1. In Medical treatment of heart failure which is false?
Explanation: Selective beta-blockers (carvedilol, bisoprolol, metoprolol succinate) are cornerstone therapies in heart failure with reduced ejection fraction (HFrEF) and have proven mortality benefits. Therefore, the statement that they have no role is false.
2. Regarding selective beta blockers, all are true except:
Explanation: Beta-blockers work by *counteracting* the deleterious effects of the sympathetic nervous system (like persistent tachycardia and adverse myocardial remodeling) in heart failure. They do not increase these effects. While they have a negative inotropic effect and can initially worsen HF symptoms (requiring careful initiation and titration), their long-term benefit is well-established.
3. Sodium-glucose cotransporter-2 inhibitors(SGLT2i): all true except
Explanation: SGLT2 inhibitors do have a mild diuretic effect due to glucosuria, but they are generally not associated with severe electrolyte disturbances compared to loop or thiazide diuretics. Their primary benefits in heart failure extend beyond simple diuresis.
4. Switching from ACE inhibitor to an ARB improves
Explanation: The characteristic dry cough associated with ACE inhibitors is due to the accumulation of bradykinin, which ACE normally degrades. ARBs do not affect bradykinin levels, so switching to an ARB typically resolves this cough. Both classes can cause renal impairment, hypotension, and hyperkalemia.
5. The drug classes that showed benefit in Heart failure management is
Explanation: ACE inhibitors, ARBs (often used if ACEi are not tolerated), ARNIs (Angiotensin Receptor-Neprilysin Inhibitors, like Sacubitril/Valsartan), Beta-blockers, Mineralocorticoid Receptor Antagonists (MRAs, like Spironolactone/Eplerenone), and SGLT2 inhibitors are all foundational therapies proven to improve outcomes (reduce mortality and hospitalizations) in HFrEF.
6. From the previous case [Assuming a standard HFrEF patient]: Which of the following is the most approved to improve the prognosis in such a patient?
Explanation: All listed drug classes (ACEi - Ramipril, Beta-blocker - Metoprolol succinate, MRA - Eplerenone, SGLT2i - Dapagliflozin) are guideline-directed medical therapies (GDMT) for HFrEF and improve prognosis. However, SGLT2 inhibitors like Dapagliflozin have shown robust benefits across a wide range of EF, including HFpEF and HFmrEF in recent trials, and are strongly recommended. Choosing 'D' reflects the significant impact of SGLT2i.
7. From the previous case: The following medication is recommended for our patient, but hypokalemia is a common side effect
Explanation: Torsemide is a loop diuretic used for symptom management (congestion) in heart failure. Loop diuretics inhibit the Na-K-2Cl cotransporter in the loop of Henle, leading to increased excretion of potassium and potentially causing hypokalemia. Sacubitril/valsartan, Nebivolol (beta-blocker), and Spironolactone (MRA) are more likely to cause hyperkalemia (especially MRAs and RAAS inhibitors).
8. From the previous case: What is the added value of sacubitril to valsartan in ARNI?
Explanation: Sacubitril inhibits neprilysin, an enzyme that degrades natriuretic peptides (like ANP and BNP). By increasing levels of these peptides, sacubitril promotes vasodilation, natriuresis (sodium excretion), and diuresis, counteracting the neurohormonal activation seen in heart failure. This effect is indirect, mediated via the potentiation of endogenous natriuretic peptides. Valsartan (an ARB) blocks the harmful effects of Angiotensin II.
9. Which B.B used in treatment of heart failure?
Explanation: Only specific beta-blockers have demonstrated mortality benefit in HFrEF trials. These are Metoprolol Succinate (long-acting formulation, not tartrate), Bisoprolol, and Carvedilol. Propranolol and Atenolol are not recommended for this indication (unlike Metoprolol Succinate, Bisoprolol, Carvedilol).
10. Treatment of acute heart failure with atrial fibrillation
Explanation: Acute heart failure (AHF) management focuses on stabilization. Furosemide (loop diuretic) addresses congestion. Atrial fibrillation requires rate/rhythm control and anticoagulation (like Warfarin or DOACs) for stroke prevention. While ACEIs are crucial for chronic HF, their initiation might be delayed in the acute setting depending on stability, but they are part of the overall management plan. Therefore, elements of all these treatments are relevant.
11. All of the following drugs may be used in congestive cardiac failure except:
Explanation: Spironolactone (MRA), Digoxin (for symptom control/rate control in AFib), and Captopril (ACEi) are used in heart failure management. Propranolol, a non-selective beta-blocker, is generally not one of the beta-blockers proven to have mortality benefit in HFrEF and is typically avoided for this indication (unlike Metoprolol Succinate, Bisoprolol, Carvedilol).
