QUESTIONS DIRECTIONS: Each of the numbered items or incomplete statements in this section is followed by answersor by completions of the statement.

Select the ONE lettered answer or completion that is BEST ineach case. ANTIHIPERTENSIVOS (CP. 11): 1. A friend has very severe hypertension and asks about a drug her doctor wishes to prescribe.Her physician has explained that this drug is associated with tachycardia and fluid retention(which may be marked) and increased hair growth. Which of the following is most likely toproduce the effects that your friend has described? (A) Captopril (B) Guanethidine (C) Minoxidil (D) Prazosin (E) Propranolol Marked tachycardia and fluid retention are compensatory responses usually seen with strongvasodilators. The fact that the unknown drug also increases hair growth points strongly at mi-noxidil. The answer is (C). 2. A patient is admitted to the emergency department with severe bradycardia tbllowing a drugoverdose. His family reports that he has been depressed about his hypertension. Each of thefollowing can slow the hem1 rate EXCEPT (A) Clonidine (B) Guanethidine (C) Hydralazine (D) Propranolol (E) Reserpine Except for alpha-blockers, any sympathoplegic can, in sufficient dosage, cause bradycardia.Conversely, any vasodilator may induce tachycardia and, unless it is also sympathoplegic or acalcium channel blocker, will never slow the heart rate. The answer is (C). 3. In comparing methyldopa and guanethidine, which one of the following is correct? (A) Guanethidine--but not methyldopa--results in salt and water retention if used alone (B) Guanethidine causes fewer CNS adverse effects (such as sedation) than methyldopa (C) Guanethidine causes more immunologic adverse effects (eg, hemolytic anemia) thanmethyldopa

(D) Guanethidine is less efficacious than methyldopa in severe hypertension (E) Methyldopa causes more orthostatic hypotension than guanethidine Guanethidine causes many peripheral adverse effects but is poorly distributed into the CNS, soit is relatively free of CNS effects. The answer is (B). 4. Which one of the following is characteristic of captopril and enalapril? (A) Competitively blocks angiotensin II at its receptor (B) Decreases angiotensin II concentration in the blood (C) Decreases renin concentration in the blood (D) Increases sodium and decreases potassium in the blood (E) Decreases sodium and increases potassium in the urine These converting enzyme inhibitors act on the enzyme, not on the angiotensin receptor. Theplasma renin level may increase as a result of the compensatory response to reduced an-giotensin lI. The answer is (B). 5. A patient is admitted to the hematology service with moderately severe hemolytic anemia. Af-ter a thorough workup, the only positive finding is a history of several months of treatmentwith an antihypertensive drug. The most likely cause of the patient's blood disorder is (A) Atenolol (B) Captopril (C) Hydralazine (D) Methyldopa (E) Minoxidil Methyldopa is the only antihypertensive drug associated with hemolytic anemia (usually pre-ceded by a positive Coombs test). Hydralazine is also associated with autoimmune toxicity.but this takes the form of a lupus-like syndrome with butterfly facial rash, fever, joint and mus-cle pains, and antinuclear antibodies. The answer is (D). 6. Postural hypotension is a common adverse effect of which one of the following types ofdrugs? (A) ACE inhibitors (B) Alpha-receptor blockers (C) Arteriolar dilators (D) Betas-selective receptor blockers (E) Nonselective beta-blockers Orthostatic hypotension is usually due to venous pooling. Venous pooling is normally pre-vented by alpha receptor activation. The answer is (B).

7. A visitor from another city comes to your office complaining of incessant cough. He has dia-betes and hypertension and has recently started taking a different antihypertensive medication.The most likely cause of his cough is (A) Enalapril (B) Losartan (C) Minoxidil (D) Propranolol (E) Verapamil Chronic cough is a common adverse effect of ACE inhibitors. It may be relieved by prior ad-ministration of aspirin. These drugs are very commonly used in diabetes. Angiotensin [I recep-tor blockers such as losartan and valsartan have a much lower incidence of cough but do causerenal damage in the fetus. The answer is (A). 8. Which one of the following is an important effect of the drug named? (A) Cyanide toxicity with hydralazine (B) Hyperglycemia with diazoxide (C) Lupus erythematosus with nitroprusside (D) Pericardial abnormalities with verapamil (E) Reduced cardiac output or atrioventricular block with minoxidil Diazoxide may cause hyperglycemia. It is sometimes used to treat hypoglycemia because itcan inhibit insulin release. The answer is (B). 9. Comparison of prazosin with propranolol shows that (A) Both decrease cardiac output (B) Both decrease renin secretion (C) Both increase heart rate (D) Both increase sympathetic outflow from the CNS (E) Both produce orthostatic hypotension Propranolol--but not prazosin--may decrease cardiac output. Prazosin may increase reninoutput (a compensatory response), but beta-blockers inhibit its release by the kidney. By re-ducing blood pressure, both may increase central sympathetic outflow (a compensatory re-sponse). Propranolol does not cause orthostatic hypotension. The answer is (D). 10. Reserpine, an alkaloid derived from the root of Rauwolfia serpentina, (A) Can be used to control hyperglycemia (B) Can cause severe depression of mood (C) Can decrease gastrointestinal secretion and motility (D) Has no cardiac effects

(E) Often causes a reflex increase in heart rate Reserpine is of no value in hyperglycemia. The drug does not induce reflex tachycardia be-cause it reduces sympathetic neurotransmitter release in the heart as well as the vessels. Thisdrug can cause severe depression of mood, including suicidal ideation. The answer is (B). 11. Which of the following is used in severe hypertensive emergencies; is very short acting; andmust be given by IV infision? (A) Captopril (B) Cocaine (C) Diazoxide (D) Guanethidine (E) Hydralazine (F) Minoxidil (G) Nifedipine (H) Nitroprusside (I1 Prazosin (J) Propranolol (K) Reserpine (L) Vesamicol Diazoxide, nitroprusside, and (rarely) nifedipine are the drugs in the list that are used in hyper-tensive emergencies. Diazoxide has a long duration of action and is given by intermittent in-jection, not by infusion. Nifedipine is almost always given orally. The answer is (H). 12. Which of the following is not a prodrug and acts by opening potassium channels? (A) Captopril (B) Cocaine (C) Diazoxide (D) Guanethidine (E) Hydralazine (F) Minoxidii (G) Nifedipine (H) Nitroprusside (I) Prazosin (J) Propranolol (K) Reserpine (L) Vesamicol Diazoxide is a potassium channel opener as given. Minoxidil sulfate, a metabolite of minoxi-dil, also acts by this mechanism. The answer is (C). 13. Which of the following is a postganglionic nerve terminal blocker that has

insignificant CNSeffects? (A) Captopril (B) Cocaine (C) Diazoxide (D) Guanethidine (E) Hydralazine (F) Minoxidil (G) Nifedipine (H) Nitroprusside (I) Prazosin (J) Propranolol (K) Reserpine (L) Vesamicol Reserpine and guanethidine are both sympathoplegics that act on the postganglionic sympa-thetic nerve terminal. Reserpine enters the CNS readily and causes important CNS toxicity.Guanethidine, on the other hand. is too polar to cross the blood-brain barrier easily and is al-most devoid of central toxicity. The answer is (D). DIRECTIONS: The following section consists of a list of lettered options followed by two numbered items.For each numbered item, select the ONE option that is most closely associated with it. Each optionmay be selected once. more than once. or not at all. Items 14-15: (A) Captopril (B) Cocaine (C) Diazoxide (D) Guanethidine (E) Hydralazine (F) Minoxidil (G) Nifedipine (H) Nitroprusside (1) Prazosin (J) Propranoiol (K) Reserpine (L) Vesamicol 14. A drug that may cause renal damage in the fetus if given during pregnancy 14. All ACE inhibitors can cause renal damage in patients with preexisting renal vascular diseaseand in the developing fetus. (The angiotensin II receptor antagonists appear to have similar re-nal toxicity.) The answer is (A). 15. A drug that will interfere with the action of guanethidine Guanethidine must be transported into the adrenergic nerve ending to exert its effects.

