CLINICAL THERAPEUTICS 2: CARDIOVASCULAR AND RENAL DISEASE (PHAB3FLY)

Transcription

1 UNIVERSITY OF EAST ANGLIA School of Pharmacy Main Series UG Examination CLINICAL THERAPEUTICS 2: CARDIOVASCULAR AND RENAL DISEASE PHAB3FLY Time allowed: 2 hours Part ONE Answer ALL questions. For each question, there is ONE correct answer. Use the answer grid provided for ALL your answers. Part TWO Answer THREE of the FOUR questions. Use a SEPARATE answer book for EACH question in Part TWO. Each question has the same value. The marks distribution is shown as a percentage for each section of each question. Answer all parts of each of the individual questions you select. The mark allocation for the paper is: Part ONE carries 40% of the total mark. Part TWO carries 60% of the total mark. You are advised to spend approximately 50 minutes on Part ONE and 70 minutes on Part TWO. The paper consists of 12 pages in total. The following is provided: Multiple choice answer grid. Notes are not permitted in this examination. Do not take this question paper out of the examinations room. Do not turn over until you are told to do so by the Invigilator. (PHAB3FLY) Module contact: Catherine Heywood, PHA Copyright of the University of East Anglia Version 2

2 2 PART ONE SECTION A TYPE 1 MCQ Answer ALL questions. For each question, there is ONE correct answer. Use the answer grid provided for ALL your answers. 1. In the heart which ONE of the following carries out the fastest rate of autorhythmicity? AV bundle AV node Bundle of His Purkinje fibres SA node 2. Which ONE of the following valves prevents regurgitation of blood from the right ventricle to the right atrium? Aortic Mitral Pulmonary Semi-lunar Tricuspid 3. Which ONE of the following is NOT a therapeutic or toxic monitoring parameter for the use of clopidogrel in the secondary prevention of myocardial infarction? Signs of bleeding Reduction in cardiovascular events Pulse Haemoglobin Symptoms of gastric irritation 4. Which ONE of the following is NOT affected by angiotensin-converting enzyme (ACE) inhibitors? Bradykinin degradation Cardiac contractility Stimulation of the sympathetic nervous system Aldosterone secretion Cardiac load

3 3 5. Which ONE of the following is NOT a cause of secondary hypertension? Pregnancy Pseudoephedrine Renal disease Spironolactone Combined oral contraceptive pill 6. According to the NICE guidelines 2011, which ONE of the following thresholds is classified as Stage 2 Hypertension? >160/100 mmhg >120/80 mmhg >180/110 mmhg >130/80 mmhg >140/90 mmhg 7. Which ONE of the following antihypertensive agents would be first-line in a 70 year old patient with hypertension and Type 2 Diabetes Mellitus? Bendroflumethiazide Atenolol Amlodipine Losartan Perindopril 8. Which ONE of the following is NOT a type of dyslipdaemia? Raised total cholesterol levels Raised total cholesterol:hdl ratio Raised HDL levels Raised triglyceride levels Raised LDL levels 9. Which ONE of the following is known to cause abnormal lipid levels? Bendroflumethiazide Ranitidine Amiloride Salbutamol Ibuprofen TURN OVER

4 4 10. Which ONE of the following best describes the mechanism by which aliskiren exerts its action? Covalent bonding to cysteine 14 and ionic bonding with aspartic acid 215 Ionic bonding to zinc and hydrogen bonding to tyrosine 14 Ionic bonding to zinc and ionic bonding with aspartic acid 215 Hydrogen bonding to tyrosine 14 and ionic bonding with aspartic acid 215 Hydrogen bonding to tyrosine 14 and covalent bonding to cysteine Which ONE of the following is the CORRECT rationale for not using celecoxib in a patient with a history of non-st elevated myocardial infarction (NSTEMI)? Patients with an NSTEMI are at an increased risk of developing renal failure associated with NSAIDs Celecoxib increases the risk of gastrointestinal bleeding in patients with NSTEMI compared to diclofenac All selective COX-II inhibitors increase the risk of cardiovascular events Celecoxib causes a reduction in blood pressure in patients with cardiovascular disease All selective COX-II inhibitors increase the risk of myopathy when used in combination with statins 12. Which ONE of the following is the mechanism by which low dose aspirin is beneficial in the prophylaxis of cerebrovascular disease and myocardial infarction? Activation of cyclo-oxygenase I in the platelets and endothelial cells of the blood vessels Activation of cyclo-oxygenase 2 in the platelets and endothelial cells of the blood vessels Inactivation of cyclo-oxygenase I in the platelets and activation of cyclooxygenase I in the endothelial cells of the blood vessels Inactivation of cyclo-oxygenase I in the platelets and endothelial cells of the blood vessels Activation of cyclo-oxygenase I in the platelets and inactivation of cyclooxygenase I in the endothelial cells of the blood vessels 13. Which ONE of the following would NOT be used in the treatment and management of a patient with stable angina? Clopidogrel Glyceryl trinitrate Diltiazem Atenolol Nicorandil

