ADULT QIII (CARDIAC/LIPIDS)

Select the best pharmacologic treatment option for hypertension in diabetics: a. thiazide diuretic plus an ace-i or arb b. loop diuretics plus CCB c. thiazide diuretic only d. thiazide diuretic plus beta blocker

a

A 41 year old, caucasian patient presents for a routine physical exam. Has no complaints at this time. Their blood pressure is >150 SBP and >90 DBP. There is no history of white coat syndrome, the test was repeated and found accurate. Select all of the following that apply According to JNC 8 treatment guidelines your plan of care will include: a. initiation of thiazide diuretic b. consider CCB, ACE-i or ARB c. ACE-i and ARB d. CCB only

a, b

Statin therapy should be initiated for which of the following patient situations? Select all that apply: a. Clinical atherosclerotic cardiovascular disease b. LDL cholesterol greater than or equal to 190mg/dL c. Diabetics aged 40 to 75 years d. LDL-cholesterol levels between 70 and 189mg/dL plus 10-year risk of atherosclerotic cardiovascular disease greater than or equal to 7.5%

a, b, c, d

A 42 year old Phillipino male with stage I hypertension presents to your clinic with an extreme gout flare up, unable to ambulate. One month ago he was started on antihypertensives. What medication do you suspect initiated the gout flare up? a. ace-i or arb b. thiazide diuretic c. K+ sparing diuretics d. CCB

b

A 59 year old AA female presents to your office for a physical. Her BP has been >140/90 of the last visits. This patient has a BMI of 24, recently ran first marathon and is helping take care of her new grandson a few days each week. No additional comorbidities are identified. What is your plan of care today? a. lifestyle modifications, return in 4 weeks b. thiazide or CCB c. ACEi or ARB d. thiazide plus ACEi or ARB

b a- you would discuss diet but you would not delay care since most HTN is primary, esp in AA and has worse outcomes when untreated c,d- CCB preferable for AA

A 59-year-old man presents to general medical clinic for his yearly checkup. He has no complaints except for a dry cough. He has a past medical history of type II diabetes, hypertension, hyperlipidemia, asthma, and depression. His home medications are sitagliptin/metformin, lisinopril, atorvastatin, albuterol inhaler, and citalopram. His vitals signs are stable, with blood pressure 126/79 mmHg. Hemoglobin A1C is 6.3%, and creatinine is 1.3 g/dL. The remainder of his physical exam is unremarkable. If this patient's cough is due to one of the medications he is taking, what would be the next step in management? a. change lisinopril to metoprolol b. change lisinopril to losartan c. change lisinopril to amlodipine d. change atorvastatin to lovastatin

b This has an angiotensin-converting enzyme (ACE) inhibitor associated cough and should be switched to angiotensin receptor blocker (ARB) such as losartan. Like ACE inhibitors, ARBs inhibit the renin-angiotensin-aldosterone (RAA) system (so are good for treating CHF, hypertension, and diabetic nephropathy), but they do not interfere with breakdown of bradykinin, and therefore, not associated with cough. This patient has type II diabetes and an elevated creatinine, and drugs that target the RAA axis have been shown to delay the progression of diabetic nephropathy.

Secondary prevention of hyperlipidemia is defined as: a. no known cardiovascular disease b. identified cardiovascular disease or a condition equivalent to cardiovascular disease c. initiation of statin therapy d. lifestyle modification

b a is primary prevention c and d are treatment options to discuss with patient when you set individualized goals

An 81-year-old year old male presents to his primary care physician for an annual checkup. He generally feels well except being "old." He has no significant past medical history except for benign prostatic hyperplasia, hip replacement, and cataract surgery. On physical exam, he has a temperature of 37.1C, heart rate of 87 bpm, and a blood pressure of 151/70. He returns to his physician 1 month later with a pressure of 149/71. Which of the following is the most appropriate management for this patient? a. Explain that he has isolated systolic hypertension which seen in most elderly patients and requires no treatment b. Explain that he has isolated systolic hypertension and recommend starting a thiazide c. Explain that he has isolated systolic hypertension and recommend starting a beta-blocker d. Explain that he has isolated systolic hypertension and recommend starting a fast-acting calcium channel blocker

b The patient in this vignette has isolated systolic hypertension, defined as a systolic pressure > 140 mmHg. The treatment of choice is a thiazide, ACE inhibitor, or long-acting CCB. The diagnosis of isolated systolic hypertension is made after measuring systolic BP > 140 (with diastolic < 90) three times, from at least two separate clinical visits. While 95% of all hypertension is idiopathic and called "essential" hypertension, isolated systolic hypertension has a distinct pathophysiology, which is a result of decreased elasticity in the arterial walls. It is strongly associated with aging. Because the diastolic pressure is reduced, there is a large increase in pulse pressure.

A 61 y/o male caucasian, retired Nurse Corps officer presents to your clinic for a two week follow up. He admits being in denial of his newly diagnosed CKD and T2DM presents with a bp >150/90 today. He just returned from a two week vacation and presents to your office ready to discuss treatment options. What will you prescribe for this patient? a. Metformin, CCB b. Metformin, ACEi or ARB plus thiazide diuretic c. ACEi or ARB plus loop diuretic d. CCB plus thiazide diuretic

b *remember that thaizide may cause hyperglycemia but it is still drug of choice per guidelines

A 75-year-old over-weight gentleman with a long history of uncontrolled hypertension, diabetes, smoking and obesity is presenting to his primary care physician with a chief complaint of increased difficulty climbing stairs and the need to sleep propped up by an increasing number of pillows at night. On physical examination the patient has an extra heart sound just before S1 heard best over the cardiac apex and clear lung fields. What is the largest contributor to this patient's symptoms? a. smoking b. uncontrolled hypertension c. sleep apnea d. obesity

b This patient is presenting with diastolic heart failure secondary to long-term uncontrolled hypertension. The extra heart sound occurs due to decreased compliance of the left ventricle. Diastolic heart failure occurs in the setting of uncontrolled hypertension due to left ventricular hypertrophy. The left ventricle is forced to generate increased pressure to overcome increased systemic blood pressure. Over time the walls of the left ventricle will remodel to accommodate the increased pressures. The result is a noncompliant left ventricle that is unable to expand and fill appropriately during diastole.

