Patient Cases Flashcards
A 66-year-old woman (weight 70 kg) with a history of MI, hypertension, hyperlipidemia, and diabetes mellitus presents with sudden-onset diaphoresis, nausea, vomiting, and dyspnea, followed by a bandlike upper
chest pain (8/10) radiating to her left arm. She had felt well until 1 month ago, when she noticed her typical
angina was occurring with less exertion. Her ECG reveals ST-segment depression in leads II, III, and aVF and
hyperdynamic T waves and positive cardiac enzymes. Blood pressure is 150/90 mm Hg, and all laboratory
results are normal; SCr is 1.2 mg/dL. Home medications are aspirin 81 mg/day, simvastatin 40 mg every night,
metoprolol 50 mg twice daily, and metformin 1 g twice daily. Which regimen is best for this patient?
A. Aspirin 325 mg, ticagrelor 180 mg one dose, and UFH 60-unit/kg bolus; then 12 units/kg/hour titrated
to 50–70 seconds with an early invasive approach.
B. Aspirin 325 mg and enoxaparin 70 mg subcutaneously twice daily with an early invasive approach.
C. An ischemia-guided strategy with tirofiban 25 mcg/kg; then 0.15 mg/kg/minute plus enoxaparin 80 mg
subcutaneously twice daily, aspirin 325 mg/day, and clopidogrel 300 mg one dose; then 75 mg once daily.
D. An ischemia-guided strategy with aspirin 325 mg and ticagrelor 180 mg one dose; plus UFH 70-unit/kg
bolus; then 15 units/kg/hour.
Answer: A
This patient’s atypical symptoms, ST-segment depression on ECG, and positive biomarkers for myocardial
necrosis suggest NSTE-ACS. She has at least three risk
factors for CAD, a history of CAD (prior MI), and positive troponins, which place her at high risk of future
events. In such high-risk patients, an early invasive
strategy (as in Answers A and B) is used to determine
whether occluded or partly occluded arteries exist,
which ones can be intervened on, and whether to make
an intervention. An ischemia-guided approach, also
called “medical management,” as in Answers C and D,
would not be preferred because of this patient’s risk category (i.e., positive troponins). Dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) is indicated for an
early invasive strategy in managing an NSTE-ACS. In
patients undergoing PCI, clopidogrel, prasugrel, or ticagrelor is appropriate (Answer A is correct). After an initial bolus of 60 units/kg and an infusion of 12 units/kg/
hour (Answer A is correct; Answer D is incorrect), UFH
can be titrated to an aPTT of 50–70 seconds. Aspirin
alone without a P2Y12 agent, as in Answer B, would
not provide adequate antiplatelet therapy. Furthermore,
enoxaparin would need to be dosed with a 30-mg intravenous bolus before initiating twice-daily subcutaneous dosing because this patient has positive troponins.
Glycoprotein IIb/IIIa inhibitors, as in Answer C, can be
useful in high-risk patients, typically those with positive troponins; however, their benefit has been shown
mainly when UFH, not low-molecular-weight heparin,
is given as the anticoagulant
A 45-year-old patient underwent an elective percutaneous transluminal coronary angioplasty and drug-eluting
stent placement in her right coronary artery. Which best represents the minimum time DAPT should be
continued?
A. 1 month.
B. 3 months.
C. 6 months.
D. 12 months.
Answer: C
Of importance, this patient case occurs in the context of
elective stent placement, not after ACS. In the non-ACS
setting, the duration of DAPT is determined by the type
of stent placed (bare metal stent vs. drug-eluting stent).
After elective drug-eluting stent placement, DAPT is
recommended for at least 6 months because the risk of
in-stent thrombosis is highest during this time (Answer
C is correct). The recommendation is for at least 1
month after bare metal stent placement because endothelialization of the stent usually occurs early, typically
within 1 month after stenting (Answer A is incorrect).
Bleeding risk may be a reason to consider earlier termination (after at least 1 month) of DAPT after bare
metal stent placement. Although European guidelines consider 3 months of DAPT after drug-eluting stent
placement appropriate, the recommended minimum
according to the U.S. guidelines is 6 months (Answer
B is incorrect). Twelve months of therapy is recommended after ACS (Answer D is incorrect).
