Cardiology for the BCPS exam: the decisions behind each regimen

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

1. Case 01

   A 42-year-old woman with heterozygous familial hypercholesterolemia has LDL-C 128 mg/dL on rosuvastatin 40 mg and ezetimibe 10 mg daily. She is starting evolocumab 140 mg by prefilled autoinjector every 2 weeks. Which counseling point is accurate?

   1. AOption A: Unrefrigerated pens remain usable for up to 6 months
   2. BOption B: Let the pen warm to room temperature for 30 minutes
   3. COption C: Shake the pen well to mix the solution before injecting
   4. DOption D: If a dose is 10 days late, inject two doses together

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   Evolocumab should be removed from the refrigerator about 30 minutes before injection; a cold injection is more uncomfortable, and the dose should be given into the abdomen, thigh, or upper arm. Shaking can denature the monoclonal antibody. A missed dose is given within 7 days, otherwise it is skipped and the original schedule resumed—never doubled—and pens kept at room temperature must be used within 30 days.

   A

   Unrefrigerated pens must be used within 30 days; six months overstates how long the antibody stays stable at room temperature.

   B

   Correct: letting the pen sit out about 30 minutes before injecting makes a cold injection less uncomfortable.

   C

   Shaking can denature a monoclonal antibody, so the pen is inspected but never shaken before use.

   D

   Doses are never doubled; a dose missed by more than 7 days is skipped and the original schedule resumes.

2. Case 02

   A 61-year-old man with a prior MI takes atorvastatin 80 mg daily. Six weeks after starting it he reports bilateral thigh aches without weakness or dark urine. CK is 3 times the upper limit of normal, TSH and SCr are normal, and he takes no interacting drugs. Which action is most appropriate?

   1. AOption A: Continue atorvastatin unchanged since CK is below 10× ULN
   2. BOption B: Hold the statin until symptoms resolve, then rechallenge
   3. COption C: Continue atorvastatin and add coenzyme Q10
   4. DOption D: Stop statins permanently and start niacin

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   For symptomatic statin-associated muscle symptoms with CK below 10 times the upper limit, ACC guidance is to hold the statin until symptoms resolve and then rechallenge at a lower dose or with a different statin, because most patients tolerate a rechallenge and his ASCVD makes statin therapy essential. Coenzyme Q10 has not been shown to relieve symptoms. Permanent discontinuation forfeits outcome benefit, and niacin adds no cardiovascular protection; continuing unchanged ignores ongoing symptoms.

   A

   CK under 10 times the upper limit does not justify pushing through symptoms that bother him; the symptoms themselves call for a pause.

   B

   Correct: a hold until the aches settle, then a rechallenge at a lower dose or with another statin, keeps statin benefit for most patients.

   C

   Coenzyme Q10 has not relieved statin muscle symptoms in trials, so adding it changes nothing about the cause.

   D

   Permanently abandoning statins after an MI forfeits outcome benefit, and niacin has shown no cardiovascular protection.

3. Case 03

   During a pharmacist follow-up call 3 days after discharge for acute decompensated heart failure, a 69-year-old patient taking furosemide 40 mg daily, carvedilol, sacubitril/valsartan, and empagliflozin reports several findings. Which finding most warrants contacting the heart failure team today to prevent readmission?

   1. AOption A: Lightheadedness on standing with home BP 112/70 mm Hg
   2. BOption B: Weight increase of 2.5 kg (5.5 lb) since discharge
   3. COption C: Mild genital itching since starting empagliflozin
   4. DOption D: Nocturia since taking the furosemide dose at 6 PM

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   A gain of more than about 2 kg (5 lb) in a week signals fluid reaccumulation and is the early warning that should prompt a diuretic adjustment before the patient is readmitted. Nocturia is fixed by moving the furosemide dose to the morning, and mild orthostasis with an SBP over 100 mm Hg can be managed with counseling and monitoring. Genital mycotic infection is a known SGLT2-inhibitor adverse effect that rarely requires stopping the drug and is not a readmission threat.

   A

   Mild orthostasis with a home SBP above 100 mm Hg is handled with counseling and slower position changes, not an urgent call.

   B

   Correct: a 2.5 kg gain within days signals fluid reaccumulation, the early warning that a diuretic adjustment can still head off.

   C

   Genital itching is a known SGLT2-inhibitor fungal effect, treated locally and seldom a reason to stop or a readmission threat.

   D

   Nocturia from an evening dose is fixed by moving furosemide to the morning; it does not signal congestion.

