1. A.A. is a 25-year-old woman with a new diagnosis ofidiopathic pulmonary arterial hypertension (IPAH). Herhome drugs include warfarin 5 mg/day, furosemide 60 mg 2times/day, and bosentan 62.5 mg 2 times/day. Which one ofthe following isthe best contraceptive strategy for this patient?A. Estrogen-progesterone oral contraceptive.B. Injectable hormonal contraceptive.C. Any hormonal contraceptive and barriermethod.D. Barrier method only.

Answer: CBosentan is an inducer of CYP3A4 and CYP2C9 isoenzymes.Bosentan decreases the plasma concentrations of all hormonalcontraceptive medications, including both estrogen- andprogesterone-containing formulations, because of its effects onCYP metabolism. Nohormonal contraceptive, including oral, injectable, topical(patch), and implantable formulations, should be used as theonly means of contraception because it may not effectivelyprevent pregnancy in patients taking bosentan. Use of a double-barrier method with a condom and diaphragm plus spermicide isindicated in patients receiving bosentan and hormonalcontraceptives. Because bosentan is also a known teratogen, abarrier method alone may not be a sufficient form ofcontraception.

2. R.P. is a 60-year-old woman with New York Heart Association(NYHA) class IV heart failure (HF) admitted for increasedshortness of breath and dyspnea at rest. Her extremitiesappear well perfused, but she has 3+ pitting edema in herlower extremities. R.P.'s vital signs include blood pressure(BP) 125/70 mm Hg, heart rate (HR) 102 beats/minute, andO2 saturation 89% on 100% facemask. After the initiation ofan intravenous diuretic, which one of the following is the bestintravenous drug totreat this patient?A. Dobutamine.B. Milrinone.C. Nesiritide.D. Metoprolol.

Answer: CThe patient is well perfused, and his CO has not changedsubstantially (i.e., his disease has not progressed). The patient isnow experiencing shortness of breath/dyspnea at rest (NYHAIV). From his presentation, the patient can be classified asForrester hemodynamic subset II(warm and wet). Because the patient is congested, intravenousdiuretics are indicated as first-line therapy. Adjunctive therapycan be recommended as second-line therapy. Dobutamine andmilrinone primarily increaseCO, which is not a considerable problem in warm and wetexacerbations. In addition, the adverse effects of these agents(increased mortality, proarrhythmia) limit their use. Intravenousmetoprolol should not be used inpatients with ADHF because of potent negative inotropic effects.However, oral metoprolol may be used once the patient isstabilized, and it should be initiated before patient discharge.Nesiritide is a balanced arterial and venous dilator that decreasesafterload and preload, respectively. It is useful in patients withacute pulmonary edema, rapidly reducing the PCWP by causingacute venous dilation. The ASCEND-HF trial showed a modestbut nonsignificant improvement in dyspnea without an increasedrisk of short-term mortality.

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3. H.E. is a 53-year-old woman admitted to thehospital after the worst headache she has everexperienced. Her medical history includesexertional asthma, poorly controlled hypertension(HTN), and hyperlipidemia. She is nonadherent tohermedications, and she has not taken her BP drugs,including clonidine, for 4 days. Vital signs includeBP 220/100 mm Hg and HR 65 beats/minute. Shereceives a diagnosis of a cerebrovascular accidentand hypertensive emergency. Which one of thefollowing choices is the best management option forthis patient's hypertensive emergency?A. Fenoldopam 0.1 mcg/kg/minute.B. Nicardipine 5 mg/hour.C. Labetalol 0.5 mg/minute.D. Enalaprilat 0.625 mg intravenously every 6hours.

Answer: BThis patient shows target organ damage from poorly controlled HTN in theform of a cerebrovascular accident. Although fenoldopam is indicated fortreating hypertensive emergency, its use is cautioned in patients with strokesymptoms because its dopamine agonistactivity can cause cerebral vasodilation and potentially reduced bloodflow tothe ischemic areas of the brain. Nicardipine is an appropriate choice for thispatient because its calcium channel blocking effects will reduce BP andpotentially decrease vasospasm in the cerebral arteries, which may lead tofurther ischemia or seizure activity. Although labetalol is an effective optionfor treating this patient's hypertensive emergency, she has a history ofasthma and a low HR, making labetalol a less-than-ideal option for treatingher symptoms. The antihypertensiveeffects of enalaprilat depend on a patient's renin activity, which is unknownin this case. Therefore, the BP reducing effects may be more difficult tocontrol than with a drug having a more consistent effect in individuals. Inaddition, the bolus nature of the drug is not ideal for tightly controlling BPwith a 25% reduction in MAP. Continuous-infusion drugs are preferable foreasier titration to effect in a hypertensive emergency.

