QUESTION: 137

A 74-year-old male with gout, osteoporosis, and type II diabetes presents for routine followup. As you review his medication list you note that he is on insulin, vitamin D, glypizide, quinidine, and allopurinol. You now diagnose him with hypertension that requires pharmacologic management. Which of the following medications would be contraindicated in this patient?

enalapril
hydrochlorothiazide
diltiazem
losartan
atenolol

Answer(s): B

Explanation:

Quinidine can prolong the Q-T interval resulting in the development of polymorphic ventricular tachycardia (torsade de pointes). Hypokalemia, a side effect of thiazide diuretics, increases the risk of torsade de pointes, which can then degenerate into fatal ventricular fibrillation. Thiazide diuretics may decrease the effectiveness of uricosuric agents, insulin, and sulfonylureas and may increase the effects of vitamin D.
However, these effects tend not to be life threatening

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QUESTION: 138

A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms.

Which of the following best describes the severity of this patient's angina?

class I
class II
class III
class IV
Prinzmetal angina

Answer(s): C

Explanation:

Two generally accepted conventions for grading the severity of angina pectoris are those of the Canadian Cardiovascular Society (CCS) and the NYHA. The NYHA classification attempts to quantify the functional limitations imposed on an individual by their symptoms. Class I angina is defined as angina which does not appear as a patient undertakes ordinary physical activity. Symptoms caused by ordinary physical activity characterize class II angina. In class III angina, there is a moderate limitation of activity such that a patient remains comfortable at rest but symptoms appear during less-than- ordinary activities. In class IV angina, symptoms are present at rest so a patient is unable to perform any physical activity without feeling discomfort. Prinzmetal angina describes a syndrome of ischemic pain occurring at rest but not necessarily with exertion; it is diagnosed with detection of transient ST-T elevation with rest pain.

The goal of treatment of angina is to relieve symptoms and prolong exercise capacity by improving the relationship of oxygen demand and supply. Nitroglycerin is a smooth muscle relaxant that produces both venodilation (reduced preload) and arteriolar dilation (reduced afterload). Although the combined effect is to reduce myocardial oxygen demands, the potential exists for reflex tachycardia and increased contractility. To avoid the potential for increased oxygen demand and decreased coronary blood flow, a beta-blocker such as propranolol may be used concurrently with nitroglycerin. Another option is the careful titration of the nitroglycerin dose used. Discontinuation of nitroglycerin without further intervention would inappropriately leave the patient's angina pain untreated. Replacing nitroglycerin with the calcium channel blocker nifedipine may not address the problem of reflex tachycardia as nifedipine can also lead to a rapid vasodilation and subsequent drop in blood pressure (which, in turn, leads to increased sympathetic outflow and an increase in heart rate). Addition of isoproterenol would be inappropriate since it increases myocardial oxygen demand.

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QUESTION: 139

A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms.
The patient states that shortly after selfadministering nitroglycerin, his heart feels like it races. He does not notice this sensation at any other times. Which of the following interventions would be most appropriate for counteracting this phenomenon?

discontinue nitroglycerin
increase the dose of nitroglycerin used
use nifedipine instead of nitroglycerin
continue nitroglycerin and start isoproterenol
continue nitroglycerin and start propranolol

Answer(s): E

Explanation:

Two generally accepted conventions for grading the severity of angina pectoris are those of the Canadian Cardiovascular Society (CCS) and the NYHA. The NYHA classification attempts to quantify the functional limitations imposed on an individual by their symptoms. Class I angina is defined as angina which does not appear as a patient undertakes ordinary physical activity. Symptoms caused by ordinary physical activity characterize class II angina. In class III angina, there is a moderate limitation of activity such that a patient remains comfortable at rest but symptoms appear during less-than- ordinary activities. In class IV angina, symptoms are present at rest so a patient is unable to perform any physical activity without feeling discomfort. Prinzmetal angina describes a syndrome of ischemic pain occurring at rest but not necessarily with exertion; it is diagnosed with detection of transient ST-T elevation with rest pain.

The goal of treatment of angina is to relieve symptoms and prolong exercise capacity by improving the relationship of oxygen demand and supply. Nitroglycerin is a smooth muscle relaxant that produces both venodilation (reduced preload) and arteriolar dilation (reduced afterload). Although the combined effect is to reduce myocardial oxygen demands, the potential exists for reflex tachycardia and increased contractility. To avoid the potential for increased oxygen demand and decreased coronary blood flow, a beta-blocker such as propranolol may be used concurrently with nitroglycerin. Another option is the careful titration of the nitroglycerin dose used. Discontinuation of nitroglycerin without further intervention would inappropriately leave the patient's angina pain untreated. Replacing nitroglycerin with the calcium channel blocker nifedipine may not address the problem of reflex tachycardia as nifedipine can also lead to a rapid vasodilation and subsequent drop in blood pressure (which, in turn, leads to increased sympathetic outflow and an increase in heart rate). Addition of isoproterenol would be inappropriate since it increases myocardial oxygen demand.

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QUESTION: 140

A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms.

The patient undergoes a cardiac catheterization and is found to have 70% narrowing of the left anterior descending and proximal left circumflex arteries. Which of the following would be the most appropriate management of this condition?

percutaneous transluminal coronary angioplasty (PTCA)
medical management with a beta-blocker, statin, and aspirin
medical management with an ACE inhibitor, statin, and aspirin
referral for coronary artery bypass grafting (CABG)
placement of a cardiac defibrillator

Answer(s): D

Explanation:

Two generally accepted conventions for grading the severity of angina pectoris are those of the Canadian Cardiovascular Society (CCS) and the NYHA. The NYHA classification attempts to quantify the functional limitations imposed on an individual by their symptoms. Class I angina is defined as angina which does not appear as a patient undertakes ordinary physical activity. Symptoms caused by ordinary physical activity characterize class II angina. In class III angina, there is a moderate limitation of activity such that a patient remains comfortable at rest but symptoms appear during less-than- ordinary activities. In class IV angina, symptoms are present at rest so a patient is unable to perform any physical activity without feeling discomfort. Prinzmetal angina describes a syndrome of ischemic pain occurring at rest but not necessarily with exertion; it is diagnosed with detection of transient ST-T elevation with rest pain.

The goal of treatment of angina is to relieve symptoms and prolong exercise capacity by improving the relationship of oxygen demand and supply. Nitroglycerin is a smooth muscle relaxant that produces both venodilation (reduced preload) and arteriolar dilation (reduced afterload). Although the combined effect is to reduce myocardial oxygen demands, the potential exists for reflex tachycardia and increased contractility. To avoid the potential for increased oxygen demand and decreased coronary blood flow, a beta-blocker such as propranolol may be used concurrently with nitroglycerin. Another option is the careful titration of the nitroglycerin dose used. Discontinuation of nitroglycerin without further intervention would inappropriately leave the patient's angina pain untreated. Replacing nitroglycerin with the calcium channel blocker nifedipine may not address the problem of reflex tachycardia as nifedipine can also lead to a rapid vasodilation and subsequent drop in blood pressure (which, in turn, leads to increased sympathetic outflow and an increase in heart rate). Addition of isoproterenol would be inappropriate since it increases myocardial oxygen demand.

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