What is the significance of bradykinin in the RAAS system
it is a peptide needed for the release of aldosterone by the adrenal gland
It is a peptide that causes blood vessels to constrict, raising blood pressure
it causes contraction of non-vascular smooth muscle
it is broken down by angiotensin converting enzyme causing vasodilation and mild dieresis
the patient complains of a dry cough, what medication would be the most likely to have this finding?
Captopril
Losartan
Amilodipine
Naproxen
angiotensin converting enzyme inhibitors (ACE inhibitors) work on what part of the RAAS system?
blocks Renin from stimulating the release of Angiotensinogen
blocks Angiotensinogen conversion to Angiotensin I
Blocks Angiotensin I conversion to Angiotensin II
blocks Angiotensin II conversion to aldosterone
what class of medications will reduce the adverse affects of Diabetes on the kidneys as well as decrease inappropriate remodeling of the heart
thiazide diuretics
angiotensin receptor blockers (ARBs)
Calcium Channel Blockers (CCBs)
angiotensin converting enzyme inhibitors (ACE inhibitors)
What statement is true regarding ACE inhibitors?
they are potassium wasting and must be monitored for hypokalema
they have little negative effect on lipids or sexual function
African-Americans & low-renin hypertensives are extremely sensitive to monotherapy
they increase the effectiveness of NSAIDs
What is considered the most serious ADR with ACE inhibitors?
Angioedema <1%
<1% neutropenia & agranulocytosis
Hyperkalemia
Proteinuria & glomerulonephritis
Ace inhibitors and ARBs would be the drug of choice for which patient?
37yo Caucasian male with Hx of MI, and kidney failure
57yo Asian Female currently taking spironolactone
49yo caucasian female with Hx of DM, HF and MIx3
46yo African American male with Hx of DM, HTN and kidney stones
which of the following statements is True about ACE inhibitors and ARBs used for the treatment of hypertension .
ACEIs affect the myocardial oxygen demand but not the myocardial oxygen supply
ACEIs affect the myocardial oxygen supply but not the myocardial oxygen demand
ACEIs affect both the myocardial oxygen supply and the myocardial oxygen demand
ACEIs and ARBs are contraindicated in treating heart failure related to CAD
where are the primary sites of metabolism and excretion for ACEI's?
all ACEIs are prodrugs and do not need to be metabolized, excretion is from the kidneys.
ACEI's are metabolized in the avieoli of the lungs, excretion is primarily by GI tract with the capsule being whole but hollow
all ACEI's are prodrugs and converted to active metabolites in the liver, The kidney is the primary organ of excretion
ACI's are prodrugs and converted to active metabolites in the liver, excretion is primarily by GI tract with the capsule being whole but hollow
What are the contraindications for the use of ACEI's?
Hypertensive Proteinuric Diabetes
Bilateral renal artery stenosis
Postmyocardial Infarction
Pregnancy
what is the first goal of Hypertension management?
Controlling isolated systolic hypertension (ISH)
Prevent the rise of BP with age
reduction in Cardio vascular risk
Improve control of HTN to below 140/90 mm Hg in adults and below 150/90 in those greater than age 60
what statement is true with reguard to Dihydropyridines
greater affinity for vascular ca+ channels than cardiac Ca+2 channels
greater affinity for cardiac Ca+2 channels than vascular ca+ channels
Blocks L-type calcium channels producing vasoconstriction
Has an intrinsic natriuretic effect requiring the use of a diuretic
select all of the adverse drug reactions for Nondihydropyridines
Reflex tachycardia
Anorexia
Constipation
Bradycardia
Most CCBs have short-acting forms with half-lives between 2 and 8 hours and sustained-release forms with half-lives of 12 to 24 hours what is the exception to this?
Digoxin, with a half life of 36-48 hours
Cardizem, with a half life of 3-4 hours
Amlodipine, with a half-life of 30 to 50 hours
isradipine with a half life of 1.5-2 hours
what is the main effect of digoxin
opens the ATPase pump allowing free flow of Na+ and Ca+
inhibits the ATPase pump preventing Na+ from leaving the cell
Blocks L-type calcium channels producing vasodilation
inhibits the ATPase pump preventing Ca+ from leaving the cell
how is dosing for digoxin determined?
The principal tissue reservoir is skeletal muscle, Dosing should be based on lean muscle mass
The principal tissue reservoir is adipose tissue, Dosing should be based on BMI%
The principal tissue reservoir is the CNS and dosing should be based on CSF results
there is not a principal tissue reservoir, dosage is determined by weight in Kg.
select the contraindications for the use of digoxen.
