BCACP Cardiovascular Disease Management 5 — Questions and Answers
Question 1: A patient with hypertension and gout is currently on hydrochlorothiazide 25 mg daily. His uric acid is 9.8 mg/dL and he just had a gout flare. What antihypertensive change is most appropriate?
- Switch to losartan, which has uricosuric properties (Correct answer)
- Switch to amlodipine with no uricosuric benefit but lower gout risk than HCTZ
- Add allopurinol while continuing HCTZ
- Switch to furosemide, which has less uricosuria than HCTZ
Correct answer: Switch to losartan, which has uricosuric properties
Losartan is the preferred ARB in hypertensive patients with gout because it has modest uricosuric properties that can lower serum uric acid, unlike other antihypertensives.
Question 2: A patient is initiated on colchicine 0.5 mg BID for recurrent pericarditis and is also taking atorvastatin and clarithromycin for a respiratory infection. What is the primary concern?
- Clarithromycin inhibits CYP3A4 and P-gp, increasing colchicine toxicity risk (Correct answer)
- Atorvastatin increases colchicine clearance, reducing efficacy
- Clarithromycin reduces colchicine absorption
- No significant interaction between these agents exists
Correct answer: Clarithromycin inhibits CYP3A4 and P-gp, increasing colchicine toxicity risk
Clarithromycin is a potent CYP3A4 and P-glycoprotein inhibitor that dramatically increases colchicine plasma levels, potentially causing life-threatening colchicine toxicity including bone marrow suppression.
Question 3: A patient with resistant hypertension (BP 158/96 mmHg on maximally tolerated doses of ACE inhibitor, calcium channel blocker, and thiazide diuretic) is being evaluated. What is the most appropriate add-on agent?
- Spironolactone (Correct answer)
- Amlodipine (already on CCB, would add another of same class)
- Clonidine
- Doxazosin
Correct answer: Spironolactone
Spironolactone is the preferred 4th-line agent for resistant hypertension, as mineralocorticoid excess is common in this population and spironolactone has demonstrated superior BP reduction over other add-on agents in trials like PATHWAY-2.
Question 4: A patient with HFpEF (EF 60%) presents with volume overload. Which pharmacologic intervention has the most robust evidence for reducing hospitalizations specifically in HFpEF?
- SGLT2 inhibitors (empagliflozin or dapagliflozin) (Correct answer)
- ACE inhibitors
- Beta-blockers
- Aldosterone antagonists
Correct answer: SGLT2 inhibitors (empagliflozin or dapagliflozin)
SGLT2 inhibitors (empagliflozin in EMPEROR-Preserved, dapagliflozin in DELIVER) have demonstrated statistically significant reductions in heart failure hospitalizations in HFpEF, unlike ACE inhibitors and beta-blockers which lack this evidence.
Question 5: A 58-year-old post-MI patient on aspirin 81 mg and clopidogrel asks about taking ibuprofen for arthritis pain. What is the pharmacist's primary concern?
- Ibuprofen competitively inhibits the COX-1 binding site, blocking aspirin's irreversible antiplatelet effect (Correct answer)
- Ibuprofen increases the risk of bleeding when combined with clopidogrel only
- Ibuprofen reduces clopidogrel absorption from the GI tract
- No interaction exists; only GI bleeding risk from combined use
Correct answer: Ibuprofen competitively inhibits the COX-1 binding site, blocking aspirin's irreversible antiplatelet effect
Ibuprofen (and other NSAIDs) reversibly occupy the COX-1 active site, sterically blocking aspirin's irreversible acetylation, thereby attenuating aspirin's antiplatelet efficacy if taken before aspirin.
Question 6: A patient is newly prescribed digoxin for rate control in atrial fibrillation with HFrEF. Which serum digoxin level range is associated with optimal outcomes in HFrEF patients?
- 0.5–0.9 ng/mL (Correct answer)
- 1.0–2.0 ng/mL
- 2.0–3.0 ng/mL
- Any level below 2.0 ng/mL is acceptable
Correct answer: 0.5–0.9 ng/mL
Post-hoc analyses of the DIG trial showed that digoxin levels of 0.5–0.9 ng/mL are associated with reduced hospitalizations and mortality in HFrEF, while higher levels increase mortality risk.
Question 7: A pharmacist counsels a patient starting sacubitril/valsartan who was previously on an ACE inhibitor. What is the mandatory washout period between stopping the ACE inhibitor and starting sacubitril/valsartan?
- 36 hours (Correct answer)
- 24 hours
- 48 hours
- 72 hours
Correct answer: 36 hours
A minimum 36-hour washout after the last ACE inhibitor dose is required before starting sacubitril/valsartan to prevent life-threatening angioedema from neprilysin-ACE inhibitor-mediated bradykinin accumulation.
BCACP Cardiovascular Disease Management 5
A patient with hypertension and gout is currently on hydrochlorothiazide 25 mg daily.
His uric acid is 9.8 mg/dL and he just had a gout flare.
What antihypertensive change is most appropriate?