PHAR 544 Cardio comprehensive exam 1 practice MC questions **just answer w/ letter or number**

According to the 2017 guidelines for hypertension, what is the BP goal for a 58-year-old African American male with diabetes and chronic kidney disease? A. <130/80 mm Hg B. <140/90 mm Hg C. <150/90 mm Hg D. <160/100 mm Hg

A

RH is a 47-year-old white woman who has been seen by her family physician twice in the last 2 weeks, and her BP (measured properly) was similar at both visits, averaging 138/88 mm Hg. RH has no significant medical history or risk factors for cardiovascular disease; she is relatively active and likes to exercise. Which of the following would be the most appropriate recommendation for RH? A. She should be seen again by her physician within 3 months to see if she has hypertension, but in the meantime work with recommended lifestyle modifications listed within this chapter. B. She should be counseled to undertake an intensive weight reduction program, with follow-up in 2 years. C. Initiate treatment with ramipril. D. Initiate treatment with atenolol. E. Initiate treatment with clonidine.

A (she has SBP 130-138 and DBP 80-89 so she has stage I HTN and we do not initiate treatment unless she gets to stage II or her ASCVD risk > 10% ...this lady is active and no risk factors so recommend the 6 non-pharm interventions: lose weight DASH diet reduce sodium supplement K+ exercise reduce alcohol)

JC is a 64-year-old African American man with HFrEF presenting with a 2-week history of SOB which limits his normal daily activities and increased lower extremity edema. His weight has recently increased by 10 lb. His physical examination is notable for BP 148/72 mm Hg, HR 68 beats/min, RR 24, rales, and 3+ lower extremity edema. Pertinent laboratory values include: sodium 138 mmol/L, potassium 5.4 mmol/L, BUN 35 mg/dL, creatinine 0.9 mg/dL, and digoxin 2.1 ng/mL. Past medical history is significant for HTN, gout, and chronic obstructive pulmonary disease (COPD). Current medications include lisinopril 20 mg daily, diltiazem CD 120 mg daily, digoxin 0.250 mg daily, and salmeterol/fluticasone 250/50 two puffs bid. JC recently began taking naproxen 220 mg tid for gout pain. In addition to counseling on salt and fluid restriction, which of the following pharmacologic options is most appropriate for managing JC's fluid overload? A. Initiate hydrochlorothiazide 50 mg daily. B. Initiate furosemide 40 mg twice daily. C. Initiate metolazone 2.5 mg daily. D. Initiate spironolactone 25 mg daily.

B

JC is a 64-year-old African American man with HFrEF presenting with a 2-week history of SOB which limits his normal daily activities and increased lower extremity edema. His weight has recently increased by 10 lb. His physical examination is notable for BP 148/72 mm Hg, HR 68 beats/min, RR 24, rales, and 3+ lower extremity edema. Pertinent laboratory values include: sodium 138 mmol/L, potassium 5.4 mmol/L, BUN 35 mg/dL, creatinine 0.9 mg/dL, and digoxin 2.1 ng/mL. Past medical history is significant for HTN, gout, and chronic obstructive pulmonary disease (COPD). Current medications include lisinopril 20 mg daily, diltiazem CD 120 mg daily, digoxin 0.250 mg daily, and salmeterol/fluticasone 250/50 two puffs bid. JC recently began taking naproxen 220 mg tid for gout pain. Once optimal fluid status has been achieved, which of the following represents the best option to manage JC's HTN? A. Initiate amlodipine 5 mg daily. B. Initiate carvedilol 3.125 mg twice daily. C. Initiate hydrochlorothiazide 25 mg daily. D. Initiate prazosin 2 mg daily.

B

Which of the following is true regarding the use of combination treatment with an ACEI and an ARB for the treatment of hypertension? A. The combination significantly reduces the risk of cardiovascular events. B. The combination increases the risk of hyperkalemia. C. The combination is more effective for controlling blood pressure than monotherapy. D. This combination is recommended because it does not reduce cardiovascular events in this setting.

B

KW is a 53-year-old man with HF (NYHA class I) receiving furosemide 40 mg twice daily, lisinopril 10 mg daily, metoprolol succinate 50 mg daily, digoxin 0.125 mg daily, and spironolactone 25 mg daily. During a routine clinic visit today, pertinent findings include: BP 120/80 mm Hg, HR 70 beats/min, RR 14, K+ 5.1 mmol/L, BUN 35 mg/dL, and creatinine 1.2 mg/dL (baseline). Which of the following is the most appropriate change to optimize KW's medical regimen? Select all that apply. A. Increase ACE inhibitor dose B. Increase β-blocker dose C. Add ivabradine D. Increase spironolactone dose

B (For HF management, ACE inhibitor and β-blocker therapy should be titrated to target doses associated with improved outcomes in clinical trials. This patient has adequate blood pressure to increase either therapy. In addition, HR is adequate to further titrate β-blocker therapy. Uptitration of β-blocker therapy is the safest medication change for this patient. *Max dose metoprolol succinate is 200 mg QD* why note ACE or aldosterone antagonist? hyperkalemiai risk why not ivabradine? beta blocker therapy is not yet at target dose so dont add ivabradine until your patient is not improving on "optimal therapy"!!)

