NU 627 Exam 4: 50 Questions with Correct Answers &
Complete Solutions | Herzing University (2026/2027 Edition)
SECTION 1: CARDIOVASCULAR PHARMACOTHERAPEUTICS
Question 1. A 72-year-old male with nonvalvular atrial fibrillation (CHA₂DS₂-VASc = 4,
HAS-BLED = 2) has a history of upper GI bleeding requiring transfusion 18 months ago.
Endoscopy at that time revealed gastric ulcers (now healed). His eGFR is 48
mL/min/1.73m². Which anticoagulation strategy is most appropriate?
A. Warfarin (INR 2.0–3.0) with PPI co-therapy
B. Apixaban 5 mg orally twice daily
C. Rivaroxaban 20 mg orally once daily
D. Dabigatran 150 mg orally twice daily
Correct Answer: B. Apixaban 5 mg orally twice daily
Rationale: Apixaban demonstrates the most favorable gastrointestinal bleeding profile
among the direct oral anticoagulants (DOACs) and is preferred in patients with prior GI
bleeding. For eGFR 30–59 mL/min/1.73m², standard apixaban dosing (5 mg BID)
applies unless two of three criteria are met (age ≥80, weight ≤60 kg, serum creatinine
≥1.5 mg/dL), which would mandate 2.5 mg BID. Rivaroxaban and dabigatran have higher
observed rates of GI bleeding in meta-analyses. Warfarin requires monitoring and has
higher overall bleeding risk.
Question 2. A 58-year-old female with resistant hypertension is taking chlorthalidone 25
mg daily, amlodipine 10 mg daily, and lisinopril 40 mg daily. Home BP averages 156/94
mmHg. Laboratory studies reveal potassium 3.1 mEq/L and eGFR 52. Which addition is
most likely to achieve BP control based on current evidence?
A. Spironolactone 25 mg daily
B. Clonidine 0.1 mg twice daily
C. Hydralazine 50 mg three times daily
D. Amlodipine 10 mg twice daily
,Correct Answer: A. Spironolactone 25 mg daily
Rationale: The PATHWAY-2 trial established spironolactone as the most effective
fourth-line agent for resistant hypertension, particularly when hypokalemia suggests
aldosterone excess or inadequate potassium control. The low potassium (3.1 mEq/L)
strongly supports this mechanism. Clonidine has significant central nervous system
side effects and rebound hypertension. Hydralazine requires three-times-daily dosing
and is reserved for refractory cases. Amlodipine is already maximized.
Question 3. A 55-year-old male with established ASCVD (prior MI 2 years ago) has an
LDL-C of 108 mg/dL while taking atorvastatin 40 mg daily. He tolerates the statin well.
According to the 2024 AHA/ACC/Multisociety Cholesterol Management Guideline, what
is the next best step?
A. Increase atorvastatin to 80 mg daily
B. Add ezetimibe 10 mg daily
C. Add bempedoic acid 180 mg daily
D. Switch to rosuvastatin 40 mg daily
Correct Answer: B. Add ezetimibe 10 mg daily
Rationale: For patients with very high-risk ASCVD and LDL-C ≥70 mg/dL on maximally
tolerated statin intensity, the 2024 guidelines recommend adding ezetimibe as the first
non-statin therapy. If LDL-C remains ≥70 mg/dL after ezetimibe, a PCSK9 inhibitor or
bempedoic acid is added. Switching statins or increasing dose provides only modest
additional LDL reduction (~6% rule). Ezetimibe provides an additional 15–20% LDL
reduction with excellent tolerability.
Question 4. A 68-year-old with HFrEF (LVEF 28%) remains dyspneic (NYHA Class III)
despite optimal guideline-directed medical therapy including sacubitril/valsartan,
metoprolol succinate, spironolactone, and dapagliflozin. Heart rate is 74 bpm in sinus
rhythm. Which addition is most likely to reduce hospitalization?
