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Old 10-23-2011
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Heart Cardiology 5 Questions(I) 10/23

1.A patient of yours returns for a followup visit after being discharged from the hospital. She is well known to you and is followed in clinic for recently diagnosed diabetes mellitus type 2 and essential hypertension. At her last visit you switched her from hydrochlorothiazide to enalapril. Approximately 3 days after starting therapy, however, the patient began to develop facial swelling that progressed to a stridorous shortness of breath. She was admitted to the hospital for close observation and was told to discontinue enalapril. She was advised to discuss which medications to take with her primary care physician. Which of the following is the most appropriate antihypertensive medication for this patient?
A. Captopril
B. Hydrochlorothiazide
C. No medications
D. Restart enalapril
E. Valsartan

2.A 36-year-old woman with known mitral valve prolapse and regurgitation calls your clinic. She leaves a message requesting information about an antibiotic prescription. She has a root canal and likely tooth extraction planned for the upcoming week, and wants to know if she needs antibiotics before then. If she needs antibiotics, she would like you to call a prescription into the pharmacy for her. Because this patient has been seen in your clinic for the last 10 years you know her well, and you last saw her a month ago.
You remember that she has no antibiotic allergies and has an incompetent mitral valve, with echocardiography-confirmed regurgitation and valve thickening, for years. Which of the following is the most appropriate course of action at this time?
A. Ask the patient to come in for physical examination before any antibiotic treatment
B. Call in a prescription for amoxicillin 2 g PO, taken 1 hour before the procedure
C. Discuss alternative dental surgery options with the patientís dentist
D. Phone the pharmacy with a prescription for clindamycin of 1-week duration
E. Return the patientís call and advise her that the situation does not warrant antibiotic therapy

3.A 72-year-old man with a history of hypertension, hyperlipidemia, and mild aortic stenosis comes to the emergency department because of new onset chest pain with exertion. His chest pain developed 2 weeks ago and has occurred with four blocks of walking. Before his chest pain started, he was extremely active in his community and was able to perform 20 minutes of walking 4 days each week. His medication included atenolol and hydrochlorothiazide for blood pressure and simvastatin for cholesterol. His temperature is 37.0 C (98.6 F), blood pressure is 150/56 mm Hg, pulse is 83/min, and respirations are 13/min. Physical examination reveals an elderly man in no acute distress. He has no jugular venous distension. His carotid upstroke is slowed. His lungs have a few scattered bibasilar crackles. His heart is regular with a long, late peaking, systolic murmur heard at the right upper sternal border. The murmur radiates to his
carotids. His S2 is paradoxically split. An S4 is appreciated. His murmur decreases with a Valsalva maneuver. He has no lower extremity edema. An echocardiogram reveals worsening of his aortic stenosis compared with a previous study with a valve area of 0.7 cm. Which of the following is the most appropriate management at this time?
A. Add furosemide to his outpatient medication regimen
B. Add long acting nitrates to his outpatient regimen
C. Refer him for balloon valvuloplasty of his aortic valve
D. Refer him for surgical valve replacement
E. Repeat the echocardiogram in 3-6 months

4.A 72-year-old man with long-standing essential hypertension is brought to the emergency department suffering from palpitations and a headache. At the time of arrival, he is found to have a blood pressure of 210/120 mm Hg, proteinuria confirmed by dipstick, and funduscopic findings of atrioventricular (AV) nicking and papilledema. When told his blood pressure, the patient is shocked. He has never had a systolic blood pressure, even before treatment, of greater than 175 mm Hg. He states that he normally takes a variety of hypertensive medications, none of which he brought with him, but ran out of ďone or two of themĒ last night. Which of the following antihypertensive medications if abruptly stopped is most likely to cause this patientís symptoms?
A. Atenolol
B. Clonidine
C. Felodipine
D. Hydrochlorothiazide
E. Lisinopril

5.A 70-year-old woman comes to the office with increasing exertional chest discomfort. She also reports recent shortness of breath. Her past medical history is notable for diabetes mellitus, and a nonĖQ-wave myocardial infarction 2 years before this presentation. Her current medications include sublingual nitroglycerin, aspirin, metformin, and atorvastatin. On examination, her blood pressure is 140/95 mm Hg and pulse is 75/min. Her cardiac and lung examinations are unremarkable. Her lipid panel is within normal limits. Her stress test is positive for inferior reversible ischemia. She undergoes coronary arteriography that reveals a 50% lesion in the right coronary artery. Which of the following is the appropriate management?
A. Amlodipine 5 mg daily
B. Atenolol 50 mg daily
C. Diltiazem of 25 mg daily
D. Isosorbide dinitrate 10 mg twice today only
E. Terazosin 5 mg daily
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Old 10-23-2011
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E. Valsartan
B. Call in a prescription for amoxicillin 2 g PO, taken 1 hour before the procedure
D. Refer him for surgical valve replacement
B. Clonidine
B. Atenolol 50 mg daily
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E
e
d
b
b
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B. Hydrochlorothiazide
A. Ask the patient to come in for physical examination before any antibiotic treatment
D. Refer him for surgical valve replacement