4. Case 04

   A 58-year-old woman with nonvalvular atrial fibrillation and hypertension (CHA₂DS₂-VASc 2) had an upper GI bleed from a gastric ulcer while taking rivaroxaban 20 mg daily. The ulcer was treated endoscopically 2 weeks ago and she now takes pantoprazole 40 mg daily. CrCl is 74 mL/min, and she weighs 70 kg. Which anticoagulant plan is most appropriate?

   1. AOption A: Switch to aspirin 81 mg daily
   2. BOption B: Switch to dabigatran 150 mg twice daily
   3. COption C: Switch to apixaban 5 mg twice daily
   4. DOption D: Resume rivaroxaban 20 mg once daily

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   Her annual stroke risk warrants resuming oral anticoagulation once hemostasis is secured, and among DOACs apixaban has the lowest GI-bleeding rate; she meets no dose-reduction criteria, so 5 mg twice daily is correct. Resuming rivaroxaban is tempting, but rivaroxaban and dabigatran 150 mg both carry higher GI-bleeding risk than warfarin. Aspirin alone is not recommended for stroke prevention in AF (2023 ACC/AHA) and still causes GI bleeding.

   A

   Aspirin is not recommended for stroke prevention in AF and still causes GI bleeding, so it trades away protection for little safety.

   B

   Dabigatran 150 mg twice daily has a higher GI-bleeding rate than warfarin, a poor pick right after an ulcer bleed.

   C

   Correct: anticoagulation should resume once hemostasis is secure, and apixaban has the lowest GI-bleeding rate among DOACs at her full dose.

   D

   Restarting rivaroxaban is tempting, but its GI-bleeding rate is higher than apixaban’s, so a switch is the safer way to resume.

5. Case 05

   A 72-year-old woman with newly diagnosed nonvalvular AF has hypertension (BP 146/88 mm Hg) and type 2 diabetes. CHA2DS2-VASc is 4 and HAS-BLED is 3 (age, uncontrolled HTN, and naproxen 500 mg twice daily for knee osteoarthritis). CrCl is 70 mL/min. Which plan is most appropriate?

   1. AOption A: Start warfarin and lower the naproxen dose
   2. BOption B: Withhold anticoagulation because HAS-BLED is ≥3
   3. COption C: Start aspirin 81 mg plus clopidogrel 75 mg daily
   4. DOption D: Start apixaban 5 mg twice daily; stop naproxen

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Her stroke risk clearly warrants oral anticoagulation, and a high HAS-BLED score is used to flag modifiable bleeding risks—here NSAID use and uncontrolled BP—not to withhold therapy. A DOAC is preferred over warfarin, and stopping naproxen (using acetaminophen or a topical NSAID instead) removes a major GI bleeding risk. Aspirin plus clopidogrel is less effective than anticoagulation with similar bleeding, and continuing any systemic NSAID with warfarin keeps the interaction and bleeding risk in place.

   A

   Warfarin is inferior to a DOAC here, and any ongoing NSAID with warfarin keeps the interaction and the GI-bleeding risk.

   B

   A HAS-BLED of 3 flags fixable bleeding risks such as NSAID use and uncontrolled BP; it is not a reason to withhold anticoagulation.

   C

   Dual antiplatelet therapy is less effective than anticoagulation for AF stroke prevention and bleeds about as often.

   D

   Correct: a CHA2DS2-VASc of 4 calls for a full-dose DOAC, and stopping naproxen removes a modifiable bleeding risk.

6. Case 06

   A 72-year-old woman taking apixaban 5 mg twice daily (last dose 4 hours ago) presents with a major upper GI bleed: BP 84/50 mm Hg after 2 units of RBCs, hemoglobin 6.8 g/dL. CrCl is 38 mL/min. Andexanet alfa is not on the hospital formulary. Which reversal agent is most appropriate?

   1. AOption A: Protamine sulfate 50 mg IV slowly
   2. BOption B: Four-factor PCC 2,000 units IV
   3. COption C: Vitamin K 10 mg IV infusion
   4. DOption D: Idarucizumab 5 g IV (2 × 2.5 g)

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   For life-threatening bleeding on a factor Xa inhibitor when andexanet alfa is unavailable, four-factor prothrombin complex concentrate (fixed dose of about 2,000 units or 25–50 units/kg) is the recommended reversal strategy. Idarucizumab is the look-alike antidote but binds only dabigatran. Protamine reverses heparin (partially LMWH), and vitamin K restores vitamin K-dependent factors depleted by warfarin and has no effect on a direct Xa inhibitor.

