Download 1 - RCRMC Family Medicine Residency

CKD, Ethics, Nutrition in Sports
and HTN
The Seventh Report of the Joint National
Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure (JNC recommends a blood pressure
(BP) goal of _______ for patients with
chronic kidney disease (CKD).
A) <140/80 mm Hg
B) <135/80 mm Hg
C) <130/80 mm Hg
D) <125/80 mm Hg
Answer
• C) <130/80 mm Hg
Introduction
• reaching blood pressure (BP) goals in patients
with chronic kidney disease (CKD) important for
preventing rapid loss of kidney function
• meta-analysis found patients with systolic BP of
150 mm Hg have glomerular filtration rate (GFR)
loss of 8 mL/min per 1.73 m2 per year (4 mL/min
per year if BP reduced to 140 mm Hg)
• Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure recommends
BP goal of <130/80 mm Hg in patients with CKD
• systolic BP <130 mm Hg helps stabilize kidney
function and prevent development of kidney
failure
Captopril
A) Useful in patients with hyperkalemia and progression to
stage 3 CKD
B) Compared to placebo, shown less likely to result in
decline in kidney function in patients with type 2 diabetic
nephropathy
C) Compared to placebo, shown less likely to result in
doubling of serum creatinine
D) Compared to placebo, shown more effective in reducing
BP in patients with type 2 diabetic nephropathy
Answer
• C) Compared to placebo, shown less likely
to result in doubling of serum creatinine
Case 1
• woman 63 yr of age with hypertensive nephrosclerosis
presents for follow-up
• medications include lisinopril (20 mg/day) and amlodipine
(5 mg/day)
• BP 154/84 mm Hg
• creatinine 1.3 mg/dL (stable relative to baseline
• stage 3 CKD)
• spot protein to creatinine ratio 1.5 g/day
• management—increase lisinopril to 40 mg/day and check
basic metabolic panel in 1 wk; after 1 wk, electrolytes
normal, but creatinine increased to 1.6 mg/dL
• What should you do?
Answer
• Transient increase in creatinine: often seen in patients with
proteinuric kidney disease started on angiotensinconverting enzyme inhibitor (ACEI) or angiotensinreceptor blocker (ARB), or when dose titrated up
• kidney function usually maintained
• long-term prognosis better
• initial bump in creatinine or decrease in GFR related to
ACEIs or ARBs reversible
• Prognosis of CKD: greater proteinuria associated with
more rapid loss of kidney function over time; as BP
increases, relative risk for progression of CKD increases
• in patients with CKD, important to decrease proteinuria
with ACEIs or ARB
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Case
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man 77 yr of age with hypertensive nephrosclerosis, congestive heart failure
(HF), chronic lower extremity edema, and recurrent cellulitis presents for
routine follow-up
medications include aspirin, carvedilol (Coreg; 80 mg/day); benazepril (40 mg
twice daily), and furosemide (eg, Delone, Furocot, Lasix; 60 mg/day)
BP 179/83 mm Hg
heart rate (HR) 56 bpm
body weight 317 lb
creatinine 1.6 mg/dL (baseline 1.9 mg/dL); electrolytes normal; hemoglobin
9.6 g/dL (baseline 11.2 g/dL)
management—consider that serum creatinine may be falsely assessed as lower
due to secondary dilutional effect in setting of severe fluid overload
kidney function unclear; furosemide increased to 100 mg/day; when basic
metabolic panel repeated in 1 wk, creatinine increased to 2.3 mg/dL
patient advised to continue current medications, and repeat basic metabolic
panel in 1 wk
important to control fluid status, to reduce risk for cellulitis, and to improve
mobility
Losartan
A) Useful in patients with hyperkalemia and
progression to stage 3 CKD
B) Compared to placebo, shown less likely to result
in decline in kidney function in patients with type 2
diabetic nephropathy
C) Compared to placebo, shown less likely to result
in doubling of serum creatinine
D) Compared to placebo, shown more effective in
reducing BP in patients with type 2 diabetic
nephropathy
Answer
• B) Compared to placebo, shown less likely
to result in decline in kidney function in
patients with type 2 diabetic nephropathy
Case 3
• woman 67 yr of age with poorly controlled diabetes,
diabetic retinopathy, and diabetic nephropathy presents for
routine follow-up
• medications include lisinopril (20 mg/day), insulin,
amlodipine (5 mg/day), and simvastatin
• BP 165/95 mm Hg; HR 71 bpm
• body mass index 36
• has trace edema;
• creatinine 1.2 mg/dL (stage 3 CKD)
• potassium slightly elevated (5.5 mEq/L)
• spot albumin to creatinine ratio >3 g/day
• What should you do:?
Answer
• management — counsel patient about
lifestyle modifications
• increase lisinopril to decrease proteinuria
add thiazide diuretic; check metabolic panel
in 1 w
Furosemide
A) Useful in patients with hyperkalemia and
progression to stage 3 CKD
B) Compared to placebo, shown less likely to
result in decline in kidney function in patients
with type 2 diabetic nephropathy
C) Compared to placebo, shown less likely to
result in doubling of serum creatinine
D) Compared to placebo, shown more
effective in reducing BP in patients with type
2 diabetic nephropathy
Answer
• A) Useful in patients with hyperkalemia and
progression to stage 3 CKD
Lifestyle modifications
• weight reduction
• sodium restriction (<2400 mg/day can
reduce BP by 8 mm Hg)
• greater consumption of fresh fruits,
vegetables, and meats
• prepare meals at home
• physical activity
• moderate alcohol intake
Antihypertensive agents and
diabetic nephropathy
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Study showed patients with type 1 diabetic nephropathy on ACEI had reduced chance of
progressing to kidney disease
other study showed that patients on captopril less likely to have doubling of serum
creatinine, compared to patients on placebo (overall BP control same in both groups)
Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan
(RENAAL) study — saw lower likelihood in decline in kidney function in patients with
type 2 diabetic nephropathy who received losartan, compared to placebo (BP control
same in both arms)
hyperkalemia —diabetes can cause structural changes in kidney tubules, leading to type
4 renal tubular acidosis (hyporeninemic hyperaldosteronism and hyperkalemic state)
monitor patients
inform patients about risk for fatal cardiac arrhythmia
advise patients to follow potassiumrestricted diet (less than 2000-3000 mg/day)
use diuretics (thiazide diuretics typically weaker than loop diuretics)
thiazide diuretics often not effective in patients progressing to advanced stage 3 CKD
(switch to, eg, furosemide or bumetanide [Bumex]);
ACEIs and ARBs cannot be used in some patients with diabetic nephropathy and CK
Which of the following novel
treatment options is approved by
the Food and Drug
Administration for the treatment
ofhypertension in CKD?