A 52-year-old man (weight 100 kg) with a history of hypertension and hypertriglyceridemia presents at a major
university teaching hospital with a cardiac catheterization laboratory. He has had 3 hours of crushing 10/10
substernal chest pain radiating to both arms that began while he was eating his lunch (seated), which is accompanied by nausea, diaphoresis, and shortness of breath. He has never before had chest pain of this character or
intensity. He usually can walk several miles without difficulty and smokes 1.5 packs/day of cigarettes. Home
medications are lisinopril 2.5 mg/day and aspirin 81 mg daily. Current vital signs include heart rate 68 beats/
minute and blood pressure 178/94 mm Hg. His ECG reveals a 3-mm ST-segment elevation in leads V2–V4, I,
and aVL. Serum chemistry values are within normal limits. The first set of cardiac markers shows positive
troponins, 0.8 mcg/L (normal defined as less than 0.1 mcg/L). Which regimen is best for this patient’s STEMI?
A. Reperfusion with primary PCI and stenting of occluded artery, together with tirofaban 25 mcg/kg; then
0.15 mg/kg/minute, clopidogrel 300 mg one dose, and aspirin 325 mg one dose.
B. Reperfusion with a reteplase 10-unit bolus twice, 30 minutes apart, plus a UFH 60-unit/kg bolus and a
12-unit/kg/hour infusion, clopidogrel, and aspirin.
C. Reperfusion with tenecteplase 25-mg intravenous push one dose, enoxaparin 30-mg intravenous bolus
plus 100 mg subcutaneously twice daily, aspirin 325 mg one dose, ticagrelor 180 mg one dose, and bivalirudin 0.75 mg/kg followed by 1.75 mg/kg/hour.
D. Reperfusion with primary PCI with stenting, prasugrel 60 mg one dose, aspirin 325 mg one dose, and
bivalirudin 0.75 mg/kg followed by 1.75 mg/kg/hour
Answer: D
Because the patient presents to a hospital that can do a
primary PCI with stent implantation, this is the preferred
reperfusion strategy (Answers B and C are incorrect).
Answer A is incorrect because an anticoagulant agent
must be administered in addition to antiplatelet therapy.
Reperfusion with fibrinolytic therapy (Answers B and
C) would only be considered if PCI were expected to be
delayed by more than 120 minutes. In addition, Answer
C is incorrect because bivalirudin has not been studied
with lytic therapy. Answer D – reperfusion with primary
PCI, DAPT with aspirin and prasugrel, and dosing of
bivalirudin as an anticoagulant strategy – is correct.
A 76-year-old male smoker (weight 61 kg) has a history of hypertension, benign prostatic hypertrophy, and
lower back pain. Three weeks ago, he began to have substernal chest pain with exertion (together with dyspnea), which radiated to both arms and was associated with nausea and diaphoresis. These episodes have
increased in frequency to four or five times daily; they are relieved with rest. He has never had an ECG. Today,
he awoke with 7/10 chest pain and went to the ED of a rural community hospital 2 hours later. He was acutely
dyspneic and had ongoing pain. Home medications are aspirin 81 mg/day for 2 months, doxazosin 2 mg/day,
and ibuprofen 800 mg three times daily. Vital signs include heart rate 42 beats/minute (sinus bradycardia) and
blood pressure 104/48 mm Hg. Laboratory results include blood urea nitrogen (BUN) 45 mg/dL, SCr 2.5 mg/
dL, and troponin 1.5 ng/L (normal value less than 0.1 ng/L). His ECG reveals a 3-mm ST-segment elevation.
Aspirin, ticagrelor, and sublingual nitroglycerin were given in the ED. The nearest hospital with a catheterization laboratory facility is 2½ hours away. Which regimen is best?
A. Give alteplase 15 units intravenously plus enoxaparin 30-mg intravenous bolus.
B. Use an ischemia-guided treatment strategy with UFH 4000-unit intravenous bolus, followed by 800 units
intravenously per hour.
C. Give tenecteplase 35 mg intravenously plus UFH 4000-unit intravenous bolus followed by 800 units intravenously per hour.
