A common lab findings with ACE Inhibitors -------- Correct Answer--------- Increase K+
ACE inhibitor =
retention of potassium.
Measure potassium one month after starting and one month after changing a dose
What should you do?
Pt on Monopril and HCTZ for hypertension. His blood pressure is 160-170/92-98 on
several blood pressure checks
? Would you add an ARB? -------- Correct Answer -------- If these are at maximum doses,
consideration should be given to adding a medication from a different class.
CALCIUM CHANNEL BLOCKER
NOT ARB - Adding an ARB may result in a precipitous decrease in his blood pressure
because he takes an ACE inhibitor and both of these medications work in the renin-
angiotensin-aldosterone system.
Significance of sildenafil and any blood pressure meds -------- Correct Answer -------- Any
antihypertensive medication .... could have an additive effect with sildenafil (or another
medication in this
A specific drug-drug interaction to be aware of is the one that can occur with sildenafil
and alpha blockers like tamsulosin, alfuzosin, prazosin, doxazosin, or terazosin. This
combination of medications may increase the risk of symptomatic hypotension because
the effect of these two drugs is additive
-------- Correct Answer -------- Consider two meds
low dose HCTZ and ARB or ace
This patient's blood pressure goal is < 140/90 according to JNC VIII. Since he is more
than 20 points above systolic goal (or greater than 10 points above diastolic goal) it is
reasonable to consider two medications
Risk assessment for dyslipidemia- what age to start assessment --------- Correct Answer
------- Start at age 2
,Dyslipidemia assessment does not necessarily mean a Dyslipidemia assessment refers
to assessing family history of dyslipidemia, premature cardiovascular disease, or
diabetes, body mass index > 85% for age and sex, or history of other systemic diseases
like Kawasaki Disease or treatment, or renal disease.
When to start lipid profiles -------- Correct Answer -------- recommended between 18 and
21 years of age.
A patient taking an ACE inhibitor should avoid: -------- Correct Answer -------- No K
supplements
ACE inhibitor potentially can produce hyperkalemia because its mechanism of action is
in the renin-angiotensin-aldosterone system where potassium is spared. If potassium is
taken in the form of potassium supplements, the effect will be additive and the risk of
hyperkalemia can be great.
An 80 year-old female who is otherwise well, has a blood pressure of 176/80. How
should she be managed pharmacologically? -------- Correct Answer -------- CCB
This patient has isolated systolic hypertension (ISH). This is common in older adults and
is associated with tragic cardiac and cerebrovascular events. The drug class of choice
to treat these patients is a long-acting calcium channel blocker. The class of calcium
channel blockers recommended for ISH has the suffix "pine" (amlodipine, felodipine,
etc).
Remember
ISH = PINE
ACE inhibitor is specifically indicated in patients who have . ---------- Correct Answer
------- hypertension, diabetes with proteinuria, heart failure.
77 year-old patient has had an increase in blood pressure since the last exam. The
blood pressure has risen to 168/88 with 2 readings. The last exam's reading was
144/90. If medication is to be started on this patient, what would be a good first choice?
-------- Correct Answer -------- CCB
This patient is 77 years old and should have a goal blood pressure of < 150/90. A
thiazide diuretic is not a good first choice in this patient because it will not be potent
enough to decrease blood pressure by 25 points to get him to goal. A long acting
calcium channel blocker is appropriate for patients with isolated systolic hypertension
and will be more likely to get this patient to goal pressure than HCTZ. Beta-blockers are
no longer recommended first line for uncomplicated hypertension. ACE inhibitors are
very effective in patients who are high renin producers. Elderly patients tend to produce
lower amounts of renin.
A 63 year-old male has been your patient for several years. He is a former smoker who
takes simvastatin, ramipril, and an aspirin daily. His blood pressure and lipids are well
controlled. He presents to your clinic with complaints of fatigue and "just not feeling
, well" for the last few days. His vital signs and exam are normal. What should be done
next?
Order a CBC and consider waiting a few days if normal.
