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Cardiovascular Pharmacology- Part 2
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1.A woman has received a cardiovascular drug that i s absolutely contraindicated (category X) in pregnancy, but in the absence of pregnancy would have been deemed beneficial because of a particular cardiovascular disorder she Unfortunately, neither she nor her physician (whom she rarely vis i ted) knew she was pregnant until she had just started the second trimester. The drug i s stopped (and a suitable and safer alternative i s started), but i t i s too late. Her baby i s delivered prematurely, and sti l lborn. It i s obvious from examination of the baby that there i s a nasal deformity: the nose i s flattened into the face, with no apparent bridge. Standard x-rays reveal stippling of all the epiphyses. These responses are characteristic of which drug?
- Heparin, low molecular weight (eg, enoxaparin)
2. A patient who has been taking an oral antihypertensive drug for about a year develops a positive Coombs’ test, and now you are worried about the possibility (although low) that hemolytic anemia may develop i f the drug i s Which drug was the most l ikely cause?
3. A patient presents with severe hypertension and Blood chemistry results, radiologic studies, and the overall cl inical presentation point to pheochromocytoma. The tumor appears operable, but the patient will have to wait a couple of weeks for the adrenalectomy. We prescribe phenoxybenzamine in the interim, with the goal of suppressing some of the major s igns and symptoms caused by the tumor and the massive amounts of epinephrine i t i s releasing. Which of the following best summarizes what phenoxybenzamine does, or how i t acts?
- Controls blood pressure by blocking α-adrenergic receptors in the peripheral vasculature
- Controls heart rate by selectively blocking β1-adrenergic receptors
- Inhibits catecholamine synthesis in the adrenal (suprarenal) medulla
- Lowers blood pressure by inhibiting angiotensin converting enzyme
- Stimulates catechol-O-methyltransferase, thereby facilitating epinephrine’s metabolic inactivation
4. A 30-year-old man who has a history of asthma has just been diagnosed Stage 1 essential He regularly uses an inhaled corticosteroid, which seems to work well as a control medication, but also needs to use an albuterol inhaler about once every 3 weeks for suppression of asthma attacks (rescue therapy). Which antihypertensive drug or drug class poses the greatest ri sk of exacerbating the patient’s asthma and counteracting the desired pulmonary effects of the albuterol, even though i t might control his blood pressure well?
5. Digoxin affects a host of cardiac electrophysiologic Some of i ts effects are caused directly by the drug. Others are indirect: they may involve increasing “vagal tone” to the heart or other compensations that arise when cardiac output i s improved in a patient with heart failure. For some parameters the direct and indirect effects may be qualitatively (but not quantitatively) opposing, but one will predominate over the other. What i s an expected and usually predominant effect of the drug?
- Increased rate of SA nodal depolarization
- Reduced atrial automaticity
- Reduced ventricular automaticity
- Slowed AV nodal conduction velocity
- Slowed conduction velocity through the atrial myocardium and His-Purkinje system
6. A patient has Stage 2 essential hypertension and heart After evaluating the responses to many other antihypertensive drugs, alone and in combination, the physician concludes that i t would be reasonable to try hydralazine. Which drug(s) i s/are l ikely to be needed, as add-ons (adjuncts), to manage the expected and unwanted cardiovascular and renal s ide effects of the hydralazine?
- Captopril plus nifedipine
- Digoxin plus spironolactone
- Digoxin plus vi tamin K
- Hydrochlorothiazide and a β-blocker Nitroglycerin
- Triamterene plus amiloride
7. A healthy adult subject participating in a cl inical trial i s given an intravenous injection of a test Both blood pressure and total peripheral resistance ri se promptly. This i s followed immediately by a reduction of heart rate. In repeated experiments we find that the vasopressor response i s not affected by pretreatment with prazosin. However, pretreatment with atropine prevents the cardiac chronotropic response. The test drug was most l ikely which of the following?
- Angiotensin II
8. We are administering nitroprusside intravenously for control of severe hypertension during The dose has gotten too high, and the drug has been administered too long. Refractoriness to the antihypertensive effects has occurred. Blood pressure i s ri s ing, and other s igns and symptoms of potentially severe toxicity develop. What nitroprusside metabolite accounts for or at least contributes to these problems?
- A highly efficacious α-adrenergic agonist
- An extraordinarily potent and i rreversible Na-K-ATPase inhibitor
- An i rreversible antagonist for angiotensin at the A-II receptors
- Nitric oxide
9. A 66-year-old man who l ives in a small rural town, and who has been treated by his family doctor for decades, presents at your medical He has coronary atherosclerosis and “mild” heart failure that has been treated for the last 10 years with digoxin and several other drugs. His chief complaints are nausea, vomiting, and diarrhea, which have not resolved despite a recommendation from his physician to take prescription medications for those conditions. His ECG reveals a bigeminal rhythm and second-degree heart block. A drug-drug interaction i s suspected. What coadministered drug most l ikely provoked the problem?
10. We have a patient who i s diagnosed with variant (vasospastic) Which drug would be most appropriate, and generally regarded as most effective, for long-term therapy aimed at reducing the incidence or severity of the coronary vasospasm?
