SM 145a - Cases in Hypertension and Heart Failure

Question 1

Which blood pressure medications are most likley to cause depression and decreases in energy?

Answer 1

Centrally acting agents: work to inhibit sympathetic outflow from the presynaptic neuron

• Methyldopa
• Clonidine (alpha-2 receptor agonist)
• Guanabenz
• Guanfacine

Question 2

What is a rare but serious side effect of sodium nitroprusside?

Answer 2

Cyanide toxicity

Question 3

Which of the following medications are NOT shown to have a mortality benefit in patients with HFrEF?

A.Amlodipine (calcium channel blocker)

B.Metoprolol succinate (beta-blocker)

C.Lisinopril (ACE-inhibitor)

D.Spironolactone (mineralocorticoid receptor antagonist)

Answer 3

A: Amlodipine (and other Ca2+ channel blockers)

Not shown to reduce mortality in patients with HFrEF

Question 4

A patient is in cardiogenic shock with low flow and high resistance

Which of the following medications would be appropriate?

A. (oral) Hydralazine

B. Amlodipine

C. Intravenous Nitroglycerin

D. Minoxidil

E. Nitroprusside

Answer 4

E. Nitroprusside

Results in immediate vasodilation; useful in hypertensive emergency, acute decompensated heart failure

Question 5

If a patient’s blood pressure is 115/75, what is their estimated mean arterial pressure?

Answer 5

~88

Mean arterial pressure = (2*DBP + SBP)/3

Question 6

A patient on an ACE-inhibitor complains of thick/heavy tongue, swollen lips, and hoarseness.

What is happening?

Is it serious?

Who is most likley to have this side effect

Answer 6

Angioedema

Very serious

Women and African Americans

Question 7

Which letter represents the site of action of chlorthalidone?

Answer 7

E: The distal convoluted tubule

Question 8

Which NYHA classification of heart failure is described below?

“Marked limitation of physical activity, comforable at rest, but less than ordinary activity causes symptoms”

Answer 8

Class III

Question 9

__________ is the only food that decreases the amount of biliary choloseterol that is produced by the body

Answer 9

Fiber is the only food that decreases the amount of biliary choloseterol that is produced by the body

Question 10

Which NYHA classification of heart failure is described below?

“No limitation of physical activity - ordinary physical activity does not cause symptoms”

Answer 10

Class I

Question 11

Which letter correctly labels the site of action of furosemide?

Answer 11

D: Thick ascending limb

Furosemide is a loop diuretic

(Also Torsemide and Bumetanide)

Question 12

What electrolyte abnormalities are associeated with thiazide-type diuretics?

Answer 12

Act on distal convoluted tubule

• Hyponatremia
• Hypokalemia
• Hypomagnesemia
  ​
• Hypercalcemia
• Hyperuricemia

Question 13

A patient is showing signs of acute decompensated heart failure.

You order furosemide 80 mg intravenously x 1. The patient feels better almost immediately. What is the mechanism underlying the beneficial effect of furosemide within minutes?

Answer 13

Acute pulmonary venodilation

Increased venous capacitance immediately. This reduces venous return -> reduces LV filling -> reduces pulmonary edema

Question 14

Which blood pressure measurement (systolic or diastolic) is most indicative of CVD risk?

Answer 14

Systolic

Diastolic can inform us of risk of renal disease, but in treating hypertension cardiologists mostly focus on systolic BP

Question 15

What LDL level (mg/dL) constitutes the upper limit of acquired hypercholesterolemia?

Answer 15

160 mg/dL

Anything above this likely indicates familial hypercholesterolemia

Question 16

Which of the following medications, would serve to partially correct hypokalemia and may be of modest benefit for heart failure with preserved ejection fraction (HFpEF)?

A. Diltiazem

B. Hydralazine

C. Spironolactone

D. Prazosin

Answer 16

C. Spironolactone

Question 17

A patient has left ventricular hypertrophy, an LVEF of 65%, and grade II diastolic dysfunction

Which of the following best depicts the changes in this patient’s pressure-volume loop? (black line: normal; red line: patient)

Answer 17

C

Increased filling pressure

Question 18

A 75-year-old woman has a lifelong history of poorly controlled hypertension along with obesity and diabetes. S4 was auscultated on her physical exam. She notes progressive shortness of breath with 1 block exertion, episodes of breathlessness at night, weight gain, and lower extremity edema. Symptoms have been intermittently present for 2-3 years.

What stage of heart failure does this patient have?

What symptom status?

Answer 18

Stage C: Structural heart disease with prior or current symptoms of HF

NYHA Class III: Marked limitation of physical activity, comfortable at rest, but less than ordinary activity causes symptoms

Question 19

Which NYHA classification of heart failure is described below?

“Severe limitation and discomfort with any phsyical activity, symptoms present even at rest”

Answer 19

Class IV

Question 20

Which NYHA classification of heart failure is described below?

“Slight limitation of physical activity, comfortable at rest, ordinary physical activity causes symptoms”

Answer 20

Class II

Question 21

An obese patient with a family history of smoke and a social history of 15 pack years of smoking has home blood pressures of 144/76, 136/84, 140/92, 139/83

What should your next step be?

Answer 21

Recommend pharmacologic therapy and lifestyle modification

Question 22

What is the benefit of weight loss in a patient who is hypertensive?

Answer 22

For every kilogram of weight loss, BP decreases by 1 point

Weight loss lowers systemic vascular resistance

Question 23

How does amlodipine exert its antihypertenisve effect?

Answer 23

Amlodipine (and other -dipine drugs): dihydropyridine Ca2+ channel blocker

Decreases peripheral vascular resistance

• Block L-type Ca2+ channels to decrease intracellular Ca2+ concentration
• Less calcium = decreased smooth muscle constriction = vasodilation

Question 24

A blood pressure of 140/94 is classified as…

Answer 24

Stage II hypertension

Question 25

Which anti-hypertensive medication may cause a loss of libido in women and gynecomastia in men?

Answer 25

Spironolactone

(Not eplerenone)

Question 26

A patient has left ventricular hypertrophy, an LVEF of 65%, and grade II diastolic dysfunction

Which curve best depicts this patient’s end-diastolic pressure volume relationship? (Red = normal)

Answer 26

Curve A

LV hypertrophy = less compliant ventricle; increased pressure at every volume, more pronounced at higher volumes

Question 27

A patient has left ventricular hypertrophy, an LVEF of 65%, and grade II diastolic dysfunction.

They are given forsemide, a loop diuretic

Which of the following arrows best depicts the direction in which the patient’s left ventricular end-diastolic pressure will move after administration of diuretic from the point shown?

Answer 27

A

Diruretics will decrease the amount of volume in the body, decreaseing LV end diastolic volume

Question 28

What is the mechanism of an ACE-inhibitor induced cough?

Answer 28

Increased bradykinin

Question 29

Which hypertensive patients would be good candidates for peripheral vasodilators, such as hydralazine, minoxidil, and nitroprusside?

Answer 29

• Patients with difficult to control blood pressure
  (Stage 2 hypertension)
  
  • taking other agents without control, or adverse side effects to those agents
• Patients in a hypertensive emergency

Question 30

For every kilogram of weight loss, systolic blood pressure decreases by ________

Answer 30

For every kilogram of weight loss, systolic blood pressure decreases by 1 point

_(_In treating blood pressure, we care most about systolic because this measurement correlates most with CVD risk; diastolic only has implications for renal failure)

Question 31

How successful is blood pressure control in an at-risk patient to prevent the onset of a first episode of heart failure?

Answer 31

Significant: ~40% risk reduction