NAPLEX Cardiology Review 2026 | HF, HTN, A-Fib, ACS, Lipids

NAPLEX weight: Cardiovascular pharmacotherapy is one of the most heavily tested therapeutic areas. Focus on guideline-directed medical therapy (GDMT) for heart failure, first-line antihypertensives, and anticoagulation for atrial fibrillation.

Heart Failure (HFrEF) — Guideline-Directed Medical Therapy

The four pillars of GDMT for HFrEF (EF ≤40%) are the most commonly tested HF concepts on the NAPLEX. All four should be initiated as quickly as tolerated.

Pillar	Drug Class	Key Examples	Mortality Benefit
1. ARNI or ACEi/ARB	RAAS inhibitors	Sacubitril/valsartan (preferred ARNI), lisinopril, losartan	✅ Yes
2. Beta-blocker	Evidence-based BBs only	Carvedilol, metoprolol succinate, bisoprolol	✅ Yes
3. MRA	Mineralocorticoid antagonist	Spironolactone, eplerenone (K+ <5, eGFR >30)	✅ Yes
4. SGLT2 inhibitor	Gliflozins	Dapagliflozin, empagliflozin (works regardless of diabetes status)	✅ Yes

NAPLEX pearl: Metoprolol tartrate is NOT evidence-based for HFrEF — only metoprolol succinate (extended-release). This is a common exam trap. Also, ARNI (sacubitril/valsartan) requires a 36-hour washout from ACEi to prevent angioedema.

Hypertension — First-Line Therapy

Current guidelines (ACC/AHA) define hypertension as BP ≥130/80 mmHg. First-line therapy includes four drug classes:

ACE Inhibitors

Lisinopril, enalapril, ramipril. Monitor: K+, SCr, dry cough. CI in pregnancy.

ARBs

Losartan, valsartan, irbesartan. Similar to ACEi without cough. CI in pregnancy.

CCBs (DHP)

Amlodipine, nifedipine. SE: peripheral edema, headache, flushing. No K+ or SCr monitoring.

Thiazide Diuretics

Chlorthalidone (preferred), HCTZ. Monitor: K+, Na+, uric acid, glucose. Hypokalemia risk.

Compelling indications: CKD/proteinuria → ACEi/ARB preferred. Black patients without CKD → CCB or thiazide first-line. Diabetes with albuminuria → ACEi/ARB required.

Atrial Fibrillation — Anticoagulation

Use the CHA₂DS₂-VASc score to determine anticoagulation need:

C = CHF (1) · H = Hypertension (1) · A₂ = Age ≥75 (2) · D = Diabetes (1) · S₂ = Stroke/TIA/SE (2) · V = Vascular disease (1) · A = Age 65-74 (1) · Sc = Sex category female (1)

Score 0 (males) or 1 (females) → no anticoagulation. Score ≥2 (males) or ≥3 (females) → oral anticoagulant recommended. DOACs preferred over warfarin (apixaban, rivaroxaban, edoxaban, dabigatran).

Acute Coronary Syndrome (ACS)

STEMI: Emergent PCI (preferred) or fibrinolysis. DAPT: aspirin + P2Y12 inhibitor (ticagrelor preferred or prasugrel, clopidogrel if others CI)
NSTEMI/UA: Anticoagulation (heparin) + DAPT. Early invasive vs conservative strategy based on risk.
Post-ACS meds: Aspirin (indefinite), P2Y12 inhibitor (12 months), statin (high-intensity), beta-blocker, ACEi/ARB (if EF ≤40% or diabetes/HTN)

Dyslipidemia — Statin Therapy

Four statin benefit groups: (1) Clinical ASCVD, (2) LDL ≥190, (3) Diabetes age 40-75, (4) 10-year ASCVD risk ≥7.5%. High-intensity statins: atorvastatin 40-80mg, rosuvastatin 20-40mg. Counsel: take at bedtime (short-acting statins), monitor LFTs, muscle pain (rhabdomyolysis risk with high doses).

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