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Pharmacotherapy II Exam 3

Pharmacotherapy Ii Exam 3

by pharmergirl, Nov. 2009

Subjects: 3 exam ii pharmacotherapy

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	RH is a 50 year old Caucasian man with a history of hypertension and Type 2 diabetes mellitus. He comes to the clinic today with complaints of pain in the chest area that is “squeezing” in character when he does daily chores such as mowing the lawn. The pain is 7 on a scale of 1 to 10, starts with exertion and is relieved by rest. His father died of a heart attack when he was 70 and his mother has hypertension. He has had both hypertension and diabetes for over 3 years, and his diabetes is well-controlled by diet and medication. His cardiologist wants to treat his ischemic heart disease medically. Meds: metformin XR 1000 mg daily ramipril 10 mg daily VS: BP 135/68 P75 RR22 T36.4 Labs: HbA1c: 6.8, other labs within normal limits Diagnosis: Chronic stable angina Which of the following changes to RH’s drug regimen would be BEST for initial angina symptom control in this patient? a. Add atenolol, sublingual nitroglycerin, and verapamil b. Add sublingual nitroglycerin and increase dose of ramipril c. Add atenolol and amlodipine d. Add atenolol and sublingual nitroglycerin e. Add verapamil and sublingual nitroglycerin	d. Add atenolol and sublingual nitroglycerin A is incorrect because we would rarely use atenolol and verapamil together (potential AV block, etc) and because one would not add 3 drugs at once. B does not offer sufficient prophylaxis of angina symptoms in this patient. C is incorrect because we would not initiate both of these drugs (atenolol and amlodipine) at the same time unless we found that atenolol alone was not sufficient to control his symptoms. E is incorrect since he does not have contraindications to a beta blocker (glycemia is under control), first line therapy should be a beta blocker, so this is not the best answer. Patients should also have SL NTG available to them for relief of acute attacks.
	Refer to Case A This patient is considered by the medical team to have “high-risk” features for subsequent adverse outcomes due to ACS, and have decided to treat him with aggressive medical management right away. Which of the following is the most significant high-risk feature that this patient exhibits? a. Tachycardia in the setting of advanced age b. Positive troponin c. Accelerating tempo of ischemic symptoms in the preceding 48 hours d. Signs of pulmonary edema e. Two of the above	b. Positive troponin A-Incorrect. Both tachycardia and Age>75 years are considered high risk features; however, this patient has neither. B- Correct. Positive troponin is considered a high risk feature, and this patient’s cardiac enzymes reveal positive troponin. C- Incorrect. While this is a high risk feature, the patient has not had this feature based on presentation. D- Incorrect. While signs of heart failure are considered high risk features, this patient’s lungs are clear on physical exam. E-Incorrect. Only B is the correct answer.
	Refer to Case A The medical team initiates aspirin and anti-thrombin therapy. Which of the following is the most appropriate intervention in this patient and why? a. Enoxaparin because it has been shown to be superior to heparin in this type of ACS b. Heparin because this patient has renal dysfunction that precludes him from receiving enoxaparin c. Fondaparinux because this patient is at sufficient bleeding risk to justify this agent d. Bivalirudin because it has been shown to have superior net clinical benefit in ACS e. None of the rationales are correct	a. Enoxaparin because it has been shown to be superior to heparin in this type of ACS A- Correct. Data from studies such as ESSENCE, TIMI 11B, and INTERACT demonstrated superiority of enoxaparin over heparin on endpoints including the composite for death/MI/need for revascularization in NSTE ACS. B-Incorrect. This patient has impaired renal function. However, this doesn’t preclude therapy with enoxaparin. In addition, reduced doses of enoxaparin can be used for treatment of NSTE and STE ACS according to the product labeling. C- Incorrect. Fondaparinux is not superior to enoxaparin for clinical endpoint reduction. While fondaparinux has a better bleeding risk profile, this patient is not at a high risk of bleeding. D-Incorrect. Bivalirudin is reserved as an alternative to heparin or enoxaparin in the cath lab/PCI, not for medical management of ACS. E-Incorrect. A is correct.
	Refer to Case A Which of the following medications would be inappropriate in this patient? a. Tenecteplase b. Abciximab c. Clopidogrel d. A and B e. A and C	d. A and B Clopidogrel is clearly warranted. It is indicated in conjunction with ASA for the medical management of people with NSTE ACS, unless they have specific contraindications. Lytics such as tenecteplase are contraindicated in people with NSTE ACS. Also, abciximab is not indicated for medical management of NSTE ACS based on the neutral effects (and perhaps trends toward harm) seen in the GUSTO-V study. Only eptifibatide and tirofiban are indicated for medical management of NSTE ACS.
