Katzung cardio Q's

6. A man is admitted to the emergency department with a brownish cyanotic appearance, marked shortness of breath, and hypotension. Which of the following is most likely to cause methemoglobinemia? (A) Amyl nitrite (B) Isosorbide dinitrate (C) Isosorbide mononitrate (D) Nitroglycerin (E) Sodium cyanide

(A) Amyl nitrite

1. A 70-year-old retired businessman is admitted with a history of recurrent heart failure and metabolic derangements. He has marked peripheral edema and metabolic alkalosis. Which of the following drugs is most appropriate for the treatment of his edema? (A) Acetazolamide (B) Digoxin (C) Dobutamine (D) Eplerenone (E) Hydrochlorothiazide

(A) Acetazolamide

10. A graduate student is planning to make a high-altitude climb in South America while on vacation. He will not have time to acclimate slowly to altitude. A drug that is useful in prevent- ing high-altitude sickness is (A) Acetazolamide (B) Amiloride (C) Demeclocycline (D) Desmopressin (E) Ethacrynic acid

(A) Acetazolamide

7. A 60-year-old patient complains of paresthesias and occasional nausea associated with one of her drugs. She is found to have hyperchloremic metabolic acidosis. She is probably taking (A) Acetazolamide for glaucoma (B) Amiloride for edema associated with aldosteronism (C) Furosemide for severe hypertension and heart failure (D) Hydrochlorothiazide for hypertension (E) Mannitol for cerebral edema

(A) Acetazolamide for glaucoma

5. A 16-year-old girl has paroxysmal attacks of rapid heart rate with palpitations and shortness of breath. These episodes occasionally terminate spontaneously but often require a visit to the emergency department of the local hospital. Her ECG during these episodes reveals an AV nodal tachycardia. The antiarrhythmic of choice in most cases of acute AV nodal tachycardia is (A) Adenosine (B) Amiodarone (C) Flecainide (D) Propranolol (E) Verapamil

(A) Adenosine

1. PJ is a 4.5-year-old boy. At his checkup, the pediatri- cian notices cutaneous xanthomas and orders a lipid panel. Repeated measures confirm that the patient's serum cholesterol levels are high (936 mg/dL). Further testing confirms a diagno- sis of homozygous familial hypercholesterolemia. Which of the following interventions will be least effective in this patient? (A) Atorvastatin (B) Ezetimibe (C) Lomitapide (D) Mipomersen (E) Niacin

(A) Atorvastatin

Questions 1-4. A 60-year-old man presents to his primary care physician with a complaint of severe chest pain when he walks uphill to his home in cold weather. The pain disappears when he rests. After evaluation and discussion of treatment options, a deci- sion is made to treat him with nitroglycerin. 4. If a β blocker were to be used for prophylaxis in this patient, what is the most probable mechanism of action in angina? (A) Block of exercise-induced tachycardia (B) Decreased end-diastolic ventricular volume (C) Increased double product (D) Increased cardiac force (E) Decreased ventricular ejection time

(A) Block of exercise-induced tachycardia

Questions 8 and 9. A 67-year-old woman presents with pain in her left thigh muscle. Duplex ultrasonography indicates the pres- ence of deep vein thrombosis (DVT) in the affected limb. 8. The decision was made to treat this woman with enoxaparin. Relative to unfractionated heparin, enoxaparin (A) Can be used without monitoring the patient's aPTT (B) Has a shorter duration of action (C) Is less likely to have a teratogenic effect (D) Is more likely to be given intravenously (E) Is more likely to cause thrombosis and thrombocytopenia

(A) Can be used without monitoring the patient's aPTT

9. Which of the following has been shown to prolong life in patients with chronic congestive failure in spite of having a negative inotropic effect on cardiac contractility? (A) Carvedilol (B) Digoxin (C) Dobutamine (D) Enalapril (E) Furosemide

(A) Carvedilol

2. A 50-year-old man has a history of frequent episodes of renal colic with calcium-containing renal stones. A careful workup indicates that he has a defect in proximal tubular calcium reabsorption, which results in high concentrations of calcium salts in the tubular urine. The most useful diuretic agent in the treatment of recurrent calcium stones is (A) Chlorthalidone (B) Diazoxide (C) Ethacrynic acid (D) Mannitol (E) Spironolactone

(A) Chlorthalidone

6. Which one of the following is a significant unwanted effect of the drug named? (A) Constipation with verapamil (B) Heart failure with hydralazine (C) Hemolytic anemia with atenolol (D) Hypokalemia with aliskiren (E) Lupus-like syndrome with hydrochlorothiazide

(A) Constipation with verapamil

10. A 5-year-old child was vomiting and was brought to the emergency department with sinus arrest and a ventricular rate of 35 bpm. An empty bottle of his uncle's digoxin was found where he was playing. Which of the following is the drug of choice in treating a severe overdose of digoxin? (A) Digoxin antibodies (B) Lidocaine infusion (C) Magnesium infusion (D) Phenytoin by mouth (E) Potassium by mouth

(A) Digoxin antibodies

6. Which row in the following table correctly shows the major effects of full therapeutic doses of digoxin on the AV node and the ECG?

