Download Propranolol

Cardiovascular
Pharmacology
Practice Quiz
HUCM Class of 2006
Unit III Exam I Prep
Question #1
Angiotensin – converting enzyme inhibitors
such as enalapril also act to increase the
activity of which of the following
substances?
Vasopressin
 Endothelins
 Brandykinin
 Substance P
 Enkephalins

Micean J. Johnikin
HUCM Class of 2006
2
Question #1
Angiotensin – converting enzyme inhibitors
such as enalapril also act to increase the
activity of which of the following
substances?

Brandykinin
– ACE inhibitors not only inhibit the formation of a
vasoconstrictor, angiotensin II, they also inhibit the
degradation of a vasodilator, bradykinin. This latter
effect results from inhibition of the kinases that
inactive bradykinin. Other peptides that cause
vasodilation include substance P and atrial natriuretic
peptide. Endothelins and vasopressin cause
vasoconstriction.
Micean J. Johnikin
HUCM Class of 2006
3
Question #2
Nifedipine and verapril share which of the
following physiologic effects?





Decrease systemic vascular resistance
Decrease heart rate
Block vascular and cardiac calcium channels
equally
Selectively block cardiac calcium channels
Selectively block calcium channels in smooth
muscle
Micean J. Johnikin
HUCM Class of 2006
4
Question #2
Nifedipine and verapril share which of the
following physiologic effects?

Decrease systemic vascular resistance
– Verapamil has approximately equal effects on calcium
channels in smooth muscle and cardiac tissue,
whereas nifedipine and other dihydropyridines
selectively block calcium channels in smooth muscle.
Both agents can lower vascular resistance, but only
verapamil decreases heart rate. Nifedipine may cause
reflex tachycardia.
Micean J. Johnikin
HUCM Class of 2006
5
Question #3
Both propranolol and hydrochlorothiazide:
Decrease blood volume and peripheral
resistance
 Decrease heart rate
 Can adversely affect serum lipids
 Can cause hypokalemia
 Elevate plasma renin activity

Micean J. Johnikin
HUCM Class of 2006
6
Question#3
Both propranolol and hydrochlorothiazide:

Can adversely affect serum lipids
– Both propanolol and hydrochlorothiazide can have
adverse effects on serum lipids. Beta – blockers can
elevate triglycerides and decrease HDL cholesterol,
whereas diuretics increase LDL in some patients.
– Only diuretics can decrease serum potassium and
cause hypokalemia. In addition, diuretics decrease
blood volume and peripheral resistance whereas renin
activity usually increases secondary to blood volume
contraction. Only B – blockers decrease heart rate.
Micean J. Johnikin
HUCM Class of 2006
7
Question #4
All of the following antihypertensive agents
decrease peripheral vascular resistance EXCEPT:
Propranolol
 Terazosin
 Nifedipine
 Hydralazine
 Methyldopa

Micean J. Johnikin
HUCM Class of 2006
8
Question #4
All of the following antihypertensive agents
decrease peripheral vascular resistance EXCEPT:

Propranolol
– B – Adrenoreceptors antagonists such as propanolol
do not lower peripheral resistance and may even
increase it either by blocking vascular B2 – receptors
or by a reflex mechanism that follows the initial
reduction in blood pressure.
– Alpha – adrenoreceptor antagonists such as terazosin,
calcium channel blockers such as nifedipine, direct –
acting vasodilators such as hydralazine, and centrally
acting sympatholytics such as methyldopa act to
decrease vascular resistance.
Micean J. Johnikin
HUCM Class of 2006
9
Question #5
Select the antihypertensive drug that is
most likely to cause each adverse effect





Propranolol
Clonidine
Prazosin
Captopril
Minoxidil





Micean J. Johnikin
First – dose syncope
Severe bronchoconstriction in
asthmatic patient
Renal failure in patients with
bilateral renal artery stenosis
Sedation and dry mouth
Hypertrichosis, particularly in
women
HUCM Class of 2006
10
Question #5
Select the antihypertensive drug that is
most likely to cause each adverse effect

Propranolol – Severe bronchoconstriction in
asthmatic patient
Clonidine – Sedation and dry mouth
 Prazosin – First Dose Syncope
 Captopril – Renal failure in patients with

bilateral renal artery stenosis
 Minoxidil - Hypertrichosis
Micean J. Johnikin
HUCM Class of 2006
11
Question#6
Match each cardiovascular drug with its effect:
Peripheral Vascular
Resistance
Cardiac Preload
Heart Rate
Myocardial Oxygen
Consumption
Increased
Decreased
Decreased
(B) Decreased
Decreased
Increased reflexively
Decreased
(C) Decreased
---
Decreased
Decreased
(D) Decreased
---
Increased reflexively
Increased or
decreased
(A)