	Refer to Case A The patient is admitted and will be transferred to a nearby hospital for Percutaneous Coronary Intervention (PCI)/stent placement tomorrow. He was given a 300 mg oral dose of clopidogrel on admission. Which of the following is most appropriate regarding this person’s clopidogrel? a. Clopidogrel is not appropriate in this patient and should not be given again b. The patient should be given an additional 300 mg dose before being transferred on the day of PCI c. The patient should be given 75 mg before being transferred on the day of PCI d. None of the above are correct	A- Incorrect. Clopidogrel is indicated in conjunction with ASA for the medical management of people with NSTE ACS as well as post stent placement, unless they have specific contraindications which this patient does not have. B- Incorrect. The 300 mg he received on admission is sufficient since he is going to the cath lab >6hrs after the dose. C is correct. The patient should be given 75 mg daily and will need a dose in the am. Correct. Clopidogrel 75 mg daily is indicated in patients post-PCI with stent. The type of stent will dictate the duration of treatment.
	Refer to Case A The medical team has decided to initiate eptifibatide. Which of the following is the appropriate regimen in this patient based on the prescribing information provided at the end of this exam? a. Bolus of 8.5 ml; infusion of 15 ml/hr b. Bolus of 8.5 ml; infusion of 15 ml/kg/hr c. Bolus of 4.25 ml; infusion of 7.5 ml/hr d. Eptifibatide is not appropriate in this patient and should not be given e. None of the above is correct	e. None of the above is correct A, B, and C are incorrect. Incorrect. The dose should be 8.5 ml bolus and renally adjusted infusion is 7.5 ml/hr. D is incorrect because this person has NSTEMI with high risk features, making medical management with a GPIIBIIIA inhibitor like tirofiban or eptifibatide acceptable. Thus, E is the correct answer.
	Refer to Case A The physician is impressed by your ability to take care of this patient with ACS. He wants to ask you a side question on one of his other patients with ACS who is going to the cath lab. The physician tells you that the patient is on enoxaparin and received their last dose 4 hours ago. He wants to know if you think the patient should get another dose of enoxaparin now on his way to the cath lab. You answer with which of the following? a. No; the patient doesn’t need another dose unless he received his last enoxaparin dose more than 8 hours ago b. Yes; the patient needs another dose since he received his last enoxaparin dose more than 2 hours ago c. It’s up to the physician; there is no good evidence either way d. No; the patient should not get another dose, but should get bivalirudin in the cath lab instead e. None of the above is correct	a. No; the patient doesn’t need another dose unless he received his last enoxaparin dose more than 8 hours ago A- Correct. If a patient on enoxaparin has received their dose within 8 hours of going to the cath lab, they don’t need a supplemental dose. B- Incorrect; patients only need supplemental doses if they received their last dose at least 8 hours ago. C- Incorrect. There is evidence that a supplemental dose for patients who have received their last dose at least 8 hours ago improves anti-coagulation D- Incorrect. Bivalirudin is generally reserved as alternative to heparin/enoxaparin in patients at high bleeding risk or allergies. E- Incorrect. A is correct.
	Refer to Case B Which of the following physical findings in this patient are most consistent with the diagnosis of heart failure? a. Elevated jugular venous pressure, third heart sound, and displaced apical pulse b. Edema, fever, hepatomegaly, and fatigue c. Tachycardia, rales, elevated white blood cell count d. Cardiomegaly, constipation, myopathy	a. Elevated jugular venous pressure, third heart sound, and displaced apical pulse Elevated jugular venous pressure, third heart sound, and displaced apical pulse are all cardinal signs of heart failure found on physical exam. Fever, elevated white blood cell count, and myopathy are not signs of heart failure.
	Refer to Case B Which of the following most accurately describes the role of diuretics in heart failure? a. Diuretics are a mainstay of heart failure treatment and should be used as monotherapy in asymptomatic patients 9 b. Diuretics decrease sympathetic outflow and reduce activation of the renin- angiotenin-aldosterone system c. Diuretics are a mainstay of heart failure treatment because of their ability to reduce volume overload and provide symptomatic relief d. Diuretics should be avoided in heart failure because of their ability to cause volume depletion and worsen renal function	c. Diuretics are a mainstay of heart failure treatment because of their ability to reduce volume overload and provide symptomatic relief Answer A is not correct because even asymptomatic patients should be treated with ACE inhibitors (stage A for treating risk factors, and all stage B, C, and D HF patients). Answer B is not correct because diuretics INCREASE sympathetic outflow and can activate the RAAS. D is incorrect because diuretics are used to improve symptoms of fluid overload. It is true however that over-diuresis should be avoided so that volume depletion and worsened renal function can be avoided. Answer C is correct because diuretics DO provide symptomatic relief by reducing volume overload.