(B) Increased Decreased Inverted

7. Comparison of prazosin with atenolol shows that (A) Both decrease heart rate (B) Both increase cardiac output (C) Both increase renin secretion (D) Both increase sympathetic outflow from the CNS (E) Both produce orthostatic hypotension

(D) Both increase sympathetic outflow from the CNS

Questions 7-10. A 43-year-old man has heterozygous familial hypercholesterolemia. His serum concentrations of total cholesterol and LDL are markedly elevated. His serum concentration of HDL cholesterol, VLDL cholesterol, and triglycerides are normal or slightly elevated. The patient's mother and older brother died of myocardial infarctions before the age of 50. This patient recently experienced mild chest pain when walking upstairs and has been diagnosed as hav- ing angina of effort. The patient is somewhat overweight. He drinks alcohol most evenings and smokes about 1 pack of cigarettes per week. 9. After being counseled about lifestyle and dietary changes, the patient was started on atorvastatin. During his treatment with atorvastatin, it is important to routinely monitor serum concentrations of which of the following? (A) Blood urea nitrogen (B) Alanine and aspartate aminotransferase (C) Platelets (D) Red blood cells (E) Uric acid

(B) Alanine and aspartate aminotransferase

4. A 73-year-old man with a history of a recent change in his treatment for moderately severe hypertension is brought to the emergency department because of a fall at home. Which of the following drug groups is most likely to cause postural hypotension and thus an increased risk of falls? (A) ACE inhibitors (B) Alpha1 -selective receptor blockers (C) Arteriolar dilators (D) Beta1-selective receptor blockers (E) Nonselective β blockers

(B) Alpha1 -selective receptor blockers

9. When working in outlying areas, this 62-year-old rancher is away from his house for 12-14 h at a time. He has an arrhythmia that requires chronic therapy. Which of the fol- lowing has the longest half-life of all antiarrhythmic drugs? (A) Adenosine (B) Amiodarone (C) Disopyramide (D) Esmolol (E) Flecainide (F) Lidocaine (G) Mexiletine (H) Procainamide (I) Quinidine (J) Verapamil

(B) Amiodarone

10. A patient develops severe thrombocytopenia in response to treatment with unfractionated heparin and still requires parenteral anticoagulation. The patient is most likely to be treated with which of the following? (A) Abciximab (B) Bivalirudin (C) Tirofiban (D) Plasminogen (E) Vitamin K1

(B) Bivalirudin

Questions 3-6. A 35-year-old woman appears to have familial combined hyperlipidemia. Her serum concentrations of total cho- lesterol, LDL cholesterol, and triglyceride are elevated. Her serum concentration of HDL cholesterol is somewhat reduced. 6. Which of the following is a major toxicity associated with gemfibrozil therapy? (A) Bloating and constipation (B) Cholelithiasis (C) Hyperuricemia (D) Liver damage (E) Severe cardiac arrhythmia

(B) Cholelithiasis

Questions 3-6. A 35-year-old woman appears to have familial combined hyperlipidemia. Her serum concentrations of total cho- lesterol, LDL cholesterol, and triglyceride are elevated. Her serum concentration of HDL cholesterol is somewhat reduced. 3. Which of the following drugs is most likely to increase this patient's triglyceride and VLDL cholesterol concentrations when used as monotherapy? (A) Atorvastatin (B) Cholestyramine (C) Ezetimibe (D) Gemfibrozil (E) Niacin

(B) Cholestyramine

9. A 45-year-old man is brought to the emergency department with mental obtundation. He is found to have a blood pres- sure of 220/160 and retinal hemorrhages. Which one of the following is used in severe hypertensive emergencies, is short- acting, acts on a G protein-coupled receptor, and must be given by intravenous infusion? (A) Aliskiren (B) Captopril (C) Fenoldopam (D) Hydralazine (E) Losartan (F) Metoprolol (G) Nitroprusside (H) Prazosin (I) Propranolol

(C) Fenoldopam

Questions 5-7. A 58-year-old woman with chronic hypertension and diabetes mellitus was recently admitted to the hospital for congestive heart failure and new onset atrial fibrillation. She is now seeing you after discharge and, though feeling better, is still in atrial fibrillation. An echocardiogram shows an ejection frac- tion of 40%; there are no valvular abnormalities. An ECG reveals only atrial fibrillation. You calculate her risk using the CHADS(2) system and the score indicates that she requires anticoagulation rather than antiplatelet therapy. 5. You are discussing the risks and benefits of anticoagulation therapy with her, including the option of using direct throm- bin inhibitors. Which of the following anticoagulants is a direct inhibitor of thrombin? (A) Abciximab (B) Dabigatran (C) Rivaroxaban (D) Warfarin