SD is a 54-year-old man with NYHA class III HF due to nonischemic cardiomyopathy. His past medical history is notable for moderate asthma since childhood and HTN. Current medications include salmeterol, one inhalation twice daily; fluticasone 88 mcg, inhaled twice daily; furosemide 80 mg twice daily; enalapril 20 mg twice daily; and spironolactone 25 mg daily. Which of the following β-blockers is the best option to treat SD's HF and minimize aggravating his asthma? a. carvedilol b. metoprolol c. propranolol d. atenolol

B (Only three β-blockers have been demonstrated to reduce mortality in HF: carvedilol, metoprolol succinate, and bisoprolol. Metoprolol succinate is the correct answer because it has proven mortality benefit in HFrEF and it is a cardio-selective β-blocker. While metoprolol is β-1 selective, it is important to recognize that β-receptor selectivity may decrease as the dose is up-titrated.)

Which of the following β-blocker regimens would represent target therapy for most HF patients? A. Toprol XL 150 mg once daily B. Coreg 25 mg twice daily C. Tenormin 100 mg once daily D. Zebeta 2.5 mg once daily

B (for patients >85 kg 50 mg twice daily is optimal)

JD is a 55-year-old African American woman with newly diagnosed hypertension. Her average BP is 164/91 mm Hg. Which of the following is the best recommendation for JD? A. Begin hydrochlorothiazide and return to clinic in 3 months. B. Begin metoprolol and prescribe monitoring blood pressure at home. C. Begin two medications since most patients with stage 2 hypertension will not reach goal with one agent alone. D. Prescribe lifestyle modifications first, and return to clinic in 1 month to determine if pharmacotherapy is warranted. E. Begin clonidine patch since a once weekly patch increases patient compliance.

C

TM was started on a new medication for her blood pressure. About a week later she noticed a persistent cough. Which of the following medications could be the cause? A. Maxzide B. Bystolic C. Vasotec D. Aldactone E. Catapres

C

Which of the following laboratory values may be helpful in differentiating HF from other disease states that cause similar symptoms? A. Serum sodium B. Serum creatinine C. BNP D. Norepinephrine

C

if your patient has symptoms they are at least stage ____ in the ACC/AHA system

C (ACC/AHA is stages that show progression of disease... NYHA is classes)

Which of the following lifestyle recommendation would have the potential to decrease the SBP the greatest in a 58-year-old patient with chronic kidney disease, diabetes, atrial fibrillation, and hypertension. The patient currently has stage 2 hypertension and is not receiving pharmacologic therapy. A. Physical activity B. Moderation of alcohol consumption C. Adopting the DASH eating plan D. Initiating an ACEI + chlorthalidone

C (d would be good for stage II HTN but the question specifically asked for lifestyle modifications ....also if you used thiazide diuretic not always great for CKD since GFR <30)

Patients should be counseled to monitor for which of the following when initiating β-blocker therapy? a. tachycardia b. dehydration c. fatigue d. hypokalemia

C (for beta blocker monitor bradycardia, hypotension, worsening heart failure symptoms)

A man starts on spironolactone for the management of heart failure. You should recommend monitoring for: (a) hypokalemia and angioedema (b) angioedema and gynecomastia (c) gynecomastia and hyperkalemia (d) bradycardia and hypokalemia

C (spironolactone is structurally similar to steroid hormones so can cause hormone-like effects .... also hyperkalemia is ADR of aldosterone antagonist basically because its potassium sparing ...furthermore if you BLOCK aldosterone then you are stopping the reabsorption of Na+ so you are increasing K+ absorption which could cause too high K+ level)

What is the target dose for carvedilol (upon completion of dose titration) for a patient weighing 66 kg. (a) carvedilol 12.5 mg po BID (b) carvedilol 50 mg po BID (c) carvedilol 25 mg po BID (d) carvedilol 100 mg po BID

C (the higher the dose of carvedilol the more the benefit and 25 mg BID is everybody's target dose unless they are more than 85 kg ~187 lbs thennnnn give carvedilol 50 mg BID !!!)

AW eventually is titrated to the following drug regimen: pravastatin (Pravachol®) 20 mg po daily, ECASA 325 mg po daily, fosinopril (Monopril®) 20 mg po daily, furosemide (Lasix®) 40 mg po daily, and digoxin 0.125 mg po daily. At follow up physical examination, your physician colleague notes the patient seems to be euvolemic with minimal peripheral edema. Vitals obtained by the nurse upon check-in include BP 125/78 and HR 95. AW is 5'10" and weights 78 kg (this represents his "dry weight"). In terms of maximizing patient's drug regimen, which change listed below is MOST appropriate today? (a) Increase furosemide (Lasix®) to 80 mg po daily (b) Initiate spironolactone 25 mg po daily (c) Initiate carvedilol (Coreg®) at 3.125 mg po twice daily (d) Increase fosinopril (Monopril®) to 40 mg po daily

C (you want an Agent to improve exercise tolerance ... He's already on diuretic, ACE & digoxin ... he probably should have already been on beta blocker but you can start that!!! he doesnt need furosemide because his fluid is in-cehck we shouldnt start spironolactone w/o getting labs for K+ levels cus could cause hyperkalemia ACE dose is OK and we are focusing on maximizing the drug regimen so better to add another drug at lower dose than raise ACE dose too high)

An 82-year-old woman is diagnosed with chronic stable angina. She reports having chest pain once or twice weekly for the past month. Although she also has a diagnosis of hypertension, she has never been treated with antihypertensive pharmacotherapy. The only drug she is currently taking is enteric-coated aspirin 81 mg/day. Her current blood pressure is 150/70 mm Hg, with a heart rate of 76 beats/minute. Which one of the following is the most appropriate initial antihypertensive therapy for this patient? a. Metoprolol b. Hydrochlorothiazide c. Metoprolol with fosinopril d. Trandolapril with spironolactone

C (need BB and ACE for "chronic stable angina")