---
Verapamil
Propranolol
Hydralazine
Nitroglycerine (sublingual)
Micean J. Johnikin
HUCM Class of 2006
12
Question#6
Match each cardiovascular drug with its effect:
Peripheral Vascular
Resistance
Cardiac Preload
Heart Rate
Myocardial Oxygen
Consumption
Increased
Decreased
Decreased
(B) Decreased
Decreased
Increased reflexively
Decreased
(C) Decreased
---
Decreased
Decreased
(D) Decreased
---
Increased reflexively
Increased or
decreased
(A)




---
Verapamil - C
Propranolol - A
Hydralazine - D
Nitroglycerine (sublingual) - B
Micean J. Johnikin
HUCM Class of 2006
13
Question #6 Explained
Propanolol decreases heart rate and myocardial contractility,
thereby decreasing myocardial oxygen consumption. Propanolol
can increase ventricular filling pressure and preload slightly, but
does not significantly decrease peripheral resistance.
 Verapamil inhibits calcium channels in vascular smooth muscle
and cardiac muscle and decreases peripheral vascular resistance
and heart rate, thereby decreasing myocardial oxygen
requirement. Verapamil has relatively little effect on venous
smooth muscle and ventricular filling pressure.
 Hydralazine relaxes arteriolar smooth muscle and markedly
reduces peripheral vascular resistance. This drug can cause a
significant reflex tachycardia and thereby increase oxygen
consumption.
 Nitroglycerin is primarily a venodilator when given sublingually:
it decreases ventricular filling pressure and cardiac oxygen
consumption, but can cause reflex tachycardia.

Micean J. Johnikin
HUCM Class of 2006
14
Practice Clinical Vignettes
Micean J. Johnikin
HUCM Class of 2006
15
Case #1
A 48 year old type 2 diabetic patient presents with complaints
of polyuria and polydipsia. Laboratory evaluation reveals a
blood glucose of 192 mg/dL. She states that her diabetes had
been well controlled and that she had been symptom – free
for the past 8 years. Recently, however, she began taking
medication for hypertension. Which of the following
antihypertensive drugs is she most likely taking?





Diltazem
Enalapril
Hydrochlorothiazide
Methyldopa
Terazosin
Micean J. Johnikin
HUCM Class of 2006
16
Case #1
A 48 year old type 2 diabetic patient presents with complaints
of polyuria and polydipsia. Laboratory evaluation reveals a
blood glucose of 192 mg/dL. She states that her diabetes had
been well controlled and that she had been symptom – free
for the past 8 years. Recently, however, she began taking
medication for hypertension. Which of the following
antihypertensive drugs is she most likely taking?

Hydrochlorothiazide
– The fact that the patient had well – controlled diabetes until the
addition of an antihypertensive medication suggests that the
new agent is responsible. Hydrochlorothiazide is a thiazide
diuretic that is know to increase fasting blood glucose in diabetic
patients.
Micean J. Johnikin
HUCM Class of 2006
17
Case #2
A 33 – year – old with a history of asthma is being
treated for symptoms of hyperthyroidism. Which
of the following beta – blockers would be an
appropriate therapy for this patient?
Isoproterenol
 Labetalol
 Metoprolol
 Propranolol
 Timolol

Micean J. Johnikin
HUCM Class of 2006
18
Case #2
A 33 – year – old with a history of asthma is being
treated for symptoms of hyperthyroidism. Which
of the following beta – blockers would be an
appropriate therapy for this patient?

Metoprolol
– Symptoms related to hyperthyroidism include
palpitations and tachycardia. If the patient is also
asthma, you should select a drug that blocks beta1 –
receptors without affecting the beta2 – receptors
found in the respiratory smooth muscle. Therefore, a
selective beta1 – blocker (such as metaprolol) would
be appropriate.
Micean J. Johnikin
HUCM Class of 2006
19
Case #2: Answer Explanations
Continued




Isoproterenol is a non – selective beta agonist, not
antagonist
Labetalol is a mixed alpha and nonselective beta
antagonist used for chronic hypertension and
hypertensive emergencies
Propanolol is a nonselective beta antagonist. It would
block both beta1 and beta2 receptors and would
therefore be contraindicated in a patient with asthma.
Timolol is also a nonselective beta – antagonist that is
used topically in the treatment of glaucoma.
Micean J. Johnikin
HUCM Class of 2006
20
Case #3
A patient with essential hypertension is starting
diuretic therapy. He has a history of calcium
oxalate renal stones. Which of the following
diuretics would be most appropriate for this
patient?