12. Loop diuretics cause all except:
Explanation: Loop diuretics inhibit calcium reabsorption in the loop of Henle, leading to increased calcium excretion and potentially *hypocalcemia*. They also cause loss of potassium (hypokalemia), magnesium (hypomagnesemia), and can sometimes lead to hyperglycemia and hyperuricemia. Thiazide diuretics, in contrast, decrease calcium excretion and can cause hypercalcemia.
13. An 80-year-old man presents with dyspnea and is found to have CHF caused by systolic dysfunction. He also has mild renal insufficiency, with a creatinine level of 1.4. Which of the following statements is true regarding ACE inhibitor therapy in this patient?
Explanation: ACE inhibitors are first-line therapy for HFrEF regardless of age, unless contraindicated. Mild renal insufficiency (like Cr 1.4) is not an absolute contraindication, but requires caution and monitoring. A small rise in creatinine (e.g., up to 30%) after starting an ACEi is often expected and acceptable. However, significant increases or progressive worsening requires dose adjustment or discontinuation. ARBs are alternatives, not necessarily preferred solely based on age.
14. The following medications are approved to improve the prognosis of heart failure except:
Explanation: Ramipril (ACEi), Metoprolol succinate (Beta-blocker), and Eplerenone (MRA) are all proven to improve prognosis (reduce mortality and hospitalizations) in HFrEF. Digoxin can help reduce hospitalizations and improve symptoms in some HFrEF patients (especially those with concurrent AFib), but it has not been shown to improve mortality and is generally considered for symptom control rather than prognostic benefit.
15. The antihypertensive drug contraindicated in diabetic patients is:
Explanation: While not absolutely contraindicated, the combination of thiazide diuretics and beta-blockers (especially older, non-vasodilating ones) is known to increase the risk of developing new-onset diabetes and can worsen glycemic control in existing diabetics. ACE inhibitors and ARBs are often preferred antihypertensives in diabetics due to their renal protective effects. Metformin is a primary treatment for type 2 diabetes, not an antihypertensive contraindicated in diabetes.
16. The antihypertensive drug used in diabetic patients is:
Explanation: ACE inhibitors (ACEI) and Angiotensin II Receptor Blockers (ARBs) are considered first-line antihypertensive agents in patients with diabetes, particularly those with albuminuria, due to their proven renal protective benefits in addition to blood pressure lowering. While Beta-blockers (BB) and Hydrochlorothiazide (HCTZ) can be used, they are less preferred as initial monotherapy due to potential metabolic side effects (see Q15). Metformin treats diabetes but is not an antihypertensive.
17. All of the following antihypertensive drugs are Safe in pregnancy except:
Explanation: ACE inhibitors (ACEI), Angiotensin II Receptor Blockers (ARBs), and Direct Renin Inhibitors (e.g., Aliskiren) are absolutely contraindicated during pregnancy (especially the 2nd and 3rd trimesters) due to the risk of fetal toxicity (renal damage, oligohydramnios, skull hypoplasia). Methyldopa, Labetalol, and long-acting Nifedipine are commonly used and considered safer options for managing hypertension during pregnancy.
18. Anti-hypertensive drug contraindicated in renal artery stenosis:
Explanation: In bilateral renal artery stenosis (or stenosis in a solitary kidney), glomerular filtration rate (GFR) becomes highly dependent on angiotensin II-mediated efferent arteriole vasoconstriction. ACE inhibitors (ACEi) and ARBs block this effect, leading to efferent arteriole dilation, a sharp drop in GFR, and potentially acute kidney injury. Therefore, they are contraindicated in this situation. Calcium channel blockers (CCBs), beta-blockers, and alpha-blockers do not have this specific detrimental effect.
19. A 29-year-old female who is 22 weeks pregnant is noted to have a blood pressure of 150/90 mmHg on 3 separate occasions. Urine protein is negative. Which of the following would be the first-line treatment?
Explanation: This patient has gestational hypertension (new-onset hypertension after 20 weeks without proteinuria). First-line agents for managing hypertension in pregnancy include Labetalol, Nifedipine (long-acting), and Methyldopa (Alpha Methyl Dopa). Methyldopa has the longest track record of safety, although Labetalol and Nifedipine are often preferred now due to better side effect profiles and potentially faster onset. Captopril (ACEi) is contraindicated. Atenolol (beta-blocker) is generally avoided due to concerns about fetal growth restriction.