Renal Impairment
AV blocks or uncontrolled ventricular arrhythmias
Atrial Fibrillation
idiopathic hypertrophic subaortic stenosis (IHSS)
Paroxysmal Supraventricular Tachycardia
what finding would make you suspect CG Toxicity?
serum levels of 4.5 ng/mL.
the patient presents with severe anorexia, nausea, vomiting, and diarrhea
ST-T wave changes on the a 12-lead ECG
pt presents with severe nausea, vomiting, and serum levels of 2.3 ng/mL.
Arrhythmias are caused either by abnormal pacemaker activity or by abnormal impulse conduction, which is NOT an example of The major mechanisms by which antiarrhythmics act?
blockade of Central Nervous System (CNS) effects on the heart
prolongation of the effective refractory period
sodium channel blockade
blockade of the calcium channel
sodium channel blockers are what class of antiarrhythmic drugs?
Class I
Class II
Class III
Class IV
Beta Blockers are what class of antiarrhythmic drugs?
Calcium Channel Blockers (CCB) are what class of antiarrhythmic drugs?
How are Antiarrhythmics metabolized.
antiarrhythmics are already in their metabolized form after absorption and are deactivated by the liver.
All antiarrhythmics are metabolized and excreated from the GI tract
all antiarrhythmics are prodrugs and do not need to be metabolized
All antiarrhythmics are metabolized By the liver
this drug class was introduced for the treatment of angina in the 19th century
ACEs
CCBs
nitrates
ARBs
what statement is true with reguard to Nitrates?
by providing more nitric oxide (NO) to vascular endothelium and arterial smooth muscle, resulting in vasodilation.
cause targeted relaxation of large veins resulting in decreased pre-load
Arterial dilation is more common with lower doses and can result in a decrease in systemic arterial pressure
Arterial dilation is more common with higher doses and can result in an increase in systemic arterial pressure
in which of the following cases would you NOT give nitrates.
33yo female c/o migraine with HR111 bp 200/120
75yo male c/o chest pain that has not improved, HR 63 bp 110/65
45yo male car vs tree, c/o dizziness, chest pain and nausea. had MI 2 years ago. HR110 BP185/96
35yo female with weakness to one side of her body, difficulty speaking and pain in the jaw that radiates to her back
which statement about Peripheral Vasodilators is FALSE?
Significant clinical improvement of PVD can rarely be seen with monotherapy
Peripheral alpha1 antagonists and central alpha2 agonists can be used to treat resistant HTN and PVD.
monotherapy is recommended to show Significant clinical improvement of PVD without associated ADRs
act by direct relaxation and dilation of arteriolar smooth muscle, thereby decreasing PVR
when prescribing reductase inhibitors, what lab tests should also be performed?
CBC
AST/ALT
BUN/creatinine
Lipid Panel
what is the clinical indication for the use of Antilipidemics?
increased LDL, decreased HDL, high VLDL
High VLDL, increased HDL, Decreased LDL
increased HDL, increased LDL, low VLDL
decreased LDL, increased HDL, low VLDL
The liver is the primary site of metabolism for most diuretics, which diuretic has nonhepatic and hepatic metabolism
Furosemide (Lasix)
spironolactone (Aldactone)
Amiloride
hydrochlorothiazide (HCTZ)
if a patient is taking an aminoglycoside medication what Adverse drug reaction would you actively assess for?
a white crystalline precipitate to form in the superficial portion of the cornea.
localized ocular toxicity
itching/swelling of the face/tongue/throat
Increased Ocular Pressure in narrow-angle glaucoma
if planning on using a combination of steroids and anti-infectives for ophthalmic Anti-Infective treatment in primary care what must be used to perform the assessment?
Keratometry
retinoscope
opthalmoscope
Tonometry device
which of the following Ophthalmic Anti-Infectives has a high hypersensitivity rate?
azithromycin
erythromycin
polymyxin B
gentamicin
what is important to remember when using Sulfacetamide
it is incompatible with silver-containing preparations
must have tonometry available
it has a high hypersensitivity rate
may cause localized ocular toxicity
Children 3 months through 8 years are most likely to have what type of Bacterial conjunctivitis select all that apply
staphylococcal
streptococcal
Haemophilus
Staphylococcus aureus
Pseudomonas aeruginosa
what is the treatment for Conjunctivitis-otitis syndrome
high-dose amoxicillin
parenteral antibiotics (ceftriaxone)
ophthalmic/otitc antibiotics
erythromycin ointment
What symptoms would make you suspect herpes keratitis? if herpes keratitis is suspected what should be done next?
intense redness of the eye, Watery/mucus discharge from the eye, fever blister on or near the eye; examination with woodslamp
Swelling of the lymph nodes in front of the ears, fever, slight Pinkness of the eye; referral to ophthalmologist
burning, gritty sensation to the eye, lesion close to or on the eye, fever; referral to ophthalmologist
Crustiness around the eyelids upon waking in the morning, cough, fever; ocular assessment with ophthalmoscope
while removing a cerumen impaction you notice that while irrigating, your patient suddenly develops nystagmus and states that they are suddenly dizzy. what is the likely cause of this?