(B) Dabigatran

7. Which one of the following drugs is associated with clinically useful or physiologically important positive inotropic effect? (A) Captopril (B) Dobutamine (C) Enalapril (D) Losartan (E) Nesiritide

(B) Dobutamine

Questions 5-7. A 58-year-old woman with chronic hypertension and diabetes mellitus was recently admitted to the hospital for congestive heart failure and new onset atrial fibrillation. She is now seeing you after discharge and, though feeling better, is still in atrial fibrillation. An echocardiogram shows an ejection frac- tion of 40%; there are no valvular abnormalities. An ECG reveals only atrial fibrillation. You calculate her risk using the CHADS(2) system and the score indicates that she requires anticoagulation rather than antiplatelet therapy. 7. She is excited about not having to come in for blood tests but wonders if there is a test, just in case the doctors need to know. Which of the following tests would provide accurate information about the coagulation status of a patient taking apixaban? (A) aPTT (B) Factor X test (C) INR (D) PT test

(B) Factor X test

Questions 9 and 10. After undergoing surgery for breast cancer, a 53-year-old woman is scheduled to receive 4 cycles of cancer chemotherapy. The cycles are to be administered every 3-5 wk. Her first cycle was complicated by severe chemotherapy-induced thrombocytopenia. 10. Twenty months after finishing her chemotherapy, the woman had a relapse of breast cancer. The cancer was now unresponsive to standard doses of chemotherapy. The deci- sion was made to treat the patient with high-dose chemo- therapy followed by autologous stem cell transplantation. Which of the following drugs is most likely to be used to mobilize the peripheral blood stem cells needed for the patient's autologous stem cell transplantation? (A) Erythropoietin (B) Filgrastim (G-CSF) (C) Folic acid (D) Intrinsic factor (E) Oprelvekin (interleukin-11)

(B) Filgrastim (G-CSF)

10. A drug was tested in the electrophysiology laboratory to determine its effects on the cardiac action potential in normal ventricular cells. The results are shown in the diagram. Which of the following drugs does this agent most resemble? (A) Adenosine (B) Flecainide (C) Mexiletine (D) Procainamide (E) Verapamil

(B) Flecainide

4. A 65-year-old woman has been admitted to the coronary care unit with a left ventricular myocardial infarction. She develops acute severe heart failure with marked pulmonary edema, but no evidence of peripheral edema. Which one of the following drugs would be most useful? (A) Digoxin (B) Furosemide (C) Minoxidil (D) Propranolol (E) Spironolactone

(B) Furosemide

6. A 62-year-old man with advanced prostate cancer is admit- ted to the emergency department with mental obtundation. An electrolyte panel shows a serum calcium of 16.5 (normal 8.5-10.5 mg/dL). Which of the following therapies would be most useful in the management of severe hypercalcemia? (A) Acetazolamide plus saline infusion (B) Furosemide plus saline infusion (C) Hydrochlorothiazide plus saline infusion (D) Mannitol plus saline infusion

(B) Furosemide plus saline infusion

Questions 1 and 2. A 76-year-old patient with rheumatoid arthri- tis and chronic heart disease is being considered for treatment with procainamide. She is already receiving digoxin, hydrochlo- rothiazide, and potassium supplements for her cardiac condition. 1. In deciding on a treatment regimen with procainamide for this patient, which of the following statements is most correct? (A) A possible drug interaction with digoxin suggests that digoxin blood levels should be obtained before and after starting procainamide (B) Hyperkalemia should be avoided to reduce the likelihood of procainamide toxicity (C) Procainamide cannot be used if the patient has asthma because it has a β-blocking effect (D) Procainamide cannot be used if the patient has angina because it has a β-agonist effect (E) Procainamide is not active by the oral route

(B) Hyperkalemia should be avoided to reduce the likelihood of procainamide toxicity

Questions 1-2. A 73-year-old man with an inadequate response to other drugs is to receive digoxin for chronic heart failure. He is in normal sinus rhythm with a heart rate of 88 and blood pressure of 135/85 mm Hg. 2. After your patient has been receiving digoxin for 3 wk, he presents to the emergency department with an arrhythmia. Which one of the following is most likely to contribute to the arrhythmogenic effect of digoxin? (A) Increased parasympathetic discharge (B) Increased intracellular calcium (C) Decreased sympathetic discharge (D) Decreased intracellular ATP (E) Increased extracellular potassium

(B) Increased intracellular calcium

1. A 32-year-old woman with hypertension wishes to become pregnant. Her physician informs her that she will have to switch to another antihypertensive drug. Which of the fol- lowing drugs is absolutely contraindicated in pregnancy? (A) Atenolol (B) Losartan (C) Methyldopa (D) Nifedipine (E) Propranolol

(B) Losartan

5. A 45-year-old male stomach cancer patient underwent tumor removal surgery. After surgery, he developed megaloblastic anemia. His anemia is caused by a deficiency of X and can be treated with Y. (A) X = intrinsic factor; Y = folic acid. (B) X = intrinsic factor; Y = vitamin B12 (C) X = extrinsic factor; Y = parenteral iron (D) X = extrinsic factor; Y = sargramostim