   A

   Protamine neutralizes heparin and only partly LMWH; it has no effect on apixaban.

   B

   Correct: with andexanet unavailable, four-factor PCC at a fixed dose of about 2,000 units is the recommended Xa-inhibitor reversal.

   C

   Vitamin K restores the factors depleted by warfarin and does nothing against a direct factor Xa inhibitor.

   D

   Idarucizumab binds only dabigatran, which makes it the look-alike antidote that cannot reverse apixaban.

7. Case 07

   A 44-year-old woman (weight 140 kg, BMI 48 kg/m², CrCl 110 mL/min) receives enoxaparin 140 mg SC every 12 hours for an acute DVT. An anti-factor Xa level drawn 4 hours after the third dose is 1.5 IU/mL. The institution’s therapeutic target for twice-daily dosing is 0.6–1.0 IU/mL. Which action is most appropriate?

   1. AOption A: Reduce the dose by about 20% and recheck the peak
   2. BOption B: Redraw the level as a trough before the next dose
   3. COption C: Continue the dose; 1.5 IU/mL is within range
   4. DOption D: Increase the dose by 20% and recheck the peak

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   A peak anti-Xa drawn 4 hours after a steady-state dose (third or fourth dose) is the correct measurement in extreme obesity, and 1.5 IU/mL is above the 0.6–1.0 IU/mL target for every-12-hour dosing, so the dose is reduced by about 20% with a repeat peak. A range of 1.0–2.0 IU/mL applies to once-daily dosing, which is the source of the tempting ‘within range’ answer. Increasing the dose worsens over-anticoagulation, and a trough does not assess the peak target.

   A

   Correct: a peak of 1.5 IU/mL exceeds the 0.6–1.0 target for every-12-hour dosing, so a cut of about 20% with a repeat peak fits.

   B

   A trough cannot be compared with a peak target, and the 4-hour level after the third dose was already drawn at the right time.

   C

   The 1.0–2.0 IU/mL range belongs to once-daily dosing, which is where this tempting misreading comes from.

   D

   Raising the dose would push an already high anti-Xa level further above target and add bleeding risk.

8. Case 08

   A 68-year-old man with severe persistent asthma (exacerbation 2 weeks ago, audible wheeze today) and knee osteoarthritis has exertional chest pressure and several cardiovascular risk factors. He cannot exercise on a treadmill, and stress imaging is ordered. Which pharmacologic stress agent is most appropriate?

   1. AOption A: Dipyridamole
   2. BOption B: Dobutamine
   3. COption C: Adenosine
   4. DOption D: Regadenoson

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   Dobutamine produces stress by raising heart rate and contractility through beta-1 stimulation and does not cause bronchospasm, so it is preferred in a patient with active bronchospastic disease. Adenosine and dipyridamole (which raises endogenous adenosine) can trigger severe bronchospasm through A2B/A3 receptors. Regadenoson is A2A-selective and is tempting, but its labeling still warns of bronchoconstriction and it should be avoided during active wheeze.

   A

   Dipyridamole raises endogenous adenosine and can trigger severe bronchospasm in a patient who is actively wheezing.

   B

   Correct: dobutamine stresses the heart through beta-1 stimulation and does not provoke bronchospasm.

   C

   Adenosine acts on airway A2B and A3 receptors and can cause severe bronchospasm with active asthma.

   D

   Regadenoson is A2A-selective, which tempts, yet its labeling still warns of bronchoconstriction, so it is avoided during active wheeze.

9. Case 09

   At a pharmacist-run cardiovascular screening event, a 64-year-old patient with hypertension and a 10-year ASCVD risk of 12% asks whether to start low-dose aspirin. The patient has no history of ASCVD and no bleeding risk factors. Which recommendation is most appropriate?

   1. AOption A: Advise against starting aspirin for primary prevention
   2. BOption B: Start aspirin 81 mg daily because 10-year risk exceeds 10%
   3. COption C: Start aspirin 325 mg daily to maximize the protective effect
   4. DOption D: Start aspirin 81 mg every other day to limit bleeding risk

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   The 2022 USPSTF guidance recommends against starting aspirin for primary prevention in adults aged 60 or older, because bleeding risk offsets the small benefit, and the 2023 Beers Criteria agree for older adults. Starting aspirin because 10-year risk exceeds 10% reflects the outdated 2016 recommendation for ages 50–59. Alternate-day or higher doses do not change the unfavorable balance of benefit and harm.

