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Drug Treatment of

Posttest

Instructions: To facilitate later discussion and review, please mark these posttest pages with your answers to the following questions. If your instructor has provided a separate answer form, mark your answers both on that form (being sure to fill in the identification section) and on these pages.

1. A 58-year-old man presents complaining of shortness of breath upon mild exertion. His heart rate is 110 beats/min. In normal sinus rhythm, crackles (rales) are present bilaterally and an S3 gallop is heard. Choose the agent below that will produce balanced vasodilation and improve the clinical status of this patient WITHOUT directly causing a positive inotropic effect.

A. ethacrynic acid B. enalapril (Vasotec®) C. verapamil (Calan®) D. digoxin (Lanoxin®) E. tolvaptan (Samsca®)

2. Identify the agent or combination of agents below that is recommended for use in ambulatory management of chronic HFrEF.

A. tolvaptan (Samsca®) B. bosentan (Tracleer®) C. milrinone (Primocor®) D. nesiritide (Natrecor®) and milrinone (Primacor®) E. hydralazine and isosorbide dinitrate (BiDil®)

3. Identify the agent or agents below that is MOST likely to improve symptoms in a 62-year-old female admitted to the ICU for her third episode of acute decompensated heart failure in the past 8 months.

A. nesiritide (Natrecor®), PO B. chlorthalidone (Thalitone®), PO C. dobutamine (Dobutrex®), PO and milrinone (Primacor®), PO D. (Bumex®), IV infusion and nitroprusside (Nipride®), IV infusion E. digoxin (Lanoxin®), PO and enalapril (VasoTec®) IV infusion

1 Drug Treatment of Heart Failure

4. On follow-up visits after addition of digoxin to enalapril therapy for HF, two patients have digoxin serum levels of 1.8 ng/mL (therapeutic range approximately 0.5 to 1.0 ng/mL). Both patients are also taking . Patient A complains of dyspnea, nausea, yellow halos around objects, and vivid dreams. Patient B complains of difficulty sleeping, swollen feet at the end of the day, and breathlessness while walking from the parking lot to his office. Patient A's heart rate is 55 beats per minute; patient B's is 95. Patient A has lost 5 kg in 2 weeks; patient B has lost 1 kg. How will you alter patient A's therapy?

A. increase the dose of digoxin and hydrochlorothiazide B. determine the serum potassium and stop hydrochlorothiazide C. decrease the dose of digoxin and determine the serum potassium D. switch to and increase the dose of digoxin E. decrease the dose of digoxin and determine the BUN

5. How will you alter patient B's therapy?

A. decrease the dose of digoxin and hydrochlorothiazide B. determine the serum potassium and stop hydrochlorothiazide C. decrease the dose of digoxin and determine the serum potassium D. switch to furosemide and maintain the dose of digoxin E. increase the dose of digoxin and determine the BUN

6. A decision is made to add (Aldactone®) to the existing drug regimen in a 54-year-old male being treated for NYHA Class III HF. The patient returns for follow-up one month later complaining that both breasts are painful and enlarged. As a result, your most appropriate choice is to change the therapy to:

A. (Inspra®). B. (Diamox®). C. furosemide (Lasix®). D. (DDADP®). E. hydrochlorothiazide (Diucardin®).

2 Drug Treatment of Heart Failure

7. Which of the following selections correctly pairs an ACE inhibitor with its primary mechanism of therapeutic action in HF?

A. Lisinopril (Zestril®, Prinivil®) is an ACE inhibitor prodrug, reducing angiotensin II levels, hypertension, and myocardial remodeling. B. Enalapril (Vasotec®) is an ACE inhibitor prodrug, reducing angiotensin II levels, hypertension, and myocardial remodeling. C. Bisoprolol (Zebeta®) is an ACE inhibitor prodrug, reducing angiotensin II levels, hypertension, and myocardial remodeling. D. Bumetanide (Bumex®) acts directly to inhibit ACE from converting angiotensin I to angiotensin II thereby preventing angiotensin II’s action to cause hypertension and myocardial remodeling. E. Isosorbide mononitrate (Imdur®) is a prodrug that must be enzymatically degraded before it can exert beneficial actions to increase myocardial preload in heart failure.

8. A 40-year-old man presents with mild nocturnal dyspnea. Echocardiography detects a left ventricular ejection fraction of 35% and an ECG shows normal sinus rhythm. No history of hypertension is found in his medical record. No crackles (rales) can be noted on auscultation and his body weight has not changed in the past year. With which of the following orally effective agents should you choose to initiate treatment in this individual?

A. furosemide (Lasix®) B. hydrochlorothiazide (Hydrodiuril®) C. digoxin (Lanoxin®) D. dobutamine (Dobutrex®) E. lisinopril (Prinivil®)

3 Drug Treatment of Heart Failure

9. The curves below were based on data from three patients: one normal, another with untreated HF, and a third with HF treated with a positive inotropic agent.

Which curve is characteristic of which type of patient?

Normal HF HF plus positive inotrope

A. X Y Z

B. Z Y X

C. Y X Z

D. Z X Y

E. Y Z X

10. A 50-year-old woman presents in the ED. She is anxious and acutely dyspneic with 3+ pitting edema above her knees. Her arms are cool to the touch above her elbows and nail beds are cyanotic. Neck veins are visibly distended to the level of her mandible at a 30 degree incline. You detect bilateral crackles (rales) and a prominent S3 gallop on auscultation and note that her serum creatinine has doubled since her last clinic visit for chronic heart failure management one week ago. Her cardiac shadow on chest X-ray extends to 80% of the chest width. Your initial diagnosis should be:

A. Stage 1 essential hypertension. B. Stage A ACC/AHA chronic heart failure. C. Acute decompensated heart failure. D. Class I NYHA systolic heart failure. E. Class II NYHA systolic heart failure.

When you have finished the posttest, see the document with the correct answers or follow your instructor's directions. 4