(B) X = intrinsic factor; Y = vitamin B12

8. The megaloblastic anemia that results from vitamin B12 deficiency is due to inadequate supplies of which of the following? (A) Cobalamin (B) dTMP (C) Folic acid (D) Homocysteine (E) N 5-methyltetrahydrofolate

(B) dTMP

8. Which of the following drugs slows conduction through the AV node and has its primary action directly on L-type calcium channels? (A) Adenosine (B) Amiodarone (C) Diltiazem (D) Esmolol (E) Flecainide (F) Lidocaine (G) Mexiletine (H) Procainamide (I) Quinidine

(C) Diltiazem

4. The above graph shows the plasma concentration of free war- farin as a function of time for a patient who was treated with 2 other agents, drugs B and C, on a daily basis at constant dos- age starting at the times shown. Which of the following is the most likely explanation for the observed changes in warfarin concentration? (A) Drug B displaces warfarin from plasma proteins; drug C displaces warfarin from tissue-binding sites (B) Drug B inhibits hepatic metabolism of warfarin; drug C displaces drug B from tissue-binding sites (C) Drug B stimulates hepatic metabolism of warfarin; drug C displaces warfarin from plasma protein (D) Drug B increases renal clearance of warfarin; drug C inhibits hepatic metabolism of drug B

(C) Drug B stimulates hepatic metabolism of warfarin; drug C displaces warfarin from plasma protein

6. Which of the following is most likely to be required by a 5-year-old boy with chronic renal insufficiency? (A) Cyanocobalamin (B) Deferoxamine (C) Erythropoietin (D) Filgrastim (G-CSF) (E) Oprelvekin (IL-11)

(C) Erythropoietin

4. A 36-year-old woman with a history of poorly controlled thyrotoxicosis has recurrent episodes of tachycardia with severe shortness of breath. When she is admitted to the emergency department with one of these episodes, which of the follow- ing drugs would be most suitable? (A) Amiodarone (B) Disopyramide (C) Esmolol (D) Quinidine (E) Verapamil

(C) Esmolol

Questions 1-4. A 23-year-old pregnant woman is referred by her obstetrician for evaluation of anemia. She is in her fourth month of pregnancy and has no history of anemia; her grandfather had perni- cious anemia. Her hemoglobin is 10 g/dL (normal, 12-16 g/dL). 2. The laboratory data for your pregnant patient indicate that she does not have macrocytic anemia but rather microcytic anemia. Optimal treatment of normocytic or mild micro- cytic anemia associated with pregnancy uses which of the following? (A) A high-fiber diet (B) Erythropoietin injections (C) Ferrous sulfate tablets (D) Folic acid supplements (E) Hydroxocobalamin injections

(C) Ferrous sulfate tablets

8. A 70-year-old woman is admitted to the emergency depart- ment because of a "fainting spell" at home. She appears to have suffered no trauma from her fall, but her blood pres- sure is 120/60 when lying down and 60/20 when she sits up. Neurologic examination and an ECG are within normal limits when she is lying down. Questioning reveals that she has recently started taking "water pills" (diuretics) for a heart condition. Which of the following drugs is the most likely cause of her fainting spell? (A) Acetazolamide (B) Amiloride (C) Furosemide (D) Hydrochlorothiazide (E) Spironolactone

(C) Furosemide

8. A patient with hypertension and angina is referred for treat- ment. Metoprolol and verapamil are among the drugs con- sidered. Both metoprolol and verapamil are associated with which one of the following? (A) Diarrhea (B) Hypoglycemia (C) Increased PR interval (D) Tachycardia (E) Thyrotoxicosis

(C) Increased PR interval

7. A 60-year-old man comes to the emergency department with severe chest pain. ECG reveals ventricular tachycardia with occasional normal sinus beats, and ST-segment changes sug- gestive of ischemia. A diagnosis of myocardial infarction is made, and the man is admitted to the cardiac intensive care unit. His arrhythmia should be treated immediately with (A) Adenosine (B) Digoxin (C) Lidocaine (D) Quinidine (E) Verapamil

(C) Lidocaine

Questions 1-4. A 23-year-old pregnant woman is referred by her obstetrician for evaluation of anemia. She is in her fourth month of pregnancy and has no history of anemia; her grandfather had perni- cious anemia. Her hemoglobin is 10 g/dL (normal, 12-16 g/dL). 4. The child in the previous question did ingest the iron-containing supplements. What immediate treatment is necessary? Correc- tion of acid-base and electrolyte abnormalities and (A) Activated charcoal (B) Oral deferasirox (C) Parenteral deferoxamine (D) Parenteral dantrolene

(C) Parenteral deferoxamine

6. A 55-year-old man is admitted to the emergency department and is found to have an abnormal ECG. Overdose of an anti- arrhythmic drug is considered. Which of the following drugs is correctly paired with its ECG effects? (A) Quinidine: Increased PR and decreased QT intervals (B) Flecainide: Increased PR, QRS, and QT intervals (C) Verapamil: Increased PR interval (D) Lidocaine: Decreased QRS and PR interval (E) Metoprolol: Increased QRS duration