	Refer to Case B Which of the following would be the most appropriate short-term change to CB’s heart failure medication regimen? a. Discontinue propranolol and start carvedilol 3.125 mg bid b. Increase HCTZ dose to 50 mg QD c. Change HCTZ to furosemide 40 mg BID d. Start spironolactone 25 mg QD	c. Change HCTZ to furosemide 40 mg BID This patient is clearly fluid overloaded and experiencing an exacerbation. This is the first priority in this patient. Thiazide diuretics are not potent enough diuretics to diuresis a patient in this situation and increasing HCTZ dose will not be adequate. Potassium-sparing diuretics are also not potent enough diuretics for an acute exacerbation. Answer A should be done, but at a later date when the patient is euvolemic. Beta-blockers should not be initiated or titrated while patients are unstable or fluid overloaded.
	Refer to Case B Which of the following additions to CB’s heart failure regimen should be made first? a. candesartan 4 mg QD b. metolazone 5mg QD c. digoxin 0.125 mg QD d. lisinopril 10 mg QD	d. lisinopril 10 mg QD This patient does not have any apparent contraindications to ACE inhibitor therapy and this is the top priority. ACE inhibitors are preferred over ARBs because of they have more data behind their use. Metalozone’s primary role is in combination with loop diuretics in resistant patients and this patient has not even been tried on furosemide yet. Digoxin does reduce hospitalizations and improve symptoms, but it does not improve mortality. Digoxin’s role in HF is for patient’s who remain symptomatic on optimum therapy. This patient is not on ACE inhibitor or appropriate beta-blocker therapy yet.
	Refer to Case B Which of the following changes to CB’s non-heart failure regimen would be most beneficial to this patient? a. Increase ibuprofen to 800 mg TID b. Start Vitamin E 1000 IU QD c. Discontinue ranitidine 150 mg QHS d. Change rosiglitazone 8mg QD to glipizide 10mg QD	d. Change rosiglitazone 8mg QD to glipizide 10mg QD
	Which of the following represents a correct statement regarding the treatment of heart failure? a. Hydralazine/isosorbide dinitrate should be substituted for ACEIs in African Americans b. Beta-blockers should be initiated when patients are euvolemic and on stable diuretic doses c. Angiotensin receptor blockers should be added to regimens when patients are on stable dose ACE inhibitor, beta-blocker, and spironolactone d. Digoxin should be withdrawn prior to the initiation of hydralazine/isosorbide dinitrate	b. Beta-blockers should be initiated when patients are euvolemic and on stable diuretic doses
	Which of the following scenarios of ACE inhibitor intolerance in a heart failure patient would it be most appropriate to switch to an angiotensin receptor blocker? a. Patient who develops renal dysfunction with ACE inhibitor treatment b. Patient who develops hyperkalemia with ACE inhibitor treatment c. Patient who develops hypotension with ACE inhibitor treatment d. Patient who develops intolerable cough with ACE inhibitor treatment	d. Patient who develops intolerable cough with ACE inhibitor treatment Renal dysfunction, hyperkalemia, and hypotension are all side effects of ACE inhibitors and ARBs. Cough is only a problem with ACE inhibitors, not ARBs because ACE inhibitors increase bradykinin and ARBs don’t.
	Which of the following is NOT a contraindication to spironolactone therapy? a. Potassium < 3.5 mmol/L b. Serum creatinine > 2.5 mg/dL c. Potassium > 5.0 mmol/L d. Recent (within 6 months) HF exacerbation e. A and D	e. A and D The contraindications to spironolactone based on the RALES study are serum creatinine > 2.5 mg/dL and potassium > 5.0 mmol/L. Class IV HF or recent HF exacerbation were inclusion criteria in the RALES trial. Spironolactone can increase potassium concentrations so a patient with low potassium could benefit from treatment with it.
	MY is a 34 year-old black woman with well-controlled hypertension. She comes to the pharmacy requesting a refill of labetalol and a new prescription from her obstetrician for prenatal vitamins. Which of the following is most correct? a. labetalol is acceptable during pregnancy, refill the prescription and counsel her on the potential risks b. valsartan is more effective in pregnancy, refill the prescription but recommend that she seek a new prescription for valsartan c. only methyldopa is safe during pregnancy, do not refill the prescription and call the doctor to change the medication d. no drugs are safe during pregnancy, do not refill the prescription and recommend sodium restriction	a. labetalol is acceptable during pregnancy, refill the prescription and counsel her on the potential risks A- Correct because labetalol is safer option for managing chronic hypertension in pregnancy. B- Incorrect because ACEI and ARBs are absolutely contraindicated in pregnant women. C- Incorrect because methyldopa, while commonly used by OB/GYNs and safe during pregnancy, other medications including beta-blockers. D- Incorrect because hypertension can be treated pharmacologically in pregnancy as above.
