Hypertensive cases + Digoxin Flashcards
Which of the following medications are most likely to be effective for initial BP lowering in patients with low renin?
A) Hydrochlorothiazide
B) Lisinopril
C) Amlodipine
D) A and B
E) A and C
E) A and C (hydrochlorothiazide and amliodipine
Hydrochlorothiazide is a thiazide diuretic and amlodipine is a dihydropyridine calcium channel blocker – both classes are considered first line agents for patients with hypertension and low renin. Lisinopril is an ace-inhibitor which is not considered a first line BP medication for low renin patients unless there is an additional compelling indication such as diabetes or chronic renal dysfunction.
A 67 yo man with asthma, BPH, and CKD is diagnosed with HTN.
What initial therapy is best to prescribe for this particular patient?
A) Hydrochlorothiazide 12.5mg daily
B) Losartan 50mg daily
C) Amlodipine 5mg daily
D) Hydralazine 25mg daily
A) Hydrochlorothiazide 12.5mg daily
Explanation: The first line therapy for HTN treatment would be either thiazide diuretic, calcium channel blocker. or ACE/ ARB. However, this patient has a compelling indication due to his CKD in which the first line therapy for all patients (no matter age, etc) with CKD is an ACEi or ARB (losartan)
Hydralazine is used in combination for treatment of heart failure in some patients, however when treating hypertension hydralazine should be reserved for patients whose hypertension does not respond to first line agents.
JM a 58-year-old man has a history of type 2 diabetes mellitus that is not well controlled. He has recently developed mild hypertension that has not been controlled by lifestyle changes. You prescribe lisinopril 20 mg daily and 2 months later you note that his serum creatinine level has increased from 1.25 mg/dL to 1.5 mg/dL (baseline 0.64–1.27) and his blood pressure has decreased from 142/88 mm Hg to 128/78 mm Hg.
Which one of the following should you do now?
A) Continue the current dosage of lisinopril
B) Decrease the dosage of lisinopril to 10 mg
C) Increase the dosage of lisinopril to 40 mg
D) Discontinue lisinopril and initiate Chlorthalidone
E) Discontinue lisinopril and initiate losartan (Cozaar)
A) Continue the current dosage of lisinopril
Explanation: your Patient is currently at his goal BP of <130/80 so no medication changes are needed unless he is experiencing adverse effects. A rise in serum creatinine is a known side effect of ACE inhibitors such as lisinopril. These medications do not need to be discontinued unless baseline creatinine increases by >30%. (This patient’s creatinine increased by 20%)
PD is a 55-year-old man has New York Heart Association class III chronic systolic heart failure due to hypertensive cardiomyopathy.
Which one medication is contraindicated in this patient?
A) Carvedilol
B) Digoxin
C) Ramipril
D) Spironolactone
E) Verapamil
E) Verapamil
Explanation: ACE inhibitors and β-blockers improve mortality in heart failure (HF). Digoxin and furosemide improve symptoms and reduce hospitalizations in systolic HF. Spironolactone, an aldosterone antagonist, reduces all-cause mortality and improves ejection fractions in systolic HF. Verapamil, due to its negative inotropic effect, is associated with worsening heart failure and an increased risk of adverse cardiovascular events.
AS is a 55-year-old man with a 4-year history of type 2 diabetes mellitus who was noted to have microalbuminuria 6 months ago, and returns for a follow-up visit. He has been on an ACE inhibitor and his blood pressure is 140/90 mm Hg.
The addition of which one of the following medications is unnecessary and might increase the likelihood that dialysis would become required?
A) Hydrochlorothiazide
B) Amlodipine
C) Atenolol
D) Clonidine
E) Losartan
E) Losartan
Explanation: Patients with diabetes mellitus, atherosclerosis, and end-organ damage benefit from ACE inhibitors and angiotensin receptor blockers (ARBs) equally when they are used to prevent progression of diabetic nephropathy. Combining an ACE inhibitor with an ARB is not recommended, as it provides no additional benefit and leads to higher creatinine levels, along with an increased likelihood that dialysis will become necessary.