(C) Verapamil: Increased PR interval

Questions 1-2. A 73-year-old man with an inadequate response to other drugs is to receive digoxin for chronic heart failure. He is in normal sinus rhythm with a heart rate of 88 and blood pressure of 135/85 mm Hg. 1. Which of the following is the best-documented mechanism of beneficial action of cardiac glycosides? (A) A decrease in calcium uptake by the sarcoplasmic reticulum (B) An increase in ATP synthesis (C) A modification of the actin molecule (D) An increase in systolic cytoplasmic calcium levels (E) A block of cardiac β adrenoceptors

(D) An increase in systolic cytoplasmic calcium levels

9. When nitrates are used in combination with other drugs for the treatment of angina, which one of the following combi- nations results in additive effects on the variable specified? (A) Beta blockers and nitrates on end-diastolic cardiac size (B) Beta blockers and nitrates on heart rate (C) Beta blockers and nitrates on venous tone (D) Calcium channel blockers and β blockers on cardiac force (E) Calcium channel blockers and nitrates on heart rate

(D) Calcium channel blockers and β blockers on cardiac force

3. Which one of the following is characteristic of nifedipine treatment in patients with essential hypertension? (A) Competitively blocks angiotensin II at its receptor (B) Decreases calcium efflux from skeletal muscle (C) Decreases renin concentration in the blood (D) Decreases calcium influx into smooth muscle (E) Decreases calcium flux into the urine

(D) Decreases calcium influx into smooth muscle

Questions 1-4. A 60-year-old man presents to his primary care physician with a complaint of severe chest pain when he walks uphill to his home in cold weather. The pain disappears when he rests. After evaluation and discussion of treatment options, a deci- sion is made to treat him with nitroglycerin. 2. In advising the patient about the adverse effects he may notice, you point out that nitroglycerin in moderate doses often produces certain symptoms. Which of the following effects might occur due to the mechanism listed? (A) Constipation (B) Dizziness due to reduced cardiac force of contraction (C) Diuresis due to sympathetic discharge (D) Headache due to meningeal vasodilation (E) Hypertension due to reflex tachycardia

(D) Headache due to meningeal vasodilation

Questions 1-3. A 55-year-old lawyer is brought to the emergency department 2 h after the onset of severe chest pain during a stress- ful meeting. He has a history of poorly controlled mild hyperten- sion and elevated blood cholesterol but does not smoke. ECG changes (ST elevation) and cardiac enzymes confirm the diagnosis of myocardial infarction. The decision is made to attempt to open his occluded artery. 2. If a fibrinolytic drug is used for treatment of this man's acute myocardial infarction, which of the following adverse drug effects is most likely to occur? (A) Acute renal failure (B) Development of antiplatelet antibodies (C) Encephalitis secondary to liver dysfunction (D) Hemorrhagic stroke (E) Neutropenia

(D) Hemorrhagic stroke

5. A significant number of patients started on ACE inhibitor therapy for hypertension are intolerant and must be switched to a different class of drug. What is the most common mani- festation of this intolerance? (A) Angioedema (B) Glaucoma (C) Headache (D) Incessant cough (E) Ventricular arrhythmias

(D) Incessant cough

3. A patient who has been taking digoxin for several years for atrial fibrillation and chronic heart failure is about to receive atropine for another condition. A common effect of digoxin (at therapeutic blood levels) that can be almost entirely blocked by atropine is (A) Decreased appetite (B) Headaches (C) Increased atrial contractility (D) Increased PR interval on ECG (E) Tachycardia

(D) Increased PR interval on ECG

Questions 1-4. A 60-year-old man presents to his primary care physician with a complaint of severe chest pain when he walks uphill to his home in cold weather. The pain disappears when he rests. After evaluation and discussion of treatment options, a deci- sion is made to treat him with nitroglycerin. 1. Which of the following is a common direct or reflex effect of nitroglycerin? (A) Decreased heart rate (B) Decreased venous capacitance (C) Increased afterload (D) Increased cardiac force (E) Increased diastolic myocardial fiber tension

(D) Increased cardiac force

Questions 7-10. A 43-year-old man has heterozygous familial hypercholesterolemia. His serum concentrations of total cholesterol and LDL are markedly elevated. His serum concentration of HDL cholesterol, VLDL cholesterol, and triglycerides are normal or slightly elevated. The patient's mother and older brother died of myocardial infarctions before the age of 50. This patient recently experienced mild chest pain when walking upstairs and has been diagnosed as hav- ing angina of effort. The patient is somewhat overweight. He drinks alcohol most evenings and smokes about 1 pack of cigarettes per week. 10. Six months after beginning atorvastatin, the patient's total and LDL cholesterol concentrations remained above normal, and he continued to have anginal attacks despite good adher- ence to his antianginal medications. His physician decided to add ezetimibe. Which of the following is the most accurate description of ezetimibe's mechanism of an action? (A) Decreased lipid synthesis in adipose tissue (B) Decreased secretion of VLDL by the liver (C) Decreased gastrointestinal absorption of cholesterol (D) Increased endocytosis of HDL by the liver (E) Increased lipid hydrolysis by lipoprotein lipase