4. The Sudden Cardiac Death in Heart Failure trialevaluated the efficacy of amiodarone or animplantable cardioverter defibrillator (ICD) versusplacebo in preventing all-cause mortality inischemic and nonischemic NYHA class II and IIIpatients with HF. There was a 7.2% absolute riskreduction and a 23% relative risk reduction in all-cause mortality at 60 months with an ICD versusplacebo. Whichof the following best demonstrates the number ofpatients needed to treat with an ICD to prevent onedeath versus placebo?A. 1.3.B. 4.3.C. 13.8.D. 43.4.

Answer: CThe number needed to treat can be calculated by 1/absolute risk reduction.Because the absolute risk reduction in mortality at 60 months was 7.2% withICD versus placebo, 1/0.072 would be used to calculate the number ofpatients needed to treat to prevent one death during this time. About 13.8patients would need to be treated with ICD to prevent one death in 60months versus placebo. Other calculations in this fashion, including relativerisk reduction and 100% minus the absolute or relative risk reduction, do notprovide useful information for interpreting the trial results and yield anincorrectnumber of patients.

5. A.D. is a 52-year-old woman with a history ofwitnessed cardiac arrest in a shopping mall; shewas resuscitated with an automatic externaldefibrillator device. On electrophysiologic study,she has inducible ventricular tachycardia (VT).Which one of the following is best for reducing thesecondary incidence of sudden cardiac death inpatients such as A.D.?A. Propafenone.B. Amiodarone.C. ICD.D. Metoprolol.

Answer: CThe Cardiac Arrest Study Hamburg trial compared ICD implantation withantiarrhythmic therapy in survivors of cardiac arrest for secondaryprevention of sudden cardiac death. The propafenone study arm wasdiscontinuedearly because of a significantly (61%) highermortality rate compared with ICDs. Although this trial had a small samplesize that prevented a statistically significant difference in total mortality frombeing shown in ICD-treated patients versus patients treated with eitheramiodarone or metoprolol, the incidence of sudden death was significantlyreduced in patients with an ICD(33% vs. 13%, p=0.005). The AVID (Antiarrhythmics Versus ImplantableDefibrillators) trial also evaluated ICD implantation versus antiarrhythmicdrug therapy(primarily amiodarone) in survivors of sudden cardiac death. Patients withICDs had a significantly higher rate of survival than those treated with drugtherapy (89% vs. 82%,p<0.02).

6. S.V. is a 75-year-old woman with a history of NYHA classIII HF (left ventricular ejection fraction [LVEF] 25%) andseveral non-ST-elevation myocardial infarctions (MIs).She had an episode of sustained VT duringhospitalization for pneumonia. Her QTc interval was380 milliseconds on the telemetry monitor, and herserum potassium (K+) and magnesium (Mg) were 4.6mmol/L and 2.2 mg/dL, respectively. Which one of thefollowing is the best treatment option for S.V.?A. Procainamide.B. Metoprolol.C. Intravenous Mg.D. Amiodarone.

Answer: DThis patient has a depressed LVEF less than 40%, so her drug therapyoptions are limited to prevent the development of worsening HF,which could occur if she were administered procainamide fortreatment of her arrhythmia. Procainamide is indicated only insecondaryprevention of sustained VT in patients with a normal LVEF greaterthan 40%. Metoprolol is indicated only for the treatment of patientswith asymptomatic nonsustained VT and SVT associated with CAD.This patient had an episode of sustained VT. Her QTc interval is notprolonged at 380 milliseconds, and her serummagnesium level is within normal limits, so she does not requireintravenous magnesium therapy. She qualifies for treatment witheither amiodarone or lidocaine. Amiodarone is first-line treatment ofpatients without contraindications because of its efficacy.

7. You are working on a review article about newertreatment strategies for hypertensive crises. You want toensure that you retrieve all relevant clinical trials andrelated articles on your subject. Whichone of the following comprehensive databases is best tosearch next to ensure that you have not missed keyarticles?A. International Pharmaceutical Abstracts.B. Iowa Drug Information Service.C. Clin-Alert.D. Excerpta Medica.

Answer: DInternational Pharmaceutical Abstracts is a database of primarilypharmaceutical abstracts in more than 750 journals, including foreignand state pharmacy journals, in addition to key U.S. medical andpharmacy journals. Many of the citations are not included onMEDLINE, so a broader search can be performed; however, subjectdescriptors are not consistently defined in a uniform way, andmultiword terms are often cited backward. The Iowa Drug InformationService database offers full-text articles from 1966 to present in about200 medical and pharmacy journals (primarily based in theUnited States). It is updated monthly, so newly available articles maytake longer to be accessed from this service. The Clin-Alert databasecontains more than 100 medical and pharmacy journals focused onadverse events, drug interactions, and medical-legal issues. Itis used primarily to look up adverse events (especially recent reports)associated with medications. Excerpta Medica is a comprehensivedatabase of more than 7000journals from 74 countries dating from 1974 to present.Recentlypublished articles appear in the system within 10 days of articlepublication, and it often contains data not found in a typicalMEDLINE search.