20. Which of the drugs can be used in hypertension with asthma except:
Explanation: Non-selective beta-blockers, such as Propranolol, block both beta-1 (heart) and beta-2 (lungs, peripheral vasculature) receptors. Blocking beta-2 receptors in the airways can cause bronchoconstriction and worsen asthma symptoms. Therefore, non-selective beta-blockers are relatively contraindicated in patients with asthma. ACE inhibitors (Ramipril), ARBs (Valsartan), CCBs, and diuretics are generally safe. Cardioselective beta-blockers (like Metoprolol, Bisoprolol) may be used with caution if strongly indicated.
21. First line in treatment of hypertension accompanied by acute coronary event:
Explanation: In hypertensive emergencies accompanied by acute coronary syndromes (ACS), intravenous Nitroglycerin is often first-line. It reduces preload and afterload, improves coronary blood flow through vasodilation, and helps control blood pressure. Beta-blockers (like Esmolol or Metoprolol) are also crucial, especially if tachycardia is present, but nitrates are key for ischemia and BP control. Nicardipine (CCB) can be used but nitrates are generally preferred initially in ACS.
22. First line in treatment of hypertension accompanied by acute aortic dissection:
Explanation: The primary goal in acute aortic dissection is to rapidly reduce heart rate (to <60 bpm) and systolic blood pressure (to 100-120 mmHg) to minimize aortic wall shear stress. Intravenous beta-blockers are first-line, with Esmolol often preferred due to its ultra-short half-life allowing for rapid titration. Labetalol (combined alpha/beta blocker) is another excellent first-line option. Vasodilators (like nitroprusside) should only be added *after* beta-blockade is achieved to avoid reflex tachycardia.
23. A 28-year-old pregnant female patient presented to you in the 8th month of gestation with elevated blood pressure. Blood pressure was 165/105 over 2 visits. On examination, bilateral pitting lower limb edema is present. The patient developed severe convulsions (Eclampsia). Which of the following is the correct combination in this emergency?
Explanation: Eclampsia is a life-threatening emergency characterized by seizures in the setting of preeclampsia. The immediate management involves: 1) Seizure control/prophylaxis with intravenous Magnesium Sulfate, and 2) Blood pressure control with agents safe in pregnancy, such as intravenous Labetalol or Hydralazine. Nitroprusside carries risks in pregnancy (cyanide toxicity). Valsartan and Enalapril (RAAS blockers) are contraindicated. Hydrochlorothiazide is generally avoided in preeclampsia/eclampsia due to potential volume depletion.
24. Which of the following anti-hypertensive drugs is contraindicated in the treatment of hypertension with dilated cardiomyopathy(heart failure)?
Explanation: Non-dihydropyridine calcium channel blockers (Non-DHP CCBs) like Verapamil and Diltiazem have significant negative inotropic (reducing contractility) and chronotropic (reducing heart rate) effects. These effects can worsen systolic heart failure (dilated cardiomyopathy). Metoprolol (specifically the succinate, a beta-blocker), Candesartan (an ARB), and Hydrochlorothiazide (a diuretic for volume control) are commonly used in heart failure management (though HCTZ doesn't improve mortality).
25. Which of the following anti-hypertensive drugs most commonly causes facial swelling around the eyes and lips?
Explanation: Facial swelling (angioedema) is a well-known, potentially life-threatening side effect most commonly associated with ACE inhibitors (like Lisinopril). It is thought to be related to the accumulation of bradykinin. While less common, ARBs can also cause angioedema. The other listed drugs are not typically associated with this specific side effect.
26. A 68-year-old man has recently been diagnosed with hypertension and started on monotherapy designed to reduce peripheral resistance and prevent sodium and water retention. Since commencing treatment, he has developed a persistent cough. Which of the following drugs would have the same benefits but would not cause the cough?
Explanation: The description points towards an ACE inhibitor (like Lisinopril) which reduces peripheral resistance (via blocking Angiotensin II formation) and prevents sodium/water retention (via reducing aldosterone), but commonly causes a dry cough due to bradykinin accumulation. An Angiotensin II Receptor Blocker (ARB) like Losartan provides similar blockade of the Renin-Angiotensin-Aldosterone System (RAAS) without affecting bradykinin levels, thus avoiding the cough. Nifedipine (CCB) and Prazosin (alpha-blocker) work differently.
27. A 48-year-old hypertensive man has been successfully treated with a thiazide diuretic for the past 4 years. Over the last 3 months, his diastolic pressure has steadily increased, and he has been started on additional antihypertensive medication. He now complains of sleep disturbances and he is no longer able to complete three sets of tennis. The second antihypertensive medication is most likely which of the following agents?