   A

   Correct: at 60 or older, USPSTF 2022 advises against starting aspirin for primary prevention because bleeding offsets the small gain.

   B

   The 10% risk trigger comes from the outdated 2016 advice for ages 50–59 and does not apply at 64.

   C

   A 325 mg dose raises bleeding without adding protection, worsening an already unfavorable balance.

   D

   Alternate-day dosing does not rescue the benefit-harm balance; at this age aspirin is simply not started for primary prevention.

10. Case 10

    A 70-year-old man with HFrEF is admitted with acute decompensated heart failure and pulmonary edema. Home dose: furosemide 40 mg orally daily. He received furosemide 80 mg IV 2 hours ago. Spot urine sodium at 2 hours is 35 mEq/L, and urine output over 6 hours is 300 mL. SCr is 1.6 mg/dL (baseline 1.4 mg/dL), BP 132/80 mm Hg, K 4.0 mEq/L. Which change is most appropriate?

    1. AOption A: Give the same daily dose as a continuous infusion
    2. BOption B: Add metolazone 5 mg orally now
    3. COption C: Double the IV dose to furosemide 160 mg
    4. DOption D: Hold diuretics because SCr has risen

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    A spot urine sodium below 50–70 mEq/L at 2 hours or a poor urine output shows an inadequate natriuretic response, and the next step is to double the loop diuretic dose (ESC/HFA diuretic algorithm); loop diuretics have a threshold, so a larger single dose is needed to reach the tubule. Switching to a continuous infusion at the same total dose gave no advantage over boluses in the DOSE trial. A thiazide such as metolazone is added after loop doses have been maximized, and a small SCr rise during decongestion is not a reason to stop diuresis.

    A

    In the DOSE trial a continuous infusion at the same total dose did no better than boluses; the problem here is too low a dose.

    B

    Metolazone is added once loop doses are maximized, and this patient has not yet had an adequate loop dose.

    C

    Correct: a urine sodium under 50–70 mEq/L at 2 hours means poor natriuresis, so the next step is doubling the loop dose.

    D

    A small SCr rise during decongestion is expected and is not a reason to stop diuresis in pulmonary edema.

11. Case 11

    A 68-year-old man with nonvalvular atrial fibrillation (CHA₂DS₂-VASc 3) on apixaban 5 mg twice daily undergoes elective PCI with a drug-eluting stent for stable angina. He received aspirin during the procedure. CrCl is 70 mL/min, weight 82 kg, and he has no prior stroke or bleeding. Which antithrombotic regimen is most appropriate after discharge?

    1. AOption A: Apixaban plus aspirin and clopidogrel for 12 months
    2. BOption B: Apixaban 5 mg twice daily plus ticagrelor 90 mg twice daily
    3. COption C: Apixaban 5 mg twice daily plus clopidogrel 75 mg daily
    4. DOption D: Aspirin 81 mg plus clopidogrel 75 mg daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    After PCI in a patient who needs oral anticoagulation, aspirin is stopped early (within about 1 week) and a DOAC plus clopidogrel is continued, which reduced bleeding without more ischemic events in AUGUSTUS. Twelve months of triple therapy is the tempting choice but markedly increases bleeding. Clopidogrel is the preferred P2Y12 inhibitor with an anticoagulant because ticagrelor and prasugrel add bleeding risk, and DAPT without an anticoagulant does not prevent AF-related stroke.

    A

    Twelve months of triple therapy markedly increases bleeding; aspirin is normally stopped within about a week after PCI.

    B

    Ticagrelor with an anticoagulant adds bleeding risk, so clopidogrel is the preferred P2Y12 partner for a DOAC.

    C

    Correct: as in AUGUSTUS, a DOAC plus clopidogrel after brief aspirin cut bleeding without more ischemic events.

    D

    Dual antiplatelet therapy without an anticoagulant leaves his AF-related stroke risk unprotected.

12. Case 12

    A 71-year-old man with permanent atrial fibrillation and HFrEF (LVEF 30%) has a resting heart rate of 112 beats/min. He takes metoprolol succinate 200 mg daily, sacubitril/valsartan 97/103 mg twice daily, apixaban 5 mg twice daily, and furosemide 40 mg daily. BP is 104/66 mm Hg; K 4.2 mEq/L; SCr 1.0 mg/dL. Which medication is most appropriate to add for rate control?