Cocainecan block the reuptake carrier. The answer is (B). VASODILATADORES Y TRATAMIENTO DE LA ANGINA DE PECHO (CP. 12): Items 1-3: Mr. Green, 60 years old, has severe chest pain when he attempts to carry parcels up-stairs to his apartment. The pain rapidly disappears when he rests. A decision is made to treat himwith nitroglycerin. 1. Nitroglycerin, either directly or through reflexes, results in which one of the following effects? (A) Decreased heart rate (B) Decreased venous capacitance (C) Increased afterload (D) Increased cardiac force (E) Increased diastolic intramyocardial fiber tension Nitroglycerin increases cardiac force because the decrease in blood pressure evokes a compen-satory increase in sympathetic discharge. The answer is (D). 2. In advising Mr. Green about the adverse effects he may notice, you point out that nitroglycerinin moderate doses often produces certain symptoms. These toxicities result from all of the fol-lowing EXCEPT (A) Meningeal vasodilation (B) Reflex tachycardia (C) Increased cardiac force (D) Methemoglobinemia (E) Sympathetic discharge Methemoglobinemia never occurs from the doses of nitroglycerin (or other nitrates) used totreat angina. The nitrites (in large doses) cause methemoglobinemia. The answer is (D). 3. Two years later, Mr. Green returns complaining that his nitroglycerin works well when hetakes it for an acute attack but that he is having frequent attacks now and would like somethingto prevent them. Useful drugs for the prophylaxis of angina of effort include which one of thefollowing? (A) Amyl nitrite (B) Diltiazem (C) Esmolol (D) Sublingual isosorbide dinitrate (E) Sublingual nitroglycerin

The calcium channel blockers and the beta-blockers are generally effective in reducing thenumber of attacks of angina of effort, and most have durations of 4-8 hours. Oral and transder-mal nitrates have similar or longer durations. Amyl nitrite, the sublingual nitrates, and esmolol(an IV beta blocker) have short durations of action and are of no value in prophylaxis. The an-swer is (B). 4. The antianginal effect of propranolol may be attributed to which one of the following? (A) Block of exercise-induced tachycardia (B) Decreased end-diastolic ventricular volume (C) Dilation of constricted coronary vessels (D) Increased cardiac force (E) Increased resting heart rate Propranolol blocks tachycardia but has none of the other effects listed. The answer is (A). 5. The major common determinant of myocardial oxygen consumption is (A) Blood volume (B) Cardiac output (C) Diastolic blood pressure (D) Heart rate (E) Myocardial fiber tension 5. The answer is (E), fiber tension. The other variables contribute to this determinant 6. You are considering therapeutic options for a new patient who presents with severe hyperten-sion and angina. In considering adverse effects, you note that an adverse effect which nitro-glycerin, guanethidine, and ganglion blockers have in common is (A) Bradycardia (B) impaired sexual function (C) Lupus erythematosus syndrome (D) Orthostatic hypotension (E) Throbbing headache These drugs all reduce venous return sufficiently to cause some degree of postural hypotension(not very prolonged in the case of nitroglycerin). Throbbing headache is a problem only withthe nitrates, bradycardia only with guanethidine, sexual problems only with sympathoplegics(ganglion blockers and guanethidine), and lupus with none of them. The answer is (D). 7. Epidemiologic surveys suggest that, in the past, workers exposed to high levels of organic ni-trates in the workplace had

(A) A high incidence of methemoglobinemia on the job (B) An increased incidence of angina at work as compared with at home (C) A high incidence of cyanide poisoning in the workplace (D) An increased incidence of headaches on Mondays as compared with other days (E) All of the above Nitrites, not nitrates, cause methemoglobinemia in adults. Headache, not angina, increasedupon returning to work on Monday. Neither nitrates nor nitrites are related to causation ofcyanide poisoning, but nitrites are used as one parl of the antidote for cyanide intoxication.The answer is (D). 8. A patient is admitted to the emergency department following a drug overdose. He is noted tohave severe tachycardia. He has been receiving therapy for hypertension and angina. A drugthat often causes tachycardia is (A) Diltiazem (B) Guanethidine (C) Isosorbide dinitrate (D) Propranolol (E) Verapamil Isosorbide dinitrate (like all the nitrates) causes reflex tachycardia, but all the other drugs listedhere slow heart rate. The answer is (C). 9. A patient being treated for another condition complains that whenever he takes that medica-tion, his angina becomes worse. Drugs that may precipitate angina when used for other indica-tions include all of the following EXCEPT (A) Amphetamine (B) Hydralazine (C) lsoproterenol (D) Reserpine (E) Terbutaline In general, drugs that cause hypertension or tachycardia--whether directly or by reflex-tendto precipitate angina in individuals with coronary obstruction unless cardiac work is greatly re-duced (as in the case of the nitrates). The answer is (D). 10. When nitrates are used in combination with other drugs for the treatment of angina, which ofthe following result in additive effects on the variable specified? (A) Beta-blockers and nitrates on end-diastolic cardiac size (B) Beta-blockers and nitrates on heart rate (C) Calcium channel blockers and beta-blockers on cardiac force

(D) Calcium channel blockers and nitrates on cardiac force (E) Calcium channel blockers and nitrates on cardiac rate The effects of beta-blockers (or calcium channel blockers) and nitrates on heart size, force, andrate are opposite. The answer is (C). 11. Which of the following is approved for the treatment of hemoThagic stroke? (A) Amyl nitrite (B) Hydralazine (C) Isosorbide mononitrate ('D) Nifedipine (E) Nimodipine (F) Nitroglycerin (sublingual) (G) Nitroglycerin (transdermal) ('H) Propranolol (I) Terbutaline (J) Verapamil Nimodipine, a dihydropyridine calcium channel blocker, is approved only for the treatment ofhemorrhagic stroke. The answer is (E). 12. Which of the following drugs used for the treatment of angina by inhalation has a very rapidonset and a brief duration of effect (2-5 minutes)? (A) Amyl nitrite (B) Hydralazine (C) [sosorbide mononitrate (D) Nifedipine (E) Nimodipine (F) Nitroglycerin (sublingual) (G) Nitroglycerin (transdermal) (H) Propranolol (I) Terbutaline (J) Verapamil Amyl nitrite, a very volatile liquid, is the only antianginal drug in this list that is usually usedby the inhalation route. (Terbutaline is used by aerosol, but it has a longer duration of actionand causes angina in susceptible patients.) The answer is (A). 13. Which of the following drugs is capable of maintaining blood levels for 24 hours but with use-ful therapeutic effects lasting only about 10 hours? (A) Amyl nitrite (B) Hydralazine (C) Isosorbide mononitrate

(D) Nifedipine (E) Nimodipine (F) Nitroglycerin (sublingual) (G) Nitroglycerin (transdermal) (H) Propranolol (I) Terbutaline (J) Verapamil Transdermal formulations of nitroglycerin are capable of maintaining blood concentrations forup to 24 hours. Unfortunately, tolerance develops after about 10 hours of continued exposure,so the beneficial effect is limited to about 8-10 hours. The answer is (G). 14. Which of the following is a vasodilator drug used for hypertension that lacks a direct effect onautonomic receptors but may provoke anginal attacks? (A) Amyl nitrite (B) Hydralazine (C) Isosorbide mononitrate (D) Nifedipine (E) Nimodipine (F) Nitroglycerin (sublingual) (G) Nitroglycerin (transdermal) (H) Propranolol (I) Terbutaline (J) Verapamil Hydralazine, a direct-acting vasodilator, often precipitates angina in susceptible individuals;the drug should never be used in patients with coronary disease unless heart rate is appropri-ately controlled. The answer is (B). DIRECTIONS (Item 15): This matching question consists of a list of ten lettered options followed by item15. Select the ONE lettered option that is most closely associated with item 15. (A) Amyl nitrite (B) Hydralazine (C) Isosorbide mononitrate D) Nifedipine(E) Nimodipine (F) Nitroglycerin (sublingual) (G) Nitroglycerin (transdermal) (H) Propranolol (I) Terbutaline (J) Verapamil 15. An active metabolite of another drug and an active antianginal drug for oral

administration inits own right. The organic nitrates are denitrated in the liver alter oral administration. Glyceryl dinitrate andisosorbide mononitrate are active metabolites. The latter agent is available as a separate drug.The answer is (C). FRMACOS UTILIZADOS EN INSUFICIENCIA CARDIACA (CP. 13) 1. Drugs that have been found to be useful in one or more types of heart failure include all of thefollowing EXCEPT (A) Na+/K + ATPase inhibitors (B) Alpha adrenoceptor agonists (C) Beta adrenoceptor agonists (D) Beta adrenoceptor antagonists (E) ACE inhibitors 1. All the drug groups listed are commonly used in heart failure except alpha agonists. Alpha-agonist drugs increase vascular resistance and would decrease the stroke volume of the weak-ened heart even more. The answer is (B). 2. The biochemical mechanism of action of digitalis is associated with (A) A decrease in calcium uptake by the sarcoplasmic reticulum (B) An increase in ATP synthesis (C) A modification of the actin molecule (D) An increase in systolic intracellular calcium levels (E) A block of sodium/calcium exchange 2. Digitalis does not alter calcium uptake or ATP synthesis: it does not modify actin.Sodium/calcium exchange is not blocked, it is merely altered. The most accurate descriptionof digitalis's mechanism in this list is thal it increases intracellular calcium. The answer is(D). 3. A patient who has been taking digoxin for several years for chronic heart failure is about to re-ceive atropine for another condition. A common effect of digoxin (at therapeutic blood levels)that can be almost entirely blocked by atropine is (A) Decreased appetite (B) Increased atrial contractility (C) Increased PR interval on the ECG (D) Headaches (E) Tachycardia The parasympathomimetic effects of digitalis can be blocked by muscarinic blockers such

asatropine. The only parasympathomimetic effect in the list provided is increased PR interval,representing slowing of AV conduction. The answer is (C). 4. A 65-year-old woman has been admitted to the coronary care unit with a left ventricular my-ocardial infarction. If this patient develops acute severe congestive failure with pulmonaryedema, which one of the following would be most useful? (A) Furosemide (B) Guanethidine (C) Minoxidil (D) Propranolol (E) Spironolactone Acute severe congestive failure with pulmonary edema often requires a vasodilator that re-duces intravascular pressures in the lungs. Furosemide has such vasodilating actions in thecontext of acute failure. Minoxidil would decrease arterial pressure and increase the heart rateexcessively. Spironolactone is useful in chronic failure but not usually in acute pulmonaryedema. The answer is (A). 5. In a patient given a cardiac glycoside, important effects of the drug on the heart include whichof the following? (A) Decreased atrioventricular conduction velocity (B) Decreased ejection time (C) Increased ectopic automaticity (D) Increased force of contraction (E) All of the above The effects of digitalis include all of those listed. The answer is (E). 6. Which of the following situations constitutes an added risk of digoxin toxicity? (A) Starting administration of captopril (B) Starting administration of quinidine (C) Hyperkalemia (D) Hypermagnesemia (E) Hypocalcemia Digitalis toxicity is facilitated by hypercalcemia, hypokalemia, or hypomagnesemia. [t is alsomore likely if a patient begins taking quinidine after being stabilized on a dose of digitalis, be-cause quinidine reduces the clearance of digoxin. The answer is (B).