Inquire about feelings of depression and hopelessness.
Order a CBC, metabolic panel, TSH, and urine analysis.
Order a B12 level, TSH, CBC, and chest x-ray -------- Correct Answer Order CBC,BMP,
TSH, u/a
Fatigue is a difficult complaint to assess and diagnose. This patient's exam and vital
signs are normal. There is no reason to think that he is infected or is bleeding, so a lone
CBC, offers little diagnostic help. However, in addition to a CBC, adding a metabolic
panel, TSH, and urine (to screen for blood in this former smoker) is a more thorough
laboratory assessment of his fatigue.
A patient with shortness of breath has suspected heart failure. What diagnostic test
would best help determine this?
Echocardiogram
B type natriuretic peptide (BNP)
EKG
Chest x-ray -------- Correct Answer ------- BNP CHEAPER
BNP is a hormone involved in regulation of blood pressure and fluid volume. When the
BNP level is 80 pg/mL or greater, the sensitivity and specificity is 98% and 92%,
favoring a diagnosis of heart failure. Alternatively, BNP levels less than 80 pg/mL
strongly suggest that heart failure is not present (Some US institutions use 100 pg/mL).
Other conditions may cause elevated BNP levels: thoracic and abdominal surgery, renal
failure, and subarachnoid hemorrhage. Consequently, careful assessment of the patient
is prudent. Echocardiograms mechanically evaluate the heart and establish an ejection
fraction. If <35-40%, then HF can usually be diagnosed. Ejection fractions do not always
correlate with patient symptoms. EKG evaluates the electrical activity of the heart.
Chest x-ray can indicate heart failure but a BNP is a more sensitive measure.
An 80 year-old patient with long standing hypertension takes Monopril and HCTZ for
hypertension. His blood pressure is 160-170/92-98 on several blood pressure checks.
What should be done about his blood pressure?
Add an angiotensin receptor blocker (ARB)
Add another diuretic
Add a calcium channel blocker
Stop the HCTZ and add a beta blocker -------- Correct Answer -------- add CCB
ACE inhibitor =
retention of potassium.
Measure potassium one month after starting and one month after changing a dose
What should you do?
Pt on Monopril and HCTZ for hypertension. His blood pressure is 160-170/92-98 on
several blood pressure checks
? Would you add an ARB? -------- Correct Answer -------- If these are at maximum doses,
consideration should be given to adding a medication from a different class.
CALCIUM CHANNEL BLOCKER
NOT ARB - Adding an ARB may result in a precipitous decrease in his blood pressure
because he takes an ACE inhibitor and both of these medications work in the renin-
angiotensin-aldosterone system.
Significance of sildenafil and any blood pressure meds -------- Correct Answer -------- Any
antihypertensive medication .... could have an additive effect with sildenafil (or another
medication in this
A specific drug-drug interaction to be aware of is the one that can occur with sildenafil
and alpha blockers like tamsulosin, alfuzosin, prazosin, doxazosin, or terazosin. This
combination of medications may increase the risk of symptomatic hypotension because
the effect of these two drugs is additive
-------- Correct Answer -------- Consider two meds
low dose HCTZ and ARB or ace
This patient's blood pressure goal is < 140/90 according to JNC VIII. Since he is more
than 20 points above systolic goal (or greater than 10 points above diastolic goal) it is
reasonable to consider two medications
Risk assessment for dyslipidemia- what age to start assessment --------- Correct Answer
------- Start at age 2
,Dyslipidemia assessment does not necessarily mean a Dyslipidemia assessment refers
to assessing family history of dyslipidemia, premature cardiovascular disease, or
diabetes, body mass index > 85% for age and sex, or history of other systemic diseases
like Kawasaki Disease or treatment, or renal disease.
When to start lipid profiles -------- Correct Answer -------- recommended between 18 and
21 years of age.
