(Test Bank) AAFP Family Medicine Test Bank Questions with accurate answers with rationale. Graded A+

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AAFP Family Medicine Questions with accurate answers with rationale. Graded A+ A 70yo M with h/o HTN and DM presents with a 2 -mo h/o increasing paroxysmal nocturnal dyspnea and SOB with minimal exertion. An echocardiogram shows an ejection fraction of 25%. Which one of the patients current medications should be discontinued? A. Lisinopril (Z estril) B. Pioglitazone (Actos) C. Glipizide (Glucotrol) D. Metoprolol (Toprol -XL) - ✔✔Pioglitzaone thiazolidinediones (TZDs) are associated with fluid retention, and their use can be complicated by the development of heart failure. Caution is necessary when prescribing TZDs in patients with known heart failure or other heart diseases, those with preexis ting edema, and those on concurrent insulin therapy What is the most common cause of hypertension in children under 6 years of age? - ✔✔Renal Parenchymal Disease The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertension. A 72 -year -old African -American male with New York Heart Association Class III heart failure sees you for follow -up. He has shortness of breath with minimal exertion. The patient is adherent to his medication regimen. His current medications include lisinopril (Prinivil, Zestril), 40 mg twice daily; carvedilol (Coreg), 25 mg twice daily; and furosemide (Lasix), 80 mg daily. His blood pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular. Findings include a few scattered bibasilar rales on examination of the lungs, an S3 gallop on examination of the heart, and no edema on examination of the legs. An EKG reveals a left bundle branch block, and echocardiography reveals an ejection fraction of 25%, but no other abnormalities. What's the appropriate next step? - ✔✔Refer for cardiac resynchronization therapy (CRT) Note: he's already on maximum doses of ACEI, loop diuretic, beta -blocker Using a pa cemaker -like device, CRT aims to get both ventricles contracting simultaneously, overcoming the delayed contraction of the left ventricle caused by the left bundle -branch block. These guidelines were refined by an April 2005 AHA Science Advisory, which sta ted that optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class III or IV despite maximal medical therapy for heart failure. Wha t dietary change recommended for the prevention and treatment of cardiovascular disease has been shown to decrease the rate of sudden death? - ✔✔increase intake of omega 3 fatty acids Omega -3 fats contribute to the production of eicosapentaenoic acid (EPA ) and docosahexaenoic acid (DHA), which inhibit the inflammatory immune response and platelet aggregation, are mild vasodilators, and may have antiarrhythmic properties. The American Heart Association guidelines state that omega -3 supplements may be recomm ended to patients with preexisting disease, a high risk of disease, or high triglyceride levels, as well as to patients who do not like or are allergic to fish. The Italian GISSI study found that the use of 850 mg of EPA and DHA daily resulted in decreased rates of mortality, nonfatal myocardial infarction, and stroke, with particular decreases in the rate of sudden death. A 75 -year -old male presents to the emergency department with a several -hour history of back pain in the interscapular region. His medic al history includes a previous myocardial infarction (MI) several years ago, a history of cigarette smoking until the time of the MI, and hypertension that is well controlled with hydrochlorothiazide and lisinopril (Prinivil, Zestril). The patient appears anxious, but all pulses are intact. His blood pressure is 170/110 mm Hg and his pulse rate is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no acute changes. A chest radiograph shows a widened mediastinum and a normal aortic arch, and CT of the chest shows a dissecting aneurysm of the descending aorta that is distal to the proximal abdominal aorta but does not involve the renal arteries. Which one of the following would be the most appropriate next step in the management of this patien t? - ✔✔Dx: aortic dissection next step: Intravenous labetalol (Normodyne, Trandate) Initial management should reduce the systolic blood pressure to 100 -120 mm Hg or to the lowest level tolerated. The use of a β -blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first -line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added. Without prior beta -blocade, vasodilation from the nitroprusside will induce reflex activa tion of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta. According to the U.S. Preventive Services Task Force, what are the screening recommendations for an abdominal aortic aneurysm? - ✔✔The guideline recommends one -time screening with ultrasonography for AAA in men 65 -75 years of age who have ever smoked. No recommendation was made for or against screening women. Men with a strong family history of AAA should be counseled about the risks a nd benefits of screening as they approach 65 years of age. A 36 -year -old white female presents to the emergency department with palpitations. Her pulse rate is 180 beats/min. An EKG reveals a regular tachycardia with a narrow complex QRS and no apparent P waves. The patient fails to respond to carotid massage or to two doses of intravenous adenosine (Adenocard), 6 mg and 12 mg. The most appropriate next step would be to administer intravenous - ✔✔verapamil (Calan) If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by the administration of intravenous verapamil or a β -blocker. If that fails, intravenous propafenone or flecainide may be necessary. It is also important to look for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances. Electrical cardioversion may be necessary if these measures fail to terminate the tachyarrhythmia. The blood pressure goal for a patient who has uncomplicated diabetes mellitus is - ✔✔BP goal: 130/80mmHg Aggressive control of blood pressure to <135/85 mm Hg in hypertensive patients and to <130/80 mm Hg in diabetic patients is recommended. Lowering blood pressure may reduce strok e rates by 40% -52% and cardiovascular morbidity by 18% -20% A 60 -year -old African -American female has a history of hypertension that has been well controlled with hydrochlorothiazide. However, she has developed an allergy to the medication. Successful mono therapy for her hypertension would be most likely with which one of the following? A. Lisinopril (Prinivil, Zestril) B. Hydralazine (Apresoline) C. Clonidine (Catapres) D. Atenolol (Tenormin) E. Diltiazem (Cardizem) - ✔✔Diltiazem (Cardizem) Mon otherapy for hypertension in African -American patients is more likely to consist of diuretics or calcium channel blockers than β -blockers or ACE inhibitors. It has been suggested that hypertension in African -Americans is not as angiotensin II -dependent as it appears to be in Caucasians. An asymptomatic 3 -year -old male presents for a routine check -up. On examination you notice a systolic heart murmur. It is heard best in the lower precordium and has a low, short tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and seems to decrease with inspiration. The remainder of the examination is normal. What is the most likely diagnosis? - ✔✔Still's murmur There are several benign murmurs of childhood that have no association w ith physiologic or anatomic abnormalities. Of these, Still's murmur best fits the murmur described. The cause of Still's murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall. A 57 -year -old male with severe renal disease presents with acute coronary syndrome. Which one of the following would most likely require a significant dosage adjustment from the standard protocol? A. Enoxaparin (Lovenox) B. Metoprolol (Lopressor, Toprol) C. Carvedilol (Coreg) D. Clopidogrel (Plavix) E. Tissue plasminogen activator (tPA) - ✔✔Enoxaparin Enoxaparin is eliminated mostly by the kidneys. When it is used in patients with severe renal impairment the dosage must be significantly reduced. For some indication s the dose normally given every 12 hours is given only every 24 hours. Although some β -blockers require a dosage adjustment, metoprolol and carvedilol are metabolized by the liver and do not require dosage adjustment in patients with renal failure. Clopido grel is currently recommended at the standard dosage for patients with renal failure and acute coronary syndrome. Thrombolytics like tPA are given at the standard dosage in renal failure, although hemorrhagic complications are increased. A 55 -year -old mal e who has a long history of marginally -controlled hypertension presents with gradually increasing shortness of breath and reduced exercise tolerance. His physical examination is normal except for a blood pressure of 140/90 mm Hg, bilateral basilar rales, a nd trace pitting edema. What study would be the preferred diagnostic tool for evaluating this patient? - ✔✔2-dimensional echocardiography with Doppler The most useful diagnostic tool for evaluating patients with heart failure is two -dimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness, and valve functi on. The test should be performed during the initial evaluation. Radionuclide ventriculography can be used to assess LVEF and volumes, and MRI or CT also may provide information in selected patients. Chest radiography (posteroanterior and lateral) and 12-lead electrocardiography should be performed in all patients presenting with heart failure, but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure. A 23 -year -old female sees you with a complaint of intermittent irregular heartbeats that occur once every week or two, but do not cause her to feel lightheaded or fatigued. They last only a few seconds and resolve spontaneously. She has never passed out, had chest pain, or had difficulty with exertion . She is otherwise healthy, and a physical examination is normal. What cardiac study should be ordered initially? - ✔✔EKG The symptom of an increased or abnormal sensation of one's heartbeat is referred to as palpitations. This condition is common to pri mary care, but is often benign. Commonly, these sensations have their basis in anxiety or panic. However, about 50% of those who complain of palpitations will be found to have a diagnosable cardiac condition. It is recommended to start the evaluation for c ardiac causes with an EKG, which will assess the baseline rhythm and screen for signs of chamber enlargement, previous myocardial infarction, conduction disturbances, and a prolonged QT interval. What is most appropriate for the initial treatment of claud ication? - ✔✔regular exercise Claudication is exercise -induced lower -extremity pain that is caused by ischemia and relieved by rest. It affects 10% of persons over 70 years of age. However, up to 90% of patients with peripheral vascular disease are asympt omatic. Initial treatment should consist of vigorous risk factor modification and exercise. Patients who follow an exercise regimen can increase their walking time by 150%. A supervised program may produce better results. Risk factors include diabetes mell itus, hypertension, smoking, and hyperlipidemia. In a patient who presents with symptoms of acute myocardial infarction, which one of the following would be an indication for thrombolytic therapy? A. New -onset ST -segment depression B. New -onset left b undle branch block C. New -onset first degree atrioventricular block D. New -onset Wenckebach second degree heart block E. Frequent unifocal ventricular ectopic beats - ✔✔New -onset left bundle branch block In patients with ischemic chest pain, the EK G is important for determining the need for fibrinolytic therapy. Myocardial infarction is diagnosed by ST elevation ≥1 mm in two or more limb leads and ≥2 mm in two or more contiguous precordial leads. In a patient with an MI, new left bundle branch block suggests occlusion of the left anterior descending artery, placing a significant portion of the left ventricle in jeopardy. Thrombolytic therapy could be harmful in patients with ischemia but not infarction - they will show ST -segment depression only. Fre quent unifocal ventricular ectopy may warrant antiarrhythmic therapy, but not thrombolytic therapy. A 68 -year -old female has an average blood pressure of 150/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteoporosis and mild depression. The most appropriate treatment at this time would be A. lisinopril (Prinivil, Zestril) B. clonidine (Catapres) C. propranolol (Inderal) D. amlodipine (Norvasc) E. hydrochlorothiazide - ✔✔HCTZ Randomized, placeb o-controlled trials have shown that isolated systolic hypertension in the elderly responds best to diuretics and to a lesser extent, β -blockers. Diuretics are preferred, although long - acting dihydropyridine calcium channel blockers may also be used. In the case described, β -blockers or clonidine may worsen the depression. Thiazide diuretics may also improve osteoporosis, and would be the most cost -effective and useful agent in this instance. A 56 -year -old white male presents with a 2 -week history of intermittent pain in his left leg. The pain usually occurs while he is walking and is primarily in the calf muscle or Achilles region. Sometimes he will awaken at night with cramps in the affected leg. He has no known risk factors for atherosclerosis. What would be the best initial test for peripheral vascular occlusive disease? - ✔✔Ankle -brachial index (ABI) The ankle -brachial index (ABI) is an inexpensive, sensitive screening tool and is the most appropriate first test for peripheral vascular occlusive disease (PVOD) in this patient. The ABI is the ratio of systolic blood pressure measured in the ankle to systolic pressure using the standard brachial measurement. A ratio of 0.9 -1.2 is considered n ormal. Severe disease is defined as a ratio <0.50. More invasive and expensive testing using Doppler ultrasonography, arteriography, or magnetic resonance angiography may be useful if the ABI suggests an abnormality. Venous ultrasonography would not detect PVOD, but it could rule out deep venous thrombosis, which is another common etiology for calf pain. A 69 -year -old male has a 4 -day history of swelling in his left leg. He has no history of trauma, recent surgery, prolonged immobilization, weight loss, or malaise. His examination is unremarkable except for a diffusely swollen left leg. A CBC, chemistry profile, prostate -specific antigen level, chest radiograph, and EKG are all normal; however, compression ultrasonography of the extremity reveals a clot in the proximal femoral vein. He has no past history of venous thromboembolic disease. In addition to initiating therapy with low molecular weight heparin, the American College of Chest Physicians recommends that warfarin (Coumadin) be instituted now and cont inued for how long? - ✔✔3 months For patients with a first episode of unprovoked deep venous thrombosis, evidence supports treatment with a vitamin K antagonist for at least 3 months (SOR A). The American College of Chest Physicians recommends that patien ts be evaluated at that point for the potential risks and benefits of long -term therapy You see a 23 -year -old gravida 1 para 0 for her prenatal checkup at 38 weeks gestation. She complains of severe headaches and epigastric pain. She has had an uneventful pregnancy to date and had a normal prenatal examination 2 weeks ago. Her blood pressure is 140/100 mm Hg. A urinalysis shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting edema of her legs. The most appropriate management at this po int would be: - ✔✔next step: Admitting the patient to the hospital, treating with parenteral magnesium sulfate, and planning prompt delivery either vaginally or by cesarean section This patient manifests a rapid onset of preeclampsia at term. The symptom s of epigastric pain and headache categorize her preeclampsia as severe. These symptoms indicate that the process is well advanced and that convulsions are imminent. Treatment should focus on rapid control of symptoms and delivery of the infant. A 67 -year -old Hispanic male comes to your office with severe periumbilical abdominal pain, vomiting, and diarrhea which began suddenly several hours ago. His temperature is 37.0 degrees C (98.6 degrees F), blood pressure 110/76 mm Hg, and respirations 28/min. His a bdomen is slightly distended, soft, and diffusely tender; bowel sounds are normal. Other findings include clear lungs, a rapid and irregularly irregular heartbeat, and a pale left forearm and hand with no palpable left brachial pulse. Right arm and lower e xtremity pulses are normal. Urine and stool are both positive for blood on chemical testing. His hemoglobin level is 16.4 g/dL (N 13.0 -18.0) and his WBC count is 25,300/mm3 (N 4300 -10,800). The diagnostic imaging procedure most likely to produce a specific diagnosis of his abdominal pain is: A. Intravenous pyelography (IVP) B. Sonography of the abdominal aorta C. A barium enema D. Celiac and mesenteric arteriography E. Contrast venography - ✔✔Celiac and mesenteric arteriography The sudden onset of severe abdominal pain, vomiting, and diarrhea in a patient with a cardiac source of emboli and evidence of a separate embolic event makes superior mesenteric artery embolization likely. In this case, evidence of a brachial artery embolus and a cardiac r hythm indicating atrial fibrillation suggest the diagnosis. Some patients may have a surprisingly normal abdominal examination in spite of severe pain. Microscopic hematuria and blood in the stool may both occur with embolization. Severe leukocytosis is pr esent in more than two -thirds of patients with this problem. Diagnostic confirmation by angiography is recommended. Immediate embolectomy with removal of the propagated clot can then be accomplished and a decision made regarding whether or not the intestin e should be resected. A second procedure may be scheduled to reevaluate intestinal viability. A 49 -year -old white female comes to your office complaining of painful, cold finger tips which turn white when she is hanging out her laundry. While there is no approved treatment for this condition at this time, what drug has been shown to be useful? - ✔✔Nifedipine (Procardia) At present there is no approved treatment for Raynaud's disease. However, patients with this disorder reportedly experience subjective sy mptomatic improvement with calcium channel antagonists. Nifedipine is the calcium channel blocker of choice in patients with Raynaud's disease. Beta -blockers can produce arterial insufficiency of the Raynaud type, so propranolol and atenolol would be contr aindicated. Drugs such as ergotamine preparations and methysergide can produce cold sensitivity, and should therefore be avoided in patients with Raynaud's disease. You perform a health maintenance examination on a 2 -year -old white male. He is asymptomati c and is meeting all developmental milestones. The only significant finding is a grade 3/6 diastolic murmur heard at the right upper sternal border. Which one of the following would be most appropriate at this time? - ✔✔Referral to a pediatric cardiologist Children who have a murmur that is diastolic or is greater than 2/6 should be referred for cardiovascular evaluation, perhaps after an echocardiogram is obtained. Other reasons for referral include cardiac symptoms, abnormal splitting of S2, a murmur th at increases on standing, a holosystolic murmur, or ejection clicks. Digoxin is not indicated at this point in this asymptomatic patient. For long -term therapy, the most effective control of heart rate in atrial fibrillation, both at rest and with exercise, occurs with which class of drugs? - ✔✔Beta -adrenergic blockers For long -term therapy, beta -adrenergic antagonist drugs provide the mos t effective control of heart rate in atrial fibrillation, both at rest and during exercise. Although calcium channel blockers also lower heart rate both at rest and with exercise, they are not as effective as beta -blockers. Digitalis is primarily effective in controlling the heart rate at rest, and often does not adequately control heart rate with exercise. The Class 1 antiarrhythmics are most useful in maintaining sinus rhythm and, in fact, may paradoxically increase heart rate. A 75 -year -old white female develops deep -vein thrombosis of the left leg 1 week after hip surgery. The patient is started on low -molecular -weight heparin (Lovenox). Daily monitoring while the patient is on low-molecular -weight heparin should include which lab tests? - ✔✔don't need to monitor lovenox with labs, just warfarin! Routine coagulation tests such as prothrombin time and partial thromboplastin time are insensitive measurements of Lovenox activity. Anti -factor Xa can be measured in patients with renal failure to monitor anti coagulation effects. Elevated levels of _________ are associated with atherosclerosis? - ✔✔homocysteine Multiple prospective and case -control studies have shown that a moderately elevated plasma homocysteine concentration is an independent risk factor fo r atherothrombotic vascular disease. A 60 -year -old African -American male was recently diagnosed with an abdominal aortic aneurysm. A lipid profile performed a few months ago revealed an LDL level of 125 mg/dL. You would now advise him that his goal LDL le vel is: - ✔✔<100 mg/dL Most physicians realize that the goal LDL level for patients with diabetes mellitus or coronary artery disease is <100 mg/dL. Many may not realize that this goal extends to people with CAD -equivalent diseases, including peripheral artery disease, symptomatic carotid artery disease, and abdominal aortic aneurysm. Which one of the following is a risk factor for perioperative arrhythmias? A. Supraventricular tachycardia B. Congestive heart failure C. Age >60 D. Premature atria l contractions E. Past history of hyperthyroidism - ✔✔Congestive heart failure Significant predictors of intraoperative and perioperative ventricular arrhythmias include preoperative ventricular (not supraventricular) ectopy, a history of congestive he art failure, and a history of cigarette smoking. Age and a history of hyperthyroidism are not significant predictors of perioperative ventricular arrhythmias. A 35 -year -old African -American female has just returned home from a vacation in Hawaii. She pres ents to your office with a swollen left lower extremity. She has no previous history of similar problems. Homan's sign is positive, and ultrasonography reveals a noncompressible vein in the left popliteal fossa extending distally. Next step? - ✔✔Enoxaparin (Lovenox) should be administered at a dosage of 1 mg/kg subcutaneously twice a day The use of low -molecular -weight heparin allows patients with acute deep vein thrombosis (DVT) to be managed as outpatients. The dosage is 1 mg/kg subcutaneously twice dai ly. Patients chosen for outpatient care should have good cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding. Oral anticoagulation with warfarin can be initiated on the first day of treatment after heparin loading is complete d. Monotherapy with warfarin is inappropriate. The incidence of thrombocytopenia with low -molecular -weight heparin is lower than with conventional heparin. The INR should be maintained at 2.0 -3.0 in this patient. The 2.5 -3.5 range is used for patients with mechanical heart valves. The therapeutic INR should be maintained for 3 -6 months