. ACE inhibitors

Answer: B. Calcium channel blockers and nitrates

27. The term “silent ischemia” refers to:

• A. Angina that occurs only at night
• B. Ischemic episodes that occur without causing chest pain or noticeable symptoms
• C. Ischemia caused by non-obstructive coronary artery disease
• D. Ischemia that is only detectable by MRI

Answer: B. Ischemic episodes that occur without causing chest pain or noticeable symptoms

28. Which diagnostic test is commonly used to assess the extent of coronary artery blockage and is considered the gold standard for diagnosing obstructive CAD?

• A. Electrocardiogram (ECG) at rest
• B. Echocardiogram
• C. Coronary angiography
• D. Chest X-ray

Answer: C. Coronary angiography

29. A common side effect of ranolazine that requires monitoring is:

• A. Bradycardia
• B. QT interval prolongation
• C. Hyperkalemia
• D. Bronchospasm

Answer: B. QT interval prolongation

30. The use of sildenafil (and other PDE-5 inhibitors) is contraindicated with nitrates due to the risk of:

• A. Severe hypertension
• B. Severe hypotension
• C. Myocardial infarction
• D. Nitrate tolerance

Answer: B. Severe hypotension

31. Isosorbide mononitrate is an active metabolite of which other commonly used nitrate?

• A. Nitroglycerin
• B. Isosorbide dinitrate
• C. Amyl nitrite
• D. Pentaerythritol tetranitrate

Answer: B. Isosorbide dinitrate

32. The primary goal of antiplatelet therapy in IHD is to:

• A. Lower cholesterol levels
• B. Prevent coronary artery spasm
• C. Prevent thrombus formation at the site of ruptured atherosclerotic plaques
• D. Reduce blood pressure

Answer: C. Prevent thrombus formation at the site of ruptured atherosclerotic plaques

33. For patients with chronic stable angina who remain symptomatic despite optimal beta-blocker therapy, what is a reasonable add-on agent?

• A. Another beta-blocker
• B. A calcium channel blocker or a long-acting nitrate
• C. High-dose aspirin
• D. A loop diuretic

Answer: B. A calcium channel blocker or a long-acting nitrate

34. The chemical structure of organic nitrates contains O-NO2 (nitrate ester) groups. The number of these groups can influence potency and duration. Nitroglycerin has how many nitrate ester groups?

• A. One
• B. Two
• C. Three
• D. Four

Answer: C. Three

35. Sulfhydryl (-SH) groups are thought to be important for the bioactivation of nitrates and can be depleted, contributing to tolerance. Which of the following can act as an SH donor?

• A. Vitamin C
• B. N-acetylcysteine (NAC)
• C. Beta-carotene
• D. Folic acid

Answer: B. N-acetylcysteine (NAC) (though its clinical utility in preventing nitrate tolerance is debatable)

36. If a patient with IHD has asthma or COPD, which type of beta-blocker would be preferred if beta-blockade is necessary?

• A. Non-selective beta-blocker (e.g., propranolol)
• B. Beta-1 selective blocker (e.g., metoprolol, atenolol)
• C. Beta-blocker with intrinsic sympathomimetic activity (e.g., pindolol)
• D. Alpha-beta blocker (e.g., carvedilol)

Answer: B. Beta-1 selective blocker (e.g., metoprolol, atenolol)

37. A major difference in the hemodynamic effects of dihydropyridine CCBs versus non-dihydropyridine CCBs (verapamil, diltiazem) in IHD is that non-DHPs:

• A. Cause more potent peripheral vasodilation
• B. Have more pronounced negative chronotropic and inotropic effects on the heart
• C. Are less likely to cause constipation
• D. Do not affect coronary blood flow

Answer: B. Have more pronounced negative chronotropic and inotropic effects on the heart

38. The term “double product” (Heart Rate x Systolic Blood Pressure) is an indirect measure of:

• A. Coronary blood flow
• B. Myocardial oxygen demand
• C. Ejection fraction
• D. Cardiac output

Answer: B. Myocardial oxygen demand

39. Which lifestyle factor is most strongly associated with an increased risk of developing IHD?

• A. Moderate alcohol consumption
• B. High intake of fruits and vegetables
• C. Sedentary lifestyle and unhealthy diet
• D. Regular fish oil supplementation

Answer: C. Sedentary lifestyle and unhealthy diet

40. The enzyme responsible for converting angiotensin I to angiotensin II, which can contribute to vasoconstriction and cardiac remodeling in IHD, is:

• A. Renin
• B. Angiotensin-Converting Enzyme (ACE)
• C. Aldosterone synthase
• D. Bradykininase

Answer: B. Angiotensin-Converting Enzyme (ACE)

41. For a patient experiencing an acute anginal attack, how many doses of sublingual nitroglycerin can typically be taken before seeking emergency medical attention if pain persists?