	LM is a 34 year-old obese white woman with diabetes and newly-diagnosed hypertension (stage 2). Which of the following most appropriately applies to the clinical management of this patient? a. 6-12 weeks of lifestyle modification should be implemented prior to starting the DASH diet b. The DASH diet should be implemented immediately as monotherapy because it will decrease her blood pressure by 8-14 mmHg c. Start monotherapy antihypertensive therapy d. Start combination antihypertensive therapy with two drugs from different classes	d. Start combination antihypertensive therapy with two drugs from different classes A-Incorrect. Drug therapy is warranted immediately and should be given concomitant with lifestyle modification, including the DASH diet 12 B-Incorrect because DASH is a dietary program that encourages nutrient-rich foods, less fats and cholesterol, higher fiber, lower sodium. Drug therapy is warranted immediately and should be given concomitant with lifestyle modification, including the DASH diet C- Incorrect because LM has stage 2 hypertension and monotherapy is unlikely to lower BP to her goal of <130/80 D- Correct because stage 2 hypertension would place LM in a category where her BP is >160/>100. If her goal as a diabetic is <130/<80, she is >20/>10 from her goal by definition and would benefit from starting on 2 drugs.
	JT is 45 year-old man that returns for follow-up 3 months later after starting Drug A for newly diagnosed hypertension. After home blood pressure monitoring during the first month of treatment, the physician maximized the dose of Drug A. His BP is still elevated at 152/98 mmHg although he had demonstrated a response (systolic is 5-10 mmHg lower) to Drug A. Which of the following is the most correct next step in this patient’s therapy? a. discontinue Drug A and start a different drug from the same class b. discontinue Drug A and start a different drug from a different class c. continue Drug A and add a drug from a different class d. continue drug Drug A and add two drugs from different classes	c. continue Drug A and add a drug from a different class A- Incorrect because the likelihood of deriving greater benefit from a drug within the same class is unlikely. B- Incorrect because the patient demonstrated some response to the initial drug choice. A second drug should be added to achieve the goal. C-Correct because adding a drug that targets a different pathophysiological component is the most logical approach to reducing the patient’s blood pressure. D-Incorrect because adding a single drug may be enough to achieve his goal of <140/<90. A third drug may be considered if he does not demonstrate a response to the 2 drug regimen at maximal doses.
	MS, a 50 year-old woman with essential hypertension who is otherwise in good health, comes to the pharmacy to refill her HCTZ, amlodipine, and ramipril. She checks her blood pressure at the machine near the pharmacy (which was recently calibrated and is accurate). She tells you her blood pressure was 185/112. She feels well and there is no evidence of target organ damage. Which of the fllowing is most appropriate at this time? a. call 911 b. advise her to see her physician within 1 week or go to the emergency room c. advise her to see her physician within 1 month d. advise her to double the dose of amlodipine until her next appointment	b. advise her to see her physician within 1 week or go to the emergency room A- Incorrect because she is not symptomatic (e.g. having a myocardial infarction, etc.) B- Correct because she is in need of urgent care, but not necessarily emergent. C- Incorrect because her level of blood pressure is high enough to raise concerns about complications. D-Incorrect because, beyond being a liability issue in recommending a dose change, she should be seen within the week.
	KN is a 67 year-old man with longstanding uncomplicated essential hypertension. He takes hydrochlorothiazide 25 mg daily. He has had a reasonably good response to hydrochlorothiazide, but his home blood pressures have been above goal, ranging from145-155/95-105 mmHg during the past several weeks. Which of the following would be the most logical modification to KN’s existing antihypertensive therapy? a. increase hydrochlorothiazide to 50 mg daily b. changing hydrochlorothiazide to atenolol 25 mg daily c. adding amlodipine 5 mg daily to hydrochlorothiazide d. adding lisinopril 10 mg daily to hydrochlorothiazide	d. adding lisinopril 10 mg daily to hydrochlorothiazide A-Incorrect because increasing the dose of HCTZ from 25 mg to 50 mg seldom produces substantial decreases in blood pressure. B-Incorrect because he has had a good response to hydrochlorothiazide so it would be better to add a drug to achieve additional decreases in blood pressure C-Incorrect because the logical addition to hydrochlorothiazide would be an ACEI or ARB (slide 26 from lecture)). D-Correct because adding a drug from a distinct class that targets renin activity is the most logical (slide 26 from lecture), and the combination of and ACEI or ARB with a diuretic tends to be very effective.