in a patient with a first DVT related to travel. What historical features is most suggestive of congestive heart failure in a 6 -month -old white male presenting with tachypnea? - ✔✔Diaphoresis with feeding Symptoms of congestive heart failure in infants are often related to feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with feedings, is characteristic, and related to adrenergic drive. Older children may have symptoms more similar to adults, but the infant's greatest exertion is related to feed ing. In which clinical situation would it be most appropriate to use a beta -blocker that has intrinsic sympathomimetic activity, such as acebutolol (Sectral) or pindolol (Visken)? - ✔✔In a hypertensive patient with symptomatic bradycardia while taking met oprolol (Lopressor) Beta -blockers with intrinsic sympathomimetic activity (ISA) are less beneficial in reducing mortality post myocardial infarction, and for this reason are not recommended for ischemic heart disease. They have a potential advantage in o nly one clinical situation. Since they tend to lower heart rates less, they may be beneficial in patients with symptomatic bradycardia while taking other beta -blockers. All beta -blockers should be used cautiously in patients with diabetes or asthma. Only s otalol, which delays ventricular depolarization, has been shown to be effective for maintenance of sinus rhythm in patients with chronic atrial fibrillation. You are treating a 50 -year -old white male for diabetes mellitus and hyperlipidemia. At the time o f his initial presentation 1 year ago, his hemoglobin A1c was 8.0% (N 3.8 -6.4), LDL 130 mg/dL, HDL 28 mg/dL, and triglycerides 450 mg/dL. After treatment with metformin (Glucophage) and high -dose simvastatin (Zocor), his most recent laboratory evaluation r evealed a hemoglobin A1c of 6.2%, LDL 95 mg/dL, HDL 32 mg/dL, and triglycerides 300 mg/dL. The patient has not had any documented coronary or peripheral vascular disease. His family history is positive for a myocardial infarction in his father at age 55. H e is a nonsmoker. He has a body mass index (BMI) of 28 and has been unable to lose weight. His blood pressure is well controlled on enalapril (Vasotec). What is the most appropriate management of his elevated triglycerides? - ✔✔Addition of a fibrate such a s gemfibrozil (Lopid) or fenofibrate (Tricor) Although the significance of elevated triglycerides and a low HDL in low -risk patients is somewhat uncertain, in a high -risk patient such as a diabetic, improvement in these results will lower the risk of subsequent cardiac events. In diabetics, metformin and thiazolidinediones (e.g., rosiglitazone) are more likely to improve lipid levels than are sulfonylureas. Nicotinic acid is problematic in diabetics, as it tends to cause deterioration in glucose control. Fibrates are good choices for this patient because they will lower the triglyceride level and raise the HDL level. Exercise and weight loss are likely to be helpful as well. What treatment or intervention has been shown to produce the most benefit for pat ients with peripheral vascular disease? - ✔✔smoking cessation Patients with peripheral vascular disease who stop smoking have a twofold increase in their 5 -year survival rate. Diet modification and lipid -lowering drugs can slow progression, but not as dra matically. Aspirin and pentoxifylline are minimally effective. A 13 -year -old male is found to have hypertrophic cardiomyopathy. His father also had hypertrophic cardiomyopathy, and died suddenly at age 38 following a game of tennis. The boy's mother asks you for advice regarding his condition. What advice should you give her? - ✔✔His siblings should undergo echocardiography Hypertrophic cardiomyopathy is an autosomal dominant condition and close relatives of affected individuals should be screened. The h ypertrophy usually stays the same or worsens with age. This patient should not participate in strenuous sports, even those considered noncontact. Beta -blockers have not been shown to alter the progress of the disease. The mortality rate is believed to be a bout 1%, with some series estimating 5%. Thus, in most cases lifespan is normal. A 70 -year -old white male has a slowly enlarging, asymptomatic abdominal aortic aneurysm. You should usually recommend surgical intervention when the diameter of the aneurysm approaches: - ✔✔5.5 cm Based on recent clinical trials, the most common recommendation for surgical repair is when the aneurysm approaches 5.5 cm in diameter. Two large studies, the Aneurysm Detection and Management (ADAM) Veteran Affairs Cooperative Stud y, and the United Kingdom Small Aneurysm Trial, failed to show any benefit from early surgery for men with aneurysms less than 5.5 cm in diameter. The risks of aneurysm rupture were 1% or less in both studies, with 6 -year cumulative survivals of 74% and 64 %, respectively. Interestingly, the risk for aneurysm rupture was four times greater in women, indicating that 5.5 cm may be too high, but a new evidence -based threshold has not yet been defined. A 75 -year -old otherwise healthy white female states that sh e has passed out three times in the last month while walking briskly during her daily walk with the local senior citizens mall walkers' club. This history would suggest what etiology of her syncope? - ✔✔aortic stenosis Syncope with exercise is a manifesta tion of organic heart disease in which cardiac output is fixed and does not rise (or even fall) with exertion. Syncope, commonly on exertion, is reported in up to 42% of patients with severe aortic stenosis. Which drug class is preferred for treating hypertension in patients who also have diabetes mellitus? - ✔✔ACE-I ACE inhibitors have proven beneficial in patients who have either early or established diabetic renal disease. They are the preferred therapy in patients with diabetes and hypertension, according to guidelines from the American Diabetes Association, the National Kidney Foundation, the World Health Organization, and the JNC VII report. A 75 -year -old Hispanic male presents with dyspnea on exertion which has worsened over the last several months. He denies chest pain and syncope, and was fairly active until the shortness of breath slowed him down recently. You hear a grade 3/6 systolic ejection murmur at the right upper sternal border which radiates into the neck. Echocardiography reveals aortic stenosis, with a mean transvalvular gradient of 55 mm Hg and a calculated valve area of 0.6 cm2. Left ventricular function is normal. Which one of the following is appropriate management for this patient? - ✔✔Aortic valve replacement Since this patient's mean aortic -valve gradient exceeds 50 mm Hg and the aortic -valve area is not larger than 1 cm2, it is likely that his symptoms are due to aortic stenosis. As patients with symptomatic aortic stenosis have a d ismal prognosis without treatment, prompt correction of his mechanical obstruction with aortic valve replacement is indicated. Medical management is not effective, and balloon valvotomy only temporarily relieves the symptoms and does not prolong survival. Patients who present with dyspnea have only a 50% chance of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis. A 73 -year -old white male nursing -home res ident has Alzheimer's dementia and hypertension. He has been weaker and less responsive over the last week and has gained 8 lb. On physical examination he has normal vital signs with a heart rate of 110 beats/min, but is noted to have marked lower extremit y edema and presacral edema. Laboratory evaluation shows a serum sodium level of 122 mmol/L (N 135 - 145). What is the most likely cause of his hyponatremia? - ✔✔Congestive Heart Failure Most decision trees for the evaluation of hyponatremia begin with an a ssessment of volume status; edema reflects volume