• A. One dose only
• B. Up to three doses, 5 minutes apart
• C. As many doses as needed until pain resolves
• D. Five doses, 1 minute apart

Answer: B. Up to three doses, 5 minutes apart

42. “Steal phenomenon” in the context of IHD refers to:

• A. Diversion of blood flow away from ischemic areas towards non-ischemic areas by potent, non-selective coronary vasodilators.
• B. The heart “stealing” oxygen from other organs during exercise.
• C. Plaque regression leading to improved blood flow.
• D. Platelets adhering to and “stealing” space within a coronary artery.

Answer: A. Diversion of blood flow away from ischemic areas towards non-ischemic areas by potent, non-selective coronary vasodilators.

43. Which of the following is NOT a primary goal in the management of chronic stable angina?

• A. To relieve anginal symptoms
• B. To prevent myocardial infarction and death
• C. To induce complete regression of atherosclerotic plaques within weeks
• D. To improve quality of life

Answer: C. To induce complete regression of atherosclerotic plaques within weeks (While plaque stabilization and some regression can occur over time with aggressive risk factor modification, complete regression in weeks is not a primary or realistic goal).

44. The chemical stability of nitroglycerin, especially in tablet form, can be affected by:

• A. Exposure to cold temperatures
• B. Light, heat, and moisture, leading to loss of potency
• C. High pH environments
• D. Interaction with plastic containers (adsorption)

Answer: B. Light, heat, and moisture, leading to loss of potency (And D is also true for some packaging) Given the options, B is a more direct chemical stability issue.

45. Ranolazine is contraindicated with strong inhibitors of which CYP enzyme due to increased plasma concentrations and risk of QT prolongation?

• A. CYP2D6
• B. CYP2C9
• C. CYP3A4
• D. CYP1A2

Answer: C. CYP3A4

46. The anti-ischemic effect of beta-blockers is reduced if they possess significant:

• A. Beta-1 selectivity
• B. Intrinsic sympathomimetic activity (ISA)
• C. Lipophilicity
• D. Long half-life

Answer: B. Intrinsic sympathomimetic activity (ISA)

47. A patient with stable angina is well-controlled on metoprolol and sublingual nitroglycerin PRN. Which additional class of medication should almost all patients with IHD be on for long-term risk reduction, unless contraindicated?

• A. Loop diuretics
• B. Statins
• C. Warfarin
• D. Digoxin

Answer: B. Statins

48. Drug-eluting stents, used in percutaneous coronary intervention (PCI), release medications like everolimus or sirolimus to:

• A. Promote endothelial cell growth
• B. Prevent restenosis by inhibiting smooth muscle cell proliferation
• C. Dissolve the existing atherosclerotic plaque
• D. Prevent platelet aggregation systemically

Answer: B. Prevent restenosis by inhibiting smooth muscle cell proliferation

49. Myocardial stunning and hibernation are conditions related to IHD. Hibernating myocardium refers to:

• A. Acutely necrotic myocardial tissue.
• B. Chronically ischemic, dysfunctional but viable myocardium that can recover function if blood flow is restored.
• C. Myocardium that is temporarily dysfunctional after a brief ischemic period but recovers spontaneously.
• D. Scar tissue within the myocardium.

Answer: B. Chronically ischemic, dysfunctional but viable myocardium that can recover function if blood flow is restored.

50. The choice between medical therapy, PCI, or CABG for managing stable IHD depends on:

• A. Patient preference only
• B. The severity and extent of coronary artery disease, symptoms, patient comorbidities, and risk assessment
• C. The availability of a cardiac surgeon
• D. The patient’s insurance coverage primarily

Answer: B. The severity and extent of coronary artery disease, symptoms, patient comorbidities, and risk assessment Sources

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