D. Transfer the patient to a facility for primary PCI.
Answer: C
Unlike the patient in case 3, this patient presents with a
STEMI to a rural community hospital where the nearest hospital with catheterization laboratory facilities is
more than 120 minutes away (i.e., lytics are indicated).
He presents within the window for fibrinolytic therapy consideration (less than 6 hours after chest pain
onset) and has no obvious contraindications. Because
he is still having ischemic chest pain and ST-segment
elevation, he should benefit from reperfusion therapy.
He is experiencing bradycardia, which could indicate
an occlusion above the area perfusing his sinoatrial or
atrioventricular nodes. Enoxaparin is a treatment option
for anticoagulant therapy given in conjunction with
fibrinolytics, but the patient is at higher risk of bleeding from impaired enoxaparin clearance and needs a
dosage adjustment. Furthermore, he is older than 75,
beyond the age at which the intravenous bolus should be
given, and the alteplase dosing is incomplete (Answer
A is incorrect). Simply treating this patient conservatively with UFH alone in the setting of ongoing chest
pain, shortness of breath, and pulmonary edema is not
optimal (Answer B is incorrect). Diagnostic catheterization and possible PCI to determine whether an artery
can be reperfused may be desirable but is complicated
because the patient’s SCr is elevated (2.5 mg/dL), and
he is in a rural hospital, where he cannot be assessed quickly enough (within 90–120 minutes) (Answer D
is incorrect). Because of the shorter half-life and ease
of administration of tenecteplase, tenecteplase may be
preferable to alteplase. Clearance of UFH with tenecteplase is not as altered as with enoxaparin, and it would
be a more appropriate therapy than enoxaparin in combination with a thrombolytic (Answer C is correct)
A 72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day.
5. Which regimen is best for treating his ADHF?
A. Carvedilol 25 mg twice daily.
B. Sodium nitroprusside 0.1 mcg/kg/min IV.
C. Furosemide 120 mg intravenously twice daily.
D. Milrinone 0.5 mcg/kg/minute.
Answer: C
This patient, who has ADHF, is receiving a β-blocker.
Although long-term β-blockers can improve HF symptoms and reduce mortality, they can also worsen symptoms in the short term. It is recommended to keep
the maintenance β-blocker therapy at the same or at a
slightly lower dose compared with the outpatient therapy in patients with ADHF; increasing the β-blocker
dose before reaching euvolemia might acutely worsen
his clinical picture (Answer A is incorrect). In patients
admitted with volume overload without substantial signs
of reduced CO, it is reasonable to try intravenous loop
diuretics initially (Answer C is correct). As gut edema
increases, oral loop diuretics (notably furosemide)
become less effective because of decreased absorption. Sodium nitroprusside could be useful if signs and
symptoms of hypoperfusion were present. Because this
patient presents mainly with warm and wet symptoms,
diuretics would be first-line (Answer B is incorrect).
Milrinone is an inotropic drug. Because of their adverse
effects, inotropes are recommended in cold and wet
exacerbations only after vasodilatory medications have
failed (Answer D is incorrect).
A 72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day.
After being initiated on intravenous loop diuretics with only minimal urinary output, the patient is transferred
to the coronary care unit for further management of diuretic-refractory decompensated HF. His Sao2 is now
87% on a 4-L nasal cannula, and an arterial blood gas is being obtained. His blood pressure is 110/75 mm
Hg and heart rate is 75 beats/minute. The patient’s SCr and K+
concentrations have begun to rise and are now 2.7 mg/dL and 5.4 mmol/L, respectively. In addition to a one-time dose of intravenous chlorothiazide, which
regimen is most appropriate for this patient?
A. Nitroglycerin 20 mcg/minute.
B. Sodium nitroprusside 0.3 mg/kg/minute.
C. Dobutamine 5 mcg/kg/minute.
D. Milrinone 0.5 mcg/kg/minute.
Answer: A
Intravenous vasodilators such as nitroglycerin (Answer
A) and sodium nitroprusside (Answer B) are reasonable
if intravenous diuretics fail and the patient progresses
to acute pulmonary edema. Both agents rapidly cause
venous vasodilation and reduce pulmonary filling
pressures, which can relieve acute shortness of breath.