7. Which row in the following table correctly shows the major effects of full therapeutic

doses ofdigoxin on the AV node and the ECG?

QuickTime and a None decompressor are needed to see this picture.

Digitalis increases the AV node refractory period--a parasympathomimetic action. Its effectson the ventricles include shortened action potential and QT interval, and a change in repolar-ization with inversion of the T wave. The answer is (B). 8. Drugs proved to reduce mortality in chronic congestive heart failure include all of the follow-ing EXCEPT (A) Captopril (B) Carvedilol (C) Digoxin (D) Enalapril (E) Spironolactone All the groups listed except digitalis have been shown to reduce mortality. Cardiac glycosidesreduce symptoms but not mortality. The answer is (C).

9. Drugs associated with clinically useful or physiologically important positive inotropic effectsinclude all of the following EXCEPT (A) Amrinone (B) Captopril (C) Digoxin (D) Dobutamine (E) Norepinephrine Although they are extremely useful in congestive heart failure, captopril and the other ACE in-hibitors have no positive inotropic effect on the heart. The answer is (B). 10. Successful therapy of congestive heart failure with digoxin will result in which one of the fol-lowing?

(A) Decreased heart rate (B) Increased afterload (C) Increased aldosterone (D) Increased renin secretion (E) Increased sympathetic outflow to the heart Digoxin reduces sympathetic outflow to the heart and vessels and reduces renin secretion (be-cause the drug replaces the need for compensatory responses). The answer is (A). 11. Which of the following is a monovalent cation that will decrease or reverse a mild to moderatedigitalis-induced arrhythmia? (A) Digibind antibodies (B) Digitoxin (C) Digoxin (D) Dobutamine (E) Enalapril (F) Furosemide (G) Lidocaine (H) Magnesium (I) Potassium (J) Quinidine Potassium is the only monovalent cation in the list, and it is used for reversing mild to moder-ate digitalis toxicity. The answer is (I). 12. Which of the following has been shown to prolong life in patients with chronic congestive fail-ure but has a negative inotropic effect on cardiac contractility? (A) Carvedilol (B) Digitoxin (C) Digoxin (D) Dobutamine (E) Enalapril (F) Furosemide Several beta-blockers, including carvedilol, have been shown to prolong life in heart failurepatients even though these drugs have a negative inotropic action on the heart. Their benefitspresumably result from some other effect. The answer is (A). 13. Which of the following is a [-selective agonist sometimes used in acute congestive failure? (A) Atenolol (B) Digoxin

(C) Dobutamine (D) Enalapril (E) Furosemide (F) Quinidine (G) Spironolactone Dobutamine is a [l-selective agonist often used in acute heart failure. The answer is (C). 14. Which of the following is the drug of choice in treating suicidal overdose of digitoxin? (A) Digoxin antibodies (B) Lidocaine (C) Magnesium (D) Potassium (E) Quinidine The drug of choice in severe, massive overdose with any cardiac glycoside is digoxin anti-body, Digibind. These antibodies are sufficiently nonselective to bind a variety of cardiac gly-cosides. The other drugs are used in moderate overdosage associated with increased automatic-ity. The answer is (A). DIRECTIONS (Item 15): The matching question in this section consists of a list of lettered options fol-lowed by item 15. Select the ONE lettered option that is most closely associated with item 15. (A) Digoxin antibodies (B) Digitoxin (C) Digoxin (D) Dobutamine (E) Enalapril (F) Furosemide (G) Lidocaine (H) Magnesium (I) Potassium (J) Quinidine Although quinidine is an antiarrhythmic drug, it is much more likely than lidocaine to precipi-tate digitalis toxicity. (See Question 14.) The answer is (G), lidocaine 15. An antiarrhythmic drug that is used to suppress digoxin-induced arrhythmias in some patients DIRECTIONS (Items 16-18): This case history is followed by questions for discussion. Write out briefanswers (two to five sentences) and then compare your answers with those

given at the end of theAnswers section. A 39-year-old man with mitral stenosis ingested 90 digoxin tablets (0.25 mg each) in a suicide at-tempt approximately 2 hours be.fore admission. Upon admission, the blood pressure was 110/70 mmHg and the pulse was 40-60Cin and irregular. The rest of the examination was normal.hfftial laboratory data included a blood ethanol of 190 mg/dL, but electrolytes were normal. Anelectrocardiogram revealed atrial flbrillation with a high degree of atrioventricular block. The ven-tricular rate did not exceed 50Cin. Atropine had no effect on the ventricular rate and a transvenouspacing catheter was therefore inserted, with ventricular pacing instituted at 60Cin.During the next 8 hours, the spontaneous ventricular rate (determined by briefly halting thetransvenous pacemaker) progressively decreased to 33Cin and then to 13Cin. No atrial activi O'could be detected on the ECG. The QRS duration reached a maximum of 0.33 s (normal: 0.1 s).Serum potassium increased to 8.7 meq/L (normal: 3.5-5 meq/L). An antidote was administered.Serum potassium rapidly fell to the normal range, and the patient made a complete recovery. 16. What was the cause and the primary source of the elevated serum potassium? The cause of the dramatic rise in serum potassium was the poisoning of membrane NaVK*ATPase (the sodium pump) in the entire body. The source of the potassium was the intracellu-lar space, particularly that of skeletal muscle (because of the large mass of this organ system). 17. Outline the conventional therapy for less severe digitalis intoxication, and explain why it wasnot us. ed in this case. What antidote was used? Conventional therapy of mild to moderate cardiac glycoside intoxication consists of the fol-lowing: (1) Normalization of low serum K +. In the present case and in mosl cases of grossoverdosage, the serum K + is high. However, in many cases of mild to moderate toxicity, theserum K + is low (because of concurrent diuretic use) or normal. If it is certain that the over-dose is not massive and serum K + is low, supplemental potassium should be given. However,potassium should never be raised above 4-5 meq/L because hyperkalemia is also arrhythmo-genic. In some cases (usually involving vomiting, diarrhea, or excessive use of loop diuretics),low serum Mg 2+ is found, and correction of this deficiency corrects the arrhythmia. (2) Use ofantiarrhythmic drugs. Lidocaine is usually tried first. (3) Avoidance of DC cardioversion un-less ventricular fibrillation occurs. These approaches were clearly not suitable for this severelyintoxicated patient. The antidote used was digoxin antibodies (Digibind). 18. This patient ingested digoxin. What treatment is available for severe intoxication with othercardiac glycosides? Antidigoxin Fab fragments cross-react sufficiently to be useful in reversing other glycosides'effects, including oleander cardiac glycoside. ANTIARRTMICOS (CP. 14) Items 1-3: An elderly patient with rheumatoid arthritis and chronic heart disease is being

consid-ered for treatment with procainamide. She is already receiving digoxin, hydrochlorothiazide, andpotassium supplements for her cardiac condition. 1. In making your decision to treat with procainamide, which of the following statements wouldbe relevant? (A) Procainamide may worsen or precipitate hyperthyroidism (B) Procainamide is not effective for atrial arrhythmias (C) Procainamide prolongs the effective refractory period in atrial and ventricular cells (D) Procainamide commonly induces thrombocytopenia (E) Procainamide commonly induces nausea, headache, and tinnitus Procainamide prolongs refractory period by blocking sodium channels and by prolonging theaction potential. All of the other statements are false. The answer is (C). 2. In deciding on a treatment regimen with procainamide for this patient, which of the followingstatements is MOST correct? (A) A possible drug interaction with digoxin suggests that digoxin blood levels should be ob-tained before and after starting procainamide (B) Hyperkalemia should be avoided to reduce the likelihood of procainamide toxicity (C) Procainamide cannot be used if the patient has asthma because it has a betablocking ef-fect (D) Procainamide has a duration of action of 20-30 hours (E) Procainamide is not active by the oral route Hyperkalemia facilitates procainamide toxicity. Procainamide is active by the oral route andhas a duration of action of 2-4 hours (in the prompt-release form). Procainamide has no docu-mented interaction with digoxin and little or no beta-blocking action. The answer is (B) 3. If this patient should manifest severe procalnamide toxicity from an overdose, rational therapywould entail the immediate administration of (A) A calcium chelator such as EDTA (B) Digitalis (C) KC1 (D) Nitroprusside (E) Sodium lactate The most effective therapy for procainamide toxicity appears to be concentrated sodium lac-tate. This drug may (1) increase sodium current by increasing the ionic gradient and (2) reducedrug-receptor binding by alkalinizing the tissue. The answer is (E).