A) Hypertension vaccine
B) Renal denervation
C) Vasopeptidase inhibitors
D) None of the above
Answer
• D) None of the above
Antihypertensive therapy in
development
Hypertension vaccine —vaccine against angiotensin II
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• phase II trial showed decreased systolic and diastolic BP after 14 wk
on 24-hr ambulatory BP monitoring, compared to placebo (most
pronounced during daylight hours)
• 2 doses given (higher dose more effective)
• renal denervation—radiofrequency applied to sympathetic nerves in
kidneys
• saw dramatic improvement in systolic and diastolic BP after 6 mo,
compared to placebo
• Vasopeptidase inhibitors—inhibit ACE and neutral endopeptidase
(causes degradation of natriuretic peptides; inhibition results in
prolongation of activation of substances, eg, atrial and brain
natriuretic peptides)
• saw statistically significant improvement in BP, compared to use of
ACEI alone
Staging of CKD based on revised
guidelines considers all the
following, except:
A) Cause of disease
B) Estimated glomerular
filtration rate
C) Albuminuria
D) Hyperkalemia
Answer
• D) Hyperkalemia
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Chronic kidney disease
must be present for 3 mo
defined by reduced kidney function (ie, estimated GFR [eGFR] <60 mL/min per 1.73 m
2) or injury or damage to kidney (through, eg, albuminuria, cysts, stones)
etiology—80% to 90% due to diabetes, hypertension, cardiovascular (CV) disease, or
HF
other systemic diseases (eg, lupus, HIV disease, urologic disease)
intrinsic kidney disease (eg, polycystic disease, glomerular disease)
Complications of CKD: end-stage renal disease (ESRD) or kidney failure
increased risk for death
atherosclerotic disease HF
risk for osteoporosis and fracture
cognitive impairment, dementia, and frailty predisposed by CKD
risks associated with medications and treatment procedures
Morbidity: most patients with CKD die before reaching dialysis
1% to 0.1% of patients with CKD reach kidney failure
data from Northwest Kaiser — 1% of patients with eGFR of 30 to 60 mL/min per 1.73
m2 reached ESRD at 5 yr, and 25% died
1 in 5 patients with eGFR of 15 to 30 mL/min per 1.73 m 2 had kidney failure at 5 yr,
and nearly 50% had die
Prognosis
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must consider kidney function (ie, eGFR) and proteinuria
recent meta-analysis— patients classified by albumin to creatinine ratio (ACR; eg, <10 mg/g, 10-30
mg/g, 30-300 mg/g, >300 mg/g)
ACR >30 mg/g or eGFR <60 mL/min per 1.73 m 2
associated with 2-fold increase in risk for death (risk higher when combined)patients with eGFR of
45 to 60 mL/min per 1.73 m 2 and no albuminuria at low increased risk of dying, but risk for death
doubles with ACR of 30 to 300 mg/g (triples with ACR >300 mg/g)
CKD staging: stage 1 — eGFR >90 mL/min per 1.73 m 2 with proteinuria or other manifestation of
kidney disease
stage 2 — eGFR 60 to 90 mL/min per 1.73 m 2 with proteinuria or other manifestation of kidney
disease
stage 3 — eGFR 30 to 60 mL/min per 1.73 m 2
stage 4 — eGFR 15 to 30 mL/min per 1.73 m2
stage 5 — eGFR <15 mL/min per 1.73 m 2
, or on dialysis
problems — difficult to distinguish between stages 1 and 2
eGFR range for stage 3 too broad; albuminuria addressed only in stages 1 and 2
disease etiology not addressed
Revised staging — due in early 2012
3-dimensional staging (cause, eGFR, and albuminuria) to replace 5-stage schema
descriptive staging (eg, hypertensive patient with eGFR of 50 mL/min per 1.73 m2 and ACR of 10
mg/g [not at high risk of developing need for dialysis]
diabetic patient with preserved eGFR and high ACR [at high risk for progressive CKD]
For primary prevention of CKD,
patients with diabetes should
undergo albumin to creatinine
ratio screening every:
A) 6 mo
B) 1 yr
C) 2 yr
D) 3 yr
Answer
• B) 1 yr
Screening for CKD
• hypertension and CV disease guidelines advise screening
for creatinine
• diabetes guidelines advise measuring creatinine and
albuminuria
• begin checking creatinine at 40 yr of age in lower-risk
populations
• in higher-risk populations (eg, blacks, American Indians)
start at 30 yr of age
• any patient with hypertension, diabetes, CV disease, or HF
should have known creatinine
• no evidence about frequency of screening
• in patients with no risk other than ethnicity, screening
every 3 to 5 yr reasonable; reasonable to screen patients
with risk factors or strong positive family history every 1
to 2 y
Estimating GFR from creatinine
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eGFR <60 mL/min per 1.73 m 2 concerning for kidney disease, but clearly not
diagnostic (25% of patients do not have low eGFR when confirmed by second test)
eGFR measurements >60 mL/min per 1.7 m 2 highly inaccurate
Cockroft-Gault equation— easily calculated, but antiquated
never been tested in women
not highly effective
used by Food and Drug Administration and pharmacies
Modification of Diet in Renal Disease (MDRD) Study equation — used in most
laboratories
Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation — used
mostly by researchers
interpretation of serum level of creatinine must be indexed for varying muscle mass
based on demographic characteristics (eg, age, sex, ethnicity)
advantages —beneficial to consider both GFR and creatinine levels
disadvantages — equations mostly validated in younger patients with kidney disease
assumes demographic characteristics alone can define muscle mass
equations developed only in whites and blacks
provides estimated value only
Screening with ACR
• for primary prevention —screen patients with
diabetes annually
• screen patients with hypertension
• screen elderly patients
• for CKD staging —screen all patients with CKD
• Screen patients with diabetes annually
• (nondiabetics every 2 yr)
• ACR <30 mg/g —normal or mildly elevated
• ACR 30 to 300 mg/g—moderately elevated
• ACR >300 mg/g—severely elevated
• Urine dipstick—“trace” indicates abnormal level
(quantify with ACR
The combination of angiotensinconverting enzyme inhibitors
(ACEIs) and angiotensin receptor
blockers (ARBs) is recommended
for most patients with proteinuria
and CKD.
