A 58-year-old woman with type 2 diabetes has BP 150/94 mmHg and urine albumin-creatinine ratio 260 mg/g; serum creatinine and potassium are normal. Ramipril is started. Its kidney-protective effect comes mainly from which action?

Efferent arteriolar dilatation lowering glomerular pressure

Increased sodium reabsorption in the distal tubule

Afferent arteriolar dilatation raising filtration

Direct blockade of glucose entry into podocytes

A 79-year-old woman was started on hydrochlorothiazide 25 mg daily for hypertension by her family doctor in Thrissur. Ten days later her daughter brings her because she is drowsy and confused. Serum sodium is 118 mmol/L, potassium 3.1 mmol/L, and she is clinically euvolaemic. What is the most likely cause?

Syndrome of inappropriate ADH from a lung tumour

Antihypertensives, heart failure and antianginal drugs

29 NEET-PG practice questions on Antihypertensives, heart failure and antianginal drugs, part of Pharmacology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 58-year-old woman with type 2 diabetes has BP 150/94 mmHg and urine albumin-creatinine ratio 260 mg/g; serum creatinine and potassium are normal. Ramipril is started. Its kidney-protective effect comes mainly from which action?
1. AIncreased sodium reabsorption in the distal tubule
2. BAfferent arteriolar dilatation raising filtration
3. CDirect blockade of glucose entry into podocytes
4. DEfferent arteriolar dilatation lowering glomerular pressure
Show answerHide answer
Answer: D · Efferent arteriolar dilatation lowering glomerular pressure
Angiotensin II constricts the efferent arteriole more than the afferent, keeping glomerular capillary pressure high. ACE inhibitors and ARBs remove this effect, so intraglomerular pressure and albuminuria fall, slowing progression of diabetic kidney disease. That is why they are preferred in hypertension with albuminuria. Creatinine may rise by up to about 30% after starting, which is expected; check potassium and creatinine in 1-2 weeks.
- A: Lower aldosterone reduces, not increases, distal sodium reabsorption.
- B: Calcium channel blockers dilate the afferent arteriole, which can raise glomerular pressure.
- C: ACE inhibitors have no direct effect on glucose entry into podocytes.
Question 2 · Medium
A 79-year-old woman was started on hydrochlorothiazide 25 mg daily for hypertension by her family doctor in Thrissur. Ten days later her daughter brings her because she is drowsy and confused. Serum sodium is 118 mmol/L, potassium 3.1 mmol/L, and she is clinically euvolaemic. What is the most likely cause?
1. AThiazide-induced hyponatraemia
2. BSyndrome of inappropriate ADH from a lung tumour
3. CPrimary adrenal insufficiency
4. DHypothyroidism
Show answerHide answer
Answer: A · Thiazide-induced hyponatraemia
Thiazides block NaCl reabsorption in the distal convoluted tubule, which is in the diluting segment, so they impair the kidney's ability to excrete free water; loop diuretics act on the concentrating mechanism as well and cause hyponatraemia less often. Elderly women of low body weight are at greatest risk, usually within the first few weeks. The low potassium supports a thiazide cause. The drug is stopped and sodium corrected slowly to avoid osmotic demyelination.
- B: SIADH from a tumour is possible but the timing after starting a thiazide, with low potassium, points to the drug.
- C: Adrenal insufficiency usually causes hyperkalaemia, not hypokalaemia.
- D: Hypothyroidism rarely causes sodium this low and does not fit the timing.
Question 3 · Easy
A 62-year-old man with heart failure with reduced ejection fraction (EF 30%) takes enalapril 10 mg twice daily. His cardiologist in Pune decides to change it to sacubitril-valsartan. What is the minimum gap needed between the last dose of enalapril and the first dose of the new drug?
1. A7 days
2. B6 hours
3. CNo gap is needed
4. D36 hours
Show answerHide answer
Answer: D · 36 hours
Neprilysin and ACE both break down bradykinin, so taking an ACE inhibitor together with sacubitril greatly raises the risk of angioedema. The ACE inhibitor must therefore be stopped at least 36 hours before the first dose of sacubitril-valsartan. No such gap is needed when switching from an ARB. A history of angioedema with an ACE inhibitor is a contraindication to the combination.
- A: A week is longer than needed and leaves the patient without RAAS blockade.