MM is a 58-year-old woman with cardiomyopathy (left ventricular ejection fraction [LVEF] 25%) following an acute MI. Immediately following her MI, she developed signs and symptoms of HF including shortness of breath (SOB) at rest. Which of the following best characterizes MM's current ACC/AHA HF stage and NYHA class? A. Stage A, NYHA class not applicable B. Stage B, NYHA class I C. Stage C, NYHA class II D. Stage C, NYHA class IV

D

Which of the following recommendations for HTN non-pharm lifestyle modification is correct? A. A minimum weight loss of 15 lb B. Sodium restriction of 4 g or less per day C. Reduce alcohol intake to no more than two drinks a day for a woman, one for a man D. Exercise for at least 30 minutes most days of the week E. Adopt an eating plan low in potassium and carbohydrates

D (<4 g is for heart failure!!! <1500 g if for HTN!!)

if your patient is comfortable at rest but has symptoms w/ moderate physical activities like mowing the lawn they are NYHA class ____

II (ACC/AHA is stages ... NYHA is classes)

EF is a 41 yo Caucasian female at her 2nd prenatal visit (10 weeks gestation) who presents with elevated BP for her 2nd consecutive visit (BP=148/92 mmHg, HR=48 bpm). She has no other pertinent medical history. From laboratory testing yesterday, her K=3.4 mEq/L. All other laboratory values are within normal limits. Her dipstick urine test today reveals no protein. Which of the following would be the best assessment of EF's BP? a. EF has chronic HTN b. EF has preeclampsia c. EF has gestational HTN d. EF has eclampsia

a

Which of the following medications is MOST likely to cause hyperkalemia? a. Valsartan b. Hydralazine c. Hydrochlorothiazide d. Carvedilol

a

Which of the following neurohormones DOES NOT contribute to heart failure pathophysiology? *just answer w/ letter* a. Insulin growth factor b. Norepinephrine c. Angiotensin II d. Aldosterone

a

Which of the following pharmacologic interventions is most likely to reduce plasma renin activity? a. Direct renin inhibition b. ACE inhibition c. Angiotensin receptor blocker d. Aldosterone receptor blocker

a

Your patient is taking carvedilol 6.25 mg po BID for heart failure. What is the next dose of carvedilol that they should receive? (a) carvedilol 12.5 mg po BID (b) carvedilol 25 mg po BID (c) carvedilol 50 mg po BID (d) carvedilol 100 mg po BID

a

Which of the following heart failure medications DOES NOT require monitoring of K+ concentration? *just answer w/ letter* a. Carvedilol b. Lisinopril c. Furosemide d. Aldosterone

a (no labs to monitor w/ CCBs or beta blockers!!! just know that watch out for hyperkalemia w/ anything that inhibits RAAS watch out for hypokalemia for thiazides)

DL is a 35-year-old man recently diagnosed with type 2 diabetes, hypertension, hyperlipidemia, and sexual dysfunction induced by diabetic neuropathy. Which of the following two-drug regimens is most appropriate to initiate in DL for antihypertensive therapy? a. amlodipine + lisinopril b. short acting nifedipine + trandolapril c. doxazosin + HCTZ d. pindolol + losartan e. HCTZ + lisinopril

a (A RAAS agent, such as an ACEI or an ARB, is indicated for renal protection in the diabetes population. Therefore, lisinopril is an appropriate first-line option for the treatment of hypertension in this patient. A CCB such as amlodipine is appropriate, given that calcium channel blockers have neutral effects on glucose and lipids)

Place the lifestyle modifications of weight reduction, moderation of alcohol consumption, and physical activity in order of the decrease in expected/approximate systolic blood pressure reduction. Start with the lowest expected decrease in SBP. a. Moderation of alcohol consumption, physical activity, weight reduction b. Weight reduction, physical activity, moderation of alcohol consumption c. Physical activity, moderation of alcohol consumption, weight reduction

a (Moderation of alcohol consumption has an approximate range of a 2 to 4 mm Hg decrease in SBP. Physical activity has an approximate range of 4 to 9 mm Hg decrease in SBP. Weight reduction has an approximate range of 5 to 20 mm Hg per 10 kg decrease in SBP.)

which improves life expectancy? *just answer w/ letter* a. Eplerenone b. Digoxin c. Metolazone d. HCTZ

a (eplerenone is aldosterone antagonist which increases mortality benefit!!!! digoxin does not have mortality benefit just symptom relief for FC III metolazone and HCTZ are thiazide diuretics which do not have mortality benefit)

You give heart failure patient a log book to begin recording their daily weight at home. They asks why his weight is so important. Which of the following explanations should NOT be included in your response? *just answer letter* a. Many of the medications used in the treatment of heart failure cause significant weight gain b. Weight management is important to all patients with cardiovascular disease c. Daily weight measurements help clinicians determine when patients are retaining sodium and water b. BB should call the clinic if his weight increases by 3 - 5 pounds in a single week.

a (generally we give meds that get the fluid off so thats obviously not correct .... B & C & D are great things to say because we want to track weight in all PTs w/ CVD a weight gain of 3-5 lbs in 1 week means youre retaining too much water)

GS is a 41 yo Hispanic male who presents to clinic today for BP assessment. He was told that he should go and see a doctor during a recent BP screening. BP = 128/84 mmHg, HR = 77 bpm, eGFR = 78 mL/min, K = 4.2 mEq/L, TChol = 240 mg/dL, HDL = 40 mg/dL, ASCVD risk = 2.5% In addition to non-pharmacologic management, which of the following would be the best plan to manage GS's BP? a. No additional treatment recommended b. Amlodipine 5 mg PO daily c. Chlorthalidone 25 mg PO daily d. Valsartan 320 mg PO daily

a (he is stage I and has ASCVD <10% so only non-pharm receommendations are necessary and follow-up in 3-6 months)