A) True
B) False
Answer
• B) False
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Treatment of CKD
goals —prevent progression to ESRD (rare)
prevent complications (eg, CV disease, HF)
ACEIs and ARBs — diabetic patients with CKD nearly always have albuminuria
Many patients have hypertension and diabetes (if ACR <30 mg/g, CKD likely due to hypertension)
ACEIs and ARBs essential for type 1 or type 2 diabetes with moderate or severe albuminuria (ACR
>30 mg/g)
studies show ACEIs and ARBs do not appear to prevent onset of albuminuria in patients with
diabetes and ACR <30 mg/g
In nondiabetic CKD, benefits of ACEIs and ARBs vary depending on patient’s proteinuria status
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) —
compared lisinopril, amlodipine, and chlorthalidone
subgroup analysis of patients with CKD (eGFR <60 mL/min per 1.73 m 2 most patients did not have
proteinuria) found no difference between ACEIs, thiazides, and calcium channel blockers in effect on
decline in kidney function or development of ESRD
advanced CKD—trial found significant benefit associated with benazepril, compared to placebo
(43% reduction in combined outcome of doubling of creatinine, ESRD, and death
52% reduction in proteinuria
effects independent of BP)
adverse events rare
speaker’s recommendations— if creatinine high, continue ACEI for as long as potassium at tolerable
level (ie, 5.5 mEq/L
consider diuretics to balance potassium
increased creatinine often occurs due to hemodynamics (does not indicate discontinuation of ACEI
All the following treatment
options slow the progression of
kidney disease, except:
A) Statins
B) ACEIs
C) ARBs
D) Glucose control
Answer
• A) Statins
Combination of ACEIs and ARBs
• ACEIs or ARBs alone have similar effects on reducing
proteinuria, and thought to have similar efficacy in CKD
• combination of ACEI and ARB results in additional
reductions in proteinuria, but risk for adverse events high
(combined therapy not recommended)
• BP targets in CKD: systolic BP control important
• often requires 3 to 4 medications at full dose
• meta-analysis found ideal systolic BP 110 to 130 mm Hg
• progressive antihypertensive agents often reduce diastolic
BP disproportionately to systolic BP (may increase risk for
adverse events)
• Diastolic BP has little effect on risk for CKD
• new CKD hypertension guidelines suggest systolic BP
target of <130 mm Hg, but recommend <140 mm Hg
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Glycemic control and Statins
type 1 diabetes— tight glucose control slows progression of kidney disease
odds ratio of progression, 0.34 (two-thirds reduction in risk)
onset of disease earlier, with resulting higher lifetime risk for kidney failure
type 2 diabetes — Action in Diabetes and Vascular Disease: Preterax and Diamicron
MR Controlled Evaluation (ADVANCE) trial showed tight glucose control lowers risk
for new or worsening nephropathy (ie, progression of albuminuria or lowered eGFR) by
20%
however, absolute difference in risk small (individualized therapy needed)
Statins: do not prevent progression of kidney disease
Associated with good outcomes in CKD patients
meta-analysis found that statins reduced all-cause mortality and CV mortality by 20%,
compared to placebo in patients with CKD
Study of Heart and Renal Protection (SHARP) trial showed 17% reduction in risk for
CV disease with combination of simvastatin and ezetimibe, compared to placebo
no change seen in kidney function
reasonable to place CKD patients at high CV risk on statins, but not those at low CV
risk
statins appear ineffective in patients on dialysis
Choose the correct statement about renal
artery stenosis.
A) Usually seen in older patients with
multiple vascular risk factors
B) Commonly due to fibromuscular
dysplasia
C) Stenting more effective treatment
than medical therapy
D) Imaging recommended for all
patients
Answer
• A) Usually seen in older patients with
multiple vascular risk factors
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Renal artery stenosis
typical clinical profile—older patient with multiple vascular risk factors and known coexisting
vascular disease
etiology usually atherosclerosis (fibromuscular dysplasia rare)
patients at extremely high risk for CV disease
have poor prognosis and low physiologic tolerance for procedures
Imaging studies —controversial
ultrasonography does not provide adequate visualization of vasculature
concern for nephrogenic systemic sclerosis with magnetic resonance imaging and gadolinium
Risk for contrast nephropathy with computed tomography angiography
direct angiography provides best images, but invasive and uses greater amount of contrast
use imaging if diagnosis challenging, or if patient has frequent flash pulmonary edema (patients often
have acute episodes of HF)
medical therapy—cornerstone of treatment
ACEIs ideal if tolerated (hypotension uncommon
hyperkalemia common [monitor carefully]); creatinine expected to rise by 50% (may double; returns
to baseline over time)
BP control in patients unable to tolerate ACEIs may require multiple antihypertensive agents
(minoxidil or hydralazine often used as fourth or fifth agent)
procedures —surgery; angioplasty
most centers favor stenting
recent trials indicate no benefit to BP or kidney function with stenting, compared to medical therapy
Indications for referral to
nephrologist
• combined hematuria and proteinuria
(concern for glomerulonephritis)
• eGFR <30 mL/min per 1.73 m 2
• (plan for dialysis)
• nephrotic proteinuria (3 g/day; potential for
treatable condition)
• need for mineral metabolism management
(eg, high phosphorus or parathyroid
hormone)
• anemia of CKD
The _______ was the first set of
guidelines primarily concerned
with research ethics.