overload and increased total body sodium caused by congestive heart failure, cirrhosis, or renal failure. If edema is absent, plasma osmolality should be determined. SIADH, Addison's disease (hypoadrenalism ), diuretic use, and renal artery stenosis all lower serum osmolality. Urine electrolytes help distinguish the other conditions: psychogenic polydipsia causes low urine sodium, while SIADH and hypoadrenalism cause inappropriately elevated urine sodium. Diu retic use, a very common cause of hyponatremia in the geriatric population, causes hypovolemic hyponatremia and can be associated with either high or low urine sodium, but there is often concomitant hypokalemia. A 28 -year -old gravida 2 para 1 presents to the emergency department at 16 weeks' gestation. She has noted the sudden onset of dyspnea, pleuritic chest pain, and mild hemoptysis. Both calves are mildly edematous and somewhat tender. A lung scan shows a high probability of pulmonary emboli. Which one of the following would be appropriate management at this time? - ✔✔Intravenous heparin for 5 -10 days followed by subcutaneous heparin for the duration of the pregnancy The risk of pulmonary embolism is five times higher in pregnant women than in nonpreg nant women of similar age, and venous thromboembolism is a leading cause of illness and death during pregnancy. Warfarin, which readily crosses the placenta, should be avoided throughout pregnancy. It is definitely teratogenic during the first trimester, a nd extensive fetal abnormalities have been associated with exposure to warfarin in any trimester. Because heparin does not cross the placenta, it is considered the safest anticoagulant to use during pregnancy. Initially, patients with venous thromboembolis m during pregnancy should be managed with heparin given according to the recommendations for nonpregnant patients. These women should receive intravenous heparin for 5 -10 days followed by subcutaneous heparin for the duration of the pregnancy. Warfarin can be given after delivery, since it is not present in breast milk. The indications for placement of an inferior vena cava filter are not changed by pregnancy, and include any contraindication to anticoagulant therapy, the occurrence of heparin -induced throm bocytopenia, and recurrence of pulmonary embolism in a patient receiving adequate anticoagulant therapy. There are no data to support the use of aspirin for treatment or prophylaxis of pulmonary embolism either during or after pregnancy. Which one of the following is considered a contraindication to the use of beta -blockers for congestive heart failure? A. Mild asthma B. Symptomatic heart block C. New York Heart Association (NYHA) Class III heart failure D. NYHA Class I heart failure in a patient w ith a history of a previous myocardial infarction E. An ejection fraction <30% - ✔✔symptomatic heart block According to several randomized, controlled trials, mortality rates are improved in patients with heart failure who receive beta -blockers in addi tion to diuretics, ACE inhibitors, and occasionally, digoxin. Contraindications to beta -blocker use include hemodynamic instability, heart block, bradycardia, and severe asthma. Beta -blockers may be tried in patients with mild asthma or COPD as long as the y are monitored for potential exacerbations. Beta -blocker use has been shown to be effective in patients with NYHA Class II or III heart failure. There is no absolute threshold ejection fraction. Beta -blockers have also been shown to decrease mortality in patients with a previous history of myocardial infarction, regardless of their NYHA classification. What is the leading cause of death in women? - ✔✔Cardiovascular disease is the leading cause of death among women. According to the CDC, 29.3% of deaths in females in the U.S. in 2001 were due to cardiovascular disease and 21.6% were due to cancer, with most resulting from lung cancer. Breast cancer is the third most common cause of cancer death in women, and ovarian cancer is the fifth most common. A 72 -year-old African -American male comes to your office for surgical clearance to undergo elective hemicolectomy for recurrent diverticulitis. The patient suffered an uncomplicated acute anterior -wall myocardial infarction approximately 18 months ago. A stress t est was normal 2 months after he was discharged from the hospital. Currently, the patient feels well, walks while playing nine holes of golf three times per week, and is able to walk up a flight of stairs without chest pain or significant dyspnea. Findings are normal on a physical examination. Which one of the following would be most appropriate for this patient prior to surgery? - ✔✔12-lead resting EKG The current recommendations from the American College of Cardiology and the American Heart Association on preoperative clearance for noncardiac surgery state that preoperative intervention is rarely needed to lower surgical risk. Patients who are not curre ntly experiencing unstable coronary syndrome, severe valvular disease, uncompensated congestive heart failure, or a significant arrhythmia are not considered at high risk, and should be evaluated for most surgery primarily on the basis of their functional status. If these patients are capable of moderate activity (greater than 4 METs) without cardiac symptoms, they can be cleared with no stress testing or coronary angiography for an elective minor or intermediate -risk operation such as the one this patient is to undergo. A resting 12 -lead EKG is recommended for males over 45, females over 55, and patients with diabetes, symptoms of chest pain, or a previous history of cardiac disease. Patients with Wolff -Parkinson -White syndrome who have episodic symptomati c supraventricular tachycardia or atrial fibrillation benefit most from: - ✔✔Radiofrequency catheter ablation of bypass tracts Radiofrequency catheter ablation of bypass tracts is possible in over 90% of patients and is safer and more cost effective than surgery, with a similar success rate. Intravenous and oral digoxin can shorten the refractory period of the accessory pathway, and increase the ventricular rate, causing ventricular fibrillation. Beta -blockers will not control the ventricular response dur ing atrial fibrillation when conduction proceeds over the bypass tract. A 67 -year -old white male sees you for a new patient visit. He is asymptomatic and has not seen a doctor in 10 years. He does not smoke or drink and takes no medication. He says he has a history of "mild high blood pressure" but has never been treated for this. His blood pressure today is 180/90 mm Hg. He has a decreased arteriovenous ratio on funduscopic examination, his point of maximal intensity is displaced laterally, and he has dec reased pedal pulses. The most appropriate management at this point would be to: - ✔✔Prescribe a diuretic Elevated blood pressure along with physical findings of cardiovascular disease establishes the diagnosis of hypertension in this patient, so it is no t necessary to take follow -up blood pressure readings prior to starting treatment. Since he has no symptoms or physical findings suggestive of secondary hypertension it is also not necessary to perform a laboratory workup prior to treatment. Because he has Stage 3 hypertension with evidence of end -organ disease, treatment with antihypertensives is indicated at this point. At least three large clinical trials, including the European Working Party on High Blood Pressure in the Elderly (EWPHE) trial, have show n that diuretics are the most effective single agents for hypertension in the elderly. A low -sodium diet can be added, as can a beta -blocker if the hypertension fails to respond to diuretics alone. A male infant weighing 3000 g (6 lb 10 oz) is born at 36 weeks' gestation, with normal Apgar scores and an unremarkable initial