1. special considerations for Thiazides: Chlorthalidone is preferred on the basis
of prolonged half-life and proven trial reduction of CVD.
Monitor for hyponatremia and hypokalemia, monitor uric acid and calcium levels.
Use with caution in patients with history of acute gout unless patient is on uric
acid-lowering therapy.
2. special considerations for ACE inhibitors: Do not use in combination with
ARBs or direct renin inhibitor.
There is an increased risk of hyperkalemia, especially in patients with CKD or in
those on K+ supplements or K+-sparing drugs.
There is a risk of acute renal failure in patients with severe bilateral renal artery
stenosis.
Do not use if patient has history of angioedema with ACE inhibitors.
ACE inhibitor cough is common, in 5 to 20 percent of patients, due to bradykinin
production.
Avoid in pregnant females or females of reproductive age without adequate contra-
ception
3. special considerations for Angiotensin receptor blockers: Do not use in
combination with ACE inhibitors or direct renin inhibitor.
There is an increased risk of hyperkalemia in CKD or in those on K+ supplements
or K+-sparing drugs.
There is a risk of acute renal failure in patients with severe bilateral renal artery
stenosis.
Do not use if patient has history of angioedema with ARBs. Patients with a history
,of angioedema with an ACE inhibitor can receive an ARB beginning 6 weeks after
ACE inhibitor is discontinued.
Avoid in pregnant females or females of reproductive age without adequate contra-
ception.
,Lower risk of cough than ACE-Is.
4. special considerations for Calcium channel blockers: Associated with
dose-related pedal edema, which is more common in females than men.
5. When should you Refer to a Nephrologist or Cardiologist in a hypertensive
patient?: -signs of end-organ damage
-evidence of a secondary cause of hypertension
-only on one to two medications
Generally, failure to achieve blood pressure goal in patients who are adhering to
full doses of an appropriate three to four drug regimen that includes a diuretic may
warrant referral to a nephrologist or cardiologist
Before referring, clinicians should first review other causes of inadequate hyperten-
sion control such as:
-Improper blood pressure measurement
-White coat hypertension
-Excess sodium intake
-Medication issues (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit
drugs, sympathomimetics, oral contraceptives)
-Excess alcohol intake
-Underlying identifiable causes of hypertension (secondary hypertension)
6. A researcher is studying potential risk factors for obesity. She sends a
questionnaire to 5000 patients who meet the CDC criteria for obesity that asks
them about sedentary lifestyle factors, consumption of processed food, and
family history of obesity. The researcher sends the same questionnaire to 5000
patients who are not obese. Which of the following best describes the design
of the study?
A. Cross-sectional study
B. Randomized controlled trial
C. Meta-analysis
D. Case-control study: Correct Answer: D. Case-control study
This is a retrospective case-control study. In this observational study design, sub-
jects are selected based on an outcome, and their prior exposures are assessed
and compared to subjects who do not have the particular outcome. The result of
the study is expressed as an odds ratio: OR = (# exposed with disease / # exposed
without disease) / (# not exposed with disease / # not exposed without disease).
A retrospective case-control study does not prove causation but demonstrates an
, association.
Incorrect
Answers:
A. A cross-sectional study is used to assess disease status and risk factors at 1 point
in time.
B. A randomized controlled trial refers to a study where a group is given a treatment
and outcomes are compared against a control group given a placebo or treated with
the standard of care.
C. A meta-analysis provides a statistical analysis of the results of multiple studies.
Vital Concepts:
In an observational study design, subjects are selected based on an outcome, and
their prior exposures are assessed and compared to subjects who do not have a
particular outcome. The result of the study is expressed as an odds ratio: OR = (#
exposed with disease / # exposed without disease) / (# not exposed with disease /
# not exposed without disease). A retrospective case-control study does not prove
causation but demonstrates an association.
7. A 49-year-old female presents to the office with a history of breast cancer
who is having frequent hot flashes who already tried first-line lifestyle changes
without improvement? What is the best treatment for this patient?
A. Hormonal therapy with estrogen and progesterone
B. Bioidentical hormones
C. Citalopram
D. Black cohosh: Correct Answer: C. Citalopram
Selective serotonin reuptake inhibitors (SSRI)s are the most effective pharmacologic
choice for the vasomotor symptoms of menopause. Citalopram is an SSRI that has
good evidence of efficacy against these symptoms and is typically well-tolerated.
Incorrect Answers:
A. Women with a history of breast cancer are not candidates for hormone replace-
ment therapy.
B. "Bioidentical hormones" are compounded mixtures of multiple hormones. There
is no evidence to support their use at this time, and again, hormone treatment would
be contraindicated in a patient with a history of breast cancer.
D. Black cohosh is an herbal remedy marketed for use with hot flashes. However,
it has not been demonstrated to be more effective than a placebo for this use. In
addition, it has been posited to have a possible estrogenic effect on breast tissue,
which should be avoided in patients with a history of breast cancer.
