Lippincott Review

Question 1

Digoxin has a profound effect on myocyte intracellular concentrations of Na+, K+, & Ca2+. These effects are caused by the inhibition of:

A) Ca2++ATPase of the sarcoplasmic reticulum
B) Na+/K+-ATPase of the myocyte membrane
C) Cardiac phosphodiesterase
D) Cardiace beta-1 receptors

Answer 1

B = Dig binds to and blocks the action of Na+/K+-ATPase leading to increased IC Na+. The diminished Na+ gradient results in less Ca2+ being extruded from the cell via the Na+/Ca2+ exchanger.

Question 2

Compensatory increases in heart rt & renin release that occur in HF may be alleviated by which of the following drugs?

A) milrinone
B) Digoxin
C) Dobutamine
D) Enalapril
E) Metoprolol

Answer 2

E = This is a Beta-1 selective antagonist. It prevents the increased heart rate and renin release that result from sympathetic stimulation which occurs as compensation for reduced CO of HF.

Question 3

A 58yo man is admitted to the hospital w/acute HF & pulmonary edema. Which drug is most helpful?

A) Digoxin
B) Dobutamine
C) Furosemide
D) Minoxidil
E) Spironolactone

Answer 3

C = Furosemide has the ability to dilate vessels in the context of AHF and mobilizes the edematous fluid while promoting excretion.

Dobutamine - incr. contractility
Dig - too slow; no vasodilating effects
Minoxidil - decr arterial P and causes reflex tachy
Spironolactone - does not alleviate edema

Question 4

ACE or ARB treatment should not be prescribed to patients who:

Answer 4

1) Have experienced life-threatening adverse runs to the drug
2) Are pregnant
3) Are at immediate risk of cariogenic shock

Question 5

A 46yo male is admitted to the ED. He has taken >90 digoxin tablets, ingesting them about 3hrs pre-admission. His pulse = 50-60bmp, EKG shows 3rd degree heart block. Serum K+ = wnl. What therapy do we start?

A) Digoxin immune Fab
B) K+ salts
C) Verpamil
D) Amiodarone

Answer 5

A = The pt is severely poisoned and we must administer antidigoxin antibodies to reduce plasma concentration.

K+ salts - may actually be used in addition to increase K+ levels
Amiodarone - would actually INCREASE toxicity.

Question 6

Name an example of a Beta-Adrenergic Agonists.

Answer 6

Dobutamine

Question 7

What drug is introduced first in HF failure for relief of S&Sxs?

Answer 7

Loop diuretics (i.e. furosemide)

Question 8

If a pt is in Stage C HF (structural heart dz, previous or current Sxs), what medications do we prescribe?

Answer 8

ACEi and BB

Question 9

A 56yo pt c/o chest pain following any sustained exercise. He is diagnosed w/atherosclerotic angina. He is prescribed sublingual nitroglycerin for treatment of acute chest pain. Which of the following adverse effects is likely to be experienced by this pt?

A) Hypertension
B) Throbbing headache
C) Bradycardia
D) Sexual dysfunction
E) Anemia

Answer 9

B - Nitroglycerin causes throbbing headache in 20-60% of pts who are taking the drug.

Question 10

56yo pt co/chest pain following exercise is being prescribed propranolol to prevent his episodes of angina. The beta-blocker has the added benefit of preventing which of the following side effects of sublingual NTG?

A) Dizziness
B) Methemoglobinemia
C) Throbbing headache
D) Reflex tachycardia
E) Edema

Answer 10

D - Nitroglycerin can cause a reflex tachycardia bc of its vasodilating properties. This reflex is blocked by propanolol.

Question 11

A 68yo man has been successfully treated for exercise-induced angina for several yrs. He recently has been c/o being awakened at night w/chest pain. Which of the following drugs would be useful in preventing this pt’s nocturnal angina?

A) Amyl nitritie
B) Nitroglycerine (sublingual)
C) Nitroglycerine (transdermal)
D) Esmolol
E) Hydralazine

Answer 11

C - transdermal NTG can cause sustain blood levels for as long as 24hrs. Bc tolerance can occur, it is recommended that the patch be removed after 8-10 hrs to allow recovery of sensitivity.

**Hydralazine may actually precipitate an angina attack.

Question 12

For an 60yo African American w/hypertension, what will you prescribe?

Answer 12

Thiazide and/or CCB

Question 13

If a 19yo female with chronic kidney disease presents with hypertension, what is the initial therapy?

Answer 13

Initial therapy should be ACE (or ARB).

Question 14

According to JNC7, what is the BEST initial therapy for a hypertensive patient who is recovering from a myocardial infarction?

Answer 14

Beta Blockers!

Question 15

Give an example of a Beta-blocker?

Answer 15

(“-olol”) atenolol, carvedilol, metprolol, propanolol, etc.

Question 16

What are examples of an Angiotensin II-Receptor Antagonists?

Answer 16

(“-sartan”) candesartan, eprosartan, losartan, olmesartan, valsartan

Question 17

A 45yo man has recently been diagnosed w/HTN & started on mono therapy designed to reduce peripheral resistance and prevent NaCl & H2O retention. He has developed a persistent cough. Which drug would have the same benefits but not cause a cough?