8. A physician on your team asks that you report an adversedrug reaction (ADR) experienced by a patient takingnesiritide. The patient had severe hypotension after theinitial bolus dose of nesiritide, even though his BP was in thenormal range before therapy initiation. The hypotension ledto reduced renal perfusion, resulting in oliguric acute kidneyinjury and subsequent hemodialysis. The patient had noknown renal insufficiency before developing thiscomplication. Which one of the following statements bestdescribes the Joint Commission requirements forinstitutional ADR reporting?A. A MedWatch form must be completed that explains thesituation in which the ADRoccurred.B. Institutions must create their own definition of ADR withwhich practitioners will be familiar.C. Hospital staff must use the Naranjo algorithm forassessing the severity of the ADR.D. Only severe or life-threatening ADRs need to be reported.

Answer: BMedWatch is a post-U.S. Food and Drug Administration (FDA)approval program established by the FDA for health careprofessionals to report the adverse events that occur after a drugis approved. Although it is commonly used only for reportingserious reactions to the FDA, it can be used to report any adverseevent. Information recorded on these forms is reported to themanufacturer and is used to determine whether black boxwarnings are necessary or whether new adverse effectsare seen with a drug. The Joint Commission requires that allinstitutions have a definition of an ADR for the institution thatall health care professionals can understand and remember. Inaddition, the Joint Commission requires that each drug doseadministered be monitored for adverse effects, that eachinstitution have a system in place for reporting ADRs, and thatthe institution ensure that the reporting mechanism identifies allkey ADRs.

9. Your Pharmacy and Therapeutics Committee wants you toperform a pharmacoeconomic analysis of a new drugavailable to treat decompensated HF. This drug worksthrough a unique mechanism of action. Unlike otheravailable inotropic therapies that can increase mortality,this drug appears to reduce long-term mortality. However,the cost is 10 times greater than that of other available drugs.Your findings will be presented at the next Pharmacy andTherapeutics Committee meeting to make a formularydecision. Which of the following types of pharmacoeconomicanalysis would be best to determine whether this new drug isa better formulary choice than currently available agents?A. Cost-minimization analysis.B. Cost-effectiveness analysis.C. Cost-benefit analysis.D. Cost-utility analysis.

Answer: BBecause the Pharmacy and Therapeutics Committee wants todiscover whether the new drug is worth the extra cost for theadded mortality benefits it can provide for patients withdecompensated HF compared with available therapies, a cost-effectiveness analysis is the best pharmacoeconomic analysis toperform. Cost minimization analysis is used to determinewhether a therapeutically equivalent drug within a class thatprovides a therapeutic outcome the same as others available canbe used for less cost. Cost-utility analysis is used to determinewhether a drug can improve the quality of a patient's life morethan other available therapies.Cost-benefit analysis is used to evaluate new programs orservices to determine whether they provide enough benefit tojustify the cost of running the program.

10. A.S. is a 56-year-old African American man with a longhistory of poorly controlled HTN secondary to medicationnonadherence and subsequent dilated cardiomyopathy(LVEF 35%). He is assessed in a community health clinictoday and reports not having taken his medications for thepast week. A.S. is asymptomatic, and his examination isunremarkable except for BP 180/120 mm Hg and HR 92beats/minute. All laboratory values are within normal limitsexcept for a serum creatinine (SCr)of 1.4 mg/dL and urinalysis with 2+ proteinuria. Which oneof the following therapeutic options would be best to manageA.S.'s condition in the clinic?A. Nifedipine 10 mg sublingually.B. Clonidine 0.2 mg orally.C. Captopril 12.5 mg orally.D. Labetalol 200 mg orally.

Answer: CThis patient is experiencing hypertensive urgency, consideringthat he has no evidence of target organ damage. Thus, his BPmay be reduced over 24 hours using oral medications. Given thispatient's concomitant comorbidities, HF, and microalbuminuria,an ACEI would be indicated. Sublingual nifedipine is no longerrecommended for management of hypertensive urgency becauseof acute BP lowering and association with life-threateningadverse events such as MI and stroke. Clonidine and labetalol areacceptable options; however, the patient has compellingindications for an ACEI. Although the patient should receive a β-blocker in additionto an ACEI for HF management, labetalol is notone of the three β-blockers recommended for chronic HFmanagement.