A. Ivabradine 5 mg twice daily
B. Digoxin 0.125 mg daily
C. Hydralazine/isosorbide dinitrate
D. Verapamil SR 120 mg daily
, Correct Answer: A. Ivabradine 5 mg twice daily
Rationale: Ivabradine inhibits the If (funny) current in the sinoatrial node and is indicated
in stable HFrEF patients on optimal GDMT with sinus rhythm and resting heart rate ≥70
bpm to reduce heart failure hospitalization (SHIFT trial). Digoxin improves symptoms
but does not reduce hospitalization or mortality in this context. Hydralazine/isosorbide
dinitrate is indicated for African Americans with HFrEF on optimal therapy or for ACE
inhibitor/ARB intolerance. Verapamil is contraindicated in HFrEF due to negative
inotropy.
Question 5. A 64-year-old with paroxysmal atrial fibrillation and well-controlled
hypertension is being considered for antiarrhythmic therapy. Which characteristic
makes dronedarone an inappropriate choice?
A. History of liver cirrhosis (Child-Pugh B)
B. Concurrent use of diltiazem for rate control
C. Permanent atrial fibrillation
D. LVEF 50%
Correct Answer: C. Permanent atrial fibrillation
Rationale: Dronedarone is absolutely contraindicated in permanent atrial fibrillation. The
ANDROMEDA and PALLAS trials demonstrated increased mortality, stroke, and heart
failure hospitalization when dronedarone was used in permanent AF or recent
decompensated heart failure. It is also contraindicated in severe hepatic impairment
and NYHA Class IV heart failure. While diltiazem increases dronedarone levels via
CYP3A4 inhibition, this requires dose adjustment rather than absolute contraindication.
LVEF 50% is acceptable.
Question 6. A patient with a mechanical mitral valve replacement (INR goal 2.5–3.5) on
warfarin develops community-acquired pneumonia. Which antibiotic significantly
increases warfarin effect via CYP2C9 inhibition and protein displacement?
A. Azithromycin
B. Levofloxacin
C. Trimethoprim-sulfamethoxazole
D. Doxycycline
Complete Solutions | Herzing University (2026/2027 Edition)
SECTION 1: CARDIOVASCULAR PHARMACOTHERAPEUTICS
Question 1. A 72-year-old male with nonvalvular atrial fibrillation (CHA₂DS₂-VASc = 4,
HAS-BLED = 2) has a history of upper GI bleeding requiring transfusion 18 months ago.
Endoscopy at that time revealed gastric ulcers (now healed). His eGFR is 48
mL/min/1.73m². Which anticoagulation strategy is most appropriate?
A. Warfarin (INR 2.0–3.0) with PPI co-therapy
B. Apixaban 5 mg orally twice daily
C. Rivaroxaban 20 mg orally once daily
D. Dabigatran 150 mg orally twice daily
Correct Answer: B. Apixaban 5 mg orally twice daily
Rationale: Apixaban demonstrates the most favorable gastrointestinal bleeding profile
among the direct oral anticoagulants (DOACs) and is preferred in patients with prior GI
bleeding. For eGFR 30–59 mL/min/1.73m², standard apixaban dosing (5 mg BID)
applies unless two of three criteria are met (age ≥80, weight ≤60 kg, serum creatinine
≥1.5 mg/dL), which would mandate 2.5 mg BID. Rivaroxaban and dabigatran have higher
observed rates of GI bleeding in meta-analyses. Warfarin requires monitoring and has
higher overall bleeding risk.
Question 2. A 58-year-old female with resistant hypertension is taking chlorthalidone 25
mg daily, amlodipine 10 mg daily, and lisinopril 40 mg daily. Home BP averages 156/94
mmHg. Laboratory studies reveal potassium 3.1 mEq/L and eGFR 52. Which addition is
most likely to achieve BP control based on current evidence?