Acetazolamide
Furosemide
Hydrochlorothiazide
Spironolactone
Triamterene
Micean J. Johnikin
HUCM Class of 2006
21
Case #3
A patient with essential hypertension is starting
diuretic therapy. He has a history of calcium
oxalate renal stones. Which of the following
diuretics would be most appropriate for this
patient?

Hydrochlorothiazide
– A thiazide diuretic would be the drug of choice for this
patient because it is the only class of diuretic that
decrease urinary secretion of calcium. Thiazide
diuretics, like hydrochlorothaizide, inhibit the Na+/Clcotransporter in the distal convoluted tubule and
promote the reabsorption of calcium.
Micean J. Johnikin
HUCM Class of 2006
22
Case#3 Explanations Continued

Acetazolamide, a carbonic anhydrase inhibitor, and
furosemide, a loop diuretic, induce diuresis at the
expense of all three major cationic electrolytes ( Na+,
K+, Ca2+), which are secreted in increased amounts.

Spironolactone and triamterene so – called
potassium – sparing diuretics block Na+/K+ exchanges
in the collecting duct. Although they decrease K+
secretion, they elevate Na+ and Ca2+ secretion.
Micean J. Johnikin
HUCM Class of 2006
23
Case #4
A 68 – year old man presents with complaints of chronic
fatigue, exertional and nocturnal dyspnea, orthopnea, and a
chronic nonproductive cough. On examination, respiratory
wheezing and rhonchi are noted. Cardiac examination reveals
a diminished first heart sound and an S3 gallop. The patient
indicates that he was recently treated for hypertension and
vasospastic angina. On the basis of his initial presentation,
which of the following agents was most likely prescribed.





Amlodipine
Captopril
Furosemide
Hydralazine
Verapril
Micean J. Johnikin
HUCM Class of 2006
24
Case #4
A 68 – year old man presents with complaints of chronic
fatigue, exertional and nocturnal dyspnea, orthopnea, and a
chronic nonproductive cough. On examination, respiratory
wheezing and rhonchi are noted. Cardiac examination reveals
a diminished first heart sound and an S3 gallop. The patient
indicates that he was recently treated for hypertension and
vasospastic angina. On the basis of his initial presentation,
which of the following agents was most likely prescribed.

Verapamil
– This patient is presenting with classic signs and symptoms of
congestive heart failure (highlighted above). Verapamil is a calcium
channel blocker used to treat both HTN and vasospastic angina.
However, it has a strong inotropic effect on the heart that can cause
signs and symptoms of heart failure. Furthermore, some clinical
studies have shown that congestive heart failure can develop in a small
percentage of individuals taking verapamil
Micean J. Johnikin
HUCM Class of 2006
25
Case#4 Explanation Continued




Amlodipine is also a calcium channel blocker used in the treatment
of both HTN and vasospastic angina. However it does not have
negative inotropic effect on the heart and does not cause signs and
symptoms of heart failure. Furthermore, amlodipine is generally
well tolerated in heart failure patients.
Captopril is an ACE inhibitor used in the treatment of both HTN
and CHF. Therefore, this agent would not show signs and
symptoms of CHF.
Furosemide is a diuretic commonly used to treat the congestion
and edema associated with heart failure. It can also be used to
treat HTN.
Hydralazine is a vasodilator used primarily to treat signs and
symptoms associated with heart failure. The use of this agent in
patients with angina is not recommended because it can potentiate
angina.
Micean J. Johnikin
HUCM Class of 2006
26
Case #5
A 59 – year old man with a history of MI presents to his physician
complaining of shortness of breath. On examination, his heart rate
is 110/min and respiratory rate is 22/min. He has rales in both long
fields, a normal sinus rhythm with an S3 gallop, and a 2+ pitting
ankle edema. A chest x – ray film reveals cardiomegaly, and his
ejection fraction on echocardiogram is calculated at 37%. Which of
the following medication would alleviate this patient’s symptoms by
significantly reducing both the preload and afterload on the heart
without affecting its inotropic state.