examination. At 48 hours of age he is noted to have dusky episodes while feeding, and does not feed well. On repeat examination the child is tachypneic, with subcostal retractions. Lung sounds are clear and there is no heart murmur. Pulse oximetry on room air is 82%. Arterial blood gases on 100% oxygen show a pCO2 of 26 mm Hg (N 27 -40), a pO2 of 66 mm Hg (N 83 - 108), a blood pH of 7.50 mg/dL (N 7.35 -7.45), and a base excess of -2 mmol/L ( N -10 to -2). Laboratory Findings: Hemoglobin - 22.0 g/dL (N 13.0 -20.0) Hematocrit - 66% (N 42 -66) WBCs - 19,000/mm3 (N 9000 -30,000) Chest radiograph - increased vascular markings; large thymus Blood culture results are pending. Which one of the following is the most likely diagnosis? - ✔✔Congenital Heart Disease Cyanotic congenital heart disease can appear at the time of ductus closure. A heart murmur is not usually audible, and murmurs heard this early are usually not due to heart disease. The failure to correct hypoxemia with 100% oxygen is diagnostic for abnormal mixing of blood from the right and left circulations. Transient tachypnea presents earlier, and the hypoxia corrects with supplemental oxygen. Hyaline membrane disease can occur at 36 weeks, bu t would cause problems in the first hours of life. It can make oxygenation difficult, but would cause extreme distress with CO2 retention in such cases. This patient has the energy to hyperventilate and has slight respiratory alkalosis as a result. Neonata l sepsis can cause V/Q mismatching and hypoxia, and can have a delayed presentation. Concern would be high enough in this case that the patient would probably receive broad -spectrum antibiotics while awaiting culture results. On the other hand, the clinici an would not want to be distracted from the evidence for congenital heart disease. The baby is polycythemic from poor intake in the first 2 days of life. The hyperviscosity syndrome can occur when the hematocrit is over 65%. It can cause poor feeding, tach ypnea, and sluggishness, but does not cause hypoxia. A 73 -year -old male with COPD presents to the emergency department with increasing dyspnea. Examination reveals no sign of jugular venous distention. A chest examination reveals decreased breath sounds a nd scattered rhonchi, and the heart sounds are very distant but no gallop or murmur is noted. There is +1 edema of the lower extremities. Chest radiographs reveal cardiomegaly but no pleural effusion. The patient's B -type natriuretic peptide level is 850 p g/mL (N <100) and his serum creatinine level is 0.8 mg/dL (N 0.6 -1.5). Which one of the following would be the most appropriate initial management? - ✔✔Furosemide (Lasix), 40 mg intravenously B-type natriuretic peptide (BNP) is secreted in the ventricles and is sensitive to changes in left ventricular function. Concentrations correlate with end -diastolic pressure, which in turn correlates with dyspnea and congestive heart failure. BNP levels can be useful when trying to determine whether dyspnea is due to cardiac, pulmonary, or deconditioning etiologies. A value of less than 100 pg/mL excludes congestive heart failure as the cause for dyspnea. If it is greater than 400 pg/mL, the likelihood of congestive heart failure is 95%. Patients with values of 100 -400 pg/mL need further investigation. There are some pulmonary problems that may elevate BNP, such as lung cancer, cor pulmonale, and pulmonary embolus. However, these patients do not have the same extent of elevation that those with acute left ventricular d ysfunction will have. If these problems can be ruled out, then individuals with levels between 100 -400 pg/mL most likely have congestive heart failure. Initial therapy should be a loop diuretic. It should be noted that BNP is partially excreted by the kidn eys, so levels are inversely proportional to creatinine clearance. A 25 -year -old female at 36 weeks gestation presents for a routine prenatal visit. Her blood pressure is 118/78 mm Hg and her urine has no signs of protein or glucose. Her fundal height sho ws appropriate fetal size and she says that she feels well. On palpation of her legs, you note 2+ pitting edema bilaterally. Which one of the following is true regarding this patient's condition? - ✔✔Her leg swelling requires no further evaluation Lower -extremity edema is common in the last trimester of normal pregnancies and can be treated symptomatically with compression stockings. Edema has been associated with preeclampsia, but the majority of women who have lower -extremity edema with no signs of elev ated blood pressure will not develop preeclampsia or eclampsia. For this reason, edema has recently been removed from the diagnostic criteria for preeclampsia. Disproportionate swelling in one leg versus another, especially associated with leg pain, should prompt a workup for deep venous thrombosis but is unlikely given this patient's presentation, as are cardiac or renal conditions. What is the medical treatment of choice for acute delirium in the intensive care unit? - ✔✔Intravenous haloperidol (Haldol) in increasing doses every 30 minutes as needed Intravenous haloperidol has been found to be more effective than lorazepam and has minimal physiologic side effects. A 72 -year -old male with a history of previous inferior myocardial infarction sees you pri or to surgery for symptomatic gallstones. He denies chest pain or dyspnea. His current medications include aspirin, 81 mg daily; ramipril (Altace), 10 mg daily; and pravastatin (Pravachol), 40 mg daily. He is in good health otherwise and has no other healt h complaints. He has been cleared for surgery by his cardiologist.What medication should be considered before and after surgery, assuming no contraindications? - ✔✔Atenolol (Tenormin) A recent development in the prophylaxis of surgery -related cardiac complications is the use of beta - blockers perioperatively for patients with cardiac risk factors. In a randomized, double -blind, placebo - controlled trial involving 200 patients who were und ergoing elective noncardiac surgery that required general anesthesia, the effect of atenolol on perioperative cardiac complications was evaluated. Patients were eligible for beta -blocker therapy if they had known coronary artery disease or two or more risk factors. Atenolol was not used if the resting heart rate was <55 beats/min, systolic blood pressure was <100 mm Hg, or there was evidence of congestive heart failure, third degree heart block, or bronchospasm. A 5 -mg dose of intravenous atenolol was given 30 minutes before surgery and then again immediately after surgery. Oral atenolol, 50 -100 mg, was then given until hospital discharge or 7 days postoperatively. The results of the study showed that mortality from cardiac causes was 65% lower in the patien ts receiving atenolol. Another study showed similar perioperative benefit using the beta - blocker bisoprolol. A 34 -year -old white female at 32 weeks' gestation develops a venous thromboembolism. Following 5 days of IV heparin in the hospital, what regimen would be most appropriate as an outpatient? - ✔✔Subcutaneous heparin every 12 hours until delivery Heparin does not cross the placenta and is safe for the fetus, whereas coumarin derivatives can cause fetal bleeding and are teratogenic during weeks 6 -12. Therefore, pregnant women with venous thromboembolism should receive intravenous heparin for 5 days, followed by adjusted -dose subcutaneous heparin every 12 hours until delivery. Increasingly, low -molecular -weight heparins are being used instead of unfrac tionated heparin because of ease of administration and the reduced need for coagulation monitoring. Intravenous heparin is not necessary after the patient leaves the hospital, and aspirin has not been shown to be beneficial. A 52 -year -old white male is be ing considered for pharmacologic