Answer A, nitroglycerin, is optimal for this patient,
given his declining renal function and the concern
for increased risk of thiocyanate toxicity with sodium
nitroprusside in this setting (Answer B is incorrect).
Dobutamine is typically used in states of low CO
decompensation and is counteracted by concomitant
β-blocker therapy, making it a poor choice in patients
receiving β-blockers (Answer C is incorrect). Although
milrinone is a more acceptable inotropic agent in a patient receiving β-blockers, the dosing strategy is
inappropriate as an initial dose (Answer D is incorrect).
Finally, inotropes are generally reserved for patients
when other therapies have failed.
A 72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day.
The patient initially responds with 2 L of urinary output overnight, and his weight decreases by 1 kg the next
day. However, by day 5, his urinary output has diminished again, and his SCr has risen to 4.3 mg/dL. He was
drowsy and confused this morning during rounds. His extremities are cool and cyanotic, blood pressure is
89/58 mm Hg, and heart rate is 98 beats/minute. It is believed that he is no longer responding to his current
regimen. A Swan-Ganz catheter is placed to determine further management. Hemodynamic values are cardiac
index 1.5 L/minute/m2
, SVR 2650 dynes/second/cm5
, and PCWP 30 mm Hg. Which regimen is most appropriate for his current symptoms?
A. Milrinone 0.2 mcg/kg/minute.
B. Dobutamine 10 mcg/kg/minute.
C. Sodium nitroprusside 0.1 mcg/kg/minute.
D. Phenylephrine 20 mcg/minute.
Answer: A
Signs of a decreased CO state in HF (e.g., increased
SCr, decreased mental status, cool extremities) suggest a cold and wet state, and adjunctive therapy is
indicated. Positive inotropic agents such as milrinone
will increase CO to maintain perfusion to vital organs.
Milrinone will also vasodilate the peripheral vessels
to unload the heart (lower SVR). Although dobutamine would be a potential choice in this patient, it is
not recommended in patients receiving β-blockers, and
the initial starting dose is too aggressive (Answer B is
incorrect). Although this patient has low blood pressure, his elevated SVR suggests that he will tolerate
the vasodilatory effects of milrinone as long as it is
appropriately renally adjusted for worsening renal dysfunction (Answer A is correct). Nitroprusside would be
relatively contraindicated in patients with an SBP less
than 100 mm Hg and is absolutely contraindicated in
patients with an SBP less than 90 mm Hg (Answer C is
incorrect). Phenylephrine has no positive beta effects;
therefore, it will not augment contractility. In addition,
it will cause vasoconstriction through alpha stimulation, which will further increase SVR and probably
worsen CO (Answer D is incorrect). Vasoconstrictors
are reserved for patients in cardiogenic shock.
A 68-year-old man is admitted after an episode of syncope, with a presyncopal syndrome of seeing black spots
and dizziness before passing out. Telemetry monitor showed sustained VT for 45 seconds. His medical history
includes HF NYHA class III, LVEF 30%, two MIs, hypertension for 20 years, LV hypertrophy, DM, and diabetic
nephropathy. His medications include lisinopril 5 mg/day, furosemide 20 mg twice daily, metoprolol 25 mg twice
daily, digoxin 0.125 mg/day, glyburide 5 mg/day, atorvastatin 40 mg, and aspirin 81 mg/day. His blood pressure is
120/75 mm Hg, with heart rate 80 beats/minute, BUN 30 mg/dL, and SCr 2.2 mg/dL.
Which is the best therapy to initiate for conversion of his sustained VT?