A patient taking an ACE inhibitor should avoid: -------- Correct Answer -------- No K
supplements
ACE inhibitor potentially can produce hyperkalemia because its mechanism of action is
in the renin-angiotensin-aldosterone system where potassium is spared. If potassium is
taken in the form of potassium supplements, the effect will be additive and the risk of
hyperkalemia can be great.
An 80 year-old female who is otherwise well, has a blood pressure of 176/80. How
should she be managed pharmacologically? -------- Correct Answer -------- CCB
This patient has isolated systolic hypertension (ISH). This is common in older adults and
is associated with tragic cardiac and cerebrovascular events. The drug class of choice
to treat these patients is a long-acting calcium channel blocker. The class of calcium
channel blockers recommended for ISH has the suffix "pine" (amlodipine, felodipine,
etc).
Remember
ISH = PINE
ACE inhibitor is specifically indicated in patients who have . ---------- Correct Answer
------- hypertension, diabetes with proteinuria, heart failure.
77 year-old patient has had an increase in blood pressure since the last exam. The
blood pressure has risen to 168/88 with 2 readings. The last exam's reading was
144/90. If medication is to be started on this patient, what would be a good first choice?
-------- Correct Answer -------- CCB
This patient is 77 years old and should have a goal blood pressure of < 150/90. A
thiazide diuretic is not a good first choice in this patient because it will not be potent
enough to decrease blood pressure by 25 points to get him to goal. A long acting
calcium channel blocker is appropriate for patients with isolated systolic hypertension
and will be more likely to get this patient to goal pressure than HCTZ. Beta-blockers are
no longer recommended first line for uncomplicated hypertension. ACE inhibitors are
very effective in patients who are high renin producers. Elderly patients tend to produce
lower amounts of renin.
A 63 year-old male has been your patient for several years. He is a former smoker who
takes simvastatin, ramipril, and an aspirin daily. His blood pressure and lipids are well
controlled. He presents to your clinic with complaints of fatigue and "just not feeling
, well" for the last few days. His vital signs and exam are normal. What should be done
next?
Order a CBC and consider waiting a few days if normal.
Inquire about feelings of depression and hopelessness.
Order a CBC, metabolic panel, TSH, and urine analysis.
Order a B12 level, TSH, CBC, and chest x-ray -------- Correct Answer Order CBC,BMP,
TSH, u/a
Fatigue is a difficult complaint to assess and diagnose. This patient's exam and vital
signs are normal. There is no reason to think that he is infected or is bleeding, so a lone
CBC, offers little diagnostic help. However, in addition to a CBC, adding a metabolic
panel, TSH, and urine (to screen for blood in this former smoker) is a more thorough
laboratory assessment of his fatigue.
A patient with shortness of breath has suspected heart failure. What diagnostic test
would best help determine this?
Echocardiogram
B type natriuretic peptide (BNP)
EKG
Chest x-ray -------- Correct Answer ------- BNP CHEAPER
BNP is a hormone involved in regulation of blood pressure and fluid volume. When the
BNP level is 80 pg/mL or greater, the sensitivity and specificity is 98% and 92%,
favoring a diagnosis of heart failure. Alternatively, BNP levels less than 80 pg/mL
strongly suggest that heart failure is not present (Some US institutions use 100 pg/mL).
Other conditions may cause elevated BNP levels: thoracic and abdominal surgery, renal
failure, and subarachnoid hemorrhage. Consequently, careful assessment of the patient
is prudent. Echocardiograms mechanically evaluate the heart and establish an ejection
fraction. If <35-40%, then HF can usually be diagnosed. Ejection fractions do not always
correlate with patient symptoms. EKG evaluates the electrical activity of the heart.
Chest x-ray can indicate heart failure but a BNP is a more sensitive measure.
An 80 year-old patient with long standing hypertension takes Monopril and HCTZ for
hypertension. His blood pressure is 160-170/92-98 on several blood pressure checks.
What should be done about his blood pressure?
Add an angiotensin receptor blocker (ARB)
Add another diuretic
Add a calcium channel blocker
Stop the HCTZ and add a beta blocker -------- Correct Answer -------- add CCB