JM is a 62 yo African-American male with no prior medical history. His BP at the last 2 clinic appointments has been elevated. JM has no known drug allergies. VS: Ht 5'8" Wt 90 kg BP 142/88 mmHg P 70 bpm All labs are within normal limits. What would be the most appropriate treatment for JM? a. Amlodipine 10 mg daily b. Lisinopril 10 mg daily c. Carvedilol 25 mg twice daily d. Clonidine 0.3 mg/day patch applied every 7 days

a (it has to be the CCB in black patient w/ HTN!!! dont choose the ACE cus not first line treatment in african american patients ...def not the beta blocker and HELLLL no to the clonidine patch not good for long-term BP control more for anxiety)

MR is a 59 yo Asian male who presents to the clinic for initial HTN management. He has no prior medical history other than obesity (BMI=36) and a 25 pack-year history of smoking. Baseline laboratory testing reveals eGFR=55 mL/min/1.73 m2, K+=5.1 mEq/L. VS: Ht 5'6" Wt 92 kg BP 138/86 mmHg P 72 bpm Which of the following would be the most appropriate intervention today in clinic? a. Chlorthalidone 25 mg PO daily b. Lisinopril 20 mg PO daily c. Amlodipine 20 mg PO daily d. Metoprolol tartrate 50 mg PO BID

a (thiazides would lower K+ plus its thiazide is first line for HTN ACE is first line but it would raise K+ which is already high not beta blocker cus not first line in HTN amlodipine 20 is a HUGE NO NO, the max dose is 10 mg daily!!! so not C)

what extra-cardiac adaption is a target of heart failure treatment : (a) Up-regulation of the renin-angiotensin-aldosterone system (b) Down-regulation of the sympathetic nervous system (c) Up-regulation of the nitric oxide system (d) Down-regulation of the jugular venous system

a (you want to STOP/INHIBIT/BLOCK raas system)

Which of the following is most likely to decrease cardiac output? a. Increased sympathetic activation b. Reduced sodium/water reabsorption c .Increased heart rate d. Reduced total peripheral resistance

b

Which of the following medications is NOT considered a 1st line agent for the treatment of hypertension in the general population? a. Hydrochlorothiazide b. Metoprolol c. Fosinopril d. Valsartan

b (ACE/ARB, thiazide, CCB are 1st line then BBlocker)

A 41-year-old woman has type 2 diabetes and gout. Her blood pressure is 168/98 mm Hg, heart rate 80 beats/minute, potassium 4.4 mEq/L, and serum creatinine 1.0 mg/dL. She started hydrochlorothiazide 12.5 mg/day two months ago, but stopped it 2 weeks later because of an acute gout attack. She is currently taking no antihypertensive therapy. Which one of the following is the most appropriate antihypertensive regimen for this patient? a. amlodipine b. benazepril c. benazepril + amlodipine d. metoprolol + verapamil

c

TM was started on new antihypertensive medication and complained of dry cough. You have identified the cause of the cough. At the next visit, TM wants to change the medication as she cannot tolerate the cough. Unfortunately, she missed her follow-up and returns to you in 6 months. In between appointments, she was admitted to the hospital and diagnosed with type 2 diabetes. Which of the following recommendations is best for TM assuming no insurance or cost issues? a. switch to lopressor b. switch to antacand c. switch to altace d. switch to cardizem e. continue as is because side effect will resolve in a couple months

b (Due to the new diagnosis of diabetes in addition to her hypertension, TM should be on an RAAS agent, either an ACEI or an ARB (Atacand = candesartan). RAAS agents are proven to slow the progression of target organ damage in patients with diabetes and should be used unless contraindicated. Since cough was the reason for discontinuing the ACEI, switching to an ARB is the best option to control TM's hypertension. ARBs do not cause the breakdown of bradykinin and therefore do not induce a nagging cough.)

RJ is a 61-year-old woman with a history of ischemic cardiomyopathy who presents to clinic with symptoms consistent with NYHA class IV HF. Past medical history includes hyperlipidemia, diabetes mellitus, MI, and hypothyroidism. RJ complains of progressive weight gain (~6 lb increase since visit 3 months ago), SOB at rest, 2 pillow orthopnea, and occasional paroxysmal nocturnal dyspnea (PND). Her physical examination is positive for 1+ pitting edema in her ankles and minimal jugular vein distention (JVD). Vital signs include BP 105/70 mm Hg and HR 91 beats/min. Laboratory results include: potassium 3.6 mmol/L, BUN 39 mg/dL, and creatinine 1.4 mg/dL (baseline creatinine 1.2-1.6 mg/dL). RJ's current medications are levothyroxine 0.05 mg daily, furosemide 40 mg twice daily, lisinopril 20 mg daily, atorvastatin 40 mg daily, aspirin 81 mg daily, insulin glargine 46 units at bedtime, and insulin as part 6 units before meals. Which of the following represents the next best option to manage RJ's HF? a. initiate metoprolol succinate 25 mg daily immediately b. initiate metoprolol succinate 25 mg daily once euvolemia is achieved c. initiate metoprolol tartrate 12.5 mg bid immediatley d. initiate digoxin 0.25 mg daily

b (Given the mortality benefit associated with β-blockers in HF, this medication should be part of the patient's medical regimen. However, β-blockers should only be initiated once euvolemia is obtained.)