Explanation: Fatigue, decreased exercise tolerance, and sleep disturbances are well-known potential side effects of beta-blockers, such as Metoprolol. These effects are less common or characteristic of CCBs (Nifedipine), ARBs (Losartan), or ACE inhibitors (Lisinopril).
28. PG is a 67-year-old man with hypertension, asthma, and atrial fibrillation. He is able to walk 6 blocks before stopping to rest, and his echo shows an EF of 57%. His rhythm is irregularly irregular, with a ventricular response between 110-160/min. Which of the following agents would be the safest in treating his hypertension and controlling his ventricular response?
Explanation: This patient needs both blood pressure control and rate control for rapid atrial fibrillation. He also has asthma, making beta-blockers (like Atenolol) relatively contraindicated. Hydrochlorothiazide and Benazepril (ACEi) control BP but not heart rate. Verapamil (a non-DHP CCB) effectively lowers blood pressure and controls heart rate in AFib by slowing AV nodal conduction, and it does not typically worsen asthma. His EF is preserved (57%), so the negative inotropic effect is less concerning than in HFrEF.
29. Hamody is a 62-year-old overweight man recently diagnosed with hypertension(143/92 mm Hg) and type 2 diabetes. Which of the following would be the best drug of first choice to manage his hypertension?
Explanation: For patients with hypertension and type 2 diabetes, ACE inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs) are considered first-line antihypertensive agents due to their proven renal protective benefits in addition to blood pressure lowering. While Beta-blockers and Hydrochlorothiazide (HCTZ) can be used, they are less preferred as initial monotherapy due to potential metabolic side effects. Metformin treats diabetes but is not an antihypertensive.
30. Ronney is a 51-year-old woman who has been on antihypertensive drug therapy for the past 3 months. During her most recent visit, her fasting blood glucose level was found to be 112 mg/dL(above normal). Which agent in an antihypertensive drug regimen would be most likely to have caused her glucose intolerance?
Explanation: Thiazide diuretics, such as Hydrochlorothiazide (HCTZ), are known to potentially impair glucose tolerance and increase blood sugar levels, possibly by affecting insulin sensitivity or secretion, and through effects related to hypokalemia. ACE inhibitors (Lisinopril) and ARBs (Losartan) are generally considered metabolically neutral or even slightly beneficial regarding glucose metabolism. Diltiazem (CCB) is also generally considered metabolically neutral.
31. Julie H is a 32-year-old woman with a history of mild hypertension who is planning to begin a family with her husband in the immediate future. She is currently being treated with Hyzaar(a combination of hydrochlorothiazide and losartan). Which agent could she be switched to that has a well-established track record for safety in the treatment of essential hypertension during pregnancy?
Explanation: ACE inhibitors (ACEI), Angiotensin II Receptor Blockers (ARBs), and Direct Renin Inhibitors (e.g., Aliskiren) are absolutely contraindicated during pregnancy (especially the 2nd and 3rd trimesters) due to the risk of fetal toxicity (renal damage, oligohydramnios, skull hypoplasia). Methyldopa has a well-established track record for safety in the treatment of essential hypertension during pregnancy. Labetalol and long-acting Nifedipine are commonly used and considered safer options for managing hypertension during pregnancy.
32. A 65-year-old patient admitted to the Tulane Emergency Department for severe chest pain is diagnosed with severe hypertension and a dissecting aorta. What i.v. medication would you choose to manage his condition?
Explanation: Sodium nitroprusside is the i.v. medication of choice to manage severe hypertension and a dissecting aorta. It is a potent vasodilator that reduces both preload and afterload, thereby lowering blood pressure rapidly. Atenolol (a beta-blocker) is not suitable for rapid control of severe hypertension in this setting. Furosemide (a loop diuretic) may be used to manage volume overload but is not the primary agent for acute blood pressure control. Phenylephrine is a vasopressor used to raise blood pressure, not lower it.
33. Which of the following classes of antihypertensive drugs is not recommended for initial treatment?
Explanation: Potassium-sparing diuretics (e.g., Spironolactone, Eplerenone) are not recommended for initial treatment of hypertension. They are typically used as add-on therapy in resistant hypertension or in patients with heart failure. Thiazide-type diuretics, ACE inhibitors, and Angiotensin II Receptor Blockers (ARBs) are all recommended as first-line therapies for hypertension.
34. During her annual physical examination, a 45-year-d patient with a history of asthma is found to have an elevated blood pressure. Elevated pressures are confirmed on 2 additional readings in the physician's office. In evaluating therapies for this patient, which class of antihypertensive drugs is contraindicated?
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