Digoxin
Diltiazem
Enalapril
Furosemide
Propanolol
Micean J. Johnikin
HUCM Class of 2006
27
Case #5
A 59 – year old man with a history of MI presents to his physician
complaining of shortness of breath. On examination, his heart rate is
110/min and respiratory rate is 22/min. He has rales in both long fields, a
normal sinus rhythm with an S3 gallop, and a 2+ pitting ankle edema. A
chest x – ray film reveals cardiomegaly, and his ejection fraction on
echocardiogram is calculated at 37%. Which of the following medication
would alleviate this patient’s symptoms by significantly reducing both the
preload and afterload on the heart without affecting its inotropic state.

Enalapril
– Everything in this case points to congestive heart failure (highlighted above).
A drug that will alleviate the symptoms by decreasing both preload and
afterload is necessary.
– Enalapril is an ACE inhibitor. ACE inhibitors work by blocking the conversion
of angiotensin I to angiotensin II in the lungs. Angiotensin II is both a
potent vasoconstrictor and a stimulator of aldosterone production.
Aldosterone acts by promoting sodium (and thus water) reabsorption by the
kidney. An Ace inhibitor will therefore promote vasodilation
(reducing afterload) as well as reduce intravascular volume
(decreasing preload). It does not affect the heart’s inotropic state.
Micean J. Johnikin
HUCM Class of 2006
28
Case #5 Explanation Continued
Although digoxin is a mainstay in the therapy of CHF, it has no effect on
either preload or afterload. Instead, it works by having a positive inotropic
effect on the heart. The mechanism involves inhibition of Na+/K+ ATPase
and consequent increase in intracellular calcium, which in turn, increases
the heart’s contractile force.
 Diltiazem is a calcium channel blocker. As their name implies, calcium
channel blockers block the influx of calcium (via specific calcium channels)
into the cell from the ECF; this interferes with excitation – contraction
coupling in cardiac muscle, producing a negative inotropic effect. Although
these drugs can be used in the treatment of hypertension and angina (they
inhibit the contraction of smooth muscle and thereby decrease peripheral
vascular resistance / afterload), they are contraindicated in patients with
CHF because of their negative inotropic effects
 Furosemide is a loop diuretic. It decreases intravascular volume (and
hence preload), but at typical doses has no significant effect on either
afterload of inotropic state. Diuretics are often used in the treatment of
CHF, and furosemide is used for the immediate relief of pulmonary
congestion.
 Propanolol is a beta – blocker. It has negative inotropic effect on the
heart and is therefore contraindicated in patients with CHF

Micean J. Johnikin
HUCM Class of 2006
29
Case #6
A patient who is being treated for a myocardial
infarction that occurred 2 hours ago is medicated
with IV nitroprusside. Which of the following is
the expected action of this drug?
Constriction of the arterioles alone
 Constriction of both arterioles and venules
 Constriction of venules alone
 Dilatation of arterioles alone
 Dilatation of arterioles and venules

Micean J. Johnikin
HUCM Class of 2006
30
Case #6
A patient who is being treated for a MI that
occurred 2 hours ago is medicated with IV
nitroprusside. Which of the following is the
expected action of this drug?

Dilatation of arterioles and venules
– Nitroprusside is somewhat tricky to use, but is a very useful IV
agent that causes dilatation of both arterioles and venules. It
has a very rapid onset of action and is typically used in an
emergency department or ICU situation. The typical setting is a
patient with acute or chronic low cardiac output and high
ventricular filling pressure due to poor systolic left ventricular
function. Underlying causes for the poor ventricular function
may be diverse: dilated cardiomyopathy (DCM), acute MI,
chronic coronary heart disease, or aortic or mitral incompetence,
Nitroprusside can improve perfusion of vital organs and
reduce the workload of the heart.
Micean J. Johnikin
HUCM Class of 2006
31
Case#6 Explanation Continued

Problems sometimes encountered with this drug
include hypotension (best avoided by starting
with a low dose and continuously monitoring
systemic arterial and pulmonary capillary wedge
pressures) and accumulation of toxic metabolites
of cyanide in patients with liver or renal failure.
Many physicians prefer to use IV nitrate rather
than nitroprusside because of its lesser toxicity.
Micean J. Johnikin
HUCM Class of 2006
32
References

Kaplan USMLE Step 1 QBook (2001)

Board Simulator Series Body Systems
Review I: Hematopoietic /
Lymphoreticular, Respiratory,
Cardiovascular 2nd Edition (1997)
Micean J. Johnikin
HUCM Class of 2006
33
Happy Studying !

Another Philippians 4:13 Production