11. D.D. is a 72-year-old man admitted to the hospital for HFdecompensation. D.D. notes progressively increased dyspneawhen walking (now 10 ft [3 m], previously 30 ft [6 m]) andorthopnea (now four pillows, previously two pillows), increasedbilateral lower extremity swelling (3+), 13-kg weight gain in thepast 3 weeks, and dietary nonadherence. He has a history ofidiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III),paroxysmal atrial fibrillation (AF), and hyperlipidemia.Pertinent laboratory values are as follows: B-type natriureticpeptide (BNP) 2300 pg/mL (0-50 pg/mL), K+ 4.9 mEq/L, bloodurea nitrogen (BUN) 32 mg/dL, SCr 2.0 mg/dL, aspartateaminotransferase (AST) 40 IU/L, alanine aminotransferase(ALT) 42 IU/L, international normalized ratio (INR) 1.3,activated partial thromboplastin time (aPTT) 42 seconds, BP108/62 mm Hg, and HR 82 beats/minute. Home drugs includecarvedilol 12.5 mg 2 times/day,lisinopril 40 mg/day, furosemide 80 mg 2 times/day,spironolactone 25 mg/day, and digoxin 0.125 mg/day. Which oneof the following is best for treating his ADHF?A. Carvedilol 25 mg 2 times/day.B. Nesiritide 2-mcg/kg bolus; then 0.01 mcg/kg/minute.C. Furosemide 120 mg intravenously 2 times/day.D. Milrinone 0.5 mcg/kg/minute.

Answer: CThis patient, who has ADHF, is receiving a β-blocker.Although long-term β-blockers can improve HF symptomsand reduce mortality, β-blockers can worsen symptoms inthe shortterm. It is recommended to keep the maintenance β-blockertherapy at the same or aslightly reduced dose compared with outpatient therapy inpatients with ADHF; increasing the β-blocker dose beforereaching euvolemia may acutely worsen his clinical picture.In patients admitted with volume overload withoutsubstantial signs of reduced CO, it isreasonable to try intravenous loop diuretics initially. As gutedema increases, oral loop diuretics (notably furosemide)become less effective because of decreased absorption.Nesiritide is a vasodilatory drug that can beinitiated if intravenous loop diuretic therapy fails, butbecause of its adverse effects and substantial cost, it is notrecommended before a trial of intravenous diuretics andother potential therapies. Milrinone is an inotropic drug.Because of their adverse effects, inotropes arerecommended in cold and wet exacerbations only aftervasodilatory medications have failed.

12. After initiation of intravenous loop diuretics with only minimalurine output, D.D. is transferred to the coronary care unit forfurther management of diuretic-refractory decompensated HF.His O2 saturation is now 87% on 4-L nasal cannula, and anarterial blood gas is being obtained. His BP is 110/75 mm Hg, andhis HR is 75 beats/ minute. D.D.'s SCr and K+ concentrationshave begun to rise; they are now 2.7 mg/dL and 5.4 mmol/L,respectively. In addition to a one-time dose of intravenouschlorothiazide, which one of the following best represents ways inwhich D.D.'s decompensated HF should be treated?A. Nitroglycerin 20 mcg/minute.B. Sodium nitroprusside 0.3 mg/kg/minute.C. Dobutamine 5 mcg/kg/minute.D. Milrinone 0.5 mcg/kg/minute.

Answer: AIntravenous vasodilators such as nitroglycerin and sodiumnitroprusside are reasonable options if intravenous diureticsfail and the patient progresses to acute pulmonary edema.Both agents rapidly cause venous vasodilation and reducepulmonary filling pressures, which can relieve acuteshortness of breath. Nitroglycerin is the optimal choice forthis patient given the declining renal function and concernabout increased risk of thiocyanate toxicity in this setting.Dobutamine is typically used in states of low COdecompensation and is counteracted by concomitant β-blocker therapy, making it a poor choice in patientsreceiving β-blockers. Although milrinone is a moreacceptable inotropic agent in a patient receiving β-blockers,the dosing strategy is not appropriate as an initial dose.Finally, inotropes are generally reserved for patients inwhom all other therapies have failed.

13. D.D. initially responds with 2 Lof urine output overnight, andhis weight decreases by 1 kg thenext day. However, by day 5, hisurine output has diminishedagain, and his SCr has risen to4.3 mg/dL. He was drowsy andconfused this morning duringrounds. His extremities are cooland cyanotic, BP is 89/58 mmHg, and HRis 98 beats/minute. It is believedthat he is no longer respondingto his current regimen. A Swan-Ganz catheter is placed todetermine further management.Hemodynamic values arecardiac index (CI) 1.5L/minute/m2, SVR 2650dynes/cm-5, and PCWP 30 mmHg. Which one of the following isthe best drug given hiscurrent symptoms?A. Milrinone 0.2 mcg/kg/minute.B. Dobutamine 5 mcg/kg/minute.C. Nesiritide 2-mcg/kg bolus;then 0.01 mcg/kg/minute.D. Phenylephrine 20mcg/minute.