RR is a 54-year-old man who sees you for a 6-month follow-up visit for hypertension. He feels well, but despite the fact that he takes his medications faithfully, his blood pressure averages 150/90 mm Hg. All laboratory tests have been WNL. His medications include chlorthalidone, 12.5 mg daily; carvedilol (Coreg), 25 mg twice daily; amlodipine (Norvasc), 10 mg daily; and lisinopril (Prinivil, Zestril), 40 mg daily. He has been intolerant to clonidine (Catapres) in the past.
Which one of the following medication changes would be most reasonable?
A) Adding isosorbide mononitrate
B) Adding spironolactone
C) Substituting furosemide for chlorthalidone
D) Substituting losartan for lisinopril
B) Adding spironolactone
Explanation: Spironolactone is recommended for treating resistant hypertension, even when hyperaldosteronism is not present. A longer acting diuretic such as chlorthalidone is also recommended for treating hypertension, particularly in resistant cases with normal renal function. There is no benefit to switching from an ACE inhibitor to an ARB. Nitrates have some effect on blood pressure but are recommended only for patients with coronary artery disease.
Your patient with recently diagnosed hypertension has very stable blood pressure at the high end of guideline values (133/85 down from 150/92 pre-treatment) while taking amlodipine 5 mg per day. Recently she noticed edema in her lower extremities and is very concerned about this adverse effect. Her other labs are stable, your examination has not found other significant findings, and her cardiac and her renal function is at healthy values and has not changed during treatment. Since she has improved her blood pressure values with amlodipine, and has no other adverse effects you would like to continue this medication. You decide to add a medication to offset the edema caused by amlodipine. You choose:
A) Hydrochlorothiazide 25mg po per day
B) Chlorthaladone 12.5 mg po per day
C) Furosemide 40 mg po twice a day
D) Losartan 50 mg po once a day
Calcium Channel Antagonist related edema is due to elevated capillary pressures, not elevated Na and Fluid. An ACE or an ARB will act to reduce the elevated capillary pressure for this patient.
As you might expect from understanding the mechanism of action for digoxin this medication is cleared from the body via metabolism. However about 30% of digoxin is cleared by the kidney. Also it is known that renal failure by itself can impair the activity of Na-K ATP’ase.
Based upon the above statements which response is correct?
A) Patients having renal insufficiency and also taking digoxin should be monitored carefully for safety and efficacy. It may be necessary to reduce the dose of digoxin in proportion to the reduced renal function to prevent serious digoxin toxicity.
B) Patients having renal insufficiency and also taking digoxin need not be monitored carefully for safety and efficacy. For most patients it will not be necessary to reduce the dose of digoxin to prevent serious digoxin toxicity.
C) Patients having renal insufficiency and also taking digoxin need not be monitored carefully for safety and efficacy. For most renal patients it will be necessary to dramatically increase the dose of digoxin to preserve digoxin efficacy.
D) Patients having renal insufficiency and also taking digoxin need not be monitored carefully for safety and efficacy. For most renal patients it will be necessary to add another medication that interferes with the metabolism of digoxin so that the effect of digoxin on Na-K ATP’ase is enhanced.
A) Patients having renal insufficiency and also taking digoxin should be monitored carefully for safety and efficacy. It may be necessary to reduce the dose of digoxin in proportion to the reduced renal function to prevent serious digoxin toxicity.
Which statement is NOT correct?
A) Digoxin interferes with Na-K ATP’ase in cardiac tissue. The resulting increase in intracellular sodium acts to inhibit the efflux of calcium.
B) Digoxin has a very narrow therapeutic index, adverse effects can be frequent and severe if patients are not monitored carefully.
C) Digoxin acts as a vagolytic
D) Digoxin is rarely considered a first line drug due to its narrow therapeutic window, and lack of benefit on mortality. However in carefully selected patiients adding digoxin can improve cardiac contractility, reduce hospitalizations and reduce patient symptoms of heart failure.
Digoxin interferes with Na-K ATP’ase in cardiac tissue. The resulting increase in intracellular sodium acts to inhibit the efflux of calcium.
Digoxin has a very narrow therapeutic index, adverse effects can be frequent and severe if patients are not monitored carefully.
Digoxin is rarely considered a first line drug due to its narrow therapeutic window, and lack of benefit on mortality. However in carefully selected patiients adding digoxin can improve cardiac contractility, reduce hospitalizations and reduce patient symptoms of heart failure.
Digoxin acts as a vagoTONIC.