(D) Increased endocytosis of HDL by the liver

Questions 3-6. A 35-year-old woman appears to have familial combined hyperlipidemia. Her serum concentrations of total cho- lesterol, LDL cholesterol, and triglyceride are elevated. Her serum concentration of HDL cholesterol is somewhat reduced. 5. The patient is started on gemfibrozil. Which of the following is a major mechanism of gemfibrozil's action? (A) Increased excretion of bile acid salts (B) Increased expression of high-affinity LDL receptors (C) Increased secretion of VLDL by the liver (D) Increased triglyceride hydrolysis by lipoprotein lipase (E) Reduced uptake of dietary cholesterol

(D) Increased triglyceride hydrolysis by lipoprotein lipase

3. Which of the following is an important effect of chronic therapy with loop diuretics? (A) Decreased urinary excretion of calcium (B) Elevation of blood pressure (C) Elevation of pulmonary vascular pressure (D) Metabolic alkalosis (E) Teratogenic action in pregnancy

(D) Metabolic alkalosis

2. A patient is admitted to the emergency department with severe tachycardia after a drug overdose. His family reports that he has been depressed about his hypertension. Which one of the following drugs increases the heart rate in a dose- dependent manner? (A) Captopril (B) Hydrochlorothiazide (C) Losartan (D) Minoxidil (E) Verapamil

(D) Minoxidil

Questions 1-4. A 23-year-old pregnant woman is referred by her obstetrician for evaluation of anemia. She is in her fourth month of pregnancy and has no history of anemia; her grandfather had perni- cious anemia. Her hemoglobin is 10 g/dL (normal, 12-16 g/dL). 3. If this patient has a young child at home and is taking iron- containing prenatal supplements, she should be warned that they are a common source of accidental poisoning in young children and advised to make a special effort to keep these pills out of her child's reach. Toxicity associated with acute iron poisoning usually includes which of the following? (A) Dizziness, hypertension, and cerebral hemorrhage (B) Hyperthermia, delirium, and coma (C) Hypotension, cardiac arrhythmias, and seizures (D) Necrotizing gastroenteritis, shock, and metabolic acidosis (E) Severe hepatic injury, encephalitis, and coma

(D) Necrotizing gastroenteritis, shock, and metabolic acidosis

Questions 7-10. A 43-year-old man has heterozygous familial hypercholesterolemia. His serum concentrations of total cholesterol and LDL are markedly elevated. His serum concentration of HDL cholesterol, VLDL cholesterol, and triglycerides are normal or slightly elevated. The patient's mother and older brother died of myocardial infarctions before the age of 50. This patient recently experienced mild chest pain when walking upstairs and has been diagnosed as hav- ing angina of effort. The patient is somewhat overweight. He drinks alcohol most evenings and smokes about 1 pack of cigarettes per week. 8. If the patient has a history of gout, which of the following drugs is most likely to exacerbate this condition? (A) Colestipol (B) Ezetimibe (C) Gemfibrozil (D) Niacin (E) Simvastatin

(D) Niacin

8. A 45-year-old woman with hyperlipidemia and frequent migraine headaches develops angina of effort. Which of the following is relatively contraindicated because of her migraines? (A) Amlodipine (B) Diltiazem (C) Metoprolol (D) Nitroglycerin (E) Verapamil

(D) Nitroglycerin

Questions 9 and 10. After undergoing surgery for breast cancer, a 53-year-old woman is scheduled to receive 4 cycles of cancer chemotherapy. The cycles are to be administered every 3-5 wk. Her first cycle was complicated by severe chemotherapy-induced thrombocytopenia. 9. During the second cycle of chemotherapy, it would be appro- priate to consider treating this patient with which of the following? (A) Darbepoetin alpha (B) Filgrastim (G-CSF) (C) Iron dextran (D) Oprelvekin (IL-11) (E) Vitamin B12

(D) Oprelvekin (IL-11)

5. A new 60-year-old patient presents to the medical clinic with hypertension and angina. He is 1.8 meters tall with a waist measurement of 1.1 m. Weight is 97 kg. Blood pressure is 150/95 and pulse 85. In considering adverse effects of pos- sible drugs for these conditions, you note that an adverse effect that nitroglycerin and prazosin have in common is (A) Bradycardia (B) Impaired sexual function (C) Lupus erythematosus syndrome (D) Orthostatic hypotension (E) Weight gain