	You are rounding with the internal medicine team, who is preparing to discharge JS, an 84 year-old woman admitted with hip fracture secondary to fall. She also has isolated systolic hypertension (average blood pressures 135-145/75-85 mmHg) and early Alzheimer’s. Her discharge medication list is as follows: acetaminophen 300 mg/ codeine 30 mg one tablet as needed alendronate 70 mg q Sunday lansoprazole 30 mg daily transdermal clonidine 0.1 mg/day apply weekly hydrochlorothiazide 25 mg daily Which of the following is the best recommendation regarding the management of her hypertension: a. Eliminate codeine from the analgesic regimen because it increases blood pressure b. change clonidine to ramipril because clonidine causes orthostasis c. decrease hydrochlorothiazide to 12.5 mg to reduce risk for further cognitive decline d. discontinue all antihypertensive drugs because treating hypertension in the very elderly is not necessary	b. change clonidine to ramipril because clonidine causes orthostasis A-Incorrect because codeine does not increase blood pressure B-Correct because clonidine can cause orthostasis, and she will likely need to continue on a 2 drug regimen. Ramipril is synergistic with hydrochlorothiazide. C-Incorrect because hydrochlorothiazide is not associated worsening of Alzheimer’s disease D-Incorrect because treating hypertension, even in the very elderly, is beneficial
	PT is a 42 year-old white man with hypertension and dyslipidemia presenting for follow-up with his primary care physician 1 week after being discharged for myocardial infarction. He is currently receiving ramipril 10 mg daily, aspirin 81 mg daily, and atorvastatin 40 mg daily. His blood pressure is 149/80 today. Which of the following is the most appropriate recommendation for this patient at this time? a. Starting carvedilol b. Increasing ramipril dose c. Changing ramipril to hydrochlorothiazide d. Starting verapamil	a. Starting carvedilol A-Correct because myocardial infarction is a compelling indication for beta-blocker therapy B-Incorrect because a beta-blocker should be added. Increasing the ramipril dose may be considered C-Incorrect because the ACE inhibitor is indicated in post-MI patients D-Incorrect because the evidence supports adding a beta-blocker rather than a nondihydropyridine CCB in post-MI patients in the absence of contraindications to beta-blockade
	JT is a 48 year-old white woman with essential hypertension. Her blood pressure has been controlled for the past 2 years on hydrochlorothiazide 25 mg daily. She complains to you about the fact that she always has to leave her desk to urinate. She wants to switch medications. Which of the following would be the best alternative? a. amlodipine b. atenolol c. irbesartan d. lisinopril	a. amlodipine A is correct because switching to a drug that targets a similar pathophysiology would be the most logical. Angiotensin receptor blockers, ACE inhibitors and beta-blockers address renin/ sympathetic related pathology, whereas diuretics and CCBs target peripheral resistance.
	Refer to Case C Which of the following are signs and symptoms of pulmonary congestion? a. +jugular venous distension, orthopnea, rales b. Weight gain, 2+ pedal edema, shortness of breath c. Shortness of breath, fatigue, orthopnea, rales d. Shortness of breath, orthopnea, rales	d. Shortness of breath, orthopnea, rales JVD and pedal edema are signs of systemic congestion and fatigue is a general symptom, likely due to a combination of low cardiac output, fluid congestion, inadequate oxygen to skeletal muscles due to peripheral vasocontriction, among others.
	Refer to Case C Regarding therapies with the potential to slow TK’s disease process and prolong her survival, which of the following is the most appropriate recommendation? a. add carvedilol once acute fluid overload corrected b. increase lisinopril to 10 mg daily now, and add carvedilol once acute fluid overload corrected c. increase lisinopril to 10 mg daily now, add digoxin now, and add carvedilol once acute fluid overload is corrected d. increase lisinopril to 10 mg daily now and furosemide to 40 mg daily now, and add carvedilol once acute fluid overload is corrected	b. increase lisinopril to 10 mg daily now, and add carvedilol once acute fluid overload corrected b is more correct than a since the lisinopril dose is not at the target survival dose and β-blocker needs added. c and d are incorrect because digoxin and furosemide do not have survival benefits.
	Refer to Case C Regarding approaches to improve her heart failure symptoms, which of the following would be the most appropriate recommendation now? a. increase furosemide to 40 mg daily and add digoxin 0.125 mg daily b. increase furosemide to 40 mg daily, increase lisinpril to 10 mg daily, add digoxin 0.125 mg daily c. increase furosemide to 40 mg daily, increase lisinopril to 10 mg daily, discontinue celecoxib and replace with acetaminophen d. increase furosemide to 40 mg daily, discontinue celecoxib and replace with acetaminophen.	c. increase furosemide to 40 mg daily, increase lisinopril to 10 mg daily, discontinue celecoxib and replace with acetaminophen a and b are incorrect because digoxin should not be added until the other therapies are optimized. c is correct because furosemide dose needs acutely increased to get off the excess fluid, lisinopril needs increased for both symptomatic benefits and to get to target survival dose. Additionally the therapy that likely caused the current exacerbation should be stopped and therapy attempted with APAP. d is incorrect because it does not include a dose increase of lisinopril, which will improve symptoms.