A) Nuremberg Code
B) Declaration of Helsinki
C) Belmont Report
D) Council for International
Organizations of Medical
Sciences Ethical Guidelines
Answer
• A) Nuremberg Code
Medical oaths
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Hippocratic Oath (Greek)
Oath of Maimonides (named for Jewish scholar)
Oath of Hindu Physician
Absolute Sincerity of Great Physicians (Chinese form of physician’s
oath)
nearly all cultures and societies place high value on medical ethics
Principles, codes, and books of medical ethics: Adab alTabib
(“Practical Ethics of the Physician”
first known book on medical ethics)
Thomas Percival's Code of Medical Ethics
American Medical Association (AMA) code of medical ethics (1847
similar to and released shortly after Percival’s code)
AMA Principles of Medical Ethics (extremely long, with annotations)
Physician’s Charter of Professionalism
Codes, declarations, and reports
on research ethics
• primarily begins with Nuremberg Code (response
to discoveries of World War II atrocities
conducted under pretext of medical research)
• Declaration of Helsinki (follows on Nuremberg
Code)
• Belmont Report (created in United States after
revelation of unethical Tuskegee Institute
experiments with syphilis)
• International Committee on Harmonization's Good
Clinical Practice guidelines
• Council for International Organizations of
Medical Sciences’ ethical guideline
Which of the following statements about
the Hippocratic Oath is not true?
A) It includes the concept of
maintenance of confidentiality
B) It includes admonitions against the
administration of lethal drugs and
abortion
C) It is the source of the phrase
"primum non nocere"
D) It is strongly religious
Answer
• C) It is the source of the phrase "primum
non nocere"
Hippocratic Oath (original version)
• exists in 3 forms (original version from Byzantine texts,
classic version used during 17th and 18th centuries, and
current version [updated for modern world])
• original oath — strong religious oath
• begins with emphasizing respect for teachers
• includes statements related to avoiding harm (with
controversial language forbidding administration of lethal
drugs and abortion), acting only in patient’s best interest,
and maintenance of confidentiality
• not typically used by modern medical schools (due to
cultural specificities associated with ancient Greece
Declaration of Geneva (1948)
• originally developed by World Medical Association
• eligible for and subjected to multiple amendments and revisions
• updated to address controversies related to “respect for life” (eg,
abortion, euthanasia)
• emphasizes “service to humanity,” respect and gratitude for teachers
• practicing with conscience and dignity
• prioritization of patient concerns
• maintenance of confidentiality
• protection of medical profession
• nondiscriminatory practices, and respect for human life
• internationally relevant
• contains clause forbidding physicians from using medical knowledge
“to violate human rights and civil liberties” (supports physicians in
resisting pressure to commit atrocities [as seen during World War II])
• secular oath (unlike Hippocratic Oath)
The American Medical Association's
(AMA) Principles of Medical Ethics
includes:
A) The obligation to report fellow
physicians deficient in character or
competence
B) The obligation to respect established
laws
C) The obligation to seek change in
laws contrary to patient interests
D) All the above
Answer
• D) All the above
AMA Principles of Medical Ethics
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standards of conduct defining essentials of honorable behavior among physicians
emphasizes dedication to competent medical care with compassion and respect for human dignity
and rights
upholding standards of professionalism
Honesty in all professional interactions
reporting of physicians deficit in character or competence (or engaging in fraud or deception) to
appropriate entities
Reporting of fellow physicians: does not necessarily imply legal involvement, but mandates review
process or action of some sort (eg, treatment in impaired physicians programs in cases of substance
abuse)
Legal obligations: physicians required to respect established laws, but also to seek changes in legal
requirements contrary to patient’s best interest
laws may forbid asking about information critical to assessment of safety of patient (eg, presence of
firearms in home)
Physicians must personally decide how to handle situations in which laws conflict with patient’s best
interest
AMA code emphasizes working within constraints of law (with regard to, eg, privacy)
Other principles: lifelong learning; consulting colleagues to address concerns outside personal
expertise
freedom to choose patients and associates during nonemergencies (which suggests that physicians
have obligation to help in true emergencies)
participation in activities contributing to improvement of community and public health
making patient first priority while providing care
supporting universal access to medical care
Which of the following
is not included as a fundamental
provision of the Physician
Charter of Professionalism?
A) Primacy of patient welfare
B) Respect for life
C) Patient autonomy
D) Social justice
Answer
• B) Respect for life
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Physician Charter (2002)
authored by American Board of Internal Medicine, in partnership with American
College of Physicians and European Federation of Internet Medicine
• endorsed by >100 medical groups (eg, AMA, American Psychiatric Association,
American Academy of Pediatrics, American Association of Family Practitioners,
American College of Surgeons, American Board of Medical Specialties, Accreditation
Counsel for Greater Medical Education, Association of American Medical Colleges,
Chinese Medical Doctors Association, Federation of Royal College of Physicians,
Turkish Medical Society, Medical Counsel of Canada)
• Preamble: “professionalism is the basis of medicine's contract with society”
• Fundamental provisions: patient autonomy; primacy of patient welfare; (social) justice;
all 3 similar to provisions of Belmont Report Commitments
• professional competence
• honesty with patients
• patient confidentiality
• maintaining appropriate
• relations with patients
• improving quality of care
• improving access to care
• just distribution of finite resources; scientific knowledge
• maintaining trust by managing conflicts of interest (subject of increased focus
after late 1990s)
professional responsibilitie
Concepts common to most medical oaths and codes
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responsibility to patients
beneficence and nonmaleficence
respect for persons (eg, patients, peers, colleagues, teachers)
justice and fairness
concern for public health
High moral character
professional responsibilities
Lifelong learning
Distinctions: codes and oaths vary due to differences in societies (eg, religious countries or organizations may place
added emphasis on respect for life), politics, and eras contemporary oaths attempt to address modern concerns (eg,
public health)
Responsibility to physician's patients: implied in Hippocratic Oath
clearly stated in Declaration of Geneva (eg, “the health of my patients will be my first consideration”) and AMA
Principles of Medical Ethics (eg, “physician shall, while caring for a patient, regard responsibility of patient as
paramount,” and "physician
shall respect the law and also recognize a responsibility to seek changes")
Physician Charter: includes primacy of patient welfare as fundamental principle, and commitment to maintaining
trust by managing conflicts of interest (ie, patients must view physician as putting their interests first)
Beneficence and nonmaleficence: included in Hippocratic Oath (“I will prescribe regiments for the good of my
patients according to my ability and my judgment, and well never do harm to anyone”)
not clearly stated in Declaration of Geneva, AMA Principles of Medical Ethics, and Physician Charter
Primum non nocere: “first, do no harm”; concept fails to address benefits (only risks)
not directly stated in any oath or codes
modern interpretations emphasize maximizing benefits while minimizing risk and harm (balancing of benefits and
risks must occur before any treatment)
Applications to psychiatry: cognitive behavioral therapy for treatment of obsessive compulsive disorder
prescribing medication to child with attention-deficit disorder; transference and countertransference (must be
cognizant of potential for negatively affecting patient’s well-being)
treating mentally ill patients with goal of competency to stand trial, or be executed (“benefit” to patient questionable
Which of the following oaths
includes a clear and definite
statement covering beneficence
and nonmaleficence?