4. When used as an antiarrhythmic drug, lidocaine typically (A) Increases action potential duration (B) Increases contractility (C) Increases PR interval (D) Reduces abnormal automaticity (E) Reduces resting potential Lidocaine reduces automaticity in the ventricles; the drug does not alter resting potential or APduration and does not increase contractility. The answer is (D). 5. All of he following can be used for chronic oral therapy of arrhythmias EXCEPT (A) Amiodarone (B) Disopyramide (C) Esmolol (D) Quinidine (E) Verapamil Esmolol is an ester that is rapidly metabolized even when given intravenously; it is inactive bythe oral route. Therefore, esmolol would not be suitable for chronic therapy. The answer is(c). 6. A 16-year-old girl is found to have paroxysmal attacks of rapid heart rate. The antiarrhythmicof choice in most cases of acute AV nodal tachycardia is (A) Adenosine (B) Amiodarone (C) Flecainide (D) Propranolol (E) Quinidine Calcium channel blockers are effective in supraventricular tachycardias. However, adenosineis just as effective in most acute nodal tachycardias and is less toxic because of its extremelyshort duration of action. The answer is (A). 7. A patient is admitted to the emergency department for evaluation of an abnormal ECG. Over-dose of an antiarrhythmic drug is considered. Which of the following drugs is correctly pairedwith its ECG effects? (A) Quinidine: Increased PR and decreased QT intervals (B) Flecainide: Increased PR, QRS, and QT intervals (C) Verapamil: Increased PR interval (D) Lidocaine: Decreased QRS and PR interval (E) Metoprolol: Increased QRS duration

All the associations listed are incorrect except verapamil. This class IV drug increases PR in-terval. The answer is (C). 8. Drugs that consistently reduce potassium (IKr) current and thereby prolong the action potentialduration include all of the following EXCEPT (A) Amiodarone (B) Ibutilide (C) Lidocaine (D) Quinidine (E) Sotalol All of the IA drugs and class III agents reduce potassium current during phase 3 and prolongthe action potential. Lidocaine, the prototype IB drug, actually shortens the duration undersome circumstances. The answer is (C). 9. Recognized adverse effects of quinidine include which one of the following? (A) Cinchonism (B) Constipation (C) Lupus erythematosus (D) Increase in digoxin clearance (E) Precipitation of hyperthyroidism Quinidine has a wide spectrum of adverse effects but causes increased--not decreased-gas-trointestinal motility and often results in diarrhea. Procainamide causes lupus; quinidine causesthrombocytopenia; amiodarone causes thyroid dysfunction. The answer is (A). 10. A drug that hyperpolarizes and prevents conduction of impulses in the AV node is (A) Adenosine (B) Digoxin (C) Lidocaine (D) Quinidine (E) Verapamil The only antiarrhythmic agent that consistently alters the resting potential of the AV node isadenosine. It apparently activates IKI potassium channels in the AV node, thus forcing themembrane potential closer to the Nernst potassium potential; thus, adenosine significantly hy-perpolarizes this tissue, preventing the conduction of action potentials. The answer is (A). 11. Which of the following is an orally active drug that blocks sodium channels and decreases ac-tion potential duration?

(A) Adenosine (B) Amiodarone (C) Disopyramide (D) Esmolol (E) Flecainide (F) Lidocaine (G) Mexiletine (H) Procainamide (I) Quinidine (J) Verapamil Class IB drugs such as lidocaine and mexiletine typically block sodium channels and decreasethe action potential duration. Mexiletine, but not lidocaine, is orally active. The answer is (G). 12. Which of the following slows conduction through the atrioventricular node and has its primaryaction directly on L-type calcium channels? (A) Adenosine (B) Amiodarone (C) Disopyrarnide (D) Esmolol (E) Flecainide (F) Lidocaine (G) Mexiletine (H) Procainamide (I) Quinidine (J) Verapamil Verapamil is the calcium channel blocker in this list. (Adenosine and beta-blockers also slowAV conduction but do not act primarily on calcium channels.) The answer is (J). 13. Which of the following has the longest half-life of all antiarrhythmic drugs? (A) Adenosine (B) Amiodarone (C) Disopyramide (D) Esmolol (E) Flecainide (F) Lidocaine (G) Mexiletine (H) Procainamide (I) Quinidine (J) Verapamil

Amiodarone has the longest half-life of all the antiarrhythmics (Table 14-2). The answer is(B). 14. A drug was tested in the electrophysiology laboratory to determine its effects on the cardiacaction potential in ventricular cells. The results are shown in the diagram. Which of the follow-ing drugs does this agent most resemble?

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(A) Adenosine (B) Disopyramide (C) Flecainide (D) Lidocaine (E) Verapamil The drug effect shown in the diagram includes slowing of the upstroke of the action potentialand shortening of the repolarization phase. This is typical of class IB drugs. The answer is (D),lidocaine. DIRECTIONS (Items 15-20): The matching questions in this section consist of a list of lettered optionsfollowed by numbered items. For each numbered item, select the ONE lettered option that is mostclosely associated with it. Each lettered option may be selected once, more than once, or not at all. (A) Adenosine (B) Amiodarone (C) Disopyrarnide (D) Esmolol (E) Flecainide (F) Lidocaine (G) Mexiletine (H) Procainamide (I) Quinidine (J) Verapamil

15. Very useful in supraventricular tachycardia; duration of action is 10-15 seconds The only drug in the list with a half-life of seconds is adenosine. The answer is (A) 16. Beta blocker, used only by the IV route Esmolol is the only beta-blocker in the list. The answer is (D). 17. Orally active drug that may cause purpuric rash Quinidine may cause thrombocytopenia; this can lead to punctate hemorrhages under the skin(purpura). The answer is (I). 18. Derived from the bark of the cinchona tree; may cause tinnitus and diarrhea Quinidine is derived, along with quinine, from cinchona bark. The answer is (I). 19. Causes reversible lupus erythematosus Procainamide frequently results in a positive antinuclear antibody (ANA) test after prolongad therapy; this may progress to typical signs of drug-induced lupus (joint, skin, and systemic butnot renal changes). The answer is (H). 20. Sodium channel blocker with little effect on AP duration; high incidence of arrhythmia induction The IC antiarrhythmic drugs have little effect on AP duration; they have been associated witha high incidence of drug-induced arrhythmias. The answer is (E). DIURTICOS (CP. 15) 1. A 70-year-old man is admitted with a history of heart failure and an acute left ventricular my-ocardial infarction. He has severe pulmonary edema. Which of the following drugs is LEASTlikely to prove useful in the treatment of acute pulmonary edema? (A) Bumetanide (B) Ethacrynic acid (C) Furosemide (D) Hydrochlorothiazide (E) Torsemide Loop diuretics have a rapid onset of action, are very efficacious, and appear to have significantdirect smooth muscle-relaxing effects in the pulmonary vessels. They are therefore drugs ofchoice in acute pulmonary edema. The only drug in the list that is not a loop agent is hy-drochlorothiazide. The answer is (D). 2. A 50-year-old man has a history of frequent episodes of renal colic with high-calcium renalstones. The most useful agent in the treatment of recurrent calcium stones is

(A) Mannitol (B) Furosemide (C) Spironolactone (D) Hydrochlorothiazide (E) Acetazolamide The thiazides are useful in the prevention of calcium stones because these drugs inhibit the re-nal excretion of calcium. In contrast, the loop agents facilitate calcium excretion. The answeris (D). 3. When used chronically to treat hypertension, thiazide diuretics have all of the following prop-erties or effects EXCEPT (A) Reduce blood volume or vascular resistance, or both (B) Have maximal effects on blood pressure at doses below the maximal diuretic dose (C) May cause an elevation of plasma uric acid and triglyceride levels (D) Decrease the urinary excretion of calcium (E) Cause ototoxicity Thiazides do not cause ototoxicity; loop diuretics do. The answer is (E).