(D) Orthostatic hypotension

3. A 57-year-old man is admitted to the emergency depart- ment with chest pain and a fast irregular heart rhythm. The ECG shows an inferior myocardial infarction and ventricular tachycardia. Lidocaine is ordered. When used as an antiar- rhythmic drug, lidocaine typically (A) Increases action potential duration (B) Increases contractility (C) Increases PR interval (D) Reduces abnormal automaticity (E) Reduces resting potential

(D) Reduces abnormal automaticity

Questions 1-3. A 55-year-old lawyer is brought to the emergency department 2 h after the onset of severe chest pain during a stress- ful meeting. He has a history of poorly controlled mild hyperten- sion and elevated blood cholesterol but does not smoke. ECG changes (ST elevation) and cardiac enzymes confirm the diagnosis of myocardial infarction. The decision is made to attempt to open his occluded artery. 1. Which of the following drugs accelerates the conversion of plasminogen to plasmin? (A) Aminocaproic acid (B) Heparin (C) Argatroban (D) Reteplase (E) Warfarin

(D) Reteplase

Questions 5-7. A 58-year-old woman with chronic hypertension and diabetes mellitus was recently admitted to the hospital for congestive heart failure and new onset atrial fibrillation. She is now seeing you after discharge and, though feeling better, is still in atrial fibrillation. An echocardiogram shows an ejection frac- tion of 40%; there are no valvular abnormalities. An ECG reveals only atrial fibrillation. You calculate her risk using the CHADS(2) system and the score indicates that she requires anticoagulation rather than antiplatelet therapy. 6. She tells you that her main reason for not wanting oral anti- coagulation is that she does not want to come to clinic for frequent blood draws. You agree on an oral alternative and start her on apixaban. You counsel her extensively on the importance of taking the medication each day, as suddenly stopping can lead to (A) Anaphylaxis (B) Excess bleeding (C) Increase in INR (D) Stroke (E) Thrombocytopenia

(D) Stroke

Questions 1-3. A 55-year-old lawyer is brought to the emergency department 2 h after the onset of severe chest pain during a stress- ful meeting. He has a history of poorly controlled mild hyperten- sion and elevated blood cholesterol but does not smoke. ECG changes (ST elevation) and cardiac enzymes confirm the diagnosis of myocardial infarction. The decision is made to attempt to open his occluded artery. 3. If this patient undergoes a percutaneous coronary angiography procedure and placement of a stent in a coronary blood vessel, he will need to be on dual antiplatelet therapy. eg, aspirin and clopidogrel for at least a year. Which of the following most accurately describes the mechanism of action of clopidogrel? (A) Clopidogrel directly binds to the platelet ADP receptors (B) Clopidogrel irreversibly inhibits cyclooxygenase (C) Clopidogrel facilitates the action of antithrombin III (D) The active metabolite of clopidogrel binds to the platelet ADP receptors (E) The active metabolite of clopidogrel binds to the platelet glycoprotein IIb/IIIa receptors

(D) The active metabolite of clopidogrel binds to the platelet ADP receptors

Questions 7-10. A 43-year-old man has heterozygous familial hypercholesterolemia. His serum concentrations of total cholesterol and LDL are markedly elevated. His serum concentration of HDL cholesterol, VLDL cholesterol, and triglycerides are normal or slightly elevated. The patient's mother and older brother died of myocardial infarctions before the age of 50. This patient recently experienced mild chest pain when walking upstairs and has been diagnosed as hav- ing angina of effort. The patient is somewhat overweight. He drinks alcohol most evenings and smokes about 1 pack of cigarettes per week. 7. Consumption of alcohol is associated with which of the fol- lowing changes in serum lipid concentrations? (A) Decreased chylomicrons (B) Decreased HDL cholesterol (C) Decreased VLDL cholesterol (D) Increased LDL cholesterol (E) Increased triglyceride

(E) Increased triglyceride

5. Which of the following diuretics would be most useful in the acute treatment of a comatose patient with traumatic brain injury and cerebral edema? (A) Acetazolamide (B) Amiloride (C) Chlorthalidone (D) Furosemide (E) Mannitol

(E) Mannitol

2. A 46-year-old woman with a history of hyperlipidemia was treated with a drug. The chart below shows the results of the patient's fasting lipid panel before treatment and 6 mo after initiating drug therapy. Normal values are also shown. Which of the following drugs is most likely to be the one that this patient received? (A) Colestipol (B) Ezetimibe (C) Gemfibrozil (D) Lovastatin (E) Niacin

(E) Niacin

Questions 3-6. A 35-year-old woman appears to have familial combined hyperlipidemia. Her serum concentrations of total cho- lesterol, LDL cholesterol, and triglyceride are elevated. Her serum concentration of HDL cholesterol is somewhat reduced. 4. If this patient is pregnant, which of the following drugs should be avoided because of a risk of harming the fetus? (A) Cholestyramine (B) Ezetimibe (C) Fenofibrate (D) Niacin (E) Pravastatin