Which of the following is correct regarding the pathophysiology of hypertension? a. Most patients with hypertension have an identifiable secondary cause such as hyperaldosteronism. b. Cardiac output and peripheral vascular resistance are the two key factors that determine blood pressure. c. Stroke volume and heart rate are the two key factors that determine blood pressure. d. In the elderly, cardiac output rises, increasing the risk of hypertension, especially diastolic hypertension.

b (HR = SVxCO ... BP=COxTPR)

JC is a 64-year-old African American man with HFrEF presenting with a 2-week history of SOB which limits his normal daily activities and increased lower extremity edema. His weight has recently increased by 10 lb. His physical examination is notable for BP 148/72 mm Hg, HR 68 beats/min, RR 24, rales, and 3+ lower extremity edema. Pertinent laboratory values include: sodium 138 mmol/L, potassium 5.4 mmol/L, BUN 35 mg/dL, creatinine 0.9 mg/dL, and digoxin 2.1 ng/mL. Past medical history is significant for HTN, gout, and chronic obstructive pulmonary disease (COPD). Current medications include lisinopril 20 mg daily, diltiazem CD 120 mg daily, digoxin 0.250 mg daily, and salmeterol/fluticasone 250/50 two puffs bid. JC recently began taking naproxen 220 mg tid for gout pain. a. initiate amlodipine 5 mg daily b. initiate carvedilol 3.125 mg BID c. initiate HCTZ 25 mg daily d. initiate prazosin 2 mg daily

b (In addition to assisting with managing JC's HTN, carvedilol is one of the three β-blockers shown to reduce mortality in HF patients. Importantly, although the blood pressure-lowering effects of carvedilol may be helpful at initiation of therapy, they tend to dissipate with time. for patients w/ HF dont use thiazide diuretics until youve gone through the big 4 ace/arb/ani + loop diuretic prn then beta blocker then spironolactone)

which symptoms is most consistent with fluid accumulation in the venous circulation? *just answer w/ letter* a. pulmonary rales b. JVD c. cough d. reduced exercise tolerance

b (JVD is jugular VENOUS distension soooo yeah major LV dysfunc = ... pulmonary edema vs. major RV dysfunc = venous pressure ...so we are talking about RIGHT SIDE RV failure signs/symptoms = peripheral *venous* edema, JVD, abdonminal jugular reflex, hepatomegaly LV signs/symptoms = Pulmonary edema, Basilar rales, S3 gallop, Pleural effusion, Cheyne-Stokes respiration)

FS is a 50-year-old woman diagnosed with osteoporosis and hypertension. Which of the following antihypertensives is likely to help the FS's osteoporosis in addition to lowering her BP? a. Demadex b. Microzide c. Capoten d. Toprol XL

b (Microzide (HCTZ) is a thiazide diuretic, the preferred initial therapy for the treatment of hypertension. they also decrease the excretion of calcium --> hypercalcemia that could be benefit to osteoprosis patient)

A 75-year-old man (height 66 inches, weight 68 kg) with hypertension (HTN), gastroesophageal reflux disease (GERD), and osteoarthritis presents to the clinic. The patient is frustrated with trying to control his blood pressure. He is adherent to a low-sodium diet, antihypertensive drugs, and regular exercise. Today, his blood pressure is 155/90 mm Hg, and his heart rate is 80 beats/minute. His laboratory test results include K 4.8 mEq/L, Na 138 mEq/L, Cr 1.5 mg/dL, CrCl 38 mL/minute/1.73 m2, and ALT (liver function alanine aminotransferase test) 25 mg/dL. His home drugs are carvedilol 25 mg twice daily, hydrochlorothiazide 25 mg/day, losartan 100 mg/day, amlodipine 10 mg/day, ibuprofen 800 mg twice daily, and omeprazole 20 mg twice daily. What is the next best step to address this patient's blood pressure control? a. Increase his carvedilol dose to 50 mg twice daily. b. Discontinue ibuprofen and start acetaminophen. c. Start spironolactone 12.5 mg/day. d. Increase his hydrochlorothiazide dose to 50 mg/day

b (Oral NSAIDs increase BP cus it impairs the synthesis of prostaglandins that are required to maintains the vasodilation of the AFFERENT arteriole ... therefore NSAIDs--> aff arteriole will not vasodilate --> aff vasoconstriction --> less blood flow to glomerulus --> less urine, fluid retention, higher preload, higher cardiac output, higher BP also remember that max HCTZ dose is 25 mg once daily so definitely not D!!!!)

SD is a 54-year-old man with NYHA class III HF due to nonischemic cardiomyopathy. His past medical history is notable for moderate asthma since childhood and HTN. Current medications include salmeterol, one inhalation twice daily; fluticasone 88 mcg, inhaled twice daily; furosemide 80 mg twice daily; enalapril 20 mg twice daily; and spironolactone 25 mg daily. Which of the following medication changes may provide further mortality benefit for SD once stabilized on β-blocker therapy? a. addition of digoxin 0.125 mg daily b. substitution of sacubitril/valsartan 49/51 mg for enalapril 20 mg twice daily c. addition of valsartan 160 mg twice daily d. addition of amlodipine 5 mg daily

b (The combination of sacubitril and valsartan demonstrated a significant mortality benefit over ACE inhibitors in patients with symptomatic HF despite receiving optimal HF therapy with β-blockers and ACE inhibitors. digoxin doesnt improve mortality valsartan is like ACE he already has so no additional benefits amlodipine has neutral effects on mortality)

In a patient with risk factors for hyperkalemia and history of hyperkalemia, which of the following agents would be acceptable treatment to avoid hyperkalemia risk? a. amiloride b. amlodipine c. enalapril d. spironolactone e. valsartan

b (dont need to monitor labs w/ CCBs or beta blockers!!!!....all the other RAAS inhibitors and amiloride which is potassium sparing Na channel blocker can cause hyperkalemia)

A 65 year old Caucasian female is seen in clinic. She tells you that she has recently been discharge from the hospital following a myocardial infarction, but lost her prescriptions shortly after discharge. She has no other medical history except seasonal allergies. Vital signs today are BP 138/76, HR 74, wt 60 kg and ht 5'4". Which would be the BEST blood pressure regimen for this patient? a. No medications, she is at her BP goal. b. Metoprolol succinate 25 mg PO daily and lisinopril 5mg PO daily c. Nifedipine 10 mg PO every 6 hours d. Valsartan 80 mg PO daily and Diltiazem (extended-release) 480 mg PO daily

b (first line for MI is beta blocker , just know that!!!)