    1. AOption A: Verapamil ER 180 mg daily
    2. BOption B: Dronedarone 400 mg twice daily
    3. COption C: Diltiazem ER 120 mg daily
    4. DOption D: Digoxin 0.125 mg once daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    Digoxin slows AV conduction without negative inotropy and is a reasonable add-on for rate control in HFrEF when a beta-blocker at maximum dose is not enough. Diltiazem and verapamil add negative inotropic and chronotropic effects to the beta-blocker and are not recommended in HFrEF because they can precipitate decompensation and heart block. Dronedarone increases mortality and HF events in permanent AF and in advanced HFrEF.

    A

    Verapamil adds negative inotropy to a maximal beta-blocker and can precipitate decompensation or heart block in HFrEF.

    B

    Dronedarone increases mortality and HF events in permanent AF and in advanced HFrEF.

    C

    Diltiazem is a non-dihydropyridine calcium channel blocker, avoided in HFrEF because it depresses contractility.

    D

    Correct: digoxin slows AV conduction without negative inotropy and suits a soft BP when the beta-blocker is already maximal.

13. Case 13

    A 65-year-old man with chronic stable angina and an MI 4 years ago undergoes elective PCI with a drug-eluting stent. He has no atrial fibrillation or other indication for anticoagulation, no prior stroke, and no high bleeding risk. He takes atorvastatin 80 mg and metoprolol succinate. Which antiplatelet regimen is most appropriate after PCI?

    1. AOption A: Aspirin 81 mg plus prasugrel 10 mg daily for 12 months
    2. BOption B: Aspirin 81 mg plus clopidogrel 75 mg daily for 6 months
    3. COption C: Aspirin 325 mg plus ticagrelor 90 mg twice daily
    4. DOption D: Rivaroxaban 2.5 mg twice daily plus clopidogrel 75 mg daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    After elective PCI for chronic coronary disease, DAPT with aspirin and clopidogrel for 6 months (1–3 months if bleeding risk is high) is recommended, followed by single antiplatelet therapy. Prasugrel and ticagrelor were studied in ACS, not elective PCI, and ticagrelor must be paired with aspirin 81 mg because higher aspirin doses reduce its efficacy. Rivaroxaban 2.5 mg twice daily is used with aspirin for long-term secondary prevention (COMPASS), not as a post-stent regimen in a patient without an anticoagulation indication.

    A

    Prasugrel was studied in ACS rather than elective PCI, and a potent 12-month regimen adds bleeding without matching benefit here.

    B

    Correct: after elective PCI for chronic coronary disease, aspirin plus clopidogrel for 6 months is the recommended DAPT.

    C

    Aspirin above 100 mg reduces ticagrelor’s efficacy, and ticagrelor is not the standard partner after elective PCI.

    D

    Low-dose rivaroxaban belongs with aspirin for long-term secondary prevention, not as a post-stent regimen without an anticoagulation need.

14. Case 14

    A 69-year-old man (78 kg) is on day 2 after PCI with a drug-eluting stent for NSTEMI. He takes aspirin 81 mg and clopidogrel 75 mg daily after a 600-mg load. Platelet function testing shows high on-treatment platelet reactivity. He had a transient ischemic attack 3 years ago and has no bleeding history. Which change is most appropriate?

    1. AOption A: Switch to prasugrel 60 mg load, then 10 mg daily
    2. BOption B: Switch to ticagrelor 180 mg load, then 90 mg BID
    3. COption C: Increase clopidogrel to 150 mg once daily
    4. DOption D: Add cilostazol 100 mg twice daily to current therapy

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    Ticagrelor is a direct-acting P2Y12 inhibitor that does not need CYP2C19 activation and is preferred over clopidogrel after ACS (2025 ACC/AHA); when switching from clopidogrel, a 180-mg load is given regardless of the last clopidogrel dose. Prasugrel is the tempting potent alternative, but it is contraindicated after a prior TIA or stroke. Doubling clopidogrel did not improve outcomes in patients with high platelet reactivity (GRAVITAS), and adding cilostazol is not a standard ACS strategy.

    A

    Prasugrel is contraindicated after a prior TIA or stroke, and this patient had a TIA 3 years ago.

    B

    Correct: ticagrelor needs no CYP2C19 activation, is preferred after ACS, and is loaded with 180 mg when switching from clopidogrel.

    C

    Doubling clopidogrel in high platelet reactivity did not improve outcomes in GRAVITAS.