irrigation was being performed too forcefully
the irrigation solution was not warmed
irrigation solution has bypassed the ear drum and is interfering with the middle ear
the patient is having a seizure
which statement is FALSE with reguard to Corticosteroids
have metabolic, anti-inflammatory, and growth-suppressing effects
high levels of cortisol can cause decreased memory recall, anxiety and disturbed sleep patterns
Glucocorticoids decrease blood glucose concentration by stimulating glycogenesis in the liver
Corticosteroids can raise your risk of infections due to the wide range of effects on the immune system
What determines systolic Blood pressure?
mean arterial pressure
Total peripheral resistance
end-diastolic volume (EDV) - end-systolic volume (ESV)
HR times stroke volume
What determines diastolic blood pressure?
Cardiac output
mean arterial pressure divided by ejection fraction
select what factors will have a direct effect on systemic arterial pressure. select all that apply.
total peripheral resistance
heart rate
Stroke volume
an increase in BP will send inhibitory impulses to the sympathetic vasomotor center in the brainstem resulting in what?
excitation of efferent nerves in the SNS results in decreased heart rate,
Inhibition of efferent nerves in the SNS that innervate cardiac and vascular smooth muscle results in increased heart rate
Inhibition of efferent nerves in the SNS that innervate cardiac and vascular smooth muscle results in vasodilation of peripheral arterioles
excitation of efferent nerves in the SNS that innervate cardiac and vascular smooth muscle
changes in BP is sensed by ____ located in _____
baroreceptors; aorta
Mechanoreceptors; carotid arteries
Nociceptors; arch of the aorta
Mechanoreceptors; kidneys
what are the ultimate goals of Angina therapy
to treat anginal chest pain and return to normal activities
reduce the risks of stroke
reduce the risks of MI
smooth muscle and cardiac relaxation
what statements are true about organic nitrates. select all that apply
Reduces preload
Increases afterload
Inhibit platelet aggregation
leads to the mediation of smooth muscle relaxation
what makes Ranolazine unique for the treatment of angina?
Have a negative chronotropic and inotropic effect and ↓ afterload, Decreases myocardial oxygen consumption, Increases myocardial perfusion
decreases peripheral vascular resistance and thereby MOD, as the heart has decreased afterload
cause arterial smooth muscle relaxation, which results in peripheral vasodilation, decreased afterload,
Has antianginal and anti-ischemic effects that do not depend on reduction in heart rate or blood pressure
what medication reduces platelet aggregation by inhibiting the synthesis of thromboxane A2
Aspirin
Nitroglycerin
Nifedipide (Procardia)
Diltiazem (Cardizem)
select what would be classified as class I according to the New York Heart Association and Canadian Cardiovascular Society
Chest pain is present for the first few hours in the morning, in cold weather or after meals
Angina that occurs when walking 1-2 blocks on level ground, or by climbing 1 flight of stairs
Angina that occurs with strenuous, rapid exertion. Ordinary physical activity like walking upstairs does not cause angina
Chest pain that occurs at rest
select what would be classified as class II according to the New York Heart Association and Canadian Cardiovascular Society
select what would be classified as class III according to the New York Heart Association and Canadian Cardiovascular Society
select what would be classified as class IV according to the New York Heart Association and Canadian Cardiovascular Society
What is considered to be the foundation of initial drug therapy for patients with angina ?
ACEI and beta-adrenergic blockers
ACEI and CCB
BB and CCB
Nitrates and BB
when diagnosing heart failure why might a chest x-ray be ordered?
it can be used to identify and distinguish between systolic dysfunction and preserved systolic function.
can show Cephalization of the vascular supply
can show left-ventricular hypertrophy and axis deviation
used to rule out pulmonary embolism
select the types of heart failure. select all that apply
low-output failure
high-output failure
Systolic dysfunction
Diastolic dysfunction
What is the most common BB used in heart failure?
Atenolol
carvedilol
clonidine
how does Digoxin work?
Digoxin decreases contractility by decreasing intracellular calcium and inhibiting the sodium-potassium-ATPase pump
Digoxin increases heart rate by increasing intracellular calcium and inhibiting the sodium-potassium-ATPase pump
Digoxin increases contractility by increasing intracellular calcium and inhibiting the sodium-potassium-ATPase pump
Digoxin decreases heart rate by increasing intracellular calcium and inhibiting the sodium-potassium-ATPase pump
Patients with left-ventricular dysfunction with current or prior symptoms of HF are classified as what stage according to ACC and AHA guidelines.