11. A 56-year-old man has heart His family doctor, who has been treating him s ince he was a young lad, has been treating him with digoxin, furosemide, and triamterene for several years. The patient now develops atrial fibrillation, and so his doctor starts quinidine and clopidogrel. What i s the most l ikely outcome of adding the quinidine?
- Development of s igns and symptoms of quinidine toxicity (cinchonism)
- Hyponatremia due to quinidine’s ability to enhance diuretic-induced sodium loss
- Onset of s igns and symptoms of digoxin toxicity
- Precipitous development of hypokalemia
- Prompt suppression of cardiac contractility, onset of acute heart failure
12. Flecainide and propafenone are in Vaughan-Williams (antiarrhythmic) Class I-C. What i s the cl inically relevant “take home” message about this class of drugs?
- Are only given for arrhythmias during acute myocardial infarction
- Are particularly suited for patients with low ejection fractions or cardiac output
- Are preferred drugs (drugs of choice) for relatively innocuous ventricular arrhythmias
- Cause pulmonary fibrosis and a hypothyroid-like syndrome when given long term
- Have a s ignificant pro-arrhythmic effect (induction of lethal arrhythmias)
13. You want to compare and contrast the cardiac and hemodynamic profiles of immediate-acting dihydropyridine-type calcium channel blockers (CCBs) and the nondihydropyridine, verapamil (or diltiazem). Which of the following best summarizes how, in general, a nondihydropyridine CCB differs from nifedipine?
- Causes a much higher incidence of reflex tachycardia
- Causes s ignificant dose-dependent s lowing of AV nodal conduction velocity
- Causes s ignificant venodilation, leading to profound orthostatic hypotension
- Has s ignificant and direct positive inotropic effects
- Is best used in conjunction with a β-blocker or digoxin
14. A patient has received excessive doses of nitroprusside, and toxic manifestations are developing in response to a Which of the following drugs or drug groups would be most effective in l imiting and ultimately counteracting the effects of the toxic product?
- Aminocaproic acid
- Protamine sulfate
- Vitamin K
15. A patient with Stage 2 essential hypertension i s treated with usually effective doses of an ACE After a suitable period of time, blood pressure has not been lowered satisfactorily. The patient has been compliant with drug therapy and other recommendations (eg, weight reduction, exercise). A thiazide i s added to the ACE inhibitor regimen. What i s the most l ikely and earliest (and probably transient) untoward outcome of this drug add-on, for which you should monitor closely?
- Fall of blood pressure sufficient to cause syncope
- Hypokalemia due to synergistic effects of the ACE inhibitor and the thiazide on renal potassium excretion
- Onset of acute heart failure from depression of ventricular contractility
- Paradoxical hypertensive cris i s
- Sudden prolongation of the P-R interval and increasing degrees of heart block
16. A 45-year-old man postmyocardial infarction (MI) i s being treated with several drugs, including intravenous unfractionated Stool guaiac on admission was negative, but i s now 4+, and he has had an episode of hematemesis. What would be the best drug to administer to counteract the effects of excessive heparin remaining in the ci rculation?
- Aminocaproic acid
- Factor IX
- Protamine sulfate
- Vitamin K
17. A 45-year-old man asks his physician for a prescription for s i ldenafil to improve his sexual Because of ri sks from a serious drug interaction, this drug should not be prescribed, and the patient should be urged not to try to obtain i t from other sources, i f he i s also taking which of the following drugs?
- Angiotensin-converting enzyme inhibitor
- β-Adrenergic blocker
- Nitrovasodilator (eg, nitroglycerin)
- Statin-type antihypercholesterolemic drug.
- Thiazide or loop diuretic
18. A physician i s preparing to administer a drug for which there i s a label warning: “do not administer this drug to patients with second-degree or greater heart block, or give with other drugs that may cause heart ” Which finding would be specifically indicative of heart block, and second-degree heart block in particular?
- Auscultation of the precordium reveals an i rregular rhythm
- Blood pressure i s low
- Heart rate i s abnormally low (bradycardia), but there i s normal s inus rhythm
- ECG reveals ventricular ectopic beats
- ECG shows an excessively prolonged PR interval, and some P waves are not followed by a normal QRS complex
- ECG shows abnormally widened QRS complexes
19. A 52-year-old woman with essential hypertension, hypercholesterolemia, and chronic-stable angina develops severe It i s attributed to one of her medications. What was the most l ikely cause?
20. We use standard invasive hemodynamic techniques to measure or calculate the effects of various drugs on such parameters as arterial pressure, total peripheral resistance, and central venous (right atrial) Our goal i s to evaluate whether the drug primarily causes arteriolar or venular dilation, or affects both s ides of the ci rculation. Which drug exerts vasodilator effects only in the arterial s ide of the ci rculation?
21. A 20-year-old collegiate varsity hockey player i s referred to you by his The young athlete has excessive bruising after a very physical match 2 days before. His knee had been bothering him, so he took two 325 mg aspirin tablets several hours before the contest. He got checked hard into the boards many times during the game, but denies any excessive or unusual trauma. As you ponder the s i tuation you order several blood tests. Which test or finding do you most l ikely expect to be abnormal as a result of the prior aspirin use?
- Activated partial thromboplastin time (APTT)
- Bleeding time
- INR (International Normalized Ratio)
- Platelet count
- Prothrombin time