4. Which of the following drugs is correctly associated with its site of action and maximal diuretic efficacy? (A) Thiazidesdistal convoluted tubule--10% of filtered Na (B) Spironolactone--proximal convoluted tubules40% (C) Bumetanide--thick ascending limb15%(D) Metolazoneollecting tubule--2% (E) All of the above Spironolactone acts in the collecting tubule, not the proximal convoluted tubule. This drug isnot usually capable of causing a 40% sodium diuresis. Bumetanide, a loop diuretic, can pro-duce a 30-40% increase in sodium excretion. Metolazone, a thiazidelike drug, acts in the dis-tal convoluted tubule, not in the collecting tubule. The answer is (A). 5. A patient with long-standing diabetic renal disease and hyperkalemia and recent-onset conges-tive heart failure requires a diuretic. Which of the following agents would be LEAST harmfulin a patient with severe hyperkalemia? (A) Amiloride (B) Hydrochlorothiazide (C) Losartan (D) Spironolactone

(E) Triamterene Hyperkalemia should not be treated with drugs that interfere with aldosterone production (eg,losartan, an angiotensin II receptor blocker) or collecting tubule potassium excretion (eg,amiloride, spironolactone, triamterene). These agents are all capable of increasing serumpotassium. Hydrochlorothiazide would not reduce serum potassium rapidly, but it would notincrease it. The answer is (B). 6. Which of the following diuretics would be most useful in a patient with cerebral edema'? (A) Acetazolamide (B) Amiloride (C) Ethacrynic acid (D) Furosemide (E) Mannitol An osmotic agent is needed to remove water from the cells of the edematous brain and reduceintracranial pressure. The answer is (E). 7. Which of the following is not a complication of therapy with thiazide diuretics? (A) Hypercalciuria (B) Hyponatremia (C) Hypokalemia (D) Hypemricemia (E) Metabolic alkalosis Thiazides produce all of the effects listed except hypercalciuria. They reduce urine calciumand for this reason are useful in chronic stone-formers. The answer is (A). 8. Which of the following therapies would be most useful in the management of severe hypercalcemia? (A) Amiloride plus saline infusion (B) Furosemide plus saline infusion (C) Hydrochlorothiazide plus saline infusion (D) Mannitol plus saline infusion (E) Spironolactone plus saline infusion Diuretic therapy of hypercalcemia requires a reduction in calcium reabsorption in the thick as-cending limb. However, a loop diuretic alone would reduce blood volume around the remaining calcium so that serum calcium would not decrease appropriately. Therefore, saline infusionshould accompany the loop diuretic. The answer is (B). 9. A 60-year-old patient complains of paresthesias and occasional nausea associated with

one ofher drugs. She is found to have hyperchloremic metabolic acidosis. She is probably taking (A) Acetazolamide for glaucoma (B) Amiloride for edema associated with aldosteronism (C) Furosemide for severe hypertension and congestive failure (D) Hydrochlorothiazide for hypertension (E) Mannitol for cerebral edema Paresthesias and gastrointestinal distress are common adverse effects of acetazolamide, espe-cially when it is taken chronically, as in glaucoma. The observation that the patient hasmetabolic acidosis also suggests the use of acetazolamide. The answer is (A). 10. A 70-year-old woman is admitted to the emergency room because of a "fainting spell" athome. She appears to have suffered no trauma from her fall, but her blood pressure is 110/60when lying down and 60/40 when she sits up. Neurologic examination and an ECG are withinnormal limits when she is lying down. Questioning reveals that she has recently started taking"water pills" (diuretics) for a heart condition. Which of the following drugs is the most likelycause of her fainting spell? (A) Acetazolamide (B) Amiloride (C) Furosemide (D) Hydrochlorothiazide (E) Spironolactone The case history suggests that the syncope (fainting) is associated with diuretic use. Complications of diuretics that can result in syncope include both postural hypotension (which this pa-tient exhibits) due to excessive reduction of blood volume and arrhythmias due to excessivepotassium loss. Potassium wasting is more common with thiazides (because of their long dura-tion of action), but these drugs rarely cause reduction of blood volume sufficient to result in or-thostatic hypotension. The answer is (C). 11. A 55-year-old patient with severe post-hepatitis cirrhosis is started on a diuretic for anothercondition. Two days later he is found in a coma. The drug most likely to cause coma in a pa-tient with cirrhosis is (A) Acetazolamide (B) Amiloride (C) Furosemide (D) Hydrochlorothiazide (E) Spironolactone The carbonic anhydrase inhibitors cause metabolic acidosis and urinary alkalosis. Patients withsevere impairment of liver function are unable to synthesize urea efficiently and become de-pendent on renal excretion of ammonium ion to rid the body of

nitrogenous wastes. However,in alkaline urine the ammonium ion is rapidly converted to ammonia gas. which is very rapidlyreabsorbed. Hyperammonemia results, with severe neurologic consequences. The answer is(A). 12. A drug that has its major effect in the distal convoluted tubule is (A) Acetazolamide (B) Amiloride (C) Demeclocycline (D) Desmopressin (E) Ethacrynic acid (F) Furosemide (G) Metolazone (H) Mannitol (I) Spironolactone (J) Triamterene Metolazone, though not a thiazide, is a sulfonamide that is often used as a thiazide substitute.Metolazone's site of action, effects, and toxicities (including sulfonamide allergy) are indistin-guishable from the true thiazides. The answer is (G). 13. A drug that increases the formation of dilute urine in water-loaded subjects and is used to treatSIADH is (A) Acetazolamide (B) Amiloride (C) Demeclocycline (D) Desmopressin (E) Ethacrynic acid (F) Furosemide (G) Metolazone (H) Mannitol (I) Spironolactone (J) Triamterene Inability to form dilute urine in the fully hydrated condition is characteristic of SIADH. Antag-onists of ADH are needed to treat this condition. The answer is (C). 14. A drug that is useful in glaucoma and high-altitude sickness is (A) Acetazolamide (B) Amiloride (C) Demeclocycline (D) Desmopressin (E) Ethacrynic acid (F) Furosemide

(G) Metolazone (H) Mannitol (I) Spironolactone (J) Triamterene Carbonic anhydrase inhibitors are useful in glaucoma and altitude sickness. The answer is (A). DIRECTIONS (Items 15-16): Different diuretic drugs act at different sites in the nephron. The diagrambelow denotes such potential sites of action with the letters A-E. For questions 15 and 16, select thelettered site of action that applies to the description given.

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15. Site of action of a drug that blocks a steroid receptor and causes potassium retention. Spironolactone is an aldosterone receptor antagonist, acts intracellularly in the cortical collect-ing tubule, and causes potassium retention. The answer is (E). 16. Site of action of a drug that blocks a sodium, potassium, and chloride cotransporter and in-creases calcium excretion. Loop diuretics block the Na+/K+/2C1 - cotransporter. The answer is (C). DIRECTIONS (Items 17-20): The diagram below shows some of the steps involved in the reabsorptionof bicarbonate. For each of the numbered items in the diagram, identify the substance denoted.

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17.Identify the substance denoted 17. (A) Bicarbonate (B) Carbon dioxide (C) Carbonic acid (D) Carbonic anhydrase (E) Hydrogen ion The substance denoted 17 results from the combination of bicarbonate ion with a proton: thisis carbonic acid. The answer is (C). 18. Identify the substance denoted 18. (A) Bicarbonate (B) Carbon dioxide (C) Carbonic acid (D) Carbonic anhydrase (E) Hydrogen ion The substance denoted 18 is countertransported against sodium in the PCT cell and combineswith bicarbonate ion to yield carbonic acid; it is a proton. The answer is (E). 19. Identify the substance denoted 19. (A) Bicarbonate (B) Carbon dioxide (C) Carbonic acid (D) Carbonic anhydrase (E) Hydrogen ion Substance 19 and water are the products of the dissociation of carbonic acid; this is

carbondioxide. The answer is (B) 20. Identify the substance denoted 20. (A) Bicarbonato (B) Carbon dioxide (C) Carbonic acid (D) Carbonic anhydrase (E) Hydrogen ion The substance denoted 20 is the enzyme that catalyzes the dissociation of carbonic acid intowater and carbon dioxide. The answer is (D). FRMACOS UTILIZADOS EN HIPERLIPIDEMIA (CP. 35) 1. Increased serum levels of which of the following may be associated with a decreased risk ofatherosclerosis? (A) Very low-density lipoproteins (VLDL) (B) Low-density lipoproteins (LDL) (C) Intermediate-density lipoproteins (IDL) (D) High-density lipoproteins (HDL)(E) Cholesterol Increased serum concentrations of most of the lipoproteins and total cholesterol is associated with in-creased risk of atherosclerosis. High serum concentrations of HDL cholesterol ("good cholesterol"),however, is associated with a decrease in the risk of atherosclerotic disease. The answer is (D). 2. A 58-year-old man with a history of hyperlipidemia was treated with a drug. The chart belowshows the results of the patient's fasting lipid panel before treatment and 6 months after initiat-ing drug therapy. Normal values are also shown. Which of the following drugs is most likelyto be the one that this man received? (All values represent mg/dL.)