A) Hippocratic Oath
B) Declaration of Geneva
C) AMA Principles of Medical
Ethics
D) Physician Charter of
Professionalism
Answer
• A) Hippocratic Oath
Which of the following concepts
is included in every medical oath
and code discussed by the
speaker?
A) Justice and fairness
B) Concern for public health
C) Patient confidentiality
D) Lifelong learning
Answer
• C) Patient confidentiality
Confidentiality of patient information
• specifically addressed in Hippocratic oath, Declaration of
Geneva (“even after the patient has died”), AMA
Principles of Medical Ethics (“within the constraints of the
law”), and Physician Charter (included as commitment)
• Applications to psychiatry: release and publication of
information from medical records has occurred after
patient’s death (eg, therapist authoring biography based on
patient records, without consent); child psychiatrists
sharing information confided by preteen patients (eg,
issues with substance abuse, pregnancy) with parents
• in cases of knowledge pertaining to child abuse, AMA
principles obligate psychiatrists to comply with laws
mandating reporting of abuse (confidentiality no longer
applies; not true of other types of confidential information,
so appropriate course of action often unclear; violating
confidentiality may be in child's best interest
According to the AMA Principles
of Medical Ethics, physicians
must make the health of patients
paramount:
A) At all times
B) When they have been
identified to others as a physician
C) Only in emergency situations
D) While providing care
Answer
• D) While providing care
Which of the following oaths
does not specifically address
conflicts of interest?
A) Hippocratic Oath
B) Declaration of Geneva
C) AMA Principles of Medical
Ethics
D) Physician's Charter of
Professionalism
Answer
• C) AMA Principles of Medical Ethics
Conflicts between patient interests and public health interests
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specifically addressed in Declaration of Geneva (as “service to humanity”),
AMA Principles of Medical Ethics (“improvement of the community and the
betterment of public health”), and Physician Charter (preamble speaks of
“contract with society”; social justice included as fundamental principle
Several commitments discuss public health activities)
Some codes imply primacy of patient's interest over public health interest (eg,
“health of patient is paramount”), but do not offer explicit prioritization
Implications: in mass casualty situations, physicians may be obligated to offer
limited care or comfort to less severely injured patients so that more serious
cases can be addressed
AMA Principles of Medical Ethics gives primary interest to patients only
during provision of care (raises question of whether physicians may consider
giving greater consideration to public health when not directly providing care
important consideration when committing patients to psychiatric facilities
[intended to benefit patient, but may also involve public health issues such as
danger of harm to others]
Also has potential to affect confidentiality issues [ie, findings may be entered
into public court records]
Addressing conflicts of interest
• speaker argues all individuals face conflicts of interest
• groups with policies about conflict of interest invariably have interests
subject to conflict
• specifically addressed in Hippocratic Oath (“for the good of my
patients, keeping myself far from”), Declaration of Geneva (“will not
permit considerations of age...or any other factor to intervene between
my duty and my patient”) and Physician Charter (“commitment to
maintaining trust by managing conflicts of interest”)
• AMA Principles of Medical Ethics do not specifically address
conflicts of interest, but state “physician shall, while caring for a
patient, regard responsibility to the patient as paramount”
• often implied or explicitly stated in oaths, codes, and principles
associated with medical and nonmedical specialties
• multiple conflicts commonly occur from different sources (eg, role as
investigator, employment by hospital, ownership of company stock,
financial stake in particular theory) or in multiple forms (eg, financial,
professional
Primum non nocere (or modern
interpretations
thereof)applies equally to all
areas of medicine.
A) True
B) False
Answer
• A) True
• primum non nocere (or maximizing benefit
and minimizing harm) applies to all areas of
medicine equally
• failures in maintaining confidentiality of
patient information led to creation of Health
Insurance Portability and Accountability
Act, and often result in leaking of medical
information about celebrities to public press
• conflicts of interest occur across all
specialties
Ethical concerns in medicine
remain essentially consistent over
time.
A) True
B) False
Answer
• B) False
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Closing
thoughts
concerns about medical ethics appear universal (eg, found in all
traditions)
medical ethics continually evolve and change in context of time period,
and as result of new concerns (eg, recent bioethical concerns about
“synthetic life”)
oaths and principles often fail to cover important ethical concepts (eg,
beneficence and nonmaleficence, primum non nocere [not included in
oaths and principles, and often oversimplified or misconstrued])
conflicts of interest — important to medical ethics
occur in multiple forms
focusing on one form of conflict can be misleading and may cause loss
of important information or dangerous situations
although medical applications have some special applications in
psychiatry, most show overwhelming similarities to other areas of
medicine
1.0 g of fat provides 9.0 kcal,
while 1.0 g of carbohydrates
provides _______.
