drk1980
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Q from UW: A 57 year old white male comes to your office for worsening of his intermittent claudication. He was diagnosed with essential hypertension 2 months ago and he had symptoms of peripheral vascular disease for atleast 1 year. His HTN was refractory to lifestyle modifications and it was decided to start pharmacological therapy with a single antihypertensive agent. He has been taking it regularly for the last 2 months and his blood pressure is well controlled. Which of the following antihypertensive agents is he most likely taking?
A) Metaprolol
B) Clonidine
C) Enalapril
D) Nifedipine
E) Hydrochlorothiazide
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| MLF
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I would say A
Pt has Peripheral vascular disease and beta blockers are contraindicated even tho they will control the blood pressure.
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| cyra
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So, this question here didn't make sense to me at all.Metoprolol is cardioselective(beta 1 blocker) and ideally shouldn't effect the peripheral circulation.I saved the following links after I got this question wrong.Apparently metoprolol is actually preferred for use in patients with peripheral vascilar disease.More on this here,here and here.Its actually scary how there are quite a few ambiguities in UW.
For the first link, scroll way down to where they talk about peripheral vascular disease.
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| alenka
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according to first aid-
the management of HTN associated with peripheral vascular disease-Ca channel blockers-
so,D would be the answer.
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| cyra
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true alenka... CCBs can be used in such a case but the question here says that there was worsening of the patient's peripheral vascular disease and they want to know what medication might have caused it.
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| alenka
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you are right,cyra.
and here is my greatest problem-i lose too many points by simply NOT paying enought attention to the question...
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| cyra
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I can relate to that alenka....my mind kinda goes blank half way through the question stem and its crazy having to go back and recollect!Anyways...hopefully we'll overcome this come time of the exam.
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| alenka
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| achilles
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A.
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| drk1980
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i wasnt sure of this answer myself...but A seems to be it. thanks for the info CYRA....
so the point of this Q is ..metoprolol is used in PVD pts, but it can worsen the PVD....okay........!!
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| AAAAA
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A
Traditional contraindications to beta-blockers are peripheral vascular diseases, diabetes mellitus, chronic obstructive pulmonary disease (COPD) and asthma
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| AAAAA
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Traditional contraindications to beta-blockers are peripheral vascular diseases, diabetes mellitus, chronic obstructive pulmonary disease (COPD) and asthma. Recent data seem to show that rigorous application of these rules are not completely justified and indicate that many patients would be inappropriately excluded from the beneficial effects of this therapy. Appraisal of clear guidelines for a safe use of beta-blockers is thus mandatory for the clinician. A brief review of the effects of beta-adrenergic receptor blockade is offered. The therapy is aimed at blocking beta 1-receptors. On the other hand, the block of beta 2-receptors causes the well known side effects, i.e. vasoconstriction, delayed response to hypoglycemia in diabetic patients, bronchoconstriction. From the first compound, propranolol, with uniform action on beta 1 and beta 2-receptors, further generation of beta-blockers were subsequently developed: beta 1-selective, with intrinsic sympathomimetic activity, and with associated vasodilating "ancillary" property. Some favorable reduction in collateral effects has thus been obtained with new compounds, without reaching complete safety. Examination of exclusion criteria applied in clinical trials offers no useful indications because of their imprecise definition. Examination of the literature and a more accurate understanding of the diseases, traditionally considered contraindications, may help setting up a uniform and clear path: peripheral vascular disease: beta-blockers should be avoided only in those patients with vasospastic disorders, rest pain with severe peripheral vascular disease or nonhealing lesions. In patients with mild to moderate disease, beta-blockers can be prescribed, but careful surveillance for any changes in symptoms related to intermittent claudicatio should be achieved; diabetes mellitus: previous apprehension for the lessening reaction to hypoglycemia in patients treated with insulin has been retracted. Beta-blockers are not contraindicated in these patients. Some caution should be addressed when signs of autonomic disease are present or in patients with difficult glycemic control. Patients on oral long-acting antidiabetic drugs should not be neglected. The risk of prolonged and paucisymptomatic hypoglycemia while taking beta-blocker agents is somewhat more relevant than in patients treated regularly with insulin; COPD and asthma: confusion may arise if rigorous definition of these diseases and their severity is not applied following the guidelines of the American Thoracic Society. Because bronchial hyperreactivity seems the crucial factor in determining collateral effects to beta-blocker agents, agreement can be reached on the following statements. Beta-blockers are contraindicated a) when history of asthma is present, b) when COPD is moderate to severe, i.e. with FEV1 reduction < 50% of the predicted value, c) in patients on chronic bronchodilator treatment, d) in chronic airflow limitation with evidence of > or = 20% reversibility in airway obstruction in response to inhaled salbutamol. When FEV1 is > 50% of the predicted value, beta-blockers can be given, providing adequate control of stability of ventilatory conditions.
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| AAAAA
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Answer still is A
This review addresses the vascular effects of beta-blockers in patients with normal peripheral circulation, with hypertension or with peripheral arterial disease. Despite conflicting data from many uncontrolled and relatively small studies some general conclusions can be drawn. In the absence of peripheral vascular disease there is no good evidence of any adverse effects of beta-blocker treatment on peripheral circulation. Nevertheless, it may be useful to change from non-selective to beta-1 selective beta-blockers or to beta-blockers with ISA when patients complain of cold extremities.
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| Geroo
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thanks AAAAA
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| docofthebigapple
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The presenting complaint is "worsening of intermittent claudication". The patient has recently been started on an antihypertensive drug. now go to the choices and try to think of a drug that can worsen this patients claudication.
Thats the answer.
Another question before you select nifedipine as your answer.
What is the plasma half life of nifedipine?
Edited by docofthebigapple on 07/13/06 - 02:50 PM
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| drk1980
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thanks docofthebigapple, the Q just got me confused on why in the first place wud the doc start him on a drug that cud worsen his already existing PVD...but anyhow, acc to the links Cyra posted and AAAAA's info, seems like beta selective are actually used in PVD!
not sure abt ur t1/2 ques....
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