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(A) Atorvastatin (B) Colestipol (C) Gemfibrozil

(D) Lovastatin (E) NiacinItems This patient presents with striking hypertriglyceridemia, elevated VLDL cholesterol, and de-pressed HDL cholesterol. Six months after drug treatment was started, his triglyceride andVLDL cholesterols have dropped dramatically and his HDL cholesterol level had doubled. Thedrug that is most likely to have achieved all of these desirable changes, particularly the largeincrease in HDL cholesterol, is niacin. While gemfibrozil and atorvastatin lower triglycerideand VLDL concentrations, they do not cause such large increases in HDL cholesterol. The an-swer is (E). 3-6: A 35-year-old woman appears to have familial combined hyperlipidemia. Her serumconcentrations of total cholesterol, LDL cholesterol, and triglyceride are elevated. Her serum con-centration of HDL cholesterol is somewhat reduced. 3. Which of the following drags is most likely to cause an increase in this patient's triglycerideand VLDL cholesterol when used as monotherapy? (A) Atorvastatin (B) Cholestyramine (C) Gemfibrozil (D) Lovastatin (E) Niacin In some patients with familial combined hyperlipidemia and elevated VLDL, the resins can in-crease VLDL and triglyceride concentrations even though they also lower LDL cholesterol.The answer is (B). 4. If this patient is pregnant, which of the following drugs should be avoided because of a risk ofharming the fetus? (A) Cholestyramine (B) Fenofibrate (C) Gemfibrozil (D) Niacin (E) Pravastatin The HMG-CoA reductase inhibitors are contraindicated in pregnancy because of the risk ofteratogenic effects. The answer is (E) 5. The patient is started on gemfibrozil. The major mechanism of action of gemfibrozil is (A) Increased excretion of bile acid salts (B) Increased expression of high-affinity LDL receptors (C) Increased lipid hydrolysis by lipoprotein lipase (D) Inhibition of secretion of VLDL by the liver

(E) Reduction of secretion of HDL by the liver The major mechanism recognized for gemfibrozil is stimulation of lipoprotein lipase. The an-swer is (C). 6. When used as monotherapy, a major toxicity of gemfibrozil is increased risk of (A) Bloating and constipation (B) Cholelithiasis (C) Hyperuricemia (D) Liver damage (E) Severe cardiac arrhythmia A major toxicity of the fibrates is increased risk of gallstone formation, which may be due toenhanced biliary excretion of cholesterol. The answer is (B). Items 7-10: A 43-year-old man has heterozygous familial hyperlipidemia. His serum concentra-tions of total cholesterol and LDL are markedly elevated. His serum concentration of HDL choles-terol. VLDL cholesterol, and triglyceride are normal or slightly elevated. This patient's mother andolder brother died of myocardial infarctions before the age of 50. This patient has recently experi-enced mild chest pain when walking up stairs and has been diagnosed as having angina of effort.The patient is somewhat overweight. He drinks alcohol most evenings and smokes about one packof cigarettes per week. 7. Alcohol drinking is associated with which of the following changes in serum lipid concentrations? (A) Decreased HDL cholesterol (B) Decreased IDL cholesterol (C) Decreased VLDL cholesterol (D) Increased LDL cholesterol (E) Increased triglyceride Chronic ethanol ingestion can increase serum concentrations of VLDL and triglyceride. This isone of the factors that puts patients with alcoholism at risk of pancreatitis. Chronic ethanol in-gestion also has the possibly beneficial effect of raising, not decreasing, serum HDL concen-trations. The answer is (E). 8. If the patient has a history of gout, which of the following drugs is most likely to exacerbatethis condition? (A) Colestipol (B) Gemfibrozil (C) Lovastatin (D) Niacin

(E) Simvastatin Niacin can exacerbate both hyperuricemia and glucose intolerance. The answer is (D). 9. After being counseled about lifestyle and dietary changes, the patient was started on atorva-statin.During his treatment with atorvastatin, it is important to routinely monitor serum concentrations of (A) Blood urea nitrogen (BUN) (B) Alanine and aspartate aminotransferase (C) Platelets (D) Red blood cells (E) Uric acid The two primary adverse effects of the HMG-CoA reductase inhibitors are hepatotoxicity andmyopathy. Patients taking these drugs should have liver function tests performed before start-ing therapy and then at regular intervals during therapy. Serum concentrations of alanine andaspartate aminotransferase are used as markers of hepatocellular toxicity. The answer is (B) 10. Six months after beginning atorvastatin, the patient's total and LDL cholesterol concentrationsremained above normal and he continued to have anginal attacks despite good adherence to hisantianginal medications. His physician decided to add niacin. The major recognized mecha-nism of action of niacin is (A) Decreased lipid synthesis in adipose tissue (B) Decreased oxidation of lipids in endothelial cells (C) Decreased secretion of VLDL by the liver (D) Increased endocytosis of HDL by the liver (E) Increased lipid hydrolysis by lipoprotein lipase The major recognized effect of niacin is reduction of VLDL secretion by the liver (Figure35-2). The answer is (C). FRMACOS UTILIZADOS EN LOS TRANSTORNOS DE LA COAGULACIN (CP. 34) Items 1-3: A 58-year-old business executive is brought to the emergency room 2 hours after theonset of severe chest pain during a vigorous tennis game. She has a histoD, of poorly controlled mildhypertension and elevated blood cholesterol but does not smoke. ECG changes confirm the diagno-sis of myocardial infarction. The decision is made to attempt to open her occluded artery,. 1. Conversion of plasminogen to plasmin is brought about by (A) Aminocaproic acid

(B) Heparin (C) Lepirudin (D) Reteplase (E) Warfarin Heparin and warfarin are anticoagulants that affect activation or formation of proteins in theclotting cascade. Lepirudin is an inhibitor of thrombin, and aminocaproic acid is an inhibitor,not an activator, of fibrinolysis and the conversion of plasminogen to plasmin. Reteplase is theonly thrombolytic drug listed. The answer is (D). 2. If a fibrinolytic drug is used tbr treatment of this woman's acute myocardial infarction, the ad-verse drug effect that is most likely to occur is (A) Acute renal failure (B) Development of antiplatelet antibodies (C) Encephalitis secondary to liver dysfunction (D) Hemorrhagic stroke (E) Neutropenia The most common serious adverse effect of the fibrolytics is bleeding, especially in the cere-bral circulation. The fibrinolytics do not usually have serious effects upon the renal, hepatic, orhematologic systems. Unlike heparin, they do not induce antiplatelet antibodies. However, streptokinase and anistreplase contain bacterial proteins and may induce formation of inacti-vating antibodies or even severe allergic reactions. The answer is (D). 3. If this patient undergoes a percutaneous coronary procedure and placement of a stent in a coro-nary blood vessel, she may be given eptifibatide. The mechanism of eptifibatide's anticlottingaction is (A) Activation of antithrombin II1 (B) Blockade of posttranslational modification of clotting factors (C) Inhibition of thromboxane production (D) Irreversible inhibition of platelet ADP receptors (E) Reversible inhibition of glycoprotein IIb/IIIa receptors Eptifibatide is a reversible inhibitor of the glycoprotein IIb/Illa receptor, an integrin on the sur-face of platelets that serves as a key regulator of platelet aggregation. Glycoprotein IIb/IIIa re-ceptor antagonists help to prevent platelet-induced occlusion of coronary stents. The answer is(E). 4. The following changes in plasma concentration of warfarin were observed in a patient whentwo other agents, drugs B and C, were given on a daily basis at constant dosage starting at thetimes shown. Which of the following statements most accurately describes what is shown inthe graph below?

(A) Drug B displaces warfarin from plasma proteins; drug C displaces warfarin from tissuebinding sites B) Drug B inhibits hepatic metabolism of warfarin; drug C displaces drug B from tissuebinding sites (C) Drug B stimulates hepatic metabolism of warfarin; drug C displaces warfarin fromplasma protein (D) Drug B increases renal clearance of warfarin; drug C inhibits hepatic metabolism ofdrug B A drug that increases metabolism (clearance) of the anticoagulant will lower the steady stateplasma concentration (both free and bound forms), whereas one that displaces the anticoagu-lant will increase the plasma level of the free form only until elimination of the drug has againlowered it to the steady state level. The answer is (C).

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Items 5-7: A 65-year-old man is brought to the emergency room 30 minutes after the onset ofright-sided weakness and aphasia (difficulty speaking). Imaging studies ruled out cerebral hemor-rhage as the cause of his acute symptoms of stroke. 5. Prompt administration of which of the following drugs is most likely to improve this patient'sclinical outcome? (A) Abciximab (B) Alteplase (C) Factor VIII (D) Streptokinase (E) Vitamin K Controlled clinical trials have shown that alteplase improves the clinical outcome in patientswith ischemic stroke if given within 3 hours after the onsel of symptoms. Similar trials ofstreptokinase resulted in unacceptably high rates of bleeding. Glycoprotein

