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PEBC Cardiology Practice Questions

Anticoagulation, heart failure, angina and hypertension: ten cardiology questions in the style of the PEBC MCQ.

Updated November 13, 2026. Written by RxReady to the 2026 PEBC blueprint. These are practice questions, not real or recalled exam questions.

Cardiology shows up across the PEBC MCQ because so many patients take cardiovascular drugs, and because the questions test judgment, not just recall: which anticoagulant fits this patient, which interaction matters, when a reading counts as hypertension.

These ten questions cover warfarin and DOAC selection, anticoagulant mechanisms and interactions, heart failure therapy, stable angina and hypertension diagnosis and treatment, written to current Canadian guidance such as Hypertension Canada and the CCS.

Read each case carefully. Small details like kidney function, valve type or a natural product the patient mentions usually decide the answer.

Practice by topic

Ten cardiology questions

Question 1 · Anticoagulation

For which of the following patients is warfarin preferred over a DOAC?

  1. AAtrial fibrillation with a bioprosthetic valve 2 years ago
  2. BAtrial fibrillation with a mechanical mitral valve
  3. CAtrial fibrillation with CrCl 45 mL/min
  4. DAtrial fibrillation in an 85-year-old patient
Show the answer

Answer: B) Atrial fibrillation with a mechanical mitral valve

DOACs are contraindicated with mechanical heart valves (dabigatran caused more thrombosis and bleeding in RE-ALIGN) and are not recommended in moderate-to-severe rheumatic mitral stenosis; warfarin is required. CCS AF guidance considers AF with a bioprosthetic valve (after 3 months), moderate renal impairment and advanced age appropriate for DOACs.

Why the other options are wrong

  • A) A bioprosthetic valve more than 3 months old is not a contraindication to a DOAC.
  • C) CrCl 45 mL/min allows a DOAC, with dose checking.
  • D) Advanced age alone favours a DOAC over warfarin because of lower intracranial bleeding.

Key point: Mechanical valve or moderate-to-severe rheumatic mitral stenosis = warfarin. Almost everyone else with AF = DOAC.

Question 2 · DOACs

EK, an 80-year-old man with atrial fibrillation, has a CrCl of 25 mL/min. Which of the following anticoagulants is contraindicated?

  1. AApixaban
  2. BRivaroxaban
  3. CEdoxaban
  4. DDabigatran
Show the answer

Answer: D) Dabigatran

Dabigatran is about 80% renally eliminated and is contraindicated in Canada when CrCl is below 30 mL/min. At CrCl 25 mL/min, apixaban (dose-adjusted per its criteria; no dosing recommendation below 25 mL/min), rivaroxaban 15 mg daily and edoxaban 30 mg daily can be used with caution.

Why the other options are wrong

  • A) Apixaban can be used with caution at CrCl 25 mL/min.
  • B) Rivaroxaban 15 mg daily can be used with caution at this CrCl.
  • C) Edoxaban 30 mg daily can be used with caution at this CrCl.

Key point: Dabigatran: contraindicated if CrCl <30 mL/min.

Question 3 · Natural products

HB, a 70-year-old man stable on warfarin, asks about natural health products. Which of the following is most likely to DECREASE his INR?

  1. AGinkgo biloba
  2. BDong quai
  3. CHigh-dose fish oil
  4. DSt. John's wort
Show the answer

Answer: D) St. John's wort

St. John's wort induces CYP2C9, CYP3A4 and P-glycoprotein, increasing warfarin clearance and lowering the INR, with reports of thrombosis. Dong quai has been reported to increase the INR, while ginkgo and high-dose fish oil can increase bleeding risk through antiplatelet effects rather than lowering the INR.

Why the other options are wrong

  • A) Ginkgo may increase bleeding risk; it doesn't lower the INR.
  • B) Dong quai has been reported to increase the INR.
  • C) High-dose fish oil may increase bleeding risk; it doesn't lower the INR.

Key point: St. John's wort is a strong inducer: it lowers INR and levels of many drugs.

Question 4 · Anticoagulant mechanisms

A patient switching from warfarin to apixaban asks why he no longer needs INR tests or a consistent vitamin K intake. Which mechanism explains this?

