Chapter 7. Stable Ischemic Heart Disease
A patient with a history of hypertension, diabetes, dyslipidemia, morbid obesity, and chronic stable angina returns to clinic for follow-up evaluation. His current treatment regimen includes aspirin 81 mg PO daily, atenolol 50 mg PO daily, candesartan 8 mg PO daily, rosuvastatin 20 mg PO daily, and nitroglycerin 0.4 mg SL as needed. The patient is currently experiencing angina at rest and states that for the past week the frequency of episodes have increased from once monthly to once daily. Blood pressure is 128/64 mm Hg; heart rate is 70 beats/min. Which of the following interventions is recommended at this time?
A. Add isosorbide mononitrate 30 mg PO daily
B. Increase atenolol to 100 mg PO daily
C. Refer the patient to the hospital
D. Schedule an outpatient coronary angiogram
Option A: Incorrect. Although isosorbide mononitrate would be a reasonable choice to prevent chronic angina symptoms, the patient is experiencing symptoms consistent with ACS and requires referral to the hospital.
Option B: Incorrect. Although increasing atenolol would be a reasonable choice to prevent chronic angina symptoms, the patient is experiencing symptoms consistent with ACS and requires referral to the hospital.
Option C: Correct. The patient's symptoms (angina at rest, increased frequency over a short period of time) are consistent with ACS. Referral to the hospital is warranted.
Option D: Incorrect. While it is likely that this patient requires an angiogram, given that the patient is experiencing symptoms consistent with ACS, referral to the hospital with potential for an inpatient angiogram is preferred to scheduling it as an outpatient.
A patient is started on ranolazine 500 mg PO twice daily for recurrent angina symptoms. Which of the following should be monitored during ranolazine therapy?
A. Blood pressure and heart rate
B. Creatinine and potassium levels
C. Drug interactions and QT interval
D. Symptoms of angioedema and heart failure
Option A: Incorrect. Ranolazine does not affect blood pressure or heart rate.
Option B: Incorrect. Ranolazine will not affect potassium levels or creatinine.
Option C: Correct. ECG should be obtained to check for significant QT prolongation and drug interaction screen should be performed as ranolazine has significant drug interactions either through additive QT prolongation potential or alterations in drug metabolism or transport (CYP, OCT2, and P-gp).