Elderly patients diagnosed with hypertension should have their treatment goal set at: a. <160/90 b. <120/80 c. <150/80 d. <140/90

c

A 65-year-old man with a history of diabetes mellitus type II presents to his primary care physician for routine care. His only medication is metformin. His vital signs are: Temperature: 37.1 Pulse: 80 Blood Pressure: 150/95 Respiratory Rate: 16 SaO2: 99% He is found to be excreting albumin in his urine at a rate of 150 mg per 24 hours, compared with 50 mg per 24 hours 3 months ago. What is the most appropriate next treatment in the care of this patient? a. insulin b. glyburide c. lisinopirl d. lifestyle modifications

c The patient's history of diabetes along with hypertension and proteinuria are consistent with diabetic nephropathy. Blood pressure control, usually with an ACE inhibitor such as lisinopril, or with a beta-blocker such as atenolol, is the most appropriate treatment to halt the progression of diabetic nephropathy. The goal of treatment and prevention of diabetic nephropathy is to lower blood pressure. Control of hypertension is usually achieved using ACE inhibitors, which provide additional cardiovascular and mortality reduction benefits. Beta-blockers, although they may mask the symptoms of hypoglycemia, may be used as second line agents. In any case, it is important to recognize that the ultimate desired endpoint is a lower BP

The best pharmacologic treatment option for hyperlipidemia is: a. fish oil supplementation b. ezetemide c. atorvastatin d. niacin

c all may affect the lab values, but statins (HMG-CoA reductase inhibitors) are the only lipid-lowering medications that have been shown to reduce cardiovascular events and mortality in both primary and secondary prevention trials (the trials that support the newest guidelines)

A 61-year-old male visits a medical student clinic booth during a health and wellness fair at his workplace. A medical student listens to his heart and lungs and then immediately asks the man if he's ever been diagnosed with hypertension. Which of the following concerning findings might have led her to suspect this man's hypertension? a. a holosystolic murmur radiating to the axilla b. a rough, scratching sound c. a dull, low-pitched sound early in diastole best heard with the bell d. an extra heart sound heard immediately before S1

d Long-standing hypertension causes left ventricular hypertrophy and may result in a stiffening of the left ventricle and production of an S4 heart sound, an extra sound heard immediately before S1.

A 52-year-old woman comes to your clinic for her annual physical exam. She is obese, does not exercise, and regularly eats fried foods. A random blood glucose is 249 mg/dL. Her hemoglobin A1C is 9.5. Which of the following treatments would be weight neutral or cause weight loss in this patient? a. glargine b. glipizide c. glyburide d. metformin

d The patient in this vignette most likely has type II diabetes. Of the given treatments, only metformin is weight neutral in the majority of cases (i.e. it does not cause significant weight gain/loss). Metformin is a first-line treatment for type II DM in most patients. Although the exact mechanism is unknown, it appears to decrease gluconeogenesis and increase insulin sensitivity. There is no risk of hypoglycemia or weight gain (though some patients even lose weight). The most high yield side effect involves lactic acidosis, particularly in patients with renal insufficiency.

A 44-year-old Caucasian man with a four-year history of diabetes mellitus presents to your office for a routine check-up. He has no complaints. His medications include metformin, aspirin, and a multivitamin. He works as an insurance salesman and has a sedentary lifestyle. He smokes one pack of cigarettes per day and drinks two cans of beer on weekends. He denies any illicit drug use. His diet includes mostly meat and large amounts of "junk food." On physical exam, his blood pressure is 157/96 mmHg, heart rate is 82 bpm. His BMI is 34.2 kg/m^2. The remainder of his physical exam is unremarkable. Laboratory studies reveal an HbA1c of 7.8%. At his last check-up one month ago, his blood pressure was 151/93 mmHg. Which of the following interventions would be most effective for lowering his blood pressure? a. smoking cessation b. dietary salt restriction c. improved glycemic control d. weight loss

d Weight loss is the most beneficial lifestyle intervention for obese patients. Systemic hypertension is a major source of morbidity and mortality worldwide. While the majority of hypertensive patients will require pharmacotherapy to meet their blood pressure goals, lifestyle modification is the first step in treatment. Weight loss is the most effective lifestyle change - every 10 kg reduction in weight can decrease systolic blood pressure by 5-20 mmHg. For all patients, the goal BMI is 18.5-24.9 kg/m^2. Regular aerobic exercise and dietary sodium restriction also help lower blood pressure, but less so than weight loss.

The best pharmacologic treatment option for hyperlipidemia in diabetics is: a. niacin b. fish oil supplementation c. ezetumide d. statin therapy

d statins are the only lipid-lowering medications that have been shown to reduce CV events and mortality in both primary and secondary prevention trials

Acute arterial occlusion is associated with the 6 "p's":

pain pallor pulselessness paresthesias poikilothermia (coolness) paralysis *she stressed knowing these