A) 10 kcal
B) 7 kcal
C) 5.1 kcal
D) 4.2 kcal
Answer
• D) 4.2 kcal
Carbohydrates
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simple —glucose
Galactose
Fructose
combine to form, eg, sucrose, lactose
complex —starches
longchain carbohydrates
glycogen stored in muscle and liver
glycemic index —index of how quickly food absorbed or
causes insulin response
• foods absorbed quickly result in high insulin spike
• dependent on many factors, eg, where food grown or how
prepared
Athletic needs
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carbohydrates —1.0 g of carbohydrates provides 4.2 kcal
extra intake leads to glycogen storage or conversion to fat or protein
5 to 10 g/kg per day needed
diet composed of 60% to 70% carbohydrates recommended for most athletes
(data conflict)
proteins—broken down to amino acids
role in protein synthesis and gluconeogenesis
branched-chain amino acids (eg, valine, leucine, isoleucine) directly
metabolized to provide energy
1.0 g of protein provides 4.1 kcal
0.6 to 0.8 g/kg per day needed
strength and power athletes need 2.0 g/kg per day; aerobic athletes need 1.5
g/kg per day
fats — intercellular fat between cells
intracellular fat within muscle cells (metabolized during exercise)
1.0 g of fat provides 9.0 kcal
important for neurologic development
vitamins A, D, E, and K fat soluble
Vitamin D
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Hormone
exposure to sunlight converts cholesterol into vitamin D
production affected by location (eg, production insufficient in areas north of
Dallas, TX
90% of population in Cleveland, OH, deficient in vitamin D during winter due
to lack of exposure to sunlight)
Sunscreen can be used judiciously (2000 cancer deaths due to exposure to sun
per year)
children <5 yr of age who do not make sufficient vitamin D develop problems
with immunosuppression, with potential risk for autism, multiple sclerosis, and
attention-deficit/hyperactivity disorder
vitamin D affects >1000 genes
important for bone growth
helpful for muscle tissue, strength, and power
high-calcium diet required for bone mineralization
active vitamin D affects physical performance and inflammatory and immune
system
exposure to sunlight best source
Minerals
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sodium required to maintain electrochemical balance
potassium required to maintain acid-base balance and modulate fluid
fluctuations
athletes (especially in southern areas) need high-salt diets
iron —leading nutritional deficiency worldwide
important for muscle function (eg, extraction of O2 by myoglobin)
Antioxidant
inefficient production of adenosine triphosphate (ATP) in individuals with
iron-deficiency negatively affects ability to exercise
adequate calcium intake important
Water: comprises two-thirds of body; three-fourths in plasma, one-fourth in
interstitial fluid
Metabolism during exercise: during intense exercise, ATP stores in muscle
exhausted within 5 to 10 sec (creatinine phosphate stores exhausted within 1015 sec); anaerobic glycolysis breaks down glucose (by-products include lactic
acid [can inhibit muscle action])
with longer aerobic exercise, oxidative phosphorylation burns carbohydrates,
fats, and proteins
Choose the correct statement about
carbohydrate absorption.
A) Carbohydrates are absorbed faster
than water
B) Sodium decreases carbohydrate
absorption
C) Warm (eg, room temperature) liquids
absorbed best
D) Fructose recommended for faster
absorption and faster gastric emptying
Answer
• A) Carbohydrates are absorbed faster than
water
Carbohydrates and exercise
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during exercise—high amount of carbohydrates improves glycogen stores in athletes;
trial found long-duration exercise improved with 6% to 8% carbohydrate drink (eg,
Gatorade), compared to water alone
drink with 6% to 8% carbohydrates absorbed faster than water
liquids better tolerated during training and running
carbohydrate intake recommended when exercising for >1 hr
sodium (30-80 mEq/L) important for increasing carbohydrate absorption
cold (40ºF) liquids absorbed best
fructose slows gastric emptying and may cause gastrointestinal (GI) distress
after exercise—replenishing glycogen stores with immediate carbohydrate intake
important
drinking carbohydrates during exercise beneficial for replenishing muscle glycogen
stores
high-glycemic index carbohydrates immediately increase insulin level
3:1 ratio of carbohydrates to proteins —shown more effective in driving carbohydrates
and proteins into muscle cells
associated with decreased cortisol and urinary 3-methylhistidine levels in one study
increases insulin and prevents tissue breakdown by blocking cortisol release during
exercise (suggests anabolic and anticatabolic effects
Proteins, Fat and exercise
• athletes have increased protein requirements
(even more so in strength-training athletes
than in aerobic athletes)
• Fats and exercise: efficient fat burning starts
20 min into aerobic exercise
• studies saw runners and cyclists on highfat
(45%) diets had improved performance and
cholesterol profiles since fat burned for
energy rather than stored
• supplementation of diet with fat (eg, whole
milk) acceptable for athletes who burn
10,000 kcal/day
Vitamin deficiencies
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unlikely in patients with well-balanced diet
consider vitamin B12 in vegetarians
vitamin deficiency — <20 ng/mL of 25-hydroxyvitamin D considered insufficient (ideal
level 50 ng/mL)
studies suggest that in some populations, 90% of athletes vitamin D-deficient
associated with stress fractures, muscular pain, back pain, poor tissue healing, impaired
balance, falls, loss of fast-twitch muscle fiber size and strength, fatty infiltration of
muscles, impairment in reaction time, common colds, influenza, gastroenteritis, increase
in tissue necrosis factor- alpha in runners, and effects on jump height
sources of vitamin D — exposure to sunlight (sunscreen on face recommended)
fortified foods
oily fish
cod liver oil
shiitake
Mushrooms
wild white reindeer meat
vitamin D3 absorbed better (1.7 times more effective than vitamin D2
Sodium supplementation with 1g salt tablets should be
considered in athletes who
routinely lose >5 lb of weight
through sweating after
exercising.
