LIPINCOTT Antihypertensives Flashcards
17.1 A 45-year-old man was just started on therapy for
hypertension and developed a persistent, dry cough.
Which is most likely responsible for this side effect?
A. Enalapril.
B. Losartan.
C. Nifedipine.
D. Prazosin.
E. Propranolol.
Correct answer = A. The cough is most likely an adverse
effect of the ACE inhibitor enalapril. Losartan is an ARB
that has the same beneficial effects as an ACE inhibitor but
is less likely to produce a cough. Nifedipine, prazosin, and
propranolol do not cause this side effect
17.2 Which may cause reflex tachycardia and/or postural
hypotension on initial administration?
A. Atenolol.
B. Hydrochlorothiazide.
C. Metoprolol.
D. Prazosin.
E. Verapamil.
Correct answer = D. Prazosin produces first-dose hypotension,
presumably by blocking α1 receptors. This effect is
minimized by initially giving the drug in small, divided doses.
The other agents do not have this adverse effect.
17.3 Which can precipitate a hypertensive crisis following
abrupt cessation of therapy?
A. Clonidine.
B. Diltiazem.
C. Enalapril.
D. Losartan.
E. Hydrochlorothiazide.
Correct answer = A. Increased sympathetic nervous system
activity occurs if clonidine therapy is abruptly stopped after
prolonged administration. Uncontrolled elevation in blood
pressure can occur. Patients should be slowly weaned
from clonidine while other antihypertensive medications
are initiated. The other drugs on the list do not produce this
phenomenon.
17.4 A 48-year-old hypertensive patient has been
successfully treated with a thiazide diuretic for the last 5
years. Over the last 3 months, his diastolic pressure has
steadily increased, and he was started on an additional
antihypertensive agent. He complains of several
instances of being unable to achieve an erection and
not being able to complete three sets of tennis as he
once did. Which is the likely second antihypertensive
medication?
A. Captopril.
B. Losartan.
C. Metoprolol.
D. Minoxidil.
E. Nifedipine
Correct answer = C. The side effect profile of β-blockers,
such as metoprolol, is characterized by interference with
sexual performance and decreased exercise tolerance.
None of the other drugs is likely to produce this combination
of side effects.
17.5 A 40-year-old male has recently been diagnosed with
hypertension due to pressure readings of 163/102
and 165/100 mm Hg. He also has diabetes that is well
controlled with oral hypoglycemic medications. Which
is the best initial treatment regimen for treatment of
hypertension in this patient?
A. Felodipine.
B. Furosemide.
C. Lisinopril.
D. Lisinopril and hydrochlorothiazide.
E. Metoprolol.
Correct answer = D. Because the systolic blood pressure
is more than 20 mm Hg above goal (10 mm Hg above goal
diastolic), treatment with two different medications is preferred.
Because the patient is diabetic, he also has a compelling
indication for an ACE inhibitor or ARB.
17.6 A 60-year-old white female has not reached her blood
pressure goal after 1 month of treatment with a low dose
of lisinopril. All of the following would be appropriate
next steps in the treatment of her hypertension except:
A. Increase dose of lisinopril.
B. Add a diuretic medication.
C. Add on a calcium channel blocker medication.
D. Add on an ARB medication.
Correct answer = D. Increasing the dose of lisinopril or adding
a second medication from a different class (such as a
calcium channel blocker or diuretic) would be appropriate
steps to control the blood pressure. Adding an ARB as the
second medication is not recommended. ARBs have a similar
mechanism of action to ACE inhibitors, and combination
therapy may increase the risk of adverse effects.
17.7 A patient returns to her health care provider for routine
monitoring 3 months after her hypertension regimen
was modified. Labs reveal elevated serum potassium.
Which is likely responsible for this hyperkalemia?
A. Chlorthalidone.
B. Clonidine.
C. Furosemide.
D. Losartan.
E. Nifedipine.
Correct answer = D. Losartan, an ARB, can cause an
increase in serum potassium similar to ACE inhibitors.
Furosemide and chlorthalidone can cause a decrease in
serum potassium. Nifedipine and clonidine do not affect
potassium levels
17.7 A patient returns to her health care provider for routine
monitoring 3 months after her hypertension regimen
was modified. Labs reveal elevated serum potassium.
Which is likely responsible for this hyperkalemia?