BB is a 73 yo male presenting to the heart failure clinic with complaints of fatigue, cough, SOB, insomnia, and upset stomach. He also describes difficulty sleeping at night unless he puts three pillows under his head. His PMH includes HTN, hyperlipidemia, and depression. Which of the following medications should be discontinued in BB? *just answer w/ letter* a. aspirin b. verapamil c. pravastatin d. fluoxetine

b (he is showing signs of heart failure cus he's using 3 pillows among other things!! ASA is OK to use CCBs are generally contraindicated w/ Heart failure cus suppresses heart contractility **ionotropy** !!! dont stop statin cus he has hyperlipidemia dont stop fluoxetine cus he has depression and its SSRI which is OK **dont use SNRIs w HTN cus increases BP w/ sympathetic activation**)

why do NSAIDs increase BP? *just answer w/ letter* a. stop the vasodilation of efferent arteriole of glomerulus by impairing prostaglandin synthesis b. stop the vasodilation of afferent arteriole of glomerulus by impairing prostaglandin synthesis c. stop vasodilation by increasing synthesis of prostaglandins d. stop vasodilation by activating NE & epi

b (prostaglandins help maintain vasodilation of afferent arteriole but oral NSAIDs impair synthesis of prostaglandins to stop imflammation but w/o them your blood pressure will rise!!!! so yes B is correct because... NSAIDs stop vasodilation of afferent arteriole of glomerulus by impairing prostaglandin synthesis)

A year later, JM is not controlled on previous medication at optimal doses. He was diagnosed with type 2 diabetes 1 week ago. All labs are within normal limits except the patient now has (+) protein noted in the urinalysis, indicative of chronic kidney disease. VS: Ht 5"8" Wt 92 kg BP 140/86 mmHg P 72 bpm Which of the following would be the most appropriate intervention today in clinic? a. Chlorthalidone 25 mg PO daily b. Lisinopril 10 mg PO daily c. Doxazosin 2 mg PO every day at bedtime d. Continue current regimen (no changes)

b (type 2 diabetes should be on ACE or ARB)

BB is a 73 yo male presenting to the heart failure clinic with complaints of fatigue, cough, SOB, insomnia, and upset stomach. He also describes difficulty sleeping at night unless he puts three pillows under his head. His PMH includes HTN, hyperlipidemia, and depression. Which of the following prescriptions should BB receive today? Select all that apply a. Carvedilol 25 mg po BID b. Furosemide 40 mg po BID c. Lisinopril 2.5 mg po QD d. Digoxin 250 mcg po QD

b c (the question is asking what should he start TODAY so pick the first-line treatment carvedilol is beta blocker w/ alpha blocking which is *2nd line agent* not the first line agent ..also we dont have dry weight so dont start beta blocker yet and we gotta titrate up to it when he is euvolumic ***furosemide is loop diuretic and first line treatment for heart failure is ACE/ARB/ARNI + loop diuretic prn ***lisinopril is ACE which is the first line but the dose is still kinda low and should be more aggressive but he SHOULD be on some sort of ACE so this is correct too digoxin is cardiac glycoside only use in class III after doing ACE/ARB/ARNI + loop prn then beta blocker then aldosterone antagonist only after those 4 should you consider digoxin for symptom relief only)

A 61-year-old woman with CAD (stent placement 1 year ago) presents today for follow-up. Her blood pressure is 148/86 mm Hg, with a similar repeat, and her heart rate is 85 beats/minute. Her laboratory values are: K 4.6 mEq/L, Na 142 mEq/L, and SCr 0.9 mg/dL. She takes lisinopril/hydrochlorothiazide 20 mg/25 mg once daily and metoprolol succinate 50 mg/day, and she reports being adherent to her regimen. She is reluctant to take more blood pressure drugs because when she uses her home blood pressure monitor the readings are usually less than 125/70 mm Hg. Which one of the following is best to recommend for this patient's blood pressure management? a. Start amlodipine 2.5 mg/day. b. Decrease her lisinopril/hydrochlorothiazide dose to 10/12.5 mg once daily. c. Order 24-hour ambulatory blood pressure monitoring. d. Increase metoprolol succinate to 100 mg daily

c

GS is a 41 yo Hispanic male who presents to clinic today for BP assessment. He was told that he should go and see a doctor during a recent BP screening. BP = 128/84 mmHg, HR = 77 bpm, TChol = 240 mg/dL, HDL = 40 mg/dL, ASCVD risk = 2.5% Which of the following is the correct BP assessment? a. Normal b. Elevated c. Stage I d. Stage II

c

JM is a 62 yo African-American male with no prior medical history. His BP at the last 2 clinic appointments has been elevated. JM has no known drug allergies. VS: Ht 5'8" Wt 90 kg BP 142/88 mmHg P 70 bpm All labs are within normal limits. What would be the most appropriate BP goal for JM? a. <150/90 mmHg b. <140/90 mmHg c. <130/80 mmHg d. Need more information