Vital Concepts:
Selective serotonin reuptake inhibitors (SSRI)s are the most effective pharmacologic
of prolonged half-life and proven trial reduction of CVD.
Monitor for hyponatremia and hypokalemia, monitor uric acid and calcium levels.
Use with caution in patients with history of acute gout unless patient is on uric
acid-lowering therapy.
2. special considerations for ACE inhibitors: Do not use in combination with
ARBs or direct renin inhibitor.
There is an increased risk of hyperkalemia, especially in patients with CKD or in
those on K+ supplements or K+-sparing drugs.
There is a risk of acute renal failure in patients with severe bilateral renal artery
stenosis.
Do not use if patient has history of angioedema with ACE inhibitors.
ACE inhibitor cough is common, in 5 to 20 percent of patients, due to bradykinin
production.
Avoid in pregnant females or females of reproductive age without adequate contra-
ception
3. special considerations for Angiotensin receptor blockers: Do not use in
combination with ACE inhibitors or direct renin inhibitor.
There is an increased risk of hyperkalemia in CKD or in those on K+ supplements
or K+-sparing drugs.
There is a risk of acute renal failure in patients with severe bilateral renal artery
stenosis.
Do not use if patient has history of angioedema with ARBs. Patients with a history
,of angioedema with an ACE inhibitor can receive an ARB beginning 6 weeks after
ACE inhibitor is discontinued.
Avoid in pregnant females or females of reproductive age without adequate contra-
ception.
,Lower risk of cough than ACE-Is.
4. special considerations for Calcium channel blockers: Associated with
dose-related pedal edema, which is more common in females than men.
5. When should you Refer to a Nephrologist or Cardiologist in a hypertensive
patient?: -signs of end-organ damage
-evidence of a secondary cause of hypertension
-only on one to two medications
Generally, failure to achieve blood pressure goal in patients who are adhering to
full doses of an appropriate three to four drug regimen that includes a diuretic may
warrant referral to a nephrologist or cardiologist
Before referring, clinicians should first review other causes of inadequate hyperten-
sion control such as:
-Improper blood pressure measurement
-White coat hypertension
-Excess sodium intake
-Medication issues (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit
drugs, sympathomimetics, oral contraceptives)
-Excess alcohol intake
-Underlying identifiable causes of hypertension (secondary hypertension)
6. A researcher is studying potential risk factors for obesity. She sends a
questionnaire to 5000 patients who meet the CDC criteria for obesity that asks
them about sedentary lifestyle factors, consumption of processed food, and
family history of obesity. The researcher sends the same questionnaire to 5000
patients who are not obese. Which of the following best describes the design
of the study?
A. Cross-sectional study
B. Randomized controlled trial
C. Meta-analysis
D. Case-control study: Correct Answer: D. Case-control study
This is a retrospective case-control study. In this observational study design, sub-
jects are selected based on an outcome, and their prior exposures are assessed
and compared to subjects who do not have the particular outcome. The result of
the study is expressed as an odds ratio: OR = (# exposed with disease / # exposed
without disease) / (# not exposed with disease / # not exposed without disease).
A retrospective case-control study does not prove causation but demonstrates an
, association.
Incorrect
Answers:
A. A cross-sectional study is used to assess disease status and risk factors at 1 point
in time.
B. A randomized controlled trial refers to a study where a group is given a treatment
and outcomes are compared against a control group given a placebo or treated with
the standard of care.
C. A meta-analysis provides a statistical analysis of the results of multiple studies.
Vital Concepts:
In an observational study design, subjects are selected based on an outcome, and
their prior exposures are assessed and compared to subjects who do not have a
particular outcome. The result of the study is expressed as an odds ratio: OR = (#
exposed with disease / # exposed without disease) / (# not exposed with disease /
# not exposed without disease). A retrospective case-control study does not prove
causation but demonstrates an association.
7. A 49-year-old female presents to the office with a history of breast cancer
who is having frequent hot flashes who already tried first-line lifestyle changes
without improvement? What is the best treatment for this patient?
A. Hormonal therapy with estrogen and progesterone
B. Bioidentical hormones
C. Citalopram
D. Black cohosh: Correct Answer: C. Citalopram
Selective serotonin reuptake inhibitors (SSRI)s are the most effective pharmacologic
choice for the vasomotor symptoms of menopause. Citalopram is an SSRI that has
good evidence of efficacy against these symptoms and is typically well-tolerated.
Incorrect Answers:
A. Women with a history of breast cancer are not candidates for hormone replace-
ment therapy.
B. "Bioidentical hormones" are compounded mixtures of multiple hormones. There
is no evidence to support their use at this time, and again, hormone treatment would
be contraindicated in a patient with a history of breast cancer.
D. Black cohosh is an herbal remedy marketed for use with hot flashes. However,
it has not been demonstrated to be more effective than a placebo for this use. In
addition, it has been posited to have a possible estrogenic effect on breast tissue,
which should be avoided in patients with a history of breast cancer.
Vital Concepts:
Selective serotonin reuptake inhibitors (SSRI)s are the most effective pharmacologic
