Questions are aligned with the American Board of Internal Medicine & American Board of Pediatrics formats. Authored & peer-reviewed by faculty, clinicians, and program directors.
Each question is written to resemble the format and topics on the exam, meaning you won’t see any negatively phrased questions, no “all of the following except,” no “A and B”…you know what we mean. Most importantly, all questions include selective distractors (incorrect answer choices), which will help you think critically.
A 74-year-old woman with a history of polymyalgia rheumatica and hyperlipidemia presents to the emergency department with crushing substernal chest pain. Her ECG demonstrates ST elevations in leads I, aVL, V2–V3, and V5–V6, with reciprocal ST depression in II, III, and aVF. She is taken emergently to cardiac catheterization, where a drug-eluting stent is placed in her left anterior descending artery. She is started on aspirin 81 mg, clopidogrel 75 mg, and metoprolol succinate 25 mg daily. Her home medication, simvastatin 10 mg, has been changed to atorvastatin 40 mg daily. She is also on prednisone 5 mg daily for her history of polymyalgia rheumatica. Echocardiogram on hospital day 2 demonstrates a left ventricular ejection fraction of 55% and no wall motion abnormalities. Her vital signs are currently stable. What is the best medication to prescribe next in the management of this patient?
Starting the patient on pantoprazole 40 mg daily is the best management at this time. This patient with an ST segment elevation myocardial infarction (STEMI) status post percutaneous coronary intervention (PCI) will need to be on dual antiplatelet therapy with aspirin and clopidogrel to reduce the risk of stent thrombosis. Gastrointestinal bleeding is the most common serious bleeding complication from using dual antiplatelet therapy. Prophylactic therapy with proton pump inhibitors is recommended for all patients with high risk for GI bleeding after PCI. This includes patients with a history of peptic ulcer disease or GI bleeding or at least two of the following risk factors: age > 65, concurrent use of another NSAID, treatment with glucocorticoids or anticoagulants, or history of Helicobacter pylori infection. Given this patient’s age > 65 and concurrent use of glucocorticoids, the best next medication to prescribe is a proton pump inhibitor. Furthermore, the use of pantoprazole is preferred over omeprazole with clopidogrel usage due to decreased inhibition of cytochrome P450 2C19.
Prescribing digoxin 0.125 mg daily (A) would be incorrect, as this woman has a preserved ejection fraction following her STEMI and is on appropriate initial medical therapy. Giving rivaroxaban 2.5 mg twice daily (C) would further increase her bleeding risk and is not currently indicated. This patient has a preserved ejection fraction following her STEMI and has no current indication for sacubitril-valsartan 24 mg/26 mg daily (D).
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Q: What is the recommended duration of dual antiplatelet therapy in patients with average bleeding risk and average risk of recurrent ischemia?REVEAL ANSWER
A: 6–12 months of dual antiplatelet therapy.