5 5 14. With respect to the assessment of cardiovascular (CV) risk which ONE of the following is CORRECT? High risk is defined as having a 10 year CV risk of >15 % The NHS Health Check service should be offered to all under the age of 40 years The ASSIGN tool to assess CV risk is based on population data from the USA The QRISK2 tool to assess CV risk takes into account ethnicity and family history The Framingham equations are recommended by NICE as the first-line choice of tool to assess CV risk 15. Which ONE of the following is NOT a risk factor for the development of a deep vein thrombosis (DVT)? Chemotherapy Pregnancy Atrial fibrillation Combined oral contraceptive pill Immobility/bed rest of greater than 4 days 16. With regard to a cerebral vascular accident (CVA) or transient ischaemic attack (TIA) which ONE of the following is CORRECT? A CVA caused by a haemorrhage is more common than that caused by an embolism or thrombosis 60% of people who have a CVA or TIA die within a month Alteplase should be used in an acute CVA within 3 hours of onset of symptoms A TIA occurs when there is loss of focal cerebral function and symptoms for more than 24 hours Dipyridamole is used first-line in the secondary prevention of CVA and TIA 17. With respect to using warfarin in the treatment of atrial fibrillation (AF), which ONE of the following is CORRECT? The target INR for warfarin in AF is 3.5 Warfarin is used in AF to prevent cerebral vascular accidents Warfarin exerts its anticoagulant effect by inhibiting Factor Xa in the clotting cascade Warfarin should not be used in combination with codeine phosphate due to the increased risk of bleeding Patients taking warfarin should avoid drinking grapefruit juice TURN OVER

6 6 18. The amount of fluid filtered from the blood through the kidneys is called which ONE of the following? The glomerular filtration rate The glomerular fixation rate The renal rate The glomerular rate The renal filtration rate 19. The kidneys have three distinct regions. Which ONE of the following describes these regions? The cortex, medulla and pelvis The cortex, medulla and proxima The cortical, medulla and pelvis The cortical, medulla and proxima The distal, cortical and medulla 20. Which ONE of the following egfr values would be classified as Stage 4 severe renal impairment? > 90 ml / min < 15 ml / min 60 to 89 ml / min 15 to 29 ml / min 30 to 44 ml / min

7 7 SECTION B TYPE 2 MCQs Decide which of the responses to the following questions is / are correct. Then choose: If (i), (ii) and (iii) are correct If (i) and (ii) only are correct If (ii) and (iii) only are correct If (i) only is correct If (iii) only is correct 21. Which of the following is/are used in the treatment of chronic renal disease? (i) (ii) (iii) Iron (III) sucrose injection Ketovite tablets Sevelamer 22. With respect to acute renal failure (ARF) which of the following statements is/are CORRECT? (i) (ii) (iii) ARF causes failure in the regulatory, excretory and endocrine functions of the kidney The most common underlying cause of ARF is a reduction in the circulation to the kidney ARF develops rapidly but is usually reversible 23. Which of the following is/are causes of heart failure? (i) (ii) (iii) Ischaemic heart disease Excessive intravenous fluid administration Hypothyroidism 24. Which of the following drug(s) are recommended by the 2010 NICE Guidelines for Chronic heart failure? (i) (ii) (iii) ACE inhibitors Aldosterone antagonists Beta-blockers 25. Which of the following is/are NOT (a) monitoring parameter(s) for the use of intravenous (IV) furosemide in the treatment of acute heart failure? (i) (ii) (iii) Weight Rate of IV administration Peak expiratory flow rate (PEFR) TURN OVER

8 8 SECTION C TYPE 3 MCQs Answer ALL questions. For each question there is ONE correct answer. Use the answer grid provided for ALL your answers. The questions consist of a statement in the left-hand column followed by a second statement in the right-hand column. Decide whether the first statement is TRUE or FALSE. Decide whether the second statement is TRUE or FALSE. Then choose: A B C D E If both statements are TRUE and the second statement is a correct explanation of the first statement. If both statements are TRUE but the second statement is NOT a correct explanation of the first statement. If the first statement is TRUE but the second statement is FALSE. If the first statement is FALSE but the second statement is TRUE. If both statements are FALSE. Directions Summarised A B C D E First Statement Second Statement 2 nd statement is a correct explanation of the first 2 nd statement is NOT a correct explanation of the first 26. FIRST STATEMENT SECOND STATEMENT Bradycardia is defined as a pulse of less than 60 bpm. Bradycardia can be caused by beta-blockers, digoxin and verapamil.