A. Chlorthalidone.
B. Clonidine.
C. Furosemide.
D. Losartan.
E. Nifedipine.
Correct answer = D. Losartan, an ARB, can cause an
increase in serum potassium similar to ACE inhibitors.
Furosemide and chlorthalidone can cause a decrease in
serum potassium. Nifedipine and clonidine do not affect
potassium levels
17.8 A 58-year-old female reports that she recently stopped
taking her blood pressure medications because of
swelling in her feet that began shortly after she started
treatment. Which is most likely to cause peripheral
edema?
A. Atenolol.
B. Clonidine.
C. Felodipine.
D. Hydralazine.
E. Prazosin
Correct answer = C. Peripheral edema is one of the most
common side effects of calcium channel blockers. None of
the other agents commonly cause peripheral edema.
17.9 Which is an appropriate choice for hypertension
treatment during pregnancy?
A. Aliskiren.
B. Fosinopril.
C. Hydralazine.
D. Valsartan.
Correct answer = C. Hydralazine is an appropriate choice
for a hypertensive pregnant patient. ACE inhibitors, ARBs,
and the direct renin inhibitor, aliskiren, are all contraindicated
in pregnancy due to their potential for fetal harm
18.1 An elderly patient with a history of heart disease is
brought to the emergency room with difficulty breathing.
Examination reveals that she has pulmonary edema.
Which treatment is indicated?
A. Acetazolamide.
B. Chlorthalidone.
C. Furosemide.
D. Hydrochlorothiazide.
E. Spironolactone.
Correct answer = C. This is a potentially fatal situation. It
is important to administer a diuretic that will reduce fluid
accumulation in the lungs and, thus, improve oxygenation
and heart function. The loop diuretics are most effective in
removing large fluid volumes from the body and are the
treatment of choice in this situation. In this situation, furosemide
should be administered intravenously. The other
choices are inappropriate.
18.2 A group of college students is planning a mountain
climbing trip to the Andes. Which would be appropriate
for them to take to prevent mountain sickness?
A. A thiazide diuretic such as hydrochlorothiazide.
B. An anticholinergic such as atropine.
C. A carbonic anhydrase inhibitor such as
acetazolamide.
D. A loop diuretic such as furosemide.
E. A β-blocker such as metoprolol.
Correct answer = C. Acetazolamide is used prophylactically
for several days before an ascent above 10,000 feet. This
treatment prevents the cerebral and pulmonary problems
associated with the syndrome as well as other difficulties,
such as nausea.
18.3 An alcoholic male has developed hepatic cirrhosis.
To control the ascites and edema, which should be
prescribed?
A. Acetazolamide.
B. Chlorthalidone.
C. Furosemide.
D. Hydrochlorothiazide.
E. Spironolactone.
Correct answer = E. Spironolactone is very effective in the
treatment of hepatic edema. These patients are frequently
resistant to the diuretic action of loop diuretics, although
a combination with spironolactone may be beneficial. The
other agents are not indicated.
18.4 A 55-year-old male with kidney stones has been placed
on a diuretic to decrease calcium excretion. However,
after a few weeks, he develops an attack of gout. Which
diuretic was he taking?
A. Furosemide.
B. Hydrochlorothiazide.
C. Spironolactone.
D. Triamterene.
E. Urea.
Correct answer = B. Hydrochlorothiazide is effective in
increasing calcium reabsorption, thus decreasing the amount
of calcium excreted, and decreasing the formation of kidney
stones that contain calcium phosphate or calcium oxalate.
However, hydrochlorothiazide can also inhibit the excretion of
uric acid and cause its accumulation, leading to an attack of
gout in some individuals. Furosemide increases the excretion
of calcium, whereas the K+-sparing osmotic diuretics, spironolactone
and triamterene, and urea do not have an effect.
18.5 A 75-year-old woman with hypertension is being treated
with a thiazide. Her blood pressure responds well and
reads at 120/76 mm Hg. After several months on the
medication, she complains of being tired and weak. An
analysis of the blood indicates low values for which of
the following?
A. Calcium.
B. Glucose.
C. Potassium.
D. Sodium.
E. Uric acid.
Correct answer = C. Hypokalemia is a common adverse
effect of the thiazides and causes fatigue and lethargy in the
patient. Supplementation with potassium chloride or foods
high in K+ corrects the problem. Alternatively, a potassiumsparing
diuretic, such as spironolactone, may be added.
Calcium, uric acid, and glucose are usually elevated by thiazide
diuretics. Sodium loss would not weaken the patient.