	LK is a 52 year old Hispanic male with a history of hyperlipidemia, type 2 diabetes mellitus, hypertension, and heart failure. His heart failure symptoms are currently classified as Class III. His current medications include atorvastatin 80 mg po qd, nateglinide 120 mg tid, acarbose 50 mg tid, lisinopril 10 mg qd, furosemide 60 mg qd, digoxin 0.25 mg qd. Current labs are as follows: fasting blood glucose 130 mg/dl, HbA1c 7.6%, Na – 135 mEq/L, K – 4.3 mEq/L, CL – 99 mEq/L, BUN 16 mg/dl, SCr 1.0 mg/dl, digoxin 1.5 ng/ml. His BP is 140/88 mmHg and pulse is 90/min. The physician wishes to start rosiglitazone in this patient. Which of the following is the best assessment of this plan? a. Additional diabetes therapy is not warranted in this patient at this time. b. Additional therapy is warranted, but pioglitazone would be preferred in this patient due to his heart failure. c. Rosiglitazone is considered contraindicated in this patient due to its propensity to cause edema and worsening heart failure. d. Rosiglitazone is considered contraindicated in this patient due to its negative inotropic effects.	c. Rosiglitazone is considered contraindicated in this patient due to its propensity to cause edema and worsening heart failure. a is incorrect as both the FBG and HgA1C indicate poor glucose control. b is incorrect because both rosiglitazone and pioglitazone are contraindicated. d is incorrect because this does not properly state the mechanism of detriment of these drugs in HF.
	LK is a 52 year old Hispanic male with a history of hyperlipidemia, type 2 diabetes mellitus, hypertension, and heart failure. His heart failure symptoms are currently classified as Class III. His current medications include atorvastatin 80 mg po qd, nateglinide 120 mg tid, acarbose 50 mg tid, lisinopril 10 mg qd, furosemide 60 mg qd, digoxin 0.25 mg qd. Current labs are as follows: fasting blood glucose 130 mg/dl, HbA1c 7.6%, Na – 135 mEq/L, K – 4.3 mEq/L, CL – 99 mEq/L, BUN 16 mg/dl, SCr 1.0 mg/dl, digoxin 1.5 ng/ml. His BP is 140/88 mmHg and pulse is 90/min. The physician also raises the issue of starting a B-blocker in this patient. Which of the following is the most appropriate response? a. While B-blockers are beneficial in heart failure, it would be contraindicated in this patient because of his diabetes. b. B-blocker is strongly indicated, and therapy should be initiated with carvedilol 6.25 mg bid. c. B-blocker is strongly indicated, and therapy should be initiated with Toprol XL 12.5 mg qd d. B-blocker should be started, but discontinued if the patient has any adverse changes in their lipid or glucose parameters.	c. B-blocker is strongly indicated, and therapy should be initiated with Toprol XL 12.5 mg qd a is incorrect because β-blockers should not be withheld in diabetic HF patients. b is a suboptimal choice because the starting dose is not right. Additionally one might argue that in a patient with poor glucose control initiation of a β1-selective agent would be preferred over a nonselective agent. d is incorrect because the survival benefits are so great as to outweigh any changes the drug may cause in the lipid or glucose control.
	LK is a 52 year old Hispanic male with a history of hyperlipidemia, type 2 diabetes mellitus, hypertension, and heart failure. His heart failure symptoms are currently classified as Class III. His current medications include atorvastatin 80 mg po qd, nateglinide 120 mg tid, acarbose 50 mg tid, lisinopril 10 mg qd, furosemide 60 mg qd, digoxin 0.25 mg qd. Current labs are as follows: fasting blood glucose 130 mg/dl, HbA1c 7.6%, Na – 135 mEq/L, K – 4.3 mEq/L, CL – 99 mEq/L, BUN 16 mg/dl, SCr 1.0 mg/dl, digoxin 1.5 ng/ml. His BP is 140/88 mmHg and pulse is 90/min. Regarding LK’s HF management, which of the following describes the best management approach to take at this time, as it relates to his current medications? a. Increase the furosemide dose for better BP and symptom control, and cut the digoxin dose in half. b. Increase the lisinopril dose for better BP and symptom control, and cut the digoxin dose in half. c. Increase the doses of lisinopril and furosemide for better BP and symptom control. d. Increase the lisinopril dose for better BP and symptom control, cut the digoxin dose in half, and D/C the atorvastatin because of it’s ability to cause a worsening of HF symptoms.	b. Increase the lisinopril dose for better BP and symptom control, and cut the digoxin dose in half. a and c are incorrect because you should not increase the furosemide dose unless the patient has congestion symptoms on the current dose. b is correct as this dose isn’t optimal and it should be increased to determine whether this will provide the needed BP control; it will likely also help control symptoms and reduce hospitalizations. Additionally, the serum digoxin concentration is too high – it should not exceed 1 and so the dose should be reduced to get it to this level. d is incorrect because atorvastatin does not have any effects of worsening HF symptoms.
	Addition of which of the following drugs would NOT be a cause for concern (assuming it’s indicated), in a heart failure patient? a. amoxicillin b. naproxen c. valdecoxib d. propafenone	a. amoxicillin Naproxen and valdecoxib have the potential to cause sodium and water retention (and thus worsen symptoms) and propafenone has negative inotropic effects.