A. Spironolactone 25 mg daily
B. Clonidine 0.1 mg twice daily
C. Hydralazine 50 mg three times daily
D. Amlodipine 10 mg twice daily
,Correct Answer: A. Spironolactone 25 mg daily
Rationale: The PATHWAY-2 trial established spironolactone as the most effective
fourth-line agent for resistant hypertension, particularly when hypokalemia suggests
aldosterone excess or inadequate potassium control. The low potassium (3.1 mEq/L)
strongly supports this mechanism. Clonidine has significant central nervous system
side effects and rebound hypertension. Hydralazine requires three-times-daily dosing
and is reserved for refractory cases. Amlodipine is already maximized.
Question 3. A 55-year-old male with established ASCVD (prior MI 2 years ago) has an
LDL-C of 108 mg/dL while taking atorvastatin 40 mg daily. He tolerates the statin well.
According to the 2024 AHA/ACC/Multisociety Cholesterol Management Guideline, what
is the next best step?
A. Increase atorvastatin to 80 mg daily
B. Add ezetimibe 10 mg daily
C. Add bempedoic acid 180 mg daily
D. Switch to rosuvastatin 40 mg daily
Correct Answer: B. Add ezetimibe 10 mg daily
Rationale: For patients with very high-risk ASCVD and LDL-C ≥70 mg/dL on maximally
tolerated statin intensity, the 2024 guidelines recommend adding ezetimibe as the first
non-statin therapy. If LDL-C remains ≥70 mg/dL after ezetimibe, a PCSK9 inhibitor or
bempedoic acid is added. Switching statins or increasing dose provides only modest
additional LDL reduction (~6% rule). Ezetimibe provides an additional 15–20% LDL
reduction with excellent tolerability.
Question 4. A 68-year-old with HFrEF (LVEF 28%) remains dyspneic (NYHA Class III)
despite optimal guideline-directed medical therapy including sacubitril/valsartan,
metoprolol succinate, spironolactone, and dapagliflozin. Heart rate is 74 bpm in sinus
rhythm. Which addition is most likely to reduce hospitalization?
A. Ivabradine 5 mg twice daily
B. Digoxin 0.125 mg daily
C. Hydralazine/isosorbide dinitrate
D. Verapamil SR 120 mg daily
, Correct Answer: A. Ivabradine 5 mg twice daily
Rationale: Ivabradine inhibits the If (funny) current in the sinoatrial node and is indicated
in stable HFrEF patients on optimal GDMT with sinus rhythm and resting heart rate ≥70
bpm to reduce heart failure hospitalization (SHIFT trial). Digoxin improves symptoms
but does not reduce hospitalization or mortality in this context. Hydralazine/isosorbide
dinitrate is indicated for African Americans with HFrEF on optimal therapy or for ACE
inhibitor/ARB intolerance. Verapamil is contraindicated in HFrEF due to negative
inotropy.
Question 5. A 64-year-old with paroxysmal atrial fibrillation and well-controlled
hypertension is being considered for antiarrhythmic therapy. Which characteristic
makes dronedarone an inappropriate choice?
A. History of liver cirrhosis (Child-Pugh B)
B. Concurrent use of diltiazem for rate control
C. Permanent atrial fibrillation
D. LVEF 50%
Correct Answer: C. Permanent atrial fibrillation
Rationale: Dronedarone is absolutely contraindicated in permanent atrial fibrillation. The
ANDROMEDA and PALLAS trials demonstrated increased mortality, stroke, and heart
failure hospitalization when dronedarone was used in permanent AF or recent
decompensated heart failure. It is also contraindicated in severe hepatic impairment
and NYHA Class IV heart failure. While diltiazem increases dronedarone levels via
CYP3A4 inhibition, this requires dose adjustment rather than absolute contraindication.
LVEF 50% is acceptable.
Question 6. A patient with a mechanical mitral valve replacement (INR goal 2.5–3.5) on
warfarin develops community-acquired pneumonia. Which antibiotic significantly
increases warfarin effect via CYP2C9 inhibition and protein displacement?
A. Azithromycin
B. Levofloxacin
C. Trimethoprim-sulfamethoxazole
D. Doxycycline