B. Clonidine
B. Atenolol 50 mg daily
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1.e
2.b
3.d
4.?
5.b
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Quote:
Originally Posted by jaimin View Post
B. Hydrochlorothiazide
A. Ask the patient to come in for physical examination before any antibiotic treatment
D. Refer him for surgical valve replacement

B. Clonidine
B. Atenolol 50 mg daily
Q 1. After side effects from ACE inhibitors, next step is to start ARBs not hydrochlorothiazide.

Q2. Please explain why we should we not just prescribe her when we already saw her a month ago.

Q 4. What is the explanation?
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B- ACE and ARB both cause angioedema so switching not really uselful

E- MVP no prophylaxis (no valvular disease is prophylaxed unless history of endocarditis) shortcut to remember prophylax cyanotic diseases only(generally)

D- AS when becomes symptomatic valve is replaced

B-clondiine alpha 2 agonist- withdrawl = rebound sympathetic increase

B- atenolol- yes its a beta blocker and automatic thought is masking signs of hypoglycemia but still its first line drug in decreasing mortality.
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Quote:
Originally Posted by docnas View Post
B- ACE and ARB both cause angioedema so switching not really uselful

E- MVP no prophylaxis (no valvular disease is prophylaxed unless history of endocarditis) shortcut to remember prophylax cyanotic diseases only(generally)

D- AS when becomes symptomatic valve is replaced

B-clondiine alpha 2 agonist- withdrawl = rebound sympathetic increase

B- atenolol- yes its a beta blocker and automatic thought is masking signs of hypoglycemia but still its first line drug in decreasing mortality.


i thought AT antagonists do not cause angiedema???
n MR doesnt require prophylaxis??
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Old 10-23-2011
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Can you prescribe ARB to a patient with ACE-inhibitor-related angioedema?


Yes, but only for populations that have demonstrated a clear benefit from angiotensin II antagonism, for example, patients with CHF and CKD.

The above recommendation has been adopted by the National Kidney Foundation guidelines and the American College of Cardiology and American Heart Association (ACC/AHA) consensus guidelines. Given the strong potential for harm with drug-induced angioedema, however, close monitoring is necessary to ensure that repeat angioedema does not occur with ARB.

==The above is a quote from one of the articles i found but from my own memory i remember reading/hearing it somewhere along my studies from either Uwolrd/kaplan vids that ACEs angioedema is also seen with ARBs ==

Endocarditis prophylaxis- according to MTB-ck pg 32( and on usmle world i was able to answer the questions correctly using this )

-Have to show 2 things
1) significant cardiac defect
2) Risk of bacterimia

risk of bacterimia = dental work with blood, Resp tract surgery -(all the GI and GU procedures were ruled out as risks)

Cardiac defects=
1) prosthetic valves
2) Hx of endocarditus
3) Cardiac transplant pt
4) Unrepaired Cyanotic Heart Disease

It specifically rules out all valvlar stenosis and regurges and MVP ,ASD HOCM

Last edited by docnas; 10-23-2011 at 11:08 AM.
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Old 10-23-2011
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Quote:
Originally Posted by witecloud View Post
Q 1. After side effects from ACE inhibitors, next step is to start ARBs not hydrochlorothiazide.

Q2. Please explain why we should we not just prescribe her when we already saw her a month ago.

Q 4. What is the explanation?
I have not started prep yet,these are my guess according to what i remember during school study.

1- i think enalapril and losartan/valsartan both causes angioedema.
2- Just call in pharmacy to give drug ,is unethical .
4- clonidine prone to cause drug withdrawl symptoms.
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1.The correct answer is B. This patient had an episode of ACE inhibitor-related angioedema. Although originally believed related solely to bradykinin-mediated effects, which are magnified by ACE inhibition, there are unfortunately reports of angioedema from angiotensin receptor blockers also, such as valsartan (choice E). As such, the best treatment for this patientís hypertension is to avoid ACE inhibitors, such as captopril (choice A) and certainly enalapril (choice D), and restart hydrochlorothiazide.
Although treatment with hydrochlorothiazide will not provide the same benefits as an ACE inhibitor, controlling hypertension has been shown to reduce progression to diabetic nephropathy and is certainly preferable to no treatment (choice C).