A) True
B) False
Answer
• A) True
Mineral deficiencies
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iron deficiency —may be due to poor dietary intake, especially in female
athletes who do not eat meat
much iron lost during exercise
90% of distance runners test positive for occult blood in stool
reasonable diets include 5 to 7 mg of iron per 1000 kcal
ferritin level of 8 to 10 ng/mL normal (in athletes, 40 ng/mL recommended)
calcium—adequate intake important for girls 6 mo before menarche
sodium— most lost through sweat
associated with muscle cramping in athletes
calculate sodium loss through sweat by multiplying sweat concentration (eg,
50 mmol/L x 0.263) by volume of sweat lost (ie, amount of weight lost during
exercise)
if athlete loses 10 lb during competition with average sweat concentration of
50 mmol/L, then athlete loses 13 g of sodium
Sodium concentration of sweat higher in some athletes than in others
If athlete routinely loses >5 lb, then consider supplementing with 1-g salt
tablets and 16 fl oz of water for each pound lost over 5 lb (use as guideline)
20-fl oz bottle of sports drink contains 0.7 g of sodium
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exercise
Water and exercise: supplement with 3 to 6 fl oz every 15 min
16 fl oz required after exercise if 1 lb of body weight lost
“Game day” nutrition: dependent on activity
before event— adequate carbohydrate intake prevent dehydration
avoid stomach upset (eg, hunger pains)
meal should be pleasant and satisfying
adequate salt and fluid intake
solid foods few hours before event, and liquids up to time of event
avoid glucose during hour before event (rise in insulin drives down blood
sugar
may affect mental performance) fructose
do not give any new foods or supplements
during event—prevent dehydration, cramps, and hyponatremia
if event lasts >1 hr, carbohydrates (eg, sports drinks) important
after event—dependent on next competition or training session
replenish glycogen stores
replace fluid and sodium
high amount of carbohydrates mixed with proteins
16 fl oz of water for each pound lost
high amount of salt for athletes at risk for, eg, cramping
Glutamine supplementation:
A) Promotes protein synthesis
B) Has been suggested in rat
studies to decrease protein
breakdown after exercise
C) Is not associated with
significant side effects
D) All the above
Answer
• D) All the above
Creatine supplements are
associated with all the
following,except:
A) Improved muscle strength
and power
B) Increased body weight
C) Renal failure
D) Muscle cramping
Answer
• C) Renal failure
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Ergogenic Aids
Branched-chain amino acids: eg, valine, leucine, isoleucine; oxidized for energy
not found to affect athletic performance, but still regularly used by athletes
Glutamine: nitrogen donor; promotes protein synthesis
studies in rats suggest role in decreasing protein breakdown after exercise and increasing protein synthesis
(anticatabolic and anabolic properties)
some evidence that it counteracts immunosuppression associated with exercise
safe
no side effects
20 g/day acceptable
Hydroxymethylbutyrate: leucine metabolite
study performed by owner of patent shown to increase muscle strength, power, and mass in novice or strengthtraining athletes (findings not replicated in other studies)
Efficacy not supported by evidence
Creatine supplements: average creatine phosphate levels 90 to 160 g
immediately replenish energy stores
provide more energy for, eg, sprinting, power lifting, jumping
improves muscle strength and power
Effective
original studies used 5 g 4 times daily for 5 days followed by maintenance dose, but 5 g/day reasonable
more effective when taken with carbohydrates
study saw improvement in testosterone profile in athletes (suggests anabolic properties)
increases body weight (ie, total body water)
may increase lean muscle mass
when stopped, muscle mass gradually decreases (returns to baseline after 3 mo, but muscle fibers may be slightly
increased)
side effects —muscle cramping
exertional compartment syndrome
no association with renal failure
Which of the following appears
most useful in improving mental
and physical performance in
activities at higher altitudes (eg,
skiing)?
A) Phosphate loading
B) Bicarbonate loading
C) Blood doping
D) Blood "spinning"
Answer
• A) Phosphate loading
Phosphate loading
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effective (especially for activities at higher altitudes [eg, skiing])
1 g 4 times daily
helps glycolysis
improves creatine phosphate stores
increases 2,3- diphosphoglycerate for higher O2 delivery to tissues
studies showed better mental and physical performance during first 2
days at higher altitudes
Bicarbonate loading: binds with lactic acid to decrease acidosis
300 to 500 mg/kg 1 hr before exercise improves performance limited
by lactic acid (high-intensity exercises that last >15 sec, eg, 400- and
800-m races)
not banned
causes GI upset
Approximately _______ of
anabolic steroid users have
problems with dependence or
depression during or after use.
A) 10%
B) 20%
C) 30%
D) 50%
Answer
• C) 30%
Anabolic steroids
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testosterone and related compounds —oral and injectable agents
estimated that 10% of high school boys and 3% to 5% of girls have used anabolic
steroids
epitestosterone—inert isomer of testosterone
ratio of epitestosterone to testosterone 1:1
maximum level 150 ng/mL (level of 200 ng/mL on drug testing indicates epitestosterone
use)
effects —increased muscle mass, spermatogenesis, and protein synthesis
increased hematopoiesis
increased aggression
increased libido in men and women
increased muscle strength and power
improved recovery after exercise
side effects — long-term cardiovascular effects (eg, cardiomyopathy with 30-yr use)
psychologic effects
Parkinsonism
30% of anabolic steroid users have problems with dependence or manic (or hypomanic)
depression during or after use (associated with positive family history of psychologic
diseases or personal or family history in first-degree relative of drug and alcohol abuse
or dependence)
“roid rage
Blood doping
• blood transfusion—increases O2-carrying capacity
• leads to longer duration of aerobic exercise
• Blood taken few months before competition and
stored
• Transfusion of 2 U of packed cells during
competition improves performance significantly
• erythropoietin —improves red cell mass
• and O2
• -carrying capacity; can cause clotting problems
and death
• banned
Use of _______ to slow the heart
rate and decrease anxiety during
professional pistol shooting and
archery competitions has been
banned.