- B: Six hours does not allow enalaprilat to be cleared, so bradykinin breakdown is still blocked.
- C: Starting at once overlaps ACE and neprilysin inhibition, the setting for angioedema.
Question 4 · Medium
A 42-year-old woman with asthma since childhood was started on propranolol for hypertension at a private clinic. Within a week she has needed her salbutamol inhaler several times a day and was nebulised in casualty. Her BP is 152/94 mmHg. Which antihypertensive is the best replacement?
1. ACarvedilol
2. BLabetalol
3. CAmlodipine
4. DAtenolol
Show answerHide answer
Answer: C · Amlodipine
Non-selective beta-blockers block beta-2 receptors on bronchial smooth muscle and can cause severe bronchospasm, and they blunt the response to salbutamol. In a patient with asthma, beta-blockers are best avoided altogether when there is no compelling indication. Amlodipine is effective, has no airway effects and may even relax bronchial smooth muscle slightly. Even cardioselective agents such as atenolol lose selectivity at higher doses.
- A: Carvedilol is non-selective for beta receptors and can worsen asthma.
- B: Labetalol blocks beta-2 receptors as well as alpha-1.
- D: Atenolol is beta-1 selective but can still provoke bronchospasm, so it is not first choice.
Question 5 · Hard
A 32-year-old man has episodes of headache, palpitations and sweating with BP up to 220/130 mmHg. A local doctor started propranolol, after which his next episode was worse, with BP 250/140 mmHg. Plasma free metanephrines are four times the upper limit, and CT shows a 4 cm right adrenal mass. Which drug should have been started first, before any beta-blocker?
1. AClonidine
2. BPhenoxybenzamine
3. CAtenolol
4. DHydrochlorothiazide
Show answerHide answer
Answer: B · Phenoxybenzamine
This is a phaeochromocytoma. Adrenaline acting on vascular beta-2 receptors causes some vasodilation, and blocking these with propranolol leaves alpha-1 vasoconstriction unopposed, so BP rises further. Alpha blockade is started first, classically with phenoxybenzamine, an irreversible non-competitive alpha blocker, given for 10-14 days before surgery with a high-salt diet and fluids to expand the contracted blood volume. A beta-blocker is added only after adequate alpha blockade, to control tachycardia.
- A: Clonidine reduces central sympathetic outflow but cannot block the tumour's catecholamines.
- C: Atenolol is still a beta-blocker and must not be started before alpha blockade.
- D: A diuretic worsens the volume contraction typical of phaeochromocytoma.
Question 6 · Medium
A 67-year-old retired bank clerk has BP 158/96 mmHg on repeated visits. He also complains of a weak stream, hesitancy and getting up three times at night to pass urine; his prostate is smoothly enlarged on rectal examination. Which drug can help both problems?
1. ATamsulosin
2. BFinasteride
3. CAmlodipine
4. DTerazosin
Answer and explanation in LearnFree account
Question 7 · Medium
A 74-year-old woman with heart failure and atrial fibrillation takes digoxin 0.125 mg daily. Her furosemide dose was doubled a week ago for leg swelling. She now has nausea, vomiting, and sees yellow halos around lights. Serum potassium is 2.9 mmol/L and the digoxin level is in the upper therapeutic range. Why did toxicity appear at this level?
1. AFurosemide inhibits the renal secretion of digoxin
2. BLow potassium raises the plasma digoxin concentration
3. CLow potassium increases digoxin binding to Na-K-ATPase
4. DFurosemide displaces digoxin from plasma albumin
Answer and explanation in LearnFree account
Question 8 · Medium
A 64-year-old man with HFrEF has taken spironolactone 25 mg daily for a year along with ramipril and bisoprolol. He now complains of painful enlargement of both breasts. Potassium is 4.8 mmol/L and creatinine 1.1 mg/dL. What is the best change to his treatment?
1. AReplace spironolactone with eplerenone
2. BStop all mineralocorticoid antagonist therapy
3. CReplace spironolactone with furosemide
4. DAdd tamoxifen and continue spironolactone
Answer and explanation in LearnFree account
Question 9 · Medium
A 56-year-old woman with type 2 diabetes and HFrEF is started on empagliflozin. At her review the endocrinology resident lists four statements: 1. It reduces heart failure hospitalisation even in people without diabetes. 2. It commonly causes hyperkalaemia, so potassium must be checked weekly. 3. Genital fungal infections are among its commonest adverse effects. 4. It can cause ketoacidosis with near-normal blood glucose. Which statements are correct?