Stage A
Stage B
Stage C
stage D
Which of the following is NOT one of the diagnostic criteria for DM?
A1C ≥6.5%
FPG ≥126 mg/dL
plasma glucose ≥200 mg/dL
classic symptoms of hyperglycemia and a random plasma glucose ≥200 mg/dL
What is true about DM type 1?
Typically diagnosed early in life
the bodies compensatory insulin production mechanisms reduce the onset of clinical symptoms for many years
90% to 95% of cases are diagnosed before the age of 30.
If the disease progresses without treatment hypoglycemia, coma and death can occur.
What are the treatment targets for Glycemic control in DM? select all that apply
2 hour postprandial plasma glucose less than 180 mg/dL
Hemoglobin A1c less than 5%
Random urine albumin/Cr less than 30mcg/mg creatinine
Preprandial plasma glucose 70 to 130 mg/dL
What is the treatment target for blood pressure when treating DM?
less than 130/80, 140/80 for patients with DM, hypertension
less than 120/60, 130/80 for patients with DM, hypertension
less than 140/80, 145/85 for patients with DM, hypertension
less than 130/80, 150/90 for patients with DM, hypertension
what are the treatment targets for lipid control when treating DM?
HDL >100mg/dl, LDL <50mg/dl, triglicerides less than 150mg/dl
HDL >150mg/dl, LDL <100mg/dl, triglicerides less than 50mg/dl
HDL >50mg/dl, LDL <100mg/dl, triglicerides less than 150mg/dl
HDL >100mg/dl, LDL <150mg/dl, triglicerides less than 50mg/dl
what factors effect the treatment plan and drug selection process when treating DM? Select all that apply
individual patient variables (race, weight, pregnant etc.)
current AHA guidelines
Desiered gylcemic target
type of diabetes
severity of the hyper/hypo glycemia
For the treatment of type 2 DM what is the first-line therapy for most patients?
Insulin
Thiazolidinediones (TZDs)
Metformin
Glipizide
Insulin with and onset of 5-30min, peak 0.5-3h and duration of 3-4h describes what type of insulin?
Rapid-Acting (RAI)
Short-acting Insulin
Intermediate-Acting (IAI)
Long-Acting (LAI)
Insulin with and onset of 30-60min, peak 2-4h and duration of 3-7h describes what type of insulin?
Insulin with and onset of 1-2h, peak 4-10h and duration of 10-16h describes what type of insulin?
Insulin with and onset of 1-2h, no peak, and duration of 20-24h describes what type of insulin?
Generally, what percentage of daily insulin is given as an intermediate or long-acting form of insulin?
0-25%
25-50%
50-75%
75-100%
a 1 Unit bolus of insulin will typically lower glucose by approximately
10-20mg/dl
60-90mg/dl
20-60mg/dl
10-40mg/dl
Each 15 gm Carbohydrate serving raises BG by approximately
15mg/dl
25mg/dl
50mg/dl
70mg/dl
what percentage of beta cells must be lost before hyperglycemia occurs?
50-60%
60-70%
70-80%
80-90%
90-100%
what statement is true about Insulin
alcohol use, increases hyperglycemia
Beta blockers mask hypoglycemic symptoms
Short-acting Insulin onset of action is 1 to 1.5 hours, and its duration is 12 to 24 hours
Rapid-Acting (RAI) duration of action is 4 to 6 hours
what is the preferred injection site that absorbs 50% more than other sites
Inhalation method
Abdominal site
upper outer area of the arm
front and outer sides of the thighs
what insulin's are pregnancy category C? select all that apply
Aspart
Humulin R
glargine
glulisine
What is important to consider if your patient has Hyperthyroidism and is taking insulin?
delays insulin breakdown, and may require less insulin units
they have improved insulin sensitivity, will require less insulin
increases renal clearance, requiring more insulin than baseline
insulin can potentiate effects of antidiuretic hormone
what is the indication for the use of Sulfonylureas when treating DM?
Excessive production of glucose by the liver
rapid intestinal glucose dumping
Insufficient production of endogenous insulin
Decreased tissue insensitivity to insulin
what patient would you NOT prescribe Metformin (Glucophage) for the treatment of type 2 DM?
20yo female who had ambulatory surgery 3 days ago
11yo male with HTN
9yo female HTN and HF
18yo male who is currently taking a sulfonylurea
your patient who is taking metformin and an alpha-glucosidase inhibitor to treat their DM presents with unsteady gait, generalized confusion and elevated anxiety CBG is 50mg/dl. what would you give to correct this?
a piece of hard candy held between the cheek
15gm CHO
sugar packets
Lactose
what DM medication should not be used with ACEIs due to the increased risk of angioedemia
Thiazolidinediones
Alpha-Glucosidase Inhibitors
Biguanides
Dipeptidyl Peptidase-4