18.6 Which is contraindicated in a patient with hyperkalemia?
A. Acetazolamide.
B. Chlorthalidone.
C. Chlorothiazide.
D. Ethacrynic acid.
E. Spironolactone.
Correct answer = E. Spironolactone acts in the collecting
tubule to inhibit Na+ reabsorption and K+ excretion. It
is extremely important that patients who are treated with
any potassium-sparing diuretic be closely monitored for
potassium levels. Exogenous potassium supplementation
is usually discontinued when potassium-sparing diuretic
therapy is instituted and spironolactone is contraindicated
in patients with hyperkalemia. The other drugs promote the
excretion of potassium.
18.7 Which of the following should be avoided in a patient
with a history of severe anaphylactic reaction to sulfa
medications?
A. Amiloride.
B. Hydrochlorothiazide.
C. Mannitol.
D. Spironolactone.
E. Triamterene.
Correct answer = B. Hydrochlorothiazide, like many thiazide
and thiazide-like diuretics, contains a sulfa moiety within its
chemical structure. It is important to avoid use in those individuals
with severe hypersensitivity to sulfa medications. It
may be used with caution, however, in those with only minor
reaction to sulfa medications.
18.8 A male patient is placed on a new medication and
notes that his breasts have become enlarged and
tender to the touch. Which medication is he most likely
taking?
A. Chlorthalidone.
B. Furosemide.
C. Hydrochlorothiazide.
D. Spironolactone.
E. Triamterene.
Correct answer = D. An adverse drug reaction to spironolactone
is gynecomastia due to its effects on androgens
and progesterone in the body. Eplerenone may be a suitable
alternative if the patient is in need of an aldosterone
antagonist but has a history of gynecomastia.
18.9 A patient presents to the emergency department with
an extreme headache. After a thorough workup, the
attending physician concludes that the pain is due to
increased intracranial pressure. Which diuretic would
work best to reduce this pressure?
A. Acetazolamide.
B. Indapamide.
C. Furosemide.
D. Hydrochlorothiazide.
E. Mannitol.
Correct answer = E. Osmotic diuretics, such as mannitol,
are a mainstay of treatment for patients with increased
intracranial pressure or acute renal failure due to shock,
drug toxicities, and trauma.
18.10 Which diuretic has been shown to improve blood
pressure in resistant hypertension or those already
treated with three blood pressure medications
including a thiazide or thiazide-like diuretic?
A. Chlorthalidone.
B. Indapamide.
C. Furosemide.
D. Mannitol.
E. Spironolactone.
Correct answer = E. Resistant hypertension, defined by
the use of three or more medications without reaching the
blood pressure goal, often responds well to aldosterone
antagonists. This effect can be seen in those with or without
elevated aldosterone levels.
19.1 Which drug may exacerbate HF?
A. Acetaminophen.
B. Cetirizine.
C. Chlorthalidone.
D. Ibuprofen.
Correct answer = D. NSAIDs, such as ibuprofen, lead to
increased fluid retention and increased blood pressure. If
possible, NSAIDs should be avoided in HF patients in order
to avoid exacerbations of HF.
19.2 Which best describes the action of ACE inhibitors on
the failing heart?
A. ACE inhibitors increase vascular resistance.
B. ACE inhibitors decrease cardiac output.
C. ACE inhibitors reduce preload.
D. ACE inhibitors increase aldosterone.
Correct answer = C. ACE inhibitors decrease vascular resistance,
decrease preload, decrease afterload, and increase
cardiac output. In addition, ACE inhibitors blunt aldosterone
release.
19.3 What makes losartan different from other ARBs?
A. Losartan is renally eliminated.
B. Losartan has an active metabolite.
C. Losartan has the shortest half-life.
D. Losartan has a small volume of distribution
Correct answer = B. Losartan is the only ARB that undergoes
first-pass metabolism to convert to its active metabolite.
Most ARBs have once-daily dosing, and all (except
candesartan) have large volumes of distribution
19.4 How do β-blockers improve cardiac function in HF?
A. By decreasing cardiac remodeling.
B. By increasing heart rate.
C. By increasing renin release.
D. By activating norepinephrine
Correct answer = A. Although it seems counterintuitive to
decrease heart rate in HF, β-blockers improve cardiac functioning
by slowing heart rate, decreasing renin release, and
preventing the direct effects of norepinephrine on cardiac
muscle to decrease remodeling