A) Diuretics
B) β-blockers
C) Tricyclic antidepressants
D) Sedative hypnotic agents
Answer
• B) β-blockers
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Stimulants: effective
studied in military personnel
Improve performance, concentration, and wakefulness
sympathomy metics
Beta-agonists
albuterol (banned; improves performance in certain athletes)
clenbuterol—not available in United States
has anabolic properties
builds tissue
antilipolytic (ie, stops fat production)
used in Europe for animal husbandry (in, eg, pork and beef production)
available by prescription in certain countries
available in Mexico over the counter
improves performance
improves fat metabolism
preserves muscle glycogen stores
side effects include jitteriness, seizure, stroke, and myocardial infarction
Beta-blockers: used by competitors who need slowed heart rate and decreased anxiety for
performance
banned in competitive pistol shooting and archery
used by golfers to reduce anxiety
Diuretics: used for weight loss, improved body image, and diluting urine to mask drug us
associated with electrolyte imbalances
Which of the following may be
helpful for "runner's trot"?
A) Loperamide
B) Diphenoxylate and atropine
C) High-bulk diet
D) All the above
Answer
• D) All the above
Off-label use of growth hormone
is acceptable for most athletes
who want to increase muscle
growth and decrease body fat.
A) True
B) False
Answer
• B) False
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Human chorionic gonadotropin
taken for 4 wk by athletes before discontinuing anabolic steroids
stimulates own testosterone production
side effects — similar to symptoms of pregnancy (eg, morning sickness)
Growth hormone (GH): half-life short
high variability
production decreases with training
peaks 1 hr after exercise
Directly affects fat (metabolizes fat preferentially over carbohydrates)
major effects through stimulation of insulin-like growth factor 1 production in liver (associated with
anabolic effects)
Increases amino acid uptake of muscle
increases protein synthesis
decreases glucose utilization
increases collagen synthesis
increases axial growth
ncreases muscle hypertrophy, endurance, and growth decreases body fat
enhances healing
animal studies showed 10% increase in mass and 15% decrease in fat
15% increase in mass seen in rats with genetic doping
Expensive
no major side effects
often used in combination with anabolic steroid
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Questions and answers
“runner’s trot”—during exercise, blood shunts away from gut, which leads to ischemic gut and
diarrhea
over-the-counter antidiarrheal medicines (eg, loperamide [eg, Imodium, Diar-aid Caplets,
Kaopectate II Caplets] and diphenoxylate with atropine [eg, Lomotil, Logen, Lomanate])
hyoscyamine (eg, Levsin, IB-Stat, Levbid) can cause problems with heat dissipation
high-bulk diet can be helpful
hyaluronic acid (eg, Euflexxa, Orthovisc, Synvisc) joint injections for articular cartilage damage—
cause pain, but no side effects
can be approved for insurance coverage; can be used on knee, shoulder, hip, ankle, big toe, base of
thumb, and wrist
resulted in significant improvement in patients who had “tennis elbow” pain for 2 yr
creatine phosphate—to be effective, athlete must engage in high-intensity exercise (eg, jumping
jacks, squats, bench presses); low-intensity exercise causes muscles to swell with water and weight
gain
carnitine—1 to 2 g daily adequate for improved fat metabolism with aerobic exercise
compared to placebo, shown to decrease angina on treadmill testing
GH—cannot be prescribed off-label; must document GH deficiency
platelet-rich plasma injections —“blood spinning”
concerns include clinicians who mix GH with growth factors
amino acids —high doses of oral or intravenous arginine or ornithine showed slight increase in GH
levels but no significant effect on muscle mass or oxidation of fat
Supplements for runner >50 yr of age—glucosamine chondroitin relatively inexpensive and
reasonable
creatine not recommended due to potential for worsening minor aches and pain (eg, arthritic knees,
low back pain) with increased mass
For which of the following outcomes
was a calcium channel blocker (CCB)
shown more beneficial than an
angiotensin-converting enzyme (ACE)
inhibitor?
A) Myocardial infarction
B) Cardiovascular (CV) death
C) Stroke reduction
D) Heart failure
Answer
• C) Stroke reduction
A study of >5000 elderly patients
found that readings taken during
home blood pressure (BP)
monitoring are more strongly
related to target organ damage
and CV outcomes than readings
taken in the physician's office.
A) True
B) False
Answer
• A) True
According to the
American Diabetes Association,
what is the recommended BP
goal for patients with diabetes
and hypertension?
A) <140/90 mm Hg
B) <140/80 mm Hg
C) <130/80 mm Hg
D) <120/80 mm Hg
Answer
• C) <130/80 mm Hg
Reducing systolic BP to <130
mm Hg in patients with chronic
kidney disease has been shown to
reduce:
A) Dialysis
B) Heart disease
C) Death
D) None of the above
Answer
• D) None of the above
Compared to hydrochlorothiazide
(HCTZ), chlorthalidone:
A) Appears less effective for resistant
hypertension
B) Is 1.5 to 2.0 times more potent
C) Is associated with hyperkalemia
D) Should not be used in patients with
lower estimated glomerular filtration rate
Answer
• B) Is 1.5 to 2.0 times more potent
Which of the following βblockers is associated with less
fatigue and less reduction in
cardiac output and heart rate?
A) Atenolol
B) Nebivolol
C) Metoprolol
D) Labetalol
Answer
• B) Nebivolol
Which of the following drug combinations is
associated with more hypotension, syncope,
and renal disease?
A) ACE inhibitor and angiotensin receptor
blocker (ARB)
B) ACE inhibitor and diuretic
C) ARB and diuretic
D) ARB and CCB
Answer
• A) ACE inhibitor and angiotensin receptor
blocker (ARB)
Unless the patient has a
compelling indication for a
specific class of drug, the class of
antihypertensive agent is less
important than achieving
appropriate BP goals.
A) True
B) False
Answer
• A) True
For which of the following drug
classes is the least amount of
evidence available about the
initial benefits for outcomes in
patients with hypertension?
A) Thiazide diuretics
B) ARBs
C) CCBs
D) β-blockers
Answer
• D) β-blockers