(E) Pravastatin

Questions 1 and 2. A 76-year-old patient with rheumatoid arthri- tis and chronic heart disease is being considered for treatment with procainamide. She is already receiving digoxin, hydrochlo- rothiazide, and potassium supplements for her cardiac condition. 2. If this patient should take an overdose and manifest severe acute procainamide toxicity with markedly prolonged QRS, which of the following should be given immediately? (A) A calcium chelator such as EDTA (B) Digitalis (C) Nitroprusside (D) Potassium chloride (E) Sodium lactate

(E) Sodium lactate

5. A 72-year-old woman has long-standing heart failure. Which one of the following drugs has been shown to reduce mortal- ity in chronic heart failure? (A) Atenolol (B) Digoxin (C) Dobutamine (D) Furosemide (E) Spironolactone

(E) Spironolactone

7. In a patient who requires filgrastim (G-CSF) after being treated with anticancer drugs, the therapeutic objective is to prevent which of the following? (A) Allergic reactions (B) Cancer recurrence (C) Excessive bleeding (D) Hypoxia (E) Systemic infection

(E) Systemic infection

7. Another patient is admitted to the emergency department after a drug overdose. He is noted to have hypotension and severe bradycardia. He has been receiving therapy for hyper- tension and angina. Which of the following drugs in high doses causes bradycardia? (A) Amlodipine (B) Isosorbide dinitrate (C) Nitroglycerin (D) Prazosin (E) Verapamil

(E) Verapamil

Questions 1-4. A 60-year-old man presents to his primary care physician with a complaint of severe chest pain when he walks uphill to his home in cold weather. The pain disappears when he rests. After evaluation and discussion of treatment options, a deci- sion is made to treat him with nitroglycerin. 3. One year later, the patient returns complaining that his nitro- glycerin works well when he takes it for an acute attack but that he is now having more frequent attacks and would like something to prevent them. Useful drugs for the prophylaxis of angina of effort include (A) Amyl nitrite (B) Esmolol (C) Sublingual isosorbide dinitrate (D) Sublingual nitroglycerin (E) Verapamil

(E) Verapamil

Questions 8 and 9. A 67-year-old woman presents with pain in her left thigh muscle. Duplex ultrasonography indicates the pres- ence of deep vein thrombosis (DVT) in the affected limb. 9. During the next week, the patient was started on warfarin and her enoxaparin was discontinued. Two months later, she returned after a severe nosebleed. Laboratory analysis revealed an INR (international normalized ratio) of 7.0 (INR value in such a warfarin-treated patient should be 2.0-3.0). To prevent severe hemorrhage, the warfarin should be discontinued and this patient should be treated immediately with which of the following? (A) Aminocaproic acid (B) Desmopressin (C) Factor VIII (D) Protamine (E) Vitamin K1

(E) Vitamin K1

10. Certain drugs can cause severe hypotension when combined with nitrates. Which of the following interacts with nitro- glycerin by inhibiting the metabolism of cGMP? (A) Atenolol (B) Hydralazine (C) Isosorbide mononitrate (D) Nifedipine (E) Ranolazine (F) Sildenafil (G) Terbutaline

(F) Sildenafil

8. A 68-year-old man with a history of chronic heart failure goes on vacation and abandons his low-salt diet. Three days later, he develops severe shortness of breath and is admitted to the local hospital emergency department with significant pulmo- nary edema. The first-line drug of choice in most cases of acute decompensation in patients with chronic heart failure is (A) Atenolol (B) Captopril (C) Carvedilol (D) Digoxin (E) Diltiazem (F) Dobutamine (G) Enalapril (H) Furosemide (I) Metoprolol (J) Spironolactone

(H) Furosemide

10. Which of the following is very short-acting and acts by releas- ing nitric oxide? (A) Atenolol (B) Captopril (C) Diltiazem (D) Fenoldopam (E) Hydrochlorothiazide (F) Losartan (G) Minoxidil (H) Nitroprusside (I) Prazosin

(H) Nitroprusside

9. A 58-year-old woman with lung cancer has abnormally low serum osmolality and hyponatremia. A drug that increases the formation of dilute urine and is used to treat SIADH is (A) Acetazolamide (B) Amiloride (C) Desmopressin (D) Ethacrynic acid (E) Furosemide (F) Hydrochlorothiazide (G) Mannitol (H) Spironolactone (I) Triamterene (J) Tolvaptan

(J) Tolvaptan

Questions 1-4. A 23-year-old pregnant woman is referred by her obstetrician for evaluation of anemia. She is in her fourth month of pregnancy and has no history of anemia; her grandfather had pernicious anemia. Her hemoglobin is 10 g/dL (normal, 12-16 g/dL). 1. If this woman has macrocytic anemia, an increased serum concentration of transferrin, and a normal serum concentra- tion of vitamin B12, the most likely cause of her anemia is deficiency of which of the following? (A) Cobalamin (B) Erythropoietin (C) Folic acid (D) Intrinsic factor (E) Iron

C. Folic acid

4. Which drug is correctly associated with its actions in the fol- lowing table? (+ indicates increase and - indicates decrease.)

D Spironolactone + - Acidosis