  1. Adirectly inhibiting thrombin
  2. Binhibiting vitamin K epoxide reductase
  3. Cdirectly inhibiting factor Xa
  4. Dpotentiating antithrombin against factor Xa
Show the answer

Answer: C) directly inhibiting factor Xa

Apixaban (like rivaroxaban and edoxaban) is a direct, reversible factor Xa inhibitor that does not depend on antithrombin or vitamin K-dependent synthesis of clotting factors, so its effect is predictable at fixed doses and does not need INR monitoring or dietary vitamin K consistency. Warfarin inhibits vitamin K epoxide reductase, dabigatran directly inhibits thrombin, and heparins act through antithrombin.

Why the other options are wrong

  • A) Direct thrombin inhibition is how dabigatran works.
  • B) Inhibiting vitamin K epoxide reductase is warfarin's mechanism, which is why it needs INR monitoring.
  • D) Potentiating antithrombin is how heparins and fondaparinux work.

Key point: Apixaban, rivaroxaban, edoxaban = direct Xa inhibitors. Dabigatran = direct thrombin inhibitor. Warfarin = vitamin K antagonist.

Question 5 · Heart failure

Which of the following is a REQUIRED condition before ivabradine can be added for a patient with heart failure with reduced ejection fraction (LVEF 30%)?

  1. AThe patient must have a resting heart rate below 60 beats/min
  2. BThe patient must be unable to tolerate any beta-blocker
  3. CThe patient must be in sinus rhythm
  4. DThe patient must have persistent atrial fibrillation
Show the answer

Answer: C) The patient must be in sinus rhythm

Ivabradine inhibits the If current in the sinoatrial node and only lowers heart rate in patients in sinus rhythm; it is indicated for symptomatic HFrEF patients in sinus rhythm whose resting heart rate remains elevated despite maximally tolerated beta-blocker therapy. It is ineffective (and not indicated) in atrial fibrillation, it is used when the heart rate is high rather than below 60 beats/min, and it is added to (not substituted for) a tolerated beta-blocker.

Why the other options are wrong

  • A) Ivabradine is used when resting heart rate stays high (70 or more), not below 60 beats/min.
  • B) Ivabradine is added to a maximally tolerated beta-blocker, not reserved for beta-blocker intolerance.
  • D) Ivabradine does not work in atrial fibrillation and is not indicated there.

Key point: Ivabradine: HFrEF in sinus rhythm with high resting HR despite max beta-blocker.

Question 6 · Stable angina

BK, a 64-year-old man who takes tadalafil 5 mg daily for BPH, is newly prescribed nitroglycerin SL spray for stable angina. Which of the following is correct?

  1. ANitroglycerin is safe if separated from tadalafil by 24 hours
  2. BSwitching tadalafil to sildenafil avoids the interaction
  3. CNitrates are contraindicated within 48 hours of tadalafil
  4. DReducing tadalafil to 2.5 mg daily avoids the interaction
Show the answer

Answer: C) Nitrates are contraindicated within 48 hours of tadalafil

PDE5 inhibitors potentiate nitrate-induced vasodilation and can cause profound hypotension; nitrates are contraindicated within 48 hours of tadalafil (long half-life) and within 24 hours of sildenafil. With daily tadalafil, there is no safe window, so the prescriber should be contacted to choose an alternative BPH therapy. Switching to sildenafil or lowering the tadalafil dose does not eliminate the interaction.

Why the other options are wrong

  • A) Tadalafil's long half-life means 24 hours is not enough separation.
  • B) Sildenafil interacts with nitrates too (within 24 hours); switching doesn't remove the interaction.
  • D) A lower daily tadalafil dose still leaves enough drug to cause profound hypotension with nitrates.

Key point: PDE5 inhibitor + nitrate = severe hypotension. Tadalafil 48 h, sildenafil 24 h.

Question 7 · Warfarin interactions

OH, a 72-year-old man with a stable INR on warfarin, is prescribed sulfamethoxazole-trimethoprim for a UTI. Which of the following is the most probable outcome?

  1. ADecreased INR from CYP2C9 induction
  2. BIncreased INR from CYP2C9 inhibition
  3. CIncreased INR from CYP1A2 inhibition
  4. DDecreased INR from reduced absorption
Show the answer

Answer: B) Increased INR from CYP2C9 inhibition

Sulfamethoxazole inhibits CYP2C9, the main enzyme that metabolizes S-warfarin (the more potent enantiomer), and may displace warfarin from albumin. This markedly increases the INR and the risk of bleeding. An alternative antibiotic or close INR monitoring with dose reduction is needed. CYP1A2 metabolizes mainly R-warfarin and is not the main issue.