A) Losartan
B) Nifedipine
C) Prazosin
D) Propranolol

Answer 17

A - Use Losartan rather than an ACEi - same benefits as ACEi but no cough

Question 18

Which of the following deus may cause a precipitous fall in bp & fainting on initial administration?

A) Atenolol
B) Hydrochlorothiazide
C) Nifedipine
D) Prazosin
E) Verapamil

Answer 18

D = Prazosin produces first-dose hypotension, presumably by blocking alpha-1-receptors.

This can be minimized by initially giving the drug in small, divided doses.

Question 19

Which one of the following anithypertensive drugs can precipitate a hypertensive crisis following abrupt cessation of therapy?

A) Clonidine
B) Diltiazem
C) Enalapril
D) Losartan
E) Hydrochlorothiazide

Answer 19

A - Increased sympathetic nervous sys activity occurs if clonidine therapy is abruptly stopped after prolonged administration. Uncontrolled elevation in bp can occur.

Pts should be slowly weaned from clonidine while other antihypertensive meds are initiated.

Question 20

A 56 yo female patient with a recent MI is in need of a hypertensive medication. Due to her history of COPD, which medication should you avoid?

Answer 20

You should give a beta-blocker but AVOID propranolol because it is NON-selective and can exasperate COPD symptoms.

Question 21

A 48yo hypertensive pt has been successfully treated w/thiazide for the last 5 yrs. Over the last 3 months, his diastolic pressure has steadily increased, and he has been started on an additional antihypertensive med. He c/o not being able to achieve an erection and that he is no longer able to complete threes sets of tennis (presumably NOT at the same time). The 2nd antihypertensive med is most likely which one of the following?

A) Captopril
B) Losartan
C) Minoxidil
D) Metoprolol
E) Nifedipine

Answer 21

D - The side effect profile of BBs, such as metoprolol, are characterized by interference w/sexual performance & decreased exercise tolerance. None of the other meds are likely to produce this combo of SEs.

Question 22

Name two platelet aggregation inhibitors.

Answer 22

Aspirin & clopidogrel (Plavix)

Question 23

Compare and contrast Heparin and Low-molecular weight heparin in the following categories:

IV half life - Heparin higher or lower than LMWH?
Anticoag. response? (predictable OR variable)
Bioavailability? Heparin ___% vs LMWH ___%
Bleeding as adverse effect? (frequent, never, less frequent?)
Setting? (Hospital, home, both?)

Answer 23

IV half life: Heparin-2hrs; LMWH-4hrs

Response: Hep-variable; LMWH-predictable

Bioavailability: Hep = 20%; LMWH = 90%

AEs: Hep - Frequent bleeding; LMWH - less frequent

Setting? Hep= hospital; LMWH - Hospital OR home

Question 24

A 63yo female presents with claudication. Which drug will you prescribe to treat THIS symptom?

A) Low-molecular weight heparin
B) Aspirin
C) Pentoxifylline
D) Dabigatran

Answer 24

C - Pentoifylline increases the deformability of RBCs and reduces blood viscosity, therefore decreasing the total systemic basilar resistance and improves blood flow/O2 perfusion.

Question 25

A 75yo woman w/HTN is being treated w/a thiazide. Her blood pressure responds and reads 120/76mmHg. After several months on the medication, she c/o being tired and weak. An analysis of the blood indicates low values for which of the following?

A) Calcium
B) Uric acid
C) Potassium
D) Sodium
E) Glucose

Answer 25

C - Hypokalemia is a common adverse effect of thiazides and can lead to fatigue & lethargy. Supplementation w/potassium chloride or with foods high in K+ corrects the problem!

*If severely hypokalemic, consider a potassium-sparing diuretic such as spirolactone.

**Calcium, uric acid, and glucose are usually elevated by thiazides.

Question 26

You are looking to add a second medication to help a patient better control their blood pressure. The patient has a history of asthma and benign prostatic hypertrophy. Which of the following would be a poor choice for this patient?

A) Calcium Channel Blocker
B) Beta blocker
C) Alpha Blocker
D) ACEI

Answer 26

B - With a history of asthma beta blockers would be best avoided

*Calcium Channel blockers would be a fine choice
With BPH alpha blockers may be a good choice,
ACE inhibitors would be OK for this patient just watch the cough.

Question 27

A patient comes in to your office for a follow up secondary to a single blood pressure reading of 148/96. At this visit his blood pressure is measured at 150/98. What is your treatment of choice at this point (according to JNC8)?

A) Continue with behavior modification, encourage patient to take BP at home and follow up in one month.
B) Begin treatment with thiazide diuretic and follow up in one month.
C) Blood pressure is in the high normal range so reassure the patient and continue to monitor.
D) Begin treatment with a calcium channel blocker and follow up in one month

Answer 27

B - According to JNC8, you will start treating this patient. For most patients without coindications, the patient will be started on thiazides.

Question 28

Which of the following is NOT a side effect of loop diuretics?

A) Gout
B) Hypokalemia
C) Hearing loss
D) Metallic taste in mouth

Answer 28

D - metallic taste in the mouth is NOT a side effect of loop diuretics.