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Practice Exam One

TJ is a 64-year-old man with long-standing hypertension. He has recently been diagnosed with chronic kidney disease and his estimated glomerular filtration rate (GFR) is 24 mL/min. He is currently taking ramipril 10 mg daily. His blood pressure is 148/86 mm Hg, HR is 58 beats/min, and electrolytes notable for a potassium of 5.1 mEq/L. Upon physical exam the patient is noted to have slight peripheral edema however ECHO was without evidence of systolic heart failure (ejection fraction estimated at 60%) however noted left ventricular dysfunction. Which of the following would be the most appropriate recommendation at this time?

A. Continue current therapy and monitor BP regularly.

B. Add HCTZ 12.5 mg daily.

C. Add furosemide 20 mg daily.

D. Start verapamil ER to 360 mg daily.

E. Add spironolactone 25 mg daily.

Feedback:

Answer C is correct.

Loop diuretics such as furosemide may be used in hypertensive patients with reduced CrCl. Loop diuretics are filtered and secreted, so when a patient loses kidney filtration ability (CrCl <30 mL/min), the loop diuretics may still be effective (thiazide diuretics would most likely not be effective in this setting because they are only filtered). The patient is also noted to have peripheral edema and due to the great excretion of Na/H20 by this agent it would be better than a thiazide or potassium-sparing diuretic.

Answer A is incorrect.

The patient's blood pressure is not at goal and requires intervention.

Answer B is incorrect.

HCTZ is unlikely to be effective because the patient has kidney dysfunction (CrCl <30 mL/min) and it has minimal water excretion effects due to it side of action.

Answer D is incorrect.

TJ does not have any compelling indication to start a NDHP CCB and with the possibility of LVD the negative chronotropic effects could be detrimental and increase risk for HF diagnosis.

Answer E is incorrect.

Spironolactone use in the setting of renal dysfunction would increase the risk of hyperkalemia. The patient's potassium level is already on the high end of the normal range.

RH is a 47-year-old white woman who has been seen by her family physician twice in the last 2 weeks, and her BP (measured properly) was similar at both visits, averaging 138/88 mm Hg. RH has no significant medical history or risk factors for cardiovascular disease; she is relatively active and likes to exercise. Which of the following would be the most appropriate recommendation for RH?

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