IIb/IIIa receptor in-hibitors like abciximab have not been tested in ischemic stroke. Vitamin K and factor VIII mayactually worsen the patient's outcome. The answer is (B). 6. Over the next 2 days, the patient's symptoms resolved completely. To prevent a recurrence ofthis disease, the patient is most likely to be treated indefinitely with (A) Aminocaproic acid (B) Aspirin (C) Enoxaparin (D) Urokinase (E) Warfarin Aspirin, an irreversible inhibitor of platelet cyclooxygenase, has been shown to prevent recur-rence of transient ischemic attacks and ischemic stroke. The answer is (B). 7. If the patient is unable to tolerate the drug identified in Question 6, he may be treated withclopidogrel. Relative to ticlopidine, clopidogrel (A) Has a shorter duration of action (B) Is less likely to cause neutropenia (C) Is more likely to induce antiplatelet antibodies (D) ls more likely to precipitate serious bleeding (E) Will have a greater antiplatelet effect Ticlopidine and clopidogrel have similar mechanisms of action and therapeutic efficacy. Thekey difference between these two drugs is that clopidogrel is less likely to cause neutropeniaand therefore does not require routine monitoring of blood cell counts during therapy. The an-swer is (B). Items 8-10: A 67-year-old woman presents with pain in her left thigh muscle. Duplex ultrasonog-raphy indicates the presence of deep vein thrombosis (DVT) in the "affected limb. 8. The decision was made to treat this woman with enoxaparin. Relative to regular heparin,enoxaparin (A) Can be used without monitoring the patient's aPTT (B) Has a shorter duration of action (C) Is less likely to have a teratogenic effect (D) ls more likely to be given intravenously (E) Is more likely to cause thrombosis and thrombocytopenia Enoxaparin is a low-molecular-weight (LMW) heparin. LMW heparins have a longer half-fifethan standard heparin and a more consistent relationship between dose and therapeutic effect.Enoxaparin is given subcutaneously, not intravenously. It is less--not more--likely to causethrombosis and thrombocytopenia. Neither LMW heparins nor

standard heparin are terato-genie. The aPTT is not useful for monitoring the effects of LMW heparins. The answer is (A). 9. If this woman has marked resistance to heparin, she is most likely to be treated with (A) Abciximab (B) Antithrombin III (C) Plasminogen (D) Urokinase (E) Vitamin K, Heparin's anticlotting effect is mediated by acceleration of the action of endogenous antithrombin III, a protease that inactivates clotting factors. Patients with genetic deficiencies inantithrombin IIl are resistant to heparin and prone to thrombosis. Antithrombin III isolatedfrom pooled human plasma is available for use in such patients. The answer is (B). 10. During the next week, the patient was started on warfarin and her heparin was discontinued.Two months later, she returned after a severe nosebleed. Laboratory analysis revealed an 1NR(international normalized ratio, the system now used for reporting results of the prothrombintime test) of 7.0 (INR value in such a warfarin-treated patient should be 2.5-3.5). In order toprevent severe hemorrhage, the warfarin should be discontinued and this patient should betreated immediately with (A) Alteplase (B) Aminocaproic acid (C) Factor VIII (D) Protamine (E) Vitamin K The elevated INR indicates excessive anticoagulation with a high risk of hemorrhage. War-farin should be discontinued and vitamin K administered to accelerate formation of vitaminK-dependent factors. The answer is (E). FRMACOS UTILIZADOS EN ASMA (CP. 20) 1. One effect that theophylline, nitroglycerin, isoproterenol, and histamine have in common is (A) Direct stinmlation of cardiac contractile force (B) Tachycardia (C) Increased gastric acid secretion (D) Postuml hypotension (E) Throbbing headache

Theophylline does not cause headache. Nitroglycerin does not increase gastric acid secretion.Isoproterenol does not cause either. Histamine may cause all of the effects listed. The answeris (B). 2. A 23-year-old woman is using a terbutaline inhaler for frequent acute episodes of asthma anddescribes symptoms that she ascribes to the terbutaline. Which of the following is not a recog-nized action of terbutaline? (A) Diuretic effect (B) Positive inotropic effect (C) Skeletal nmscle tremor (D) Smooth muscle relaxation (E) Tachycardia Terbutaline is a "'selective" [3a-receptor agonist, but in moderate to high doses it induces 13 car-diac effects as well as [3a-mediated smooth and skeletal muscle effects. The answer is (A). 3. A 10-year-old child has severe asthma and was hospitalized five times between the ages of 7and 9. He is now receiving outpatient medications that have greatly reduced the frequency ofsevere attacks. Which of the following is most likely to have adverse effects when used dailyover long periods for severe asthma? (A) Albuterol by aerosol (B) Beclomethasone by aerosol (C) Cromolyn by inhaler (D) Prednisone by mouth (E) Theophylline in long-acting oral form If oral corticosteroids must be used, alternate-day therapy is preferred because it interferes lesswith normal growth in children. The answer is (D). 4. Cromolyn has as its major action (A) Block of calcium channels in lymphocytes (B) Block of mediator release from mast cells (C) Block of phosphodiesterase in mast cells and basophils (D) Smooth muscle relaxation in the bronchi (E) Stimulation of cortisol release by the adrenals The answer is (B), inhibition of mediator release from mast cells. The mechanism for this ef-fect is not known. Items 5-6: A 16-year-old patient is in the emergency room receiving nasal oxygen. She has aheart rate of 135/min, a respiratory rate of 40/min, and a peak expiratory flow (PEF) less than 50%of the predicted value. Wheezing and rales are audible without a

stethoscope. 5. Drugs that can dilate bronchi during an acute asthmatic attack include all of the following EXCEPT (A) Epinephrine (B) Terbutaline (C) Nedocromil (D) Theophylline (E) Ipratropium Neither nedocromil nor cromolyn is capable of reversing bronchospasm; their action is pro-phylactic. The answer is (C). 6. After successful treatment of the acute attack, the patient was referred to the outpatient clinicfor follow-up treatment of her asthma. Successful strategies currently in use for asthma includeall of the following EXCEPT (A) Avoidance of antigen exposure (B) Blockade of histamine receptors (C) Blockade of leukotriene receptors (D) Inhibition of phospholipase A 2 (E) Inhibition of release of mediators from mast cells and leukocytes Histamine does not appear to play a significant role in asthma, and antihistaminic drugs, evenin high doses, are of little or no value. The answer is (B) 7. Mr. Green is a 60-year-old former smoker with severe chronic obstructive pulmonary (COPD)and cardiac disease associated with frequent episodes of bronchospasm. Which of the follow-ing is a bronchodilator useful in COPD and least likely to cause cardiac arrhythmia? (A) Aminophylline (B) Cromolyn (C) Epinephrine (D) Ipratropium (E) Metaproterenol (F) Metoprolol (G) Prednisone/prednisolone (H) Salmeterol (I) Zafirlukast (J) Zileuton Ipratropium is the bronchodilator that is most likely to be useful in COPD without causing ar-rhythmias. The answer is (D).

8. Which of the following is a nonselective but very potent and efficacious bronchodilator that isnot active by the oral route? (A) Aminophylline (B) Cromolyn (C) Epinephrine (D) Ipratropium (E) Metaproterenol (F) Metoprolol (G) Prednisone/prednisolone (H) Salmeterol (I) Zafiflukast (J) Zileuton Epinephrine is still one of the most potent and efficacious agents available for asthma. However, because it is nonselective, [3a-selective agents are preferred. The answer is (C). 9. Which of the following is a prophylactic agent that appears to stabilize mast cells? (A) Aminophylline (B) Cromolyn (C) Epinephrine (D) Ipratropium (E) Metaproterenol (F) Metoprolol (G) Prednisonelprednisolone (H) Salmeterol (I) Zafirlukast (J) Zileuton Cromolyn is useful only for prophylaxis. The drug stabilizes mast cells, ie, prevents mediatorrelease. The answer is (B). 10. Which of the following is a direct bronchodilator that is most often used in asthma by the oralroute? (A) Aminophylline (B) Cromolyn (C) Epinephrine (D) Ipratropium (E) Metaproterenol (F) Metoprolol (G) Prednisone/prednisolone (H) Salmeterol (I) Zafirlukast

(J) Zileuton Aminophylline, a salt of theophylline, is a bronchodilator that is active by the oral route. Theanswer is (A). 11. Which of the following in its parenteral form is lifesaving in severe status asthmaticus andacts, at least in part, by inhibiting phospholipase A2? (A) Aminophylline (B) Cromolyn (C) Epinephrine (D) Ipratropium (E) Metaproterenol (F) Metoprolol (G) Prednisone/prednisolone (H) Salmeterol (I) Zafirlukast (J) Zileuton Parenteral corticosteroids such as prednisolone are lifesaving in status asthmaticus. They prob-ably act by reducing production of leukotrienes (see Chapter 18). The answer is (G). 12. Which of the following has overdose toxicity that includes insomnia, arrhythmms, and convulsions? (A) Aminophylline (B) Cromolyn (C) Epinephrine (D) Ipratropium (E) Metaproterenol (F) Metoprolol (G) Prednisone/prednisolone (H) Salmeterol (I) Zafirlukast (J) Zileuton Aminophylline is a salt of theophylline. Like the base theophylline, aminophylline can causesevere and potentially lethal overdose toxicity. The answer is (A). 13. Which of the following is a very long-acting 32-selective agonist that is used for asthma pro-phylaxis? (A) Aminophylline (B) Cromolyn (C) Epinephrine (D) Ipratropium