1. A1, 3 and 4 only
2. B1 and 2 only
3. C1, 2 and 4 only
4. D2 and 4 only
Answer and explanation in LearnFree account
Question 10 · Medium
A 60-year-old man in the heart failure clinic of a Mumbai hospital is being switched to sacubitril-valsartan. The resident is asked to check four statements about the drug: 1. Sacubitril is a prodrug whose active metabolite inhibits neprilysin. 2. It must not be started within 36 hours of the last dose of an ACE inhibitor. 3. Because it raises natriuretic peptides, NT-proBNP can no longer be used to follow his heart failure. 4. A past episode of angioedema on an ACE inhibitor is a contraindication. Which statements are correct?
1. A2 and 4 only
2. B3 and 4 only
3. C1, 2 and 4 only
4. D1 and 4 only
Answer and explanation in LearnFree account
Question 11 · Medium
A 59-year-old woman from Kozhikode was started on amlodipine 10 mg daily for hypertension. Six weeks later she has swelling of both ankles that is worse in the evening. JVP is normal, there are no basal crackles, and urine protein and serum albumin are normal. What is the mechanism of her ankle swelling?
1. AFall in plasma oncotic pressure
2. BIncreased capillary permeability from histamine release
3. CPrecapillary arteriolar dilatation raising capillary pressure
4. DSodium and water retention by the kidney
Answer and explanation in LearnFree account
Question 12 · Medium
A 27-year-old woman with chronic hypertension has taken methyldopa throughout her pregnancy. At 34 weeks she is pale and tired; Hb is 8.1 g/dL, reticulocytes 9%, indirect bilirubin is raised and the direct antiglobulin (Coombs) test is positive with anti-IgG. What is the most likely cause of her anaemia?
1. AHELLP syndrome
2. BAutoimmune haemolysis induced by methyldopa
3. CHaemolysis from G6PD deficiency
4. DIron deficiency anaemia of pregnancy
Answer and explanation in LearnFree account
Question 13 · Medium
A 52-year-old man with recurrent gouty attacks of the big toe has BP 150/96 mmHg. His serum uric acid is 9.2 mg/dL. Which antihypertensive also lowers his serum uric acid?
1. AHydrochlorothiazide
2. BMetoprolol
3. CLosartan
4. DFurosemide
Answer and explanation in LearnFree account
Question 14 · Medium
A retired 71-year-old tailor from Varanasi, obese and hypertensive for 20 years, was discharged last month after his second admission for pulmonary oedema. His echo shows a thick-walled LV with an ejection fraction of 58% and impaired relaxation; NT-proBNP is high. He is now dry on oral furosemide. Which drug has been shown to reduce his risk of further heart failure hospitalisation?
1. AIvabradine
2. BDiltiazem
3. CEmpagliflozin
4. DDigoxin
Answer and explanation in LearnFree account
Question 15 · Medium
A 63-year-old man has chronic stable angina despite maximal doses of metoprolol and a long-acting nitrate; his BP is 104/66 mmHg and pulse 56/min, so the doses cannot be increased. His cardiologist adds ranolazine, which does not lower BP or heart rate. How does ranolazine relieve angina?
1. AInhibits the late inward sodium current in myocytes
2. BBlocks L-type calcium channels in arterioles
3. COpens ATP-sensitive potassium channels
4. DSelectively blocks the If current in the SA node
Answer and explanation in LearnFree account
Question 16 · Easy
A 58-year-old man with stable angina who keeps sublingual glyceryl trinitrate tablets for chest pain asks the cardiology OPD doctor for a prescription of sildenafil for erectile dysfunction. Why must the two drugs not be combined?
1. AAdditive cGMP rise causing severe hypotension
2. BBoth drugs prolong the QT interval
3. CSildenafil blocks the conversion of nitrate to nitric oxide
4. DNitrates induce the enzyme that breaks down sildenafil
Answer and explanation in LearnFree account
Question 17 · Easy
A 60-year-old man with stable angina takes isosorbide mononitrate 20 mg at 8 am, 2 pm and 10 pm. Over three months his angina, which first improved, has returned at the same level of effort. He takes the tablets regularly. What is the most likely explanation?
1. ANitrate tolerance from continuous exposure
2. BPoor absorption of the oral nitrate
3. CProgression to unstable angina
4. DRebound vasospasm between doses