A. Amiodarone 150 mg intravenously for 10 minutes, then 1 mg/minute for 6 hours, then 0.5 mg/minute.
B. Sotalol 80 mg twice daily titrated to QTc of about 450 milliseconds.
C. Dofetilide 500 mcg twice daily titrated to QTc of about 450 milliseconds.
D. Procainamide 20 mg/minute, with a maximum of 17 mg/kg.
Answer: A
Treatment options for sustained VT depend on concomitant disease states, particularly LVEF (40% cutoff). In
a patient with LV dysfunction, class I agents such as
procainamide are contraindicated (Answer D is incorrect). In a patient whose CrCl is less than 60 mL/minute,
sotalol requires a considerable dose reduction to avoid
an excess risk of torsades de pointes. Sotalol is not an
effective cardioversion drug but is more useful for preventing future episodes of arrhythmias (maintaining
sinus rhythm) once sinus rhythm is achieved (Answer
B is incorrect). Dofetilide is indicated only for AF, not
for ventricular arrhythmias; similarly, cardioversion
rates with dofetilide are low (Answer C is incorrect).
Amiodarone is first-line therapy for sustained VT in
patients with severe renal insufficiency, HF, and SHD
(Answer A is correct).
A 68-year-old man is admitted after an episode of syncope, with a presyncopal syndrome of seeing black spots
and dizziness before passing out. Telemetry monitor showed sustained VT for 45 seconds. His medical history
includes HF NYHA class III, LVEF 30%, two MIs, hypertension for 20 years, LV hypertrophy, DM, and diabetic
nephropathy. His medications include lisinopril 5 mg/day, furosemide 20 mg twice daily, metoprolol 25 mg twice
daily, digoxin 0.125 mg/day, glyburide 5 mg/day, atorvastatin 40 mg, and aspirin 81 mg/day. His blood pressure is
120/75 mm Hg, with heart rate 80 beats/minute, BUN 30 mg/dL, and SCr 2.2 mg/dL.
The patient presents to the ED 3 months after amiodarone maintenance initiation (he refused ICD placement)
after a syncopal episode, during which he lost consciousness for 30 seconds, according to witnesses. He also
has rapid heart rate episodes during which he feels dizzy and lightheaded. He feels very warm all the time (he wears shorts, even though it is winter), cannot sleep, and has lost 3 kg in weight. He received a diagnosis of
hyperthyroidism caused by amiodarone therapy. On telemetry, he has runs of nonsustained VT. Which best
predicts the duration of amiodarone-associated hyperthyroidism in this patient?
A. Never.
B. 1 month.
C. 6 months.
D. 18 months.
Answer: C
With the prolonged half-life of amiodarone and extensive fat tissue volume of distribution, hyperthyroid
adverse effects would be expected to last for 3–5 halflives of the drug, which is 5–8 months (Answer C is
correct; Answer A is incorrect). Although therapeutic
concentrations may decrease substantially by then,
1 month is too soon for the effects to subside (Answer
B is incorrect). Although some iodine and amiodarone
molecules will probably remain absorbed in fat stores
for years, if not for life, therapeutic concentrations
should not exist for longer than what is predicted by the
half-life (Answer D is incorrect).
A 64-year-old woman presents to the ED with the chief concern of palpitations. Her medical history includes
hypertension controlled with a diuretic and an inferior-wall MI 6 months ago. She is pale and diaphoretic but
can respond to commands. The patient’s laboratory values are within normal limits. Her vital signs include
blood pressure 95/70 mm Hg and heart rate 145 beats/minute; telemetry shows sustained VT. Although initially unresponsive to β-blockers, the patient is successfully treated with lidocaine. Subsequent electrophysiologic testing reveals inducible VT, and sotalol 80 mg orally twice daily is prescribed. Two hours after the
second dose, the patient’s QTc is 520 milliseconds. Which regimen change would be most appropriate for this
patient?
A. Continue sotalol at 80 mg orally twice daily.
B. Increase sotalol to 120 mg orally twice daily.
C. Discontinue sotalol and initiate dofetilide 125 mcg orally twice daily.
D. Discontinue sotalol and initiate amiodarone 400 mg orally three times daily
Answer: D
This patient is having QT prolongation with sotalol, placing her at an elevated risk of developing lifethreatening torsades de pointes. Sotalol should be discontinued immediately (Answers A and B are incorrect). Given the QT prolongation that occurred with
sotalol, the same will probably occur with dofetilide
(Answer C is incorrect). Amiodarone is associated with
minimal risk of torsades de pointes and therefore would
be an appropriate alternative agent to prevent ventricular arrhythmias (Answer D is correct).