	TJ is a 67 year old African American male with a history of nonischemic cardiomyopathy (EF = 30%), and longstanding hypertension. His current medication regimen is: lisinopril 20 mg bid, carvedilol 12.5 mg bid, furosemide 40 mg qd, KCl 20 mEq qd. His heart failure symptoms are currently well-controlled and he has minimal limitations to his activities. VS: BP-148/72 mmHg P-72/min R-12/min, afebrile TJ is in for a 6 month follow-up visit. Which of the following would be most appropriate regarding TJ’s therapy? a. Increase carvedilol to 25 mg bid b. Add amlodipine 5 mg qd c. Make no changes since his heart failure is currently well controlled d. Add spironolactone 25 mg qd	a. Increase carvedilol to 25 mg bid a is correct because the patient is not currently at the target carvedilol dose and his HR of 72 suggests he is not fully beta-blocked. Additionally his BP is poorly controlled and so an increase in carvedilol is appropriate. b is incorrect because you want to optimize standard HF drugs before adding others for BP control. c is incorrect because the BP is poorly controlled and BB dose not optimized for HF benefits. d is incorrect because the patient doesn’t meet the severity criterion. Additionally there is not sufficient information on the patient’s renal function or K to assess appropriateness of such an addition.
	PL is a 45 year old African American male with difficult to control hypertension. Prior to treatment, his blood pressure was 166/110 mmHg. He is currently taking diltiazem SR 180 mg bid, HCTZ 25 mg qd and quinapril 40 mg qd. His blood pressure is typically 135-150/85-95 mmHg on this regimen. Which of the following OTC medications would most likely adversely affect PL’s hypertension control and thus should be avoided? a. pseudoephedrine b. chlorpheniramine c. loratidine d. acetaminophen	a is correct because pseudoephedrine in a sympathomimetic with the known potential to raise BP. Chlorpheniramine and loratidine are H2-blockers, which do not raise BP. Similarly acetominophen does not raise BP.
	PL is a 45 year old African American male with difficult to control hypertension. Prior to treatment, his blood pressure was 166/110 mmHg. He is currently taking diltiazem SR 180 mg bid, HCTZ 25 mg qd and quinapril 40 mg qd. His blood pressure is typically 135-150/85-95 mmHg on this regimen. You have gone to a number of lengths to document that PL is adherent to therapy, yet most of his blood pressures are still slightly > 140/90 mmHg and so there is a desire for better blood pressure control. What would be the most appropriate recommendation regarding achieving better blood pressure control in PL? a. The patient has achieved a substantial reduction in BP, so it is not necessary to produce a further lowering in BP. b. Add eplerenone c. Increase the diltiazem dose d. Increase the HCTZ dose	c. Increase the diltiazem dose a is incorrect because the patient has not achieved the goal BP, despite having a significant BP reduction. Thus additional lowering is warranted. b is incorrect because Eplerenone would not be considered until the current drug doses are optimized. c is correct because the patient has room to increase the diltiazem dose and CCBs are a group that due to kinetic variability should definitely be dose optimized. d is incorrect because doses above 25 mg typically provide little additional antihypertensive effect and many additional increases in risk of metabolic abnormalities, e.g. hypokalemia.
	TT is a 76 year old African American female with a history of bradycardia, probably secondary to sick sinus syndrome. At present, her blood pressure is 172/82 mmHg and heart rate is 53/min. Her only cardiovascular medication is HCTZ 25 mg qd and she has no other significant cardiovascular disease history. Which of the following would be most appropriate for this patient? a. Add metoprolol 50 mg twice daily b. Add doxazosin 5 mg daily c. Add amlodipine 5 mg daily d. Optimize HCTZ dose to 50 mg daily	c. Add amlodipine 5 mg daily a is incorrect because of the negative chronotropic effects. b is incorrect because alpha blockers are not considered first line therapy and additionally should not be considered early in therapy for elderly because of their potential to cause orthostatic hypotension. c is correct as this would be a safe drug to add and is likely to produce additional BP reduction. d is incorrect because generally you want to avoid doses of HCTZ above 25 mg since higher doses have minimal antihypertensive effect and more metabolic adverse effects.
	OJ in a 54 year old African Ameraican female who was diagnosed with hypertension 3 months ago. She was started on diltiazem with a couple dose titrations, and has been taking diltiazem SR 360 mg daily for the last month. Her blood pressure has gone from 152/99 mmHg at baseline to 146/96 mmHg on the current dose. Which of the following would be the most appropriate recommendation for the management of OJ at this time? a. add trandolapril b. discontinue diltiazem and start chlorthalidone c. add HCTZ d. discontinue diltiazem and start metoprolol	d. discontinue diltiazem and start metoprolol a is not the best option because it would mean adding a drug to one that is minimally effective (having produced a 4% reduction in SBP and 3% for DBP). b is not the most appropriate because the minimal response to diltiazem is likely to also translate into a minimal response to chlorthalidone. c is not most appropriate for several reasons; first adding to an ineffective drug doesn’t make sense, secondly the combination of a thiazide/CCB is pharmacologically not very logical. d is the best choice since this is a drug that works via the alternative pathophysiological mechanisms. Given the poor response to CCB, selection of an ACEI, ARB or BB as new monotherapy would be most logical.