Answer and explanation in LearnFree account
Question 18 · Hard
A 76-year-old man has had chest pain on walking and two episodes of fainting on climbing stairs. He has a slow-rising pulse and a harsh ejection systolic murmur radiating to the carotids. In the OPD he is given sublingual glyceryl trinitrate for chest pain and collapses; BP falls from 128/76 to 70/40 mmHg. What explains his collapse?
1. ACoronary steal from dilated collateral arteries
2. BMethaemoglobinaemia caused by the nitrate
3. CFall in preload with a fixed outflow obstruction
4. DReflex bradycardia from nitrate-induced vagal stimulation
Answer and explanation in LearnFree account
Question 19 · Medium
A 72-year-old man takes atenolol 50 mg daily for hypertension. For worsening angina, a doctor adds verapamil 80 mg three times a day. Three days later he is brought to casualty with dizziness; pulse is 36/min and BP 88/56 mmHg. ECG shows complete heart block. Why did this happen?
1. AAdditive depression of SA and AV nodal conduction
2. BReflex sympathetic activation by verapamil
3. CAtenolol blocks the metabolism of verapamil
4. DVerapamil raises the plasma level of atenolol
Answer and explanation in LearnFree account
Question 20 · Medium
A 66-year-old man with chronic stable angina has taken nicorandil 10 mg twice daily for two years. He now has several deep, painful ulcers on the tongue and inside the cheeks that have not healed with mouthwash for six weeks. A biopsy shows non-specific ulceration with no malignancy. What is the best next step?
1. AStart oral acyclovir
2. BStop nicorandil and substitute another antianginal
3. CStart topical triamcinolone and continue nicorandil
4. DRefer for wide surgical excision
Answer and explanation in LearnFree account
Question 21 · Hard
A 52-year-old man with acute type B aortic dissection has been in the ICU of a Chennai hospital on IV sodium nitroprusside at a high rate for 72 hours, with esmolol. He becomes confused and agitated. ABG: pH 7.21, HCO3 12 mmol/L, PaCO2 30 mmHg, lactate 8.5 mmol/L; central venous oxygen saturation is unusually high. SpO2 is 99% and BP 118/70 mmHg. Which treatment should be given along with stopping nitroprusside?
1. AIV sodium bicarbonate alone
2. BHydroxocobalamin
3. CMethylene blue
4. DFresh frozen plasma
Answer and explanation in LearnFree account
Question 22 · Hard
A 76-year-old woman with HFrEF has been stable for a year on ramipril 5 mg, spironolactone 25 mg, bisoprolol and furosemide; her potassium has stayed 4.6-4.9 mmol/L. A doctor prescribes cotrimoxazole double-strength for a urinary infection. Five days later she is weak, and serum potassium is 6.9 mmol/L with creatinine unchanged at 1.2 mg/dL. Which mechanism best explains the new hyperkalaemia?
1. ATrimethoprim inhibiting the metabolism of spironolactone
2. BTrimethoprim blocking ENaC in the collecting duct
3. CHaemolysis releasing potassium from red cells
4. DSulfamethoxazole causing acute interstitial nephritis
Answer and explanation in LearnFree account
Question 23 · Easy
A 54-year-old schoolteacher from Madurai was started on lisinopril for hypertension two months ago. Her BP is now 128/82 mmHg, but she has a persistent dry, tickly cough that disturbs her classes. Her chest X-ray is normal and she does not smoke. What is the best change to her treatment?
1. AReplace lisinopril with losartan
2. BReplace lisinopril with enalapril
3. CAdd an inhaled corticosteroid
4. DAdd codeine linctus at night
Answer and explanation in LearnFree account
Question 24 · Medium
A 61-year-old man has had hypertension controlled on atenolol 50 mg daily for 8 years. After an anterior wall MI, echo shows an ejection fraction of 30%. He is now euvolaemic. Which change to his beta-blocker is recommended?
1. AChange atenolol to bisoprolol
2. BChange atenolol to labetalol
3. CIncrease the atenolol dose
4. DChange atenolol to propranolol
Answer and explanation in LearnFree account
Question 25 · Medium
A 58-year-old man without diabetes has heart failure with reduced ejection fraction (EF 32%). His cardiologist adds dapagliflozin to sacubitril-valsartan, bisoprolol and spironolactone. Where in the nephron does dapagliflozin act?
1. AEarly proximal convoluted tubule
2. BThick ascending limb of the loop of Henle
3. CEarly distal convoluted tubule
4. DCortical collecting duct
Answer and explanation in LearnFree account