Answer: ASigns of a decreased CO state in HF, such as increased SCr, decreased mental status, and coolextremities, suggest a cold and wet state, and adjunctive therapy is indicated. Positive inotropicagents, such as milrinone, will increase CO to maintain perfusion to vital organs.Milrinone will also vasodilate the peripheral vessels to unload the heart (lower SVR). Again,although dobutamine would be a potential choice in this patient, it is not recommended inpatients receiving β-blockers. Although this patient has low BP, the elevated SVR suggests that hewill tolerate the vasodilatory effects of milrinone. Although nesiritide would provide venous andarterial vasodilation, it is relatively contraindicated in patients with systolic BP less than 100 mmHg and absolutely contraindicated in patients with systolic BP less than 90 mm Hg.Phenylephrine has no positive beta effects, so it will not augment contractility. In addition, it willcause vasoconstriction through alpha stimulation, which will further increase SVR and likelyworsen CO. Vasoconstrictors are reserved for patients in cardiogenic shock. Even though thispatient shows signs of significant hypoperfusion, the BP is not so low that it warrantsvasopressor therapy.

14. C.D. is a 68-year-old man admitted after an episode of syncope, with a presyncopalsyndrome of seeing black spots and experiencing dizziness before passing out.Telemetry monitor showed sustained VT for 45 seconds. His medical historyincludes HF NYHA class III, LVEF 30%, MI × 2, HTN × 20 years, LV hypertrophy,diabetes mellitus, and diabetic nephropathy. His drugs include lisinopril 5 mg/day,furosemide 20 mg 2 times/day, metoprolol 25 mg 2 times/day, digoxin 0.125 mg/day,glyburide 5 mg/day, and aspirin 325 mg/day. His laboratory tests show BP 120/75mm Hg, HR 80 beats/minute, BUN 30 mg/dL, and SCr 2.2 mg/dL.Which one of the following is the best therapy to initiate for conversion of hissustained VT?A. Amiodarone 150 mg intravenously for 10 minutes; then 1 mg/minute for 6 hours;then 0.5 mg/minute.B. Sotalol 80 mg 2 times/day titrated to QTc of about 450 milliseconds.C. Dofetilide 500 mcg 2 times/day titrated to QTc of about 450 milliseconds.D. Procainamide 20 mg/minute, with a maximum of 17 mg/kg.

Answer: ATreatment options for sustained VTare dependent on concomitantdisease states, particularly LVEF(40% cutoff). In a patient with LVdysfunction, class I agents such asprocainamide are contraindicated. Ina patientwhose creatinine clearance (CrCl) isless than 60 mL/minute, sotalolrequires a considerable dosagereduction to avoid excess torsades depointes. Sotalol is not an effectivecardioversion drug but is more usefulfor preventing future episodes ofarrhythmias (maintaining sinusrhythm) once sinus rhythm isachieved. Dofetilide is indicated onlyfor AF, not for ventriculararrhythmias; similarly, cardioversionrates with dofetilide are low.Amiodarone is first-line therapy forsustained VT in patients with severerenal insufficiency, HF, andstructuralheart disease.

15. C.D. presents to the emergency department 3 months after amiodarone maintenanceinitiation (he refused ICD placement) after a syncopal episode during which he lostconsciousness for 30 seconds, according to witnesses. He also has rapid HRepisodes during which he feels dizzy and light-headed. He feels very warm all thetime (he wears shorts, even though it is winter), is unable to sleep, and hasexperienced a 3-kg weight loss. He received a diagnosis of hyperthyroidism causedby amiodarone therapy. On telemetry, he shows runs of nonsustained VT. Which ofthe following would best predict the duration of amiodarone-associatedtachyarrhythmia in this patient?A. Never.B. 1 month.C. 6 months.D. 1 year.

Answer: CWith the prolonged half-life ofamiodarone and extensive fat tissuevolume of distribution, it would beexpected that hyperthyroid adverseeffects would last for at least 3-5 half-lives of the drug, which is anywherefrom 5 to 8 months. Althoughtherapeutic levels may fall offsubstantially by then, 1 month is toosoon toexpect the effects to subside. Eventhough some iodine and amiodaronemolecules will likely remain absorbedin fat stores for years, if not for life,therapeutic levels should not exist forlonger than what is predicted by thehalf-life.

16. S.L., a 64-year-old woman, presents to the emergency department with achief concern of palpitations. Her medical history includes HTNcontrolled with a diuretic and inferior-wall MI 6 months ago. She is paleand diaphoretic but able to respond to commands. S.L.'s laboratoryparameters are within normal limits. Her vital signs include BP 95/70mm Hg and HR 145 beats/minute; telemetry shows sustained VT.Although initially unresponsive to β-blockers, S.L. is successfully treatedwith lidocaine. Subsequent electrophysiologictesting reveals inducible VT, and sotalol 80 mg orally twice daily isprescribed. Two hours after the second dose, S.L.'s QTc is 520milliseconds. Which one of the following changes would be best withrespect to S.L.'s antiarrhythmic regimen?A. Continue sotalol at 80 mg orally twice daily.B. Increase sotalol to 120 mg orally twice daily.C. Discontinue sotalol and initiate dofetilide 125 mcg orally twice daily.D. Discontinue sotalol and initiate amiodarone 400 mg orally 3times/day.

