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A 45-year-old woman has had worsening shortness of breath for 3

years. She now has to sleep sitting up on two pillows. She has had
difficulty swallowing for the past year. She has no history of chest
pain. A month ago, she had a 'stroke' with resultant inability to move
her left arm. She is afebrile. A chest radiograph reveals a nearnormal left ventricular size with a prominent left atrial border. Which
of the following conditions is most likely to account for her findings?
A Essential hypertension
B Cardiomyopathy
C Mitral valve stenosis
D Aortic coarctation
E Patent foramen ovale

A 63-year-old woman has the sudden onset of 'knife-like' pain in the

chest radiating to the back. She has been previously healthy except
for a history of poorly controlled hypertension. She is transported to
the hospital and on arrival she has a heart rate of 90/minute,
respirations 20/minute, temperature 36.8C, and blood pressure
150/100 mm Hg. No murmurs, rubs, or gallops are audible. A chest
radiograph reveals a widened mediastinum. Laboratory findings
include a total serum creatine kinase of 55 U/L, creatinine 0.9 mg/dL,
and glucose 123 mg/dL. Which of the following is the most likely
A Fibrinous pericarditis
B Aortic dissection
C Infective endocarditis
D Dilated cardiomyopathy
E Myocardial infarction
A 45-year-old man was rushed to the hospital following the sudden
onset of an episode of crushing substernal chest pain. He receives
advanced life support measures. An EKG shows changes consistent
with a large transmural anterolateral area of infarction involving wall

of the left ventricle. He develops cardiogenic shock. Which of the

following microscopic findings is most likely to be present in this area
4 days following the onset of his chest pain?
A Fibroblasts and collagen deposition
B Capillary proliferation and macrophages
C Myofiber necrosis with neutrophils
D Granulomatous inflammation
E Perivascular lymphocytic infiltrates

Case #1.
You are seeing a 60-year-old man for the first
time. He has untreated hypertension (168/106
mm Hg and blood pressure has been elevated
on at least 3 occasions). There is currently no
evidence of target organ dysfunction (heart,
neurological, or eyegrounds).
From a therapeutic perspective, what is the best initial approach?
A. Initiate treatment with 25 mg of hydrochlorothiazide.
B. Consider initiating treatment with a 2-agent combination pill.
C. Delay pharmacologic intervention and treat with salt restriction.
ANSWER: B. Consider initiating treatment with a 2-agent combination pill.
The patient qualifies for a diagnosis of stage 2 hypertension (blood pressure
>160/>100 mm Hg). A single agent will not suffice to lower the patients blood
pressure to target level. Many studies have also demonstrated
that combination therapy reduces the risk of cardiac events, is more

efficacious, and improves adherence, blood pressure control, and time-to2

target blood pressure. Combination therapy with appropriately chosen agents


(such as amlodipine and an angiotensin receptor blocker [ARB]) augments

effects of either agent taken alone. The days of maxing out monotherapy
before initiating combinations are over!

Case #2.
You evaluate a woman with chronic
hypertension whose blood pressure remains
above target despite a daily regimen of
benazepril 20 mg, chlorthalidone 25 mg, and
amlodipine 10 mg.
Your next step should be:
A. Add an agent from another class, such as hydralazine or clonidine.
B. Characterize the patient as having resistant hypertension and initiate
therapy with 25 mg of spironolactone (potassium levels permitting).
C. Add an ARB.
D. Switch from amlodipine to verapamil.
ANSWER: B. Characterize the patient as having resistant hypertension and
initiate therapy with 25 mg of spironolactone (potassium levels permitting).
Resistant hypertension is defined as blood pressure not controlled on a
complimentary 3-drug regimen with a diuretic as one of the agents.
Spironolactone has become a go-to agent for treating resistant
hypertension. If it works, it may allow the patient to discontinue other

antihypertensive agents. It is a pharmaceutical backbone for resistant

hypertension treatment.

Case #3.
You see a patient whose previous physician
has retired. The patients blood pressure is not
controlled on a regimen of hydralazine 20 mg
three times a day, atenolol 50 mg daily, and
12.5 mg of hydrochlorothiazide daily. The
patient has stage 3 chronic kidney disease
(GFR 38 mL/min).
You should (choose all that apply):
A. Switch the diuretic to chlorthalidone.
B. Consider other medications in lieu of hydralazine and atenolol.
C. Add clonidine
D. Increase hydrochlorothiazide to 25 mg.

ANSWERS: A. and B. Switch the diuretic to chlorthalidone and consider

other medications in lieu of hydralazine and atenolol.