2.The correct answer is B. This patient needs antimicrobial prophylaxis to reduce her risk of endocarditis. She has a valve that is predisposed to bacterial infection caused by the transient bacterial seeding of the blood that occurs during invasive dental procedures. The treatment of choice in patients without a penicillin allergy is amoxicillin.
There is no reason to repeat the physical examination (choice A). The patient was just in the clinic a month ago, is asking for a medication for a known condition, and is not at risk for being lost to follow-up.
Although this particular dental work places the patient at risk for infective endocarditis, the risk is still a small one that can be mitigated with antimicrobial therapy. There is no reason to discuss alternative dental surgery (choice C).
Clindamycin (choice D) is commonly used for this purpose in patients who have a penicillin allergy. It can be taken 1 hour before the procedure, but is not needed for a whole week before the procedure.
Her condition does warrant antimicrobial prophylaxis therefore choice E is incorrect.

3.The correct answer is D. This patient has symptomatic aortic stenosis (AS). Medical management is ineffective for this condition. Symptoms of AS include chest pain and shortness of breath with exertion, syncope, and signs of left heart failure. It is best to treat these patients with valve replacement when their valve area is less than 0.8 cm. If valve replacement is delayed until the development of symptoms, operative mortality is higher. Once a patient with AS becomes symptomatic, surgical therapy if tolerated is most appropriate.
Furosemide (choice A) can be used carefully to manage CHF while awaiting valve replacement, but care must be taken not to diurese aggressively to avoid hypotension. This patient is symptomatic from AS and therefore cannot be sent home with an outpatient furosemide regimen.
The same is true for outpatient nitrates (choice B). Our patient has chest pain from his severe AS and needs surgery. Outpatient nitrates would be suboptimal therapy and would be potentially dangerous because they can cause hypotension.
Balloon valvuloplasty (choice C) is not first-line treatment for symptomatic AS. Although it provides some immediate relief of symptoms, the complication rate is greater than 10%. In addition, within 6-12 months restenosis and clinical deterioration is seen in many patients. This procedure should be reserved for those patients who cannot tolerate surgery (very advanced age or comorbidity) or those patients who need a ―bridge‖ to surgery.
This patientís echocardiogram revealed a valve area of 0.7 cm. The normal cutoff for severe AS is 0.8 cm or less. In addition, this patient has symptoms of AS. Watchful waiting with repeat echocardiograms (choice E) is inappropriate.


4.The correct answer is B. Clonidine is a short-acting sympathetic blocker that acts by central alpha-adrenergic stimulation. Abrupt cessation can cause a rebound hypertension that is greater than the patientís original blood pressure range. If clonidine is used for outpatient therapy, it often is used in a transdermal form to minimize the possibility of rebound hypertension.

Atenolol (choice A), if stopped abruptly, can cause an increase in blood pressure. It is much less likely than clonidine to cause sympathetic rebound hypertension, however, as its long half-life provides a slow taper.

Other agents, including long-acting calcium channel blockers (choice C), thiazide diuretics (choice D), and ACE inhibitors (choice E) usually do not cause severe rebound hypertension.

5.The correct answer is B. Given this patientís history of coronary artery disease, a long-acting beta-blocker is an important component of her medical regimen. Use of beta-blockers may mask hypoglycemia. However, if the patient is vigilant about monitoring glucose levels with finger-sticks, then this problem can be avoided. Studies have proven the mortality benefit of long-acting beta-blockers in patients with coronary artery disease.

Amlodipine (choice A) is a good medication in the management of hypertension. However, studies do not conclusively indicate that it decreases mortality that is specific to coronary artery disease.

Similarly, diltiazem (choice C) can be used for hypertension control. However, if the patient is unable to tolerate beta-blockers, then a calcium channel blocker should be considered.

Nitrates such as isosorbide dinitrate (choice D) help increase coronary perfusion. However, it is more important that this patient be placed on a beta-blocker first. Thereafter, a nitrate may be added to her regimen.

Alpha-blockers such as terazosin (choice E) have not been conclusively shown to have a mortality benefit in patients with coronary disease
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Old 10-23-2011
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i thought thiazides r contraindicated in diabetics...???bt anyway given these options i think hydrochlorthiazide is the most likely answer...
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Old 10-24-2011
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@drnpatel

http://emedicine.medscape.com/articl...view#aw2aab6b2

http://www.medscape.org/viewarticle/555596

these are the current guidelines of endocarditus prophylaxis recommendations which are whats found in MTB-CK . I guess kaplan hasnt updated their qbank to follow the new recomendations so dont make a mistake because of them.

Antibiotic prophylaxis is indicated for the following high-risk cardiac conditions:

Prosthetic cardiac valve

History of infective endocarditis

Congenital heart disease (CHD) (except for the conditions listed, antibiotic prophylaxis is no longer recommended for any other form of CHD): (1) unrepaired cyanotic CHD, including palliative shunts and conduits; (2) completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure; and (3) repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization)

Cardiac transplantation recipients with cardiac valvular disease
---

This is a quote from emedicine check out the first link for the full article
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