A 68-year-old man with a history of stage 5 chronic kidney disease receiving hemodialysis, hypertension,
CAD post-MI, moderately depressed LVEF, and gastroesophageal reflux disease presents with acute-onset
shortness of breath and chest pain. After his recent dialysis, he was nonadherent to medical therapy for 2
days and noticed he had gained 2 kg in 24 hours. His baseline orthopnea worsened to sleeping sitting up in a
chair for the 2 nights before admission. He admits smoking cocaine within the past 24 hours and developed
acute-onset chest tightness with diaphoresis and nausea, and his pain was 7/10. He went to the ED, where
his blood pressure was 250/120 mm Hg. He had crackles halfway up his lungs on examination, and chest
radiography detected bilateral fluffy infiltrates with prominent vessel cephalization. His ECG revealed sinus
tachycardia, heart rate 122 beats/minute, and ST-segment depressions in leads 2, 3, and aVF. He was admitted
for a hypertensive emergency. Laboratory results are as follows: BUN 48 mg/dL, SCr 11.4 mg/dL, BNP 2350
pg/mL, troponin T 1.5 ng/L (less than 0.1 mcg/L), creatine kinase 227 units/L, and creatine kinase-MB 22
units/L. Which medication is best for this patient’s hypertensive emergency?
A. Intravenous nitroglycerin 5 mcg/minute titrated to a 25% reduction in MAP.
B. Labetalol 2 mcg/minute titrated to a 50% reduction in MAP.
C. Sodium nitroprusside 0.25 mcg/kg/minute titrated to a 25% reduction in MAP.
D. Clonidine 0.1 mg orally every 2 hours as needed for a 50% reduction in MAP.
Answer: A
Hypertensive emergency should be treated immediately by no more than a 25% reduction in MAP over
the first hour, followed by a further reduction to a blood
pressure of 160/100 mm Hg over the next 2–6 hours.
The patient’s comorbidities guide the optimal therapy.
His dialysis and SCr of 11.4 mg/dL are contraindications to sodium nitroprusside (Answer C is incorrect)
because of possible thiocyanate toxicity. Labetalol
(and β-blockers in general) is controversial in patients
who have taken cocaine, but its nonselective nature
makes it an option; however, a reduction of 50% initially is too rapid a decrease in blood pressure for safety
(Answer B is incorrect). Clonidine is not appropriate
for a hypertensive emergency because its oral form is
difficult to titrate and can lead to precipitous drops in
blood pressure beyond the goal 25% reduction and possibly stroke or worsening MI (Answer D is incorrect).
Nitroglycerin is optimal, considering the patient’s lack
of contraindications to this therapy and his evolving
MI and symptoms of HF (Answer A is correct).
A 56-year-old white woman with a long history of hypertension because of nonadherence and recently diagnosed HF (EF 35%) presents to the local ED with blood pressure 210/120 mm Hg and heart rate 105 beats/
minute. She states that she felt a little lightheaded but that she now feels okay. She ran out of her blood pressure
medications (including hydrochlorothiazide, carvedilol, and lisinopril) 3 days ago. Her current laboratory values are within normal limits. Which medication is best for this patient?
A. Sodium nitroprusside 0.25 mcg/kg/minute titrated to a 25% reduction in MAP.
B. Labetalol 80 mg intravenously; repeat until blood pressure is less than 120/80 mm Hg.
C. Resumption of home medications; refer for follow-up within 2 days.
D. Resumption of home medications; initiate amlodipine 10 mg daily; refer for follow-up in 1 week.
Answer: C
In an asymptomatic hypertensive crisis (without acute
target-organ damage), giving intravenous medications,
as in Answers A and B, and admitting the patient to
the hospital are unnecessary (Answers A and B are
incorrect). This patient is likely presenting because
of recent nonadherence. Resuming her home medications (Answer C is correct) at this time would be most
appropriate, with a close follow-up to ensure that her
prescribed regimen is working. Adding a fourth agent
(Answer D is incorrect) at this time is unnecessary,
considering that her disease could be controlled on her
current drug regimen if she were adherent. Follow-up
should occur within the first few days, rather than waiting 1 week