Why the other options are wrong

  • A) SMX inhibits, not induces, CYP2C9.
  • C) CYP1A2 metabolizes mainly the less potent R-warfarin.
  • D) Absorption isn't the mechanism; the INR rises.

Key point: Warfarin + SMX-TMP → INR rises (CYP2C9). Choose another antibiotic or monitor closely.

Question 8 · Diabetes

According to Diabetes Canada, which of the following patients with type 2 diabetes and no history of cardiovascular disease has an indication for statin therapy?

  1. AA 33-year-old woman diagnosed with diabetes 5 years ago
  2. BA 42-year-old man with no microvascular complications
  3. CA 28-year-old man diagnosed with diabetes 2 years ago
  4. DA 36-year-old woman diagnosed with diabetes 4 years ago
Show the answer

Answer: B) A 42-year-old man with no microvascular complications

Diabetes Canada recommends statin therapy for people with diabetes who are 40 years of age or older, as well as for those with clinical ASCVD, microvascular disease (retinopathy, nephropathy, neuropathy), age 30 or older with diabetes duration over 15 years, or a warranted indication based on other risk factors. The 42-year-old qualifies on age alone, while the younger patients (all under 40) have diabetes durations well under 15 years and no stated microvascular disease.

Why the other options are wrong

  • A) Under 40 with only 5 years of diabetes and no microvascular disease, she has no statin indication.
  • C) Under 40 with only 2 years of diabetes, he has no statin indication.
  • D) Under 40 with only 4 years of diabetes, she has no statin indication.

Key point: Diabetes Canada: statin if age 40+, ASCVD, microvascular disease, or age 30+ with diabetes >15 years.

Question 9 · Hypertension

SR, a 50-year-old woman without diabetes, has an automated office BP average of 146/90 mmHg. Her 7-day home BP average is 138/86 mmHg. Which of the following is correct?

  1. AHypertension is confirmed
  2. BShe has white coat hypertension
  3. CShe has masked hypertension
  4. DHome BP is normal because it is below 140/90
Show the answer

Answer: A) Hypertension is confirmed

Hypertension Canada defines hypertension as a standardized office BP of 130/80 mmHg or higher, while the out-of-office thresholds are 135/85 mmHg for home BP and daytime ambulatory BP (130/80 for a 24-hour ambulatory average). Her automated office average (146/90) and her home average (138/86) both exceed their thresholds, so hypertension is confirmed. White coat hypertension would require a normal out-of-office average, and masked hypertension a normal office reading. 140/90 is not the home BP threshold.

Why the other options are wrong

  • B) White coat hypertension needs a normal out-of-office average; her home BP is high.
  • C) Masked hypertension means normal office but high out-of-office BP; her office BP is high.
  • D) The home BP threshold is 135/85, not 140/90, and 138/86 exceeds it.

Key point: Thresholds: standardized office 130/80; home and daytime ambulatory 135/85.

Question 10 · Hypertension

WB, a 70-year-old man with newly diagnosed hypertension, has no other medical conditions. Which of the following proposed initial therapies should the pharmacist question?

  1. AChlorthalidone
  2. BAtenolol
  3. CTelmisartan
  4. DPerindopril/amlodipine
Show the answer

Answer: B) Atenolol

Hypertension Canada's 2025 guideline emphasizes a low-dose single-pill combination (e.g., ARB or ACE inhibitor with a thiazide/thiazide-like diuretic or CCB) for initial therapy, and thiazide/thiazide-like diuretics, ACE inhibitors, ARBs and long-acting dihydropyridine CCBs remain the first-line drug classes. Beta-blockers are not first-line for uncomplicated hypertension (less stroke reduction, more discontinuation) and are reserved for compelling indications such as heart failure, angina, post-MI or rate control. Atenolol is therefore the choice to question.

Why the other options are wrong

  • A) Chlorthalidone is a first-line thiazide-like diuretic.
  • C) Telmisartan (an ARB) is first-line.
  • D) A single-pill ACEi/CCB combination is a recommended initial strategy.

Key point: Uncomplicated hypertension: thiazide-like, ACEi/ARB, long-acting DHP CCB, or a single-pill combo. Not a beta-blocker.

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