Answer: DThis patient is experiencing QT prolongation withsotalol, placing the patient at an increased risk ofdeveloping life-threatening torsades de pointes.Sotalol should be immediately discontinued. Giventhe QT prolongation that occurred with sotalol,the same will likely occur with dofetilide.Amiodarone is associated withminimal risk of QT prolongation and thus wouldbe an appropriate alternative agent to preventventricular arrhythmias.

17. R.W. is a 38-year-old obese woman who presents with increasingsymptoms of fatigue and shortness of breath. She could walk only 10-20 ftat baseline and is now short of breath at rest. Her arterial blood gas is pH7.31/Pco2 65/Po2 53/85% O2 saturation. She has three-pillow orthopneaand 3+ pitting edema in her lowerextremities. Medical history is significant only for AF. Computerizedtomographic angiography shows that her pulmonary artery trunk issubstantially enlarged, with a mean pressure of 56 mm Hg.Echocardiography shows right atrial and ventricular hypertrophy. Chestradiography detects prominent interstitial markings.Pertinent laboratory test values are BUN 21 mg/dL, SCr 1.2 mg/dL, AST 145IU/L, ALT 90 IU/L, INR 2.1, and PTT 52 seconds; vital signs include BP108/62 mm Hg and HR 62 beats/minute. Home medications arewarfarin 2.5 mg/day, ipratropium 2 puffs every 6 hours, salmeterol 2puffs 2 times/day, and diltiazem 480 mg/day. Her diagnosis is IPAH.From the options below, which one of the following is the best evidencebased management strategy?A. Increase diltiazem to 600 mg/day.B. Start sildenafil 20 mg 3 times/day.C. Start epoprostenol 2 ng/kg/minute.D. Start bosentan 62.5 mg 2 times/day.

Answer: CThis patient is already receiving therapy withcalcium channel blockers to control her HRcaused by AF. She is taking a considerable dose ofdiltiazem, and her HR likely will not toleratefurther increases in therapy.Sildenafil is indicated for functional class IIpatients to improve symptoms or for patientswhose other therapies have failed. Althoughbosentan is an attractive oral option to manageher PAH, her liver enzymes are elevated more than3 times the upper limit of normal. In thissetting, administering bosentan is notrecommended. If liver transaminases are elevatedtransiently because of hepatic congestion,bosentan may be reconsidered later.Because this patient is currently in functionalclass IV with symptoms at rest, epoprostenol isindicated for a survival benefit.

18. L.S., a 48-year-old man with IPAH, is admitted to the medical intensivecare unit for severe respiratory distress. Medications before admissioninclude bosentan and sildenafil. His vital signs include BP 87/45mm Hg, HR 130 beats/minute, and respiratory rate 24 breaths/minute,and his oxygen requirements are increasing. Recently, during a previoushospital admission, pulmonary artery catheter placement revealed anmPAP of 40 mm Hg, right atrial pressure 16 mm Hg, CI 1.2 L/minute, andPCWP 15 mm Hg. Echocardiography reveals EF 60% with significant rightventricular dilation. Which one of the following is the best therapy?A. Epoprostenol and add phenylephrine if needed for BP support.B. Furosemide and add norepinephrine if needed for BP support.C. Nitroprusside and add epinephrine if needed for BP support.D. Dobutamine to increase CO.

Answer: AEpoprostenol is now warranted to manage thispatient's underlying disease because he has notresponded to two oral PAH therapies and is nowconsidered high risk because of the presence ofright ventricle (RV) dysfunction and low CI. Thepatient has normal filling pressures for a patientwith RV dysfunction, and diuresis withfurosemide may only worsen his low CI. Theunderlying cause of his low CI is not elevatedarterial resistance; thus, nitroprusside wouldlikely worsen his hypotension. Correcting theelevated pulmonary pressures should correct thelow CI; thus, dobutamine is not indicated at thistime, and it would likely only worsen histachycardia.

19. A.W., a 68-year-old man with a history of chronic kidney disease stageV on hemodialysis, HTN, CAD post-MI, moderately depressed LVEF,and gastroesophageal reflux disease, presents with acute-onsetshortness of breath and chest pain. After his recent dialysis, he had alarge barbecue meal with salt and smoked some marijuana laced withcocaine. He was nonadherent to medical therapy for 2 days andnoticed he had gained 2 kg in 24 hours. His baseline orthopneaworsened to sleeping sitting up in a chair for the 2 nights beforeadmission. He developed acute-onset chest tightness withdiaphoresis and nausea, pain 7/10. He went to theemergency department, where a BP of 250/120 mm Hg was noted. Hehad crackles halfway up his lungs onexamination, and chest radiography detected bilateral fluffyinfiltrates with prominent vessel cephalization.Electrocardiography showed sinus tachycardia HR 122 beats/minuteand ST depressions in leads 2, 3, and aVF. He was admitted forhypertensive emergency. Laboratory results are as follows: BUN 48mg/dL, SCr 11.4 mg/dL, BNP 2350 pg/mL, troponin T 1.5 mcg/L (lessthan 0.1 mcg/L), creatine kinase 227 units/L, and creatine kinase-MB22 units/L. Which one of the following medications is best to manageA.W.'s hypertensive emergency?A. Intravenous nitroglycerin 5 mcg/minute titrated to a 25% reductionin MAP.B. Labetalol 2 mcg/minute titrated to a 50% reduction in MAP.C. Sodium nitroprusside 0.25 mcg/kg/ minute titrated to a 25%reduction in MAP.D. Clonidine 0.1 mg orally every 2 hours as needed for a 50% reductionin MAP.