9 9 Directions Summarised A B C D E First Statement Second Statement 2 nd statement is a correct explanation of the first 2 nd statement is NOT a correct explanation of the first 27. FIRST STATEMENT SECOND STATEMENT Amiodarone can cause hyperthyroidism or hypothyroidism. Amiodarone tablets contain iodine. 28. FIRST STATEMENT A patient with renal failure, cardiac failure or a head injury has increased fluid requirements. SECOND STATEMENT An isotonic intravenous fluid has lower electrolyte concentrations than that of the body cells. 29. FIRST STATEMENT Lisinopril, ibuprofen and gentamicin are all potential causes of renal impairment. SECOND STATEMENT Acute renal failure can be treated with fluids, antibiotics and IV furosemide. 30. FIRST STATEMENT Allopurinol in combination with azathioprine causes severe bone marrow suppression. SECOND STATEMENT Aspirin is the first-line choice of treatment for acute gout. END OF PART ONE TURN OVER

10 10 PART TWO Answer THREE of the FOUR questions. Use a SEPARATE answer book for EACH question. 31. Answer ALL parts (a) to (d). Mr HB is a 68 year old man and has been a regular patient in your pharmacy for several years. He has a history of Type 2 Diabetes Mellitus (for which he has been prescribed metformin 500 mg three times daily) and hypertension. For his hypertension he has previously been prescribed: Perindopril 8 mg daily. H O O N H N H O O OH Perindopril He has been to his GP today and his prescription has been changed to: Losartan 50 mg daily and Amlodipine 5 mg daily (a) With the aid of diagrams, discuss the renin angiotensin system and identify where drug therapy can be introduced for the treatment of high blood pressure. [40%] (b) Explain the rationale behind his initial drug therapy for his hypertension and the subsequent changes. Your answer should include consideration of evidence based medicine and side-effects of his medication. [40%] (c) Provide a diagram of the main binding interactions between perindopril and its major target enzyme. [10%] (d) Losartan contains a tetrazole ring. Why is this an effective isostere for a carboxylic acid group? [10%]

11 Answer ALL parts (a) to (c). Mr CB is a 76 year old man who has a history of chronic renal failure caused by diabetic nephropathy. (a) Using a diagram to aid your answer, describe the structure of the nephron and label the relevant structures. [30%] (b) Describe how the loop of Henle facilitates the establishment of a countercurrent multiplier mechanism in the kidney. [20%] (c) Describe the underlying pathophysiology, clinical manifestations and treatment of the following complications of chronic renal failure: (i) Hyperphosphataemia [20%] (ii) Renal Bone disease [30%] 33. Answer ALL parts (a) to (d). Mrs VG is a 68 year old woman admitted to hospital with an ischaemic cerebral vascular accident (CVA) (stroke). (a) List the risk factors for the development of an ischemic CVA? [25%] (b) List the signs and symptoms of an ischemic CVA? [25%] (c) Platelets are critical for the development of thromboembolic disease. Describe the cellular processes involved in platelet activation, adhesion and aggregation. [40%] (d) List the main types of anti-platelet drugs available and their mechanisms of action. [10%] TURN OVER

12 Answer ALL parts (a) to (c). Mr JB is a 54 year old man admitted to hospital with severe central chest pain. His ECG shows he has had an ST elevated myocardial infarction (STEMI) which is confirmed by a rise in troponin levels in his blood. (a) Describe the pharmacological and non-pharmacological management of a ST elevated myocardial infarction (STEMI) in terms of: (i) Acute/immediate care [25%] (ii) Secondary prevention [25%] (b) Explain the pathophysiology of atherosclerosis. [20%] (c) Beta-blockers are used for the treatment of coronary heart disease (i) Describe the pharmacology and mechanism of action of beta-blockers. [10%] (ii) Describe how each of the following characteristics can be used to predict the side-effects of beta-blockers: Cardioselectivity Lipid/water solubility Intrinsic sympathomimetic activity [20%] END OF PAPER