treatment of hyperlipidemia because of an LDL cholesterol level of 180 mg/dL. Before beginning medication for his hyperlipidemia, he should be screened for: - ✔✔Hypothyroidism According to the Summary of the National Chole sterol Education Program (NCEP) Adult Treatment Panel III Report of 2001, any person with elevated LDL cholesterol or any other form of hyperlipidemia should undergo clinical or laboratory assessment to rule out secondary dyslipidemia before initiation of lipid - lowering therapy. Causes of secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, and some medications. A 56 -year -old African -American male with longstanding hypertension and a 30 -pack -year smoking history has a 2 -day history of dyspnea on exertion. Physical examination is unremarkable except for rare crackles at the bases. Which serologic test would be most helpful for detecting left ventricular dysfunction? - ✔✔Beta -natriuretic peptide ( BNP) Beta -natriuretic peptide (BNP) is a 32 -amino acid polypeptide secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles, and because of its minimal prese nce in storage granules, its release is directly proportional to ventricular dysfunction. It is a simple and rapid test that reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram. A 35 -year -old white male with know n long QT syndrome has a brief episode of syncope requiring cardiopulmonary resuscitation. Which one of the following is most likely responsible for this episode? - ✔✔Torsades de pointes Patients with long QT syndrome that have sudden arrhythmia death sy ndrome usually have either torsades de pointes or ventricular fibrillation. An 83 -year -old female presents to your office as a new patient. She recently moved to the area to be closer to her family. A history reveals that she has been in excellent health, has no complaints, and is on no medications except occasional acetaminophen for knee pain. She has never been in the hospital and has not had any operations. She says that she feels well. The examination is normal, with expected age - related changes, excep t that her blood pressure on three different readings averages 175/70 mm Hg. These readings are confirmed on a subsequent follow -up visit. In addition to lifestyle changes, which one of the following would be most appropriate for the initial management of this patient's hypertension? - ✔✔A thiazide diuretic Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least 160 mm Hg. (Systolic hypertension is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of less than 90 mm Hg.) The studies most strongly support the use of thiazide diuretics and long -acting calcium channel blockers as first -line therapy. Alpha -blockers are not recommended. ACE inhibitors, be ta-blockers, and angiotensin receptor blockers are used when certain compelling indications are present, e.g., in a patient with diabetes or who has had a myocardial infarction. What is the INITIAL treatment of choice in the management of severe hypertens ion during pregnancy? - ✔✔Labetalol (Trandate, Normodyne) intravenously In pregnant women with severe hypertension, the primary objective of treatment is to prevent cerebral complications such as encephalopathy and hemorrhage. Intravenous hydralazine, in travenous labetalol, or oral nifedipine may be used. Sublingual nifedipine can cause severe hypotension, and reserpine is not indicated. Nitroprusside can be used for short intervals in patients with hypertensive encephalopathy, but fetal cyanide toxicity is a risk with infusions lasting more than 4 hours. ACE inhibitors are never indicated for hypertensive therapy during pregnancy. What would be a contraindication to initiating beta -blocker therapy in a patient with congestive heart failure? - ✔✔Recent ho spital admission for decompensated heart failure In general, it is advisable to avoid initiating beta -blocker therapy during or immediately after admission for decompensated heart failure. What medication is preferred for chronic treatment of congestive heart failure due to left ventricular systolic dysfunction? - ✔✔ACE inhibitors ACE inhibitors are the preferred drugs for congestive heart failure due to left ventricular systolic dysfuncti on, because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be used cautiously. It is not known whether digoxin affects mortality, although it can help wit h symptoms. Which one of the following is most predictive of increased perioperative cardiovascular events associated with noncardiac surgery in the elderly? A. An age of 80 years B. Left bundle -branch block C. Atrial fibrillation with a rate of 80 beats/min D. A history of previous stroke E. Renal insufficiency (creatinine 2.0 mg/dL) - ✔✔Renal insufficiency (creatinine 2.0 mg/dL) Clinical predictors of increased perioperative cardiovascular risk for elderly patients include major risk factors s uch as ● unstable coronary syndrome (acute or recent myocardial infarction, unstable angina) ● decompensated congestive heart failure ● significant arrhythmia (high -grade AV block, symptomatic ventricular arrhythmia ● supraventricular arrhythmias with unc ontrolled ventricular rate) ● severe valvular disease Intermediate predictors are: ● mild angina ● previous myocardial infarction ● compensated congestive heart failure ● diabetes mellitus ● renal insufficiency Minor predictors are: ● advanced age ● an abnormal EKG - left ventricular hypertrophy, left bundle -branch block, ST and T -wave abnormalities, rhythm other than sinus, ● low functional capacity ● history of stroke ● uncontrolled hypertension. The use of automated external defibrillators by l ay persons in out -of-hospital settings: - ✔✔Has been shown to contribute to significant gains in full neurologic and functional recovery The use of automated external defibrillators (AEDs) by lay persons, trained and otherwise, has been quite successful, with up to 40% of those treated recovering full neurologic and functional capacity. At present, 45 states have passed Good Samaritan laws covering the use of AEDs by well -intentioned lay persons. There are initiatives for widespread placement of AEDs, to i nclude commercial airlines and other public facilities A 74 -year -old white male complains of pain in the right calf that recurs on a regular basis. He smokes 1 pack of cigarettes per day and is hypertensive. He has a history of a previous heart attack but is otherwise in fair health. Which one of the following findings would support a diagnostic impression of peripheral vascular disease? - ✔✔Treadmill arterial flow studies showing a 20 -mm Hg decrease in ankle systolic blood pressure immediately following e xercise Peripheral vascular disease (PVD) is a clinical manifestation of atherosclerotic disease and is caused by occlusion of the arteries to the legs. Patients with significant arterial occlusive disease will have a prominent decrease in the ankle -brac hial index from baseline following exercise, and usually a 20 -mm Hg or greater decrease in systolic blood pressure. Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf is found in those with Baker's cysts . Peripheral nerve pain commonly begins immediately upon walking and is unrelieved by rest. Doppler waveform analysis is useful in the diagnosis of PVD and will reveal attenuated waveforms at a point of decreased blood flow. Employment of the ankle -brachia l index is encouraged in daily practice as a simple means to diagnose the presence of PVD. Generally, ankle -brachial indices in the range of 0.91 -1.30 are thought to be normal. In a 34 -year -old primigravida at 35 weeks' gestation, which one of the followi ng supports a diagnosis of MILD preeclampsia rather than severe preeclampsia? A. A blood pressure of 150/100 mm Hg B. A 24 -hr protein level of 6 g C. A platelet count <100,000/mm3 D. Liver enzyme elevation with epigastric tenderness E. Altered me ntal status - ✔✔A blood pressure of 150/100 mm Hg The criteria for severe preeclampsia is: ● blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include ● proteinuria above 5 g/24 hr ● thrombocytopenia with a platele t count <100,000/mm3 ● liver enzyme abnormalities ● epigastric or right upper quadrant pain ● alteration of mental status. A 72 -year -old white female is scheduled to undergo a total knee replacement for symptomatic osteoarthritis. She is otherwise healthy, with no history of vascular disease or deep vein thrombosis. She takes no routine medications. What medication is most app ropriate for prophylaxis against deep vein thrombosis? - ✔✔Enoxaparin (Lovenox), 30 mg subcutaneously every 12 hours Prophylaxis is indicated with total knee or hip replacements. The two regimens recommended are low - molecular -weight heparin and adjusted -dose warfarin. These may be augmented by intermittent pneumatic compression. What medication is contraindicated in the treatment of patients with cocaine -induced arrhythmias? - ✔✔Metoprolol (Lopressor) When treating arrhythmias related to cocaine toxici ty, hypertonic sodium bicarbonate and benzodiazepines may be given when the distinction between sodium channel blockade -induced QRS - complex widening and ischemia -induced ventricular tachycardia is unclear. Lidocaine may subsequently be utilized if necessar y. Verapamil has been shown to reverse cocaine -induced coronary vasospasm. Beta -adrenergic blocking drugs have been shown to exacerbate coronary vasospasm by resulting in unopposed alpha -adrenergic activity. Beta -blockers are therefore contraindicated in t he treatment of cocaine -induced cardiac problems. A 34 -year -old white primigravida in her first trimester had established moderate hypertension before becoming pregnant. She currently has a blood pressure of 168/108 mm Hg. You are considering how to best manage her hypertension during the pregnancy. What medication is associated with the greatest risk of fetal growth retardation if used for hypertension throughout pregnancy? - ✔✔Atenolol (Tenormin) Atenolol and propranolol are associated with intrauterin e growth retardation when used for prolonged periods during pregnancy. They are class D agents during pregnancy. Other beta -blockers may not share this risk. Methyldopa, hydralazine, and calcium channel blockers have not been associated with intrauterine g rowth retardation. They are generally acceptable agents to use for established, significant hypertension during pregnancy A 72 -year -old male with class III congestive heart failure (CHF) due to systolic dysfunction asks if he can take ibuprofen for his "a ches and pains." Appropriate counseling regarding NSAID use and heart failure should include: - ✔✔NSAIDs, including high -dose aspirin, should be avoided in CHF patients because they can cause fluid retention. If possible, NSAIDs should be avoided in patie nts with heart failure. They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation. Patients with heart failure who take NSAIDs have a tenfold increased risk of hospitalization for exacerbation of their CHF. NSAIDs alone in patients with normal ventricular function have not been associated with initial episodes of heart failure. NSAIDs, including high -dose aspirin (325 mg/day), may decrease or negate entirely the beneficial unloadin g effects of ACE inhibition. They have been shown to have a negative impact on the long -term morbidity and mortality benefits that ACE inhibitors provide. Sulindac and low -dose aspirin (81 mg/day) are less likely to cause these negative effects. A 72 -year -old male presents to your clinic in atrial fibrillation with a rate of 132 beats/min. He has hypertension, but no history of congestive heart failure or structural heart disease. He is otherwise healthy and active. The best INITIAL approach to his atrial fibrillation would be: - ✔✔Ventricular rate control with a calcium channel blocker or beta -blocker, and warfarin for anticoagulation Five recent randomized, controlled trials have indicated that in most patients with atrial fibrillation, an initial approa ch of rate control is best. Patients who were stratified to the rhythm control arm of the trials did NOT have a morbidity or mortality benefit and were more likely to suffer from adverse drug effects and increased hospitalizations. The most efficacious dru gs for rate control are calcium channel blockers and beta -blockers. Digoxin is less effective for rate control and should be reserved as an add -on option for those not controlled with a beta -blocker or calcium channel blocker, or for patients with signific ant left ventricular systolic dysfunction. In patients 65 years of age or older or with one or more risk factors for stroke, the best choice for anticoagulation to prevent thromboembolic disease is warfarin. Of note, in patients who are successfully rhythm controlled and maintained in sinus rhythm, the thromboembolic rate is equivalent to those managed with a rate control strategy. Thus, the data suggest that patients who choose a rhythm control strategy should be maintained on anticoagulation regardless of whether they are consistently in sinus rhythm. Ref: Snow V, Weiss K, LeFevre M, et al: Management of newly detected atrial fibrillation: A clinical practice guideline from the AAFP and the ACP. Cilostazol (Pletal) has been found to be a useful drug for t he treatment of intermittent claudication. This drug is contraindicated in patients with: - ✔✔Congestive heart failure Cilostazol is a drug with phosphodiesterase inhibitor activity introduced for the symptomatic treatment of arterial occlusive disease a nd intermittent claudication. Cilostazol should be avoided in patients with congestive heart failure. There are no limitations on its use in patients with previous stroke or a history of diabetes. It has been found to have beneficial effects on HDL cholest erol levels and in the treatment of third degree heart block. What medication has been shown to decrease mortality late after a myocardial infarction? - ✔✔Beta - blockers and ACE inhibitors have been found to decrease mortality late after myocardial infarct ion. Aspirin has been shown to decrease nonfatal myocardial infarction, nonfatal stroke, and vascular events. Nitrates, digoxin, thiazide diuretics, and calcium channel antagonists have not been found to reduce mortality after myocardial infarction. A 72 -year -old white male has new -onset hypertension with a current blood pressure of 190/110 mm Hg. What medication can be used as part of a test for diagnosing renovascular hypertension, but would also increase the risk for azotemia if used for treatment? - ✔✔Captopril (Capoten) ACE inhibitors can significantly worsen renal failure in patients with hypertension caused by renovascular disease. Hyperkalemia is an associated problem. Captopril renography is a useful diagnostic screening test. The other agen ts are useful for lowering blood pressure but may cause mild creatinine elevations. They do not, however, cause the significant elevations of creatinine seen with ACE inhibitors in cases of significant renovascular disease. Patients with symptomatic conge stive heart failure associated with a reduced systolic ejection fraction or left ventricular remodeling should be initially treated with? - ✔✔An ACE inhibitor It has been shown that congestive heart failure (CHF) patients treated with ACE inhibitors surv ive longer, and all such patients should take these agents if tolerated. Warfarin and/or antiarrhythmic drugs should be given only to selected CHF patients. Verapamil may adversely affect cardiac function and should be avoided in patients with CHF. Hydrala zine can be used, but because of its side effect profile would be a second -line agent.