Answer: AHypertensive emergency should be treated immediatelyby a 25% reduction in MAP, followed by a slowreduction to goal for 5-7 days. The patient'scomorbidities guide the optimal therapy. His dialysisand SCr of 11.4 mg/dL are a contraindication tosodium nitroprusside caused by possible thiocyanatetoxicity. Labetalol (β-blockers in general) iscontroversial in patients who have taken cocaine, butits nonselective nature makesit an option; however, a reduction of 50% initially istoo rapid a decrease in BP for safety. Clonidine is notan appropriate drug for hypertensive emergencybecause itsunpredictable oral nature is difficult to titrate and canlead to precipitous drops in BP beyond the goal 25%reduction and possibly stroke or worsening MI.Nitroglycerin is an optimal choice, considering thepatient's lack of contraindications to this therapy andhis evolvingMI.

20. M.R., a 56-year-old white woman with a long history of HTN becauseof non-adherence and recently diagnosedHF (EF 35%), presents to the local emergency department with thesudden onset of severe, sharp, and diffuse chest pain that radiates toher back. A physical examination reveals BP 210/120 mm Hg and HR105 beats/minute but otherwise within normal limits. Currentlaboratory values are also within normal limits,except for a toxicology screen positive for cocaine. A chest radiographreveals a widened mediastinum, and a subsequent chest computedtomography scan reveals aortic arch dissection. Which one of thefollowing medications is best to manage M.R.'s hypertensiveemergency?A. Esmolol 25 mcg/minute.B. Esmolol 25 mcg/minute followed by sodium nitroprusside 0.5mcg/kg/minute.C. Sodium nitroprusside 0.5 mcg/kg/minute.D. Labetalol 2 mg/minute followed by sodium nitroprusside 0.5mcg/kg/minute.

Answer: DIn the setting of cocaine-induced HTN, a dual β- andα-blocking drug is preferable to a β-blocker alone. Inthe setting of aortic dissection, sodium nitroprussideshould not be used before using β-blocker therapy firstto prevent reflex tachycardia. Thus, the optimalregimen for a patient with cocaine-induced HTNresulting in aortic dissection is labetalol followed bysodium nitroprusside

21. B.C. is a 50-year-old man admitted forADHF (acute decompensated heartfailure). At baseline, he has NYHA(New York Heart Association) class IIheart failure (HF). During the pastfew days, he has been short of breathat rest. He is initiated on furosemide100 mg intravenous bolus but has ahistory of diuretic resistance. B.C.'sbaseline vital signs include a bloodpressure (BP) of 89/72 mm Hg andheart rate (HR) of 85 beats/minute.Which one of the following is the nextbest option for treating B.C.'sdecompensated HF? A. Changing to a furosemide infusion.B. Initiating intravenous vasodilatorymedications.C. Initiating intravenous inotropicmedications.D. Switching to a different loopdiuretic.

Answer AChanging to a furosemide infusion. According to the ADHF (acute decompensated heartfailure) guidelines, intravenous loop diuretics are the drug of choice for treating an acutedecompensation. If this therapy does not completely alleviate a patient's symptoms,switching the patient to a continuous infusion of loop diuretic (Answer A) or adding adiuretic with a different mechanism of action should be considered. Intravenousvasodilators (Answer B) may be considered in addition to intravenous loop diuretics toimprove symptoms rapidly or to manage persistent symptoms despite maximal loopdiuretics; however, these agents should be avoided in patients with low blood pressure(BP). Intravenous inotropic medications (Answer C) are indicated only for patients withevidence of diminished peripheral perfusion or end-organ dysfunction (low outputsyndrome) and for patients who are refractory to or intolerant of the above therapies.Switching to another loop diuretic (Answer D) is less likely to improve diuresis in a patientalready receiving intravenous diuretics

22. A Task Force at an HMO (healthmaintenance organization) isevaluating the use of medications inpatients seen for coronary arterydisease (CAD) in the CardiologyClinic. The committee identifies theneed to implement minimumevidence-based performancemeasures for the use of medicationsin treating CAD in a clinic-basedsetting. Which one of the followingbest describes a health careorganization that has set suchstandards? A. Joint Commission on Accreditationof Healthcare Organizations.B. Community Health AccreditationProgram.C. Health Care FinancingAdministration.D. National Committee for QualityAssurance.