c

Which of the following is the most likely explanation for ACEI-induced cough? a. Hypotension b. Hypokalemia c. Bradykinin accumulation d. Preliminary allergic reaction e. Lack of appropriate dose-titration

c

You are presenting an in-service to the nursing staff on the differences and similarities between ACE inhibitors, ARBs, and renin inhibitors. Which of the following is a CORRECT statement? a. ARBs and ACE inhibitors are associated with the development of a bradykinin-induced cough b. When comparing the three classes of drugs, the risk of angioedema is highest with the ARBs c. All three classes of drugs are contraindicated in pregnancy d. Only ACE inhibitors and ARBs should be given with diuretics. Renin inhibitors are contraindicated with diuretics

c

what is the most important parameter for monitoring when starting furosemide (a) Daily jugular venous pressures (b) Serum BUN each clinic visit (c) Weight on a daily basis (d) serum NE concentration at each clinic visit

c

FS is a 56-year-old man with diabetes mellitus and newly diagnosed hypertension. His mean blood pressure in clinic today after three proper measurements is 158/101 mm Hg. He is not currently on treatment. Which of the following drug regimens would be the most appropriate to treat FS? a. chlorthalidone b. quinapril c. benazepril + amlodipine d. benazepril + losartan e. atenolol + HCTZ

c (Because the patient has diabetes, ACEI therapy should be part of the combination regimen. The addition of a CCB has been shown to be beneficial in this setting because stage II HTN)

After discussing BP goals, EF states that she would like to start a chronic BP medication that she could continue throughout her pregnancy. Which of the following would be the best medication for EF? a. clonidine 0.1 mg PO BID b. losartan 50 mg PO QD c. amlodipine 10 mg PO QD d. hctz 25 mg PO QD

c (CCBS! but nifedipine is preferred....cant do clonidine until 3rd trimester)

TJ is a 64-year-old man with long-standing hypertension. He has recently been diagnosed with chronic kidney disease and his estimated glomerular filtration rate (eGFR) is 24 mL/min. He is currently taking ramipril 10 mg daily. His blood pressure is 148/86 mm Hg, heart rate is 58 beats/min, and electrolytes notable for a potassium of 5.1 mEq/L. Upon physical examination, the patient is noted to have slight peripheral edema; however, ECHO was without evidence of systolic heart failure (ejection fraction estimated at 60%) however noted left ventricular dysfunction. Which of the following would be the most appropriate recommendation at this time? a. continue current therapy and monitor BP regularly b. add HCTZ 12.5 mg daily c. add furosemide 20 mg daily d. start verapamil ER to 360 mg daily e. add spironolactone 25 mg daily

c (HCTZ not effective cus GFR <30 and deifinitely dont start CCB!!! Loop diuretics such as furosemide may be used in hypertensive patients with reduced CrCl. Loop diuretics are filtered and secreted, so when a patient loses kidney filtration ability (CrCl <30 mL/min), the loop diuretics may still be effective (thiazide diuretics would most likely not be effective in this setting because they are only filtered). The patient is also noted to have peripheral edema and due to the great excretion of Na/H2O by this agent it would be better than a thiazide or potassium-sparing diuretic.)

While counseling a patient about a carvedilol up-titration you review the 3 most common adverse events associated with this process. Which of the following correctly lists the 3 adverse events around which you should focus your discussion? *just answer with letter* A. hypotension, nausea, insomnia b. cough, angioedema, hyperkalemia c. bradycardia, hypotension, worsening heart failure symptom d. dizziness, nausea, bronchospasm

c (beta blockers worsen Heart failure symptoms AT FIRST but overtime you will get more beta receptors on cardiomyocytes & they will be more responsive!!)

Which of the following is NOT a primary effect of RAAS activation? a. Increased sympathetic activation b. Increased sodium/water reabsorption c. Increased heart rate d. Increased total peripheral resistance

c (body may actually compensate Ang II's vasoconstriction by lowering the heart rate)

your patient is a white male with NYHA stage III heart failure. He presents to the clinic today due to worsening exercise tolerance and nighttime orthopnea, that often requires him to sleep in his arm-chair at night. BP = 142/75, HR = 70, RR = 22. ME is 5'11" and weighs 220 lbs. His current medications include aspirin 81 mg po QD, lisinopril 20 mg po QD, carvedilol 50 mg po BID, furosemide 80 mg po BID, and KCl 20 mEq po BID. Physical examination found trace edema in the ankles, with minimal breath sounds upon auscultation. However, you do note a positive S3 sound upon cardiac exam. Given this clinical presentation, which of the following interventions is most likely to improve your patient's complaints? a. increase furosemide dose b. increase carvedilol dose c. start digoxin d. start hydralazine/isosorbide

c (do not increase furosemide because he only has trace edema/peripheral fluid accumulation is not major complaint cannot increase carvedilol dose because max dose for patient >85 kg is 50 mg BID digoxin is last one to add and helps w/ contractility & symptoms like improving exercise tolerance but has NO mortality benefit ... but he is stage III so digoxin 125 mg daily OK at this point plus he has S3 gallop so that is indication of contractility issues hydralazine/isosorbide dinitrate is only for African americans)

Which of the following is most likely to lower blood pressure WITHOUT lowering heart rate? a. diltiazem b. verapamil c. nifedipine d. propranolol e. nadolol

c (nifedipine is right answer cus ccb dhp just arterial vasodilation & actually ADR is reflex tachy ccb non-dhp will slow AV node so not A or B beta blocker works by lowering heart rate)