(E) Metaproterenol (F) Metoprolol (G) Prednisone/prednisolone (H) Salmeterol (I) Zafirlukast (J) Zileuton Salmeterol is a long-acting 2-selective sympathomimetic agent that is approved for prophy-lactic use in asthma. The answer is (H). DIRECTIONS (Items 14-1 5): The two matching questions in this section consist of a list of lettered op-tions followed by two numbered items. For each numbered item, select the ONE lettered option thatis most closely associated with it. Each lettered option may be selected once, more than once, or notat all. (A) Aminophylline (B) Cromolyn (C) Epinephrine (D) Ipratropium (E) Metaproterenol (F) Metoprolol (G) Prednisonelprednisolone (H) Salmeterol (I) Zafirlukast (J) Zileuton 14. A drug that directly inhibits 5-1ipoxygenase and reduces leukotriene synthesis Zileuton is a selective inhibitor of 5-1ipoxygenase. The answer is (J). 15. Inhibitor of LTD 4 receptors Zafirlukast inhibits LTD 4 at its receptors. The answer is (I). DIRECTIONS (Items 16-18): This case history* is followed by discussion questions. Write out brief answers (two to five sentences) and then compare your answers with those given at the end of the Answers section. A businesswoman with a history of mild asthma attacks had onset of symptoms of bronchocon-striction in a restaurant. Repeated self-medication with an i nhaler did not provide relief, and symp-toms progressed until she became cyanotic. Paramedics administered a subcutaneous drug upon ar-rival and nasal oxygen during transport. She was admitted to the hospital emergency room in severerespiratory distress. Her pulse was lO0/min, respiratory rate 32/min, and blood pressure 140/90 mmHg on nasal oxygen. Severe wheezing was present.After this evaluation, she was given another dose of the subcutaneous medication that had beenpreviously administered by the paramedics. Fifteen minutes later, her symptoms had decreasedmarkedly, but she still had

some respiratory wheezing. Use of a bronchodilator administered byhandheld nebulizer abolished the wheezing, and oxygen could be discontinued. She was discharged3 hours later. 16. What are the probable mediators of the bronchoconstriction noted in this woman's asthma at-tack? The mediators probably most important in causing asthmatic bronchoconstriction are leu-kotrienes LTC 4 and LTD 4. Another leukotriene (LTB4) , prostaglandins, peptides, some en-zymes, and histamine probably also play a role. 17. What medications are commonly used for the outpatient treatment of mild and moderateasthma? What are their mechanisms of action? The most commonly used bronchodilators are the beta-adrenoceptor agonists. In some pa-tients, a muscarinic blocking drug (eg, ipratropium) has a useful bronchodilating effect. Cro-molyn and nedocromil inhibit the degranulation of mast ceils and are useful as prophylacticagents in some patients. They are not useful in an acute attack. Systemic corticosteroids are re-served for patients with severe asthma who do not respond adequately to other agents, but in-haled steroids (eg, beclomethasone) are standard prophylactic therapy for all individuals withmoderate or severe recurrent asthma. 18. What drug was administered subcutaneously by the paramedics and later in the emergencyroom? Which agents are suitable for nebulizer use? The drug administered by the paramedics and by the personnel in the emergency room wasepinephrine. This agent is extremely effective and has a rapid onset of action. However, it isprobably no more effective than inhaled -selective agonists (albuterol, metaproterenol, terbu-taline). The drugs used in nebulizers include the 2-selective agonists, epinephrine, and(rarely) isoproterenol. Note that nebulized drug is less efficacious than pressurized aerosols be-cause the latter consist of smaller particles of drug-containing liquid that reach farther downinto the airways.Routine modern therapy of severe exacerbations of asthma includes oxygen in addition tofrequent inhalation of 2-selective bronchodilators and, frequently, systemic corticosteroids.Therapy of status asthmaticus is more complicated, requiring intubation and respiratory assis-tance, sedation, parenteral corticosteroids, and bronchodilators. Captulo 36. Antiinflamatorios 1. The effects of aspirin do not include (A) Reduction of fever (B) Reduction of prostaglandin synthesis in inflamed tissues (C) Impaired autoregulation of kidney function (D) Reduction of bleeding tendency (E) Tinnitus and vertigo

Aspirin clearly increases bleeding tendency (by its antiplatelet effects). The answer is (D). 2. Which one of the following pairs of a drug effect and mechanism of action is false? (A) Allopurinol action in gout: Inhibits oxidation of hypoxanthine (B) Aspirin antiplatelet action: Inhibits cyclooxygenase (C) Hydroxychloroquine antirheumatic action: Interferes with T lymphocyte action (D) Probenecid uricosuric action: Increases secretion of uric acid by the loop of Henle (E) Indomethacin closure of patent ductus arteriosus: Blocks PGE production in the ductusof the newborn Probenecid inhibits the reabsorption of uric acid in the proximal tubule. (Both secretion and re-absorption of weak acids occur in the proximal tubule, not the loop of Henle.) The answer is(D). 3. Which one of the following effects does not occur in salicylate intoxication? (A) Hyperventilation (B) Hypothermia (C) Metabolic acidosis (D) Respiratory alkalosis (E) Tinnitus Salicylate intoxication is associated with hyperthermia, not hypothermia, because the drugcauses uncoupling of oxidative phosphorylation, resulting in increased metabolism. The an-swer is (B). 4. Which one of the following drugs is not useful in dysmenorrhea? (A) Aspirin (B) Colchicine (C) Ibuprofen (D) Rofecoxib (D) Naproxen Primary dysmenorrhea is caused by excessive production of prostaglandin F2. NSAIDs thatinhibit cyclooxygenase are far more effective in relieving symptoms than other analgesics.Colchicine, which is not analgesic and is anti-inflammatory only in gout and Mediterraneanfever, would never be used in this condition. The answer is (B). 5. Which of the following drugs is MOST likely to increase serum concentrations of conven-tional doses of methotrexate, a weak acid that is primarily cleared in the urine? (A) Acetaminophen

(B) Allopurinol (C) Colchicine (D) Hydroxychloroquine (E) Probenecid Methotrexate, a weak acid, depends upon active tubular excretion in the proximal tubule forefficient elimination. Probenecid competes with methotrexate for binding to the proximaltubule transporter and thereby decreases the rate of clearance of methotrexate. The answer is(E). 6. The main advantage of ketorolac over aspirin is that ketorolac (A) Can be combined more safely with an opioid such as codeine (B) Can be obtained as an over-the-counter agent (C) Does not prolong the bleeding time (D) Is available in a parenteral formulation that can be injected intramuscularly or intravenously (E) Is less likely to cause acute renal failure in patients with some preexisting degree of renalimpairment Ketorolac exerts typical NSAID effects. It prolongs the bleeding time and can impair renalfunction, especially in a patient with preexisting renal disease. Ketorolac is not available over-the-counter. Its primary use is as a parenteral agent for pain management, especially for treat-ment of postoperative patients. The answer is (D) Items 7-8: A 52-year-old woman presented with intense pain, warmth, and redness in the first toeon her left foot. Examination of fluid withdrawn from the inflamed joint revealed crystals of uricacid. 7. In the treatment of this woman's acute attack of gout, the advantage of using indomethacin in-stead of colchicine is that indomethacin is (A) Less likely to cause acute renal failure (B) Less likely to cause severe diarrea (C) Less likely to precipitate sudden gastrointestinal bleeding (D) More likely to prevent another acute attack (E) More likely to reduce the symptoms of inflammation Indomethacin and colchicine have equivalent efficacy in the treatment of acute gout. Colchicineis now more likely to be used chronically to prevent other attacks. Indomethacin is more--notless--likely to precipitate sudden gastrointestinal bleeding and acute renal failure. In the doseused to treat acute gout, colchicine frequently causes significant diarrhea. The answer is (B) 8. Over the next 7 months, the patient had two more attacks of acute gout. Her serum concentra-tion of uric acid was elevated. The decision was made to put her on chronic

drug therapy to tryto prevent subsequent attacks. Which of the following drugs could be used to decrease thiswoman's rate of production of uric acid? (A) Allopurinol (B) Aspirin (C) Colchicine (D) Hydroxychloroquine (E) Probenecid Allopurinol is the only drug listed that decreases production of uric acid. Probenecid increasesuric acid excretion. Colchicine and hydroxychloroquine do not affect uric acid metabolism.Aspirin actually slows renal secretion of uric acid and raises uric acid blood levels. It shouldnot be used in gout. The answer is (A). Items 9-10: A 54-year-old woman presented with signs and symptoms consistent with an earlystage of rheumatoid arthritis. The decision was made to initiate NSAID therapy. 9. Which of the following patient characteristics is a possible reason for the use of celecoxib inthe treatment of her arthritis? (A) A history of a severe rash after treatment with a sulfonamide antibiotic (B) A history of gout (C) A history of peptic ulcer disease (D) A history of sudden onset of bronchospasm after treatment with aspirin (El A history of type 2 diabetes Celecoxib is a COX-2-selective inhibitor. Its advantage over nonselective NSAIDs may be re-duced gastrointestinal toxicity. Celecoxib is being used in patients who need NSAIDs but whoalso have a high risk of gastrointestinal toxicity, such as patients with a history of ulcer dis-ease. Celecoxib is a sulfonamide, so it should be avoided in patients with sulfonamide allergy.Like all NSAIDs, it should not be used in patients with hypersensitivity to aspirin. It does notoffer any advantages over other NSAIDs in patients with gout or diabetes. The answer is (C) 10. Although the patient's disease was adequately controlled with an NSAID and methotrexate forsome time, her symptoms began to worsen and radiologic studies of her hands indicated pro-gressive destruction in the joints of several fingers. Treatment with a new second-line agent forrheumatoid arthritis was considered. This drug is available only in a parenteral formulation; itsmechanism of anti-inflammatory action is antagonism of tumor necrosis factor. The drug beingconsidered is (A) Cyclosporine (B) Etanercept (C) Penicillamine (D) Phenylbutazone

(E) Sulfasalazine Etanercept is a recombinant protein that binds to tumor necrosis factor and prevents its inflam-matory effects. The answer is (B).