4 more Antihypertensives, heart failure and antianginal drugs questions

Answer them one by one, keep your score and see your weak topics in Learn. Signed-out visitors try 25 per exam; sign in with Google to see them all.

Study Pharmacology

Antihypertensives, heart failure and antianginal drugs

A 58-year-old woman with type 2 diabetes has BP 150/94 mmHg and urine albumin-creatinine ratio 260 mg/g; serum creatinine and potassium are normal. Ramipril is started. Its kidney-protective effect comes mainly from which action?

A 62-year-old man with heart failure with reduced ejection fraction (EF 30%) takes enalapril 10 mg twice daily. His cardiologist in Pune decides to change it to sacubitril-valsartan. What is the minimum gap needed between the last dose of enalapril and the first dose of the new drug?

A 42-year-old woman with asthma since childhood was started on propranolol for hypertension at a private clinic. Within a week she has needed her salbutamol inhaler several times a day and was nebulised in casualty. Her BP is 152/94 mmHg. Which antihypertensive is the best replacement?

A 67-year-old retired bank clerk has BP 158/96 mmHg on repeated visits. He also complains of a weak stream, hesitancy and getting up three times at night to pass urine; his prostate is smoothly enlarged on rectal examination. Which drug can help both problems?

A 64-year-old man with HFrEF has taken spironolactone 25 mg daily for a year along with ramipril and bisoprolol. He now complains of painful enlargement of both breasts. Potassium is 4.8 mmol/L and creatinine 1.1 mg/dL. What is the best change to his treatment?

A 52-year-old man with recurrent gouty attacks of the big toe has BP 150/96 mmHg. His serum uric acid is 9.2 mg/dL. Which antihypertensive also lowers his serum uric acid?

A 63-year-old man has chronic stable angina despite maximal doses of metoprolol and a long-acting nitrate; his BP is 104/66 mmHg and pulse 56/min, so the doses cannot be increased. His cardiologist adds ranolazine, which does not lower BP or heart rate. How does ranolazine relieve angina?

A 58-year-old man with stable angina who keeps sublingual glyceryl trinitrate tablets for chest pain asks the cardiology OPD doctor for a prescription of sildenafil for erectile dysfunction. Why must the two drugs not be combined?

A 60-year-old man with stable angina takes isosorbide mononitrate 20 mg at 8 am, 2 pm and 10 pm. Over three months his angina, which first improved, has returned at the same level of effort. He takes the tablets regularly. What is the most likely explanation?

A 72-year-old man takes atenolol 50 mg daily for hypertension. For worsening angina, a doctor adds verapamil 80 mg three times a day. Three days later he is brought to casualty with dizziness; pulse is 36/min and BP 88/56 mmHg. ECG shows complete heart block. Why did this happen?

A 54-year-old schoolteacher from Madurai was started on lisinopril for hypertension two months ago. Her BP is now 128/82 mmHg, but she has a persistent dry, tickly cough that disturbs her classes. Her chest X-ray is normal and she does not smoke. What is the best change to her treatment?

A 61-year-old man has had hypertension controlled on atenolol 50 mg daily for 8 years. After an anterior wall MI, echo shows an ejection fraction of 30%. He is now euvolaemic. Which change to his beta-blocker is recommended?

A 58-year-old man without diabetes has heart failure with reduced ejection fraction (EF 32%). His cardiologist adds dapagliflozin to sacubitril-valsartan, bisoprolol and spironolactone. Where in the nephron does dapagliflozin act?