What two classes medications should be offered to patients with NYHA FC I heart failure? *just answer w/ letter* a. Thiazide diuretics/Beta-blockers b. ACE inhibitors/Digoxin c. Loop diuretics/ACE inhibitors d. Beta-blockers/Loop diuretics

c (no CCBs at all in HF & dont use beta-blockers inappropriately *only carvedilol, metoprolol, or bisoprolol* ... start with ACE/ARB/ARNI & loop diuretic prn then you can add on ...remember for thiazide diuretics the only good one is metolazone to "pee like a race horse" for symptom relief in FC III)

Which of the following modifications is LEAST likely to improve BP in patients with HTN? a. Ibuprofen (oral) --> Diclofenac (topical) b. Duloxetine (SNRI) --> Fluoxetine (SSRI) c. Coffee (twice daily) --> Diet coke (twice daily) d. Dexamethasone (oral) --> Fluticasone (nasal)

c (switching from coffee to diet coke will not improve BP ... similar amts of caffeine)

Which of the following non-pharmacologic therapies is most likely to result in the largest blood pressure reduction? a. Reduced salt intake (1.5 g sodium/day) b. Physical activity (30 min/day most days of the week) c. Weight loss (10-20 kg) d. Moderation of alcohol intake (2 drinks/day [men]; 1 drink/day [women])

c (you can sodium ur way into high blood pressure but u cant always sodium ur way out)

AK is a 57 year-old white male who was admitted to the hospital last week for heart failure. He now takes furosemide 20 mg daily, lisinopril 5 mg daily, and metoprolol succinate 12.5 mg daily. His blood pressure is 105/70 mm Hg and his heart rate is 65 beats/minute. He has no symptoms of orthostatic hypotension (OH), but he asks whether his blood pressure is too low. Which one of the following is the best response to AK's inquiry? a. His blood pressure is too low; discontinue metoprolol succinate. b. His blood pressure is too low; discontinue lisinopril. c. Reassure him that his blood pressure should be this low; no changes are needed. d. Reassure him that there is no concern for his blood pressure; no changes are needed.

d

ER is a 72-year-old male who presents to clinic. He is currently on lisinopril 40 mg daily, HCTZ 25 mg daily, and Amlodipine 10 mg daily. His blood pressure in clinic supports his elevated home readings, providing an average BP of 162/89 mm Hg. He is open to going adding therapy in addition to altering his diet with reduced sodium intake (however, in discussion his diet seemed appropriate). You have agreed to start spironolactone 25 mg daily. What side effects do you educate the patient about regarding the addition of spirlonlactone? a. retrograde ejaculation b. rebound HTN if immediately discontinued c. hypokalemia d. gynecomastia

d

JC is a 64-year-old African American man with HFrEF presenting with a 2-week history of SOB which limits his normal daily activities and increased lower extremity edema. His weight has recently increased by 10 lb. His physical examination is notable for BP 148/72 mm Hg, HR 68 beats/min, RR 24, rales, and 3+ lower extremity edema. Pertinent laboratory values include: sodium 138 mmol/L, potassium 5.4 mmol/L, BUN 35 mg/dL, creatinine 0.9 mg/dL, and digoxin 2.1 ng/mL. Past medical history is significant for HTN, gout, and chronic obstructive pulmonary disease (COPD). Current medications include lisinopril 20 mg daily, diltiazem CD 120 mg daily, digoxin 0.250 mg daily, and salmeterol/fluticasone 250/50 two puffs bid. JC recently began taking naproxen 220 mg tid for gout pain. Within the following 24 hours, JC experiences a brisk diuresis with considerable improvement in HF signs and symptoms. What additional medication changes should be considered? a. continue current regimen and initiate HCTZ 50 mg daily b. continue current regime n and initiate spironolactone 25 mg daily c. discontinue lisinopril and initiate combination hydralazine 25 mg and ISDN 20 mg TID d. discontinue OTC naproxen and initiate colchicine 0.6 mg bid until gout pain resolves

d

What diagnostic classification is an average blood pressure of 158/104 mm Hg on June 1st and an average blood pressure of 150/110 mm Hg on June 4th (both blood pressure averages were taken on two separate clinic dates as the patient refused to go to the emergency department)? A. Normal B. Elevated C. Stage 1 hypertension D. Stage 2 hypertension

d

Which of the following therapies decreases HR via inhibition of the If current in the sinoatrial node? a. metoprolol succinate b. carvedilol c. digoxin d. ivabradine

d

Which of the following would be most likely to induce the largest BP reduction in a patient with HTN? a. Smoking cessation b. Reduced dietary potassium c. Increased omega-3 fatty acid intake d. Resistance exercise

d (smoking cessation is good for you but doesnt necessarily help reduce blood pressure long term, it will reduce risk of heart attack & stroke)

AC is a 46-year-old white man with a medical history significant for type 2 diabetes obesity, and new-onset hypertension. His current HA1c is 7.2%. He was started on lisinopril 10 mg daily 6 weeks ago and the dose was increased after 2 weeks to 20 mg daily. It has been 4 weeks since any alterations in therapy and in clinic his BP is 146/94 mm Hg and his heart rate is 67 beats/min. Which of the following is the most appropriate recommendation for AC? a. continue current regimen b. discontinue lisinopril and start diltiazem c. discontinue lisinopril and start HCTZ d. add atenolol e. add amlodipine

e (The CCB, amlodipine, is the best option due to limited side effects and its ability to work on peripheral vascular resistance without the risk of electrolyte abnormalities and limited glucose abnormalities caused by particular blood pressure agents. dont want to not do anything cus BP not at goal not atenolol because thiazides & beta blockers may worsen glucose in patient whose A1C is already 7.2 not B or C cus we dont want to discontinue lisinopril!!)