    D

    Adding cilostazol is not a standard ACS strategy and leaves the poor clopidogrel response in place.

15. Case 15

    A 70-year-old man with ischemic cardiomyopathy (LVEF 25%) and an ICD has received three appropriate shocks for sustained monomorphic ventricular tachycardia in the past month. He takes metoprolol succinate 200 mg daily, sacubitril/valsartan, spironolactone and dapagliflozin. QTc is 450 ms, and K and Mg are normal. Which antiarrhythmic is most appropriate to add?

    1. AOption A: Diltiazem
    2. BOption B: Dronedarone
    3. COption C: Amiodarone
    4. DOption D: Flecainide

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    Amiodarone added to a β-blocker reduces ICD shocks for recurrent VT (OPTIC) and is safe in severe LV dysfunction because it has little negative inotropy. Dronedarone is the tempting amiodarone-like option but increases mortality in patients with recent decompensated or advanced heart failure. Flecainide is a class IC agent that increases mortality in structural heart disease (CAST), and diltiazem is negatively inotropic and does not suppress VT.

    A

    Diltiazem is negatively inotropic at an LVEF of 25% and does not suppress ventricular tachycardia.

    B

    Dronedarone resembles amiodarone but increases mortality in advanced or recently decompensated heart failure.

    C

    Correct: amiodarone with a beta-blocker reduced ICD shocks for recurrent VT in OPTIC and has little negative inotropy.

    D

    Flecainide is a class IC agent that raised mortality in structural heart disease in CAST.

16. Case 16

    A 58-year-old man with no ASCVD or diabetes has an LDL-C of 140 mg/dL and a 10-year PREVENT risk of 6% (intermediate). He is reluctant to take a lifelong medication and asks whether he really needs a statin. Which next step best supports a guideline-concordant shared decision?

    1. AOption A: Start high-intensity atorvastatin, which the guideline mandates
    2. BOption B: Offer CAC scoring to inform a shared statin decision
    3. COption C: Defer statin discussion until LDL-C reaches 190 mg/dL
    4. DOption D: Recommend red yeast rice as an equivalent statin alternative

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    For intermediate-risk primary prevention, statin therapy is a shared decision rather than a mandate, and a coronary artery calcium score is a recognized way to refine that decision when the patient is unsure: a score of zero supports deferring in many patients, while a positive score favors treating. An LDL-C of 190 mg/dL or higher is a separate severe-hypercholesterolemia category, not a threshold to wait for. Red yeast rice products are unregulated, with variable monacolin content, and lack outcome data.

    A

    At intermediate risk a statin is a shared decision, not a mandate, so presenting it as required ignores his reluctance.

    B

    Correct: a coronary artery calcium score refines an uncertain intermediate-risk decision and gives him concrete data to decide on.

    C

    An LDL-C of 190 mg/dL or more is a separate high-risk category, not a threshold to wait for before discussing therapy.

    D

    Red yeast rice is unregulated, with variable monacolin content and no outcome data, so it is no equivalent to a statin.

17. Case 17

    A 70-year-old woman with HFrEF is discharged on sacubitril/valsartan, carvedilol, spironolactone, dapagliflozin, and furosemide 40 mg daily. Her dry weight is 68 kg (150 lb). Which home-monitoring instruction is most appropriate?

    1. AOption A: Weigh every evening after dinner; call if up 1 lb
    2. BOption B: Weigh once a week; call if up 10 lb over a single month
    3. COption C: Weigh each morning; call if up 2–3 lb/day or 5 lb/week
    4. DOption D: Weigh only when ankles swell; then double the furosemide

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    Daily morning weights (after voiding, before eating, same scale and clothing) detect fluid retention days before symptoms, and a gain of 2–3 lb in a day or about 5 lb in a week is the usual trigger to contact the team or follow a diuretic plan. Weekly weights and a 10-lb threshold detect congestion too late. Evening weights fluctuate with meals, and waiting for edema with self-doubling of the diuretic is both late and unsafe.

    A

    Evening weights swing with meals and fluid intake, and a 1-lb threshold triggers calls for normal day-to-day noise.

    B

    Weekly weights with a 10-lb monthly threshold detect congestion far too late to prevent readmission.

    C

    Correct: daily morning weights catch fluid retention early, and 2–3 lb in a day or 5 lb in a week is the usual trigger to call.

    D

    Waiting for ankle swelling is late, and self-doubling furosemide without guidance risks AKI and electrolyte loss.