	WF is a 76 year old who was diagnosed with hypertension over a decade ago. She is currently taking HCTZ 25 mg daily and her BP is 166/84 mmHg. She has serious financial constraints and so drug cost is an important issue. Which of the following would be the most appropriate recommendation for WF? a. Add nifedipine SR b. Add candesartan c. Add carvedilol d. Add enalapril	d. Add enalapril a is not the most appropriate choice because the combination of a CCB and thiazide is not an optimal combination. b is incorrect because it is a branded product and so will be quite expensive for the patient. c is incorrect because it is also a branded product and is very expensive. d is a good choice since it represents a logical combination and is available generically.
	VM is a 52 year old Hispanic female with type 2 diabetes and hypertension. She is currently treated with ramipril 10 mg daily and her BP is 138/84 mmHg. Which of the following is the most appropriate recommendation? a. continue current therapy as her BP is well controlled b. add HCTZ c. add verapamil d. add metoprolol	c. add verapamil a is incorrect because her BP is not to target for a diabetic. b is incorrect because it has metabolic adverse effects and agents without such effects should be attempted first. c is the best choice because it is a logical combination with an ACEI and also because it does not have any adverse effects in diabetics. d is incorrect because it is not a logical combination with ACEI and also because it has numerous potential problems in diabetics.
	BP is a 37 year old white female with a 5 year history of hypertension, currently treated and controlled with enalapril. She comes to your pharmacy to purchase prenatal vitamins, and upon questioning, she tells you she is pregnant. Which of the following would be the most appropriate course of action that would likely lead to the best outcomes? a. Encourage her to talk to her Ob/Gyn physician before the end of the first trimester to discuss changing her antihypertensive drug. b. Contact her MD immediately and suggest changing her blood pressure medication to metoprolol c. Contact her MD immediately and suggest changing her blood pressure medication to losartan d. Contact her MD immediately and suggest changing her blood pressure medication to diltiazem	b. Contact her MD immediately and suggest changing her blood pressure medication to metoprolol a is incorrect because recent evidence suggests that there are also problems with ACEI in the first trimester. b is the best choice because it is commonly used in pregnancy and works by generally the same pathophysiological mechanism as the ACEI, so is most likely to control her HTN. c is incorrect because ARBs are also contraindicated in pregnancy. d is not optimal because it works on the opposite pathophysiology as the ACEI. Thus, while it might be fine to use in pregnancy, is probably less likely than metoprolol to control her HTN.
	JL is a 65 year old white female recently diagnosed with stage I hypertension. Her blood pressure at diagnosis averaged 148-156/94-98 mmHg. She was started on atenolol 50 mg daily, and then increased two weeks ago to 100 mg daily for inadequate blood pressure control on the initial dose. She has call your pharmacy because she has felt extremely fatigued since the most recent dose increase. She takes her blood pressure at home and reports that this AM it was: BP 134/86 mmHg, HR 50/min What would be the most appropriate recommendation for management of JL? a. discontinue atenolol and start enalapril b. discontinue atenolol and start felodipine c. reduce atenolol dose to 50 mg daily and add chlorthalidone d. consider switching from atenolol to metoprolol since she may be sleeping poorly (leading to the fatigue) and this would likely improve with metoprolol	a. discontinue atenolol and start enalapril a is the best choice because she had a good BP response to atenolol but at the dose with a good response she had symptomatic bradycardia. b would be less optimal because it switches treatment approaches to the other mechanism. c is not logical because the lower dose of atenolol did not control her BP and this approach would lead to use of 2 drugs when 1 may suffice. d is not correct because the fatigue she is experiencing is due to bradycardia and reports of dreams/nightmares with beta-blockers are not thought to differ substantially between drugs in the class.
	KW is a 55 year old woman with a known history of asthma who presents to the emergency department with substernal chest pain of unknown duration. Initial work-up reveals the following: VSs – BP 120/80 mmHg, HR 88, RR 22, T afebrile. ECG: non-specific ST changes. Initial impression is unstable angina and the patient is prepared for cardiac catheterization. The following two questions refer to this patient. Which of the following would be LEAST beneficial initial therapy for this patient? a. Metoprolol (Lopressor) b. Verapamil (Verelan and others) c. Sublingual nitroglycerin d. Diltiazem (Cardizem, Dilacor, others)	a. Metoprolol (Lopressor) Selection “a” is correct; please see objectives 2 and 5. Metoprolol is contraindicated in this patient since she has a history of asthma.

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