Answer DNational Committee for Quality Assurance. The Joint Commission on Accreditation ofHealthcare Organizations (Joint Commission) (Answer A) uses a core set of evidence-based performance measures to standardize the accreditation of hospitals. Performancemeasures exist for acute MI (myocardial infarction), HF (heart failure), pneumonia,surgical infection prevention, pregnancy, and others. The Community Health AccreditationProgram (Answer B) is an alternative to the Joint Commission for accreditation of homehealth care and hospice organizations. The Health Care Financing Administration(Answer C) is the federal agency that administers Medicare, Medicaid, and child healthinsurance programs. It also coregulates accreditation standards in long-term care facilities,particularly with respect to Medicare policies. The National Committee for QualityAssurance (NCQA) (Answer D) is a private, nonprofit organization dedicated to improvinghealth care quality. The NCQA uses HEDIS, or health employer data and information set,"report cards" to measure performance in key disease states such as cancer, heart disease,asthma, and diabetes mellitus to certify a variety of managed care organizations for healthcare services.

23. A pharmacoeconomic analysis isto be performed to determinewhether the exclusive use ofdabigatran would be lessexpensive than the use ofwarfarin because of the lack ofmonitoring of internationalnormalized ratio (INR) levels.Which one of the following typesof pharmacoeconomic analysis ismost appropriate? A. Cost-effectiveness analysis.B. Cost-minimization analysis.C. Cost-benefit analysis.D. Cost-utility analysis.

Answer BCost-minimization analysis. Cost-effectiveness analysis (Answer A) is incorrect. It is used fornew drug therapies to determine whether added benefits (e.g., mortality reduction vs. othertherapies) outweigh the increased price associated with the medication compared with others.Cost-minimization analysis (Answer B) is the correct answer. It is used to determine whether atherapeutically equivalent drug within a class that provides the same therapeutic outcome asother drugs can be used for less cost. When dabigatran is compared with warfarin, cost-minimization analysis will determine whether the lack of blood testing required for monitoringpatients receiving dabigatran is less expensive than the cost of drawing several INR(international normalized ratio) levels in patients receiving warfarin. Cost-utility analysis(Answer D) is incorrect. It is used to determine whether a drug can improve the quality of apatient's life more than other available therapies. Cost-benefit analysis (Answer C) is incorrectsince it is used to evaluate new programs or services to determine whether they provide enoughbenefit to be worth the cost of running the program.

24. S.S. is a 70-year-old man admittedfor atrial fibrillation with a rapidventricular rate. The physicianprescribes warfarin 5 mg orallydaily for 3 days and requestsclinical pharmacy services toadjust the dose to maintain INR2-3. The pharmacist dispensesthe warfarin as prescribed butfails to check the INR level. Thepharmacist's action is bestdescribed by which one of thefollowing types of medicationerrors? A. Adherence error.B. Omission error.C. Monitoring error.D. Wrong administrationtechnique error.

Answer CMonitoring error. An adherence error (Answer A) is incorrect. It is one committed by the patientwhen the correct medication is either not taken by the patient or is taken at inappropriateintervals by the patient. An omission error (Answer B) is also incorrect. It is the failure toadminister the drug, either because of a patient's refusal or because the medication is withheldbecause of perceived contraindications. A monitoring error (Answer C) is correct since it a typeof error made by a pharmacist, either by failing to check the prescription for problems or errorsor by failing to use appropriate laboratory or clinical data when assessing a given prescriptionfor problems, as in this case. A wrong administration technique error (Answer D) is incorrect. Itis an error in which an inappropriate technique is used to administer the drug. This can includeusing the incorrect rate of administration.

25. S.R. is a 57-year-old man admittedto the hospital with severeheadache. His medical historyincludes uncontrolled HTN, gout,and medication nonadherence.Vital signs include blood pressure240/110 mm Hg and pulse of 50beats/minute. He is given adiagnosis of hypertensiveemergency. Which one of thefollowing choices is the bestmanagement option for thispatient? A. Esmolol 25 mcg/kg/minuteintravenously.B. Clonidine 0.1 mg/hour orally.C. Enalaprilat 0.625 mgintravenously every 6 hours.D. Metoprolol 5 mg intravenouslyevery 6 hours.

Answer CEnalaprilat 0.625 mg intravenously every 6 hours. Both esmolol (Answer A) and metoprolol(Answer D) are incorrect since both would be contraindicated given the patient's low HR.Clonidine (Answer B) is also incorrect. It may also reduce HR by reducing sympathetic drive. Itis appropriate for hypertensive urgency but not hypertensive emergency, given its inability toreliably reduce BP within 30-60 minutes. Enalaprilat (Answer C) is the best option to rapidlyand reliable reduce BP and does not slow HR.