1-3.

Mr Green, 60 years old, has severe chest pain when he walks uphill in
cold weather to his home. The pain disappears when he rests. A decision is
made to treat him with nitro glycerin. 1. Nit roglycerin, either directly or
through reflexes, results in which one of the following effects?

(A) Decreased heart rate

(B) Decreased venous capacitance

(C) Increased afterload

(D) Increased cardiac force

(E) Increased diastolic intramyocardial fiber tension

1. Nitroglycerin increases cardiac force because the

decrease in blood prcssure evokes a compensatory

increase in sympathetic discharge. The answer is O.

2. In advising Mr Green about the adverse effects he may notice, you point
out that nitroglycerin in moderate doses often produces certain
symptoms.Which of the following effects might occur due to the mechanism
listed?

(A) Headache due to meningeal vasodilation

(B) Hypertension due to reflex tachycardia

(C) Dizziness due to meningeal vasodilation

(D) Dizziness due to reduced cardiac force of contraction

(E) Diuresis due to sympathetic discharge

2. Nitroglycerin causes hypotension as a result of arterial and venous dilation.

Dilation of meningeal arteries has no effect on CNS function bur does cause
headache. The answer is A.
3. Two years later, Mr Green returns complaining that his nitroglycerin
works well when he takes it for an acute attack but that he is having
frequent attacks now and would like something to prevent them.Useful drugs
for the prophylaxis of angina of effort include which one of the following?

(A) Amyl nitrite

(B) Diltiazem

(C) Esmolol

(D) Sublingual isosorbide dinitrate

(E) Sublingual nitroglycerin

3. The calcium channel blockers and the ~-blockers are generally effective in
reducing the number of attacks of angina of effort, and most have durations of
4-8 h. Oral and transdermal nitrates have similar or longer durations. Amyl
nitrite, the sublingual nitrates, and esmolol (an intravenous ~-blocker) have
short durations ofaction and are ofno value in prophylaxis. The answer is B.

4. The antianginal effect of propranolol may be attributed to which one of

the following?

(A) Block of exercise-induced tachycardia

(B) Decreased end-diastolic ventricular volume

(C) Dilation of constricted coronary vessels

(D) Increased cardiac force

(E) Decreased ventricular ejection time

4. Propranolol blocks tachycardia but has none of the other effects listed. The
answer is A.
5. The major common determinant of myocardial oxygen consumption is

(A) Blood volume

(B) Cardiac output

(C) Diastolic blood pressure

(D) Heart rate

(E) Myocardial fiber tension

5. The answer is E, fiber tension. The other variables

contribute to this determinant.

6. M.A. is a new patient who presents with hypertension and angina. In

considering adverse effects of possible drugs, you note that an adverse
effect that ~itroglycerin.' prazosin, and ganglion blockers have III common
IS

(A) Bradycardia

(B) Impaired sexual function

(C) Lupus erythematosus syndrome

(D) Orthostatic hypotension

(E) Throbbing headache

6. These drugs all reduce venous return sufficiently to cause some degree of
postural hypotension. Throbbing headache is a problem only with the nitrates,
sexual problems only with ganglion blockers, and bradycardia and lupus with none
of them.The answer is O.
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7. Which of the following is most likely to cause methemoglobinemia?

(A) Sodium cyanide

(B) Amyl nitrite

(C) Isosorbide mononitrate

(D) Isosorbide dinitrate

(E) Nitroglycerin

7. Nitrites , not nitrates , cause methemoglobinemia in adults.

Methemoglobinemia is deliberately induced in one of the treatments of cyanide
poisoning. The answer is B.

8. A patient is admitted to the emergency department followinga drug

overdose. He is noted to have severe tachycardia. He has been receiving
therapy for hypertension and angina. A drug that often causes tachycardia
is

(A) Diltiazem

(B) Guanethidine

(C) Isosorbide dinitrate

(D) Propranolol

(E) Verapamil

8. Isosorbide dinitrate (like all the nitrates) can cause reflextachycardia, but all
the other drugs listed here slow heart rate. The answer is C.
9. A patient being treated for another condition complains that whenever he
takes that medication, his angina becomes worse. Drugs that may
precipitate angina when used for other indications do NOT include

(A) Amphetamine

(B) Hydralazine

(C) Isoproterenol

(D) Metoprolol

(E) Terbutaline

9. In general, drugs that cause hypertension or tachycardia-whether directly or

by reflex-tend to precipitate angina in individuals with coronary obstruction
unless cardiac work is greatly reduced (as in the case of the nitrates). The
answer is O. (Note: "all ... except" and "do not include" type questions are no
longer used in USMLE examinations but may be encountered elsewhere.)

10. When nitrates are used in combination with other drugs for the
treatment of angina, which one of the following combinations results in
additive effects on the variable specified?

(A) Beta-blockers and nitrates on end-diastolic cardiac size

(B) Beta-blockers and nitrates on heart rate

(C) Calcium channel blockers and ~-blockers on cardiac force

(0) Calcium channel blockers and nitrates on cardiac ejection time

(E) Calcium channel blockers and nitrates on heart rate

10. The effects of ~-blockers (or calcium channel blockers) and nitrates on
heart size, force, ejection time, and rate are opposite. The answer is C.
 Edited by Foxit Reader
Copyright(C) by Foxit Software Company,2005-2008
For Evaluation Only.

11. Which of the following is approved for the treatment of hemorrhagic

stroke?

(A) Amyl nitrite

(B) Hydralazine

(C) Isosorbide mononitrate

(0) Nifedipine

(E) Nimodipine

(F) Nitroglycerin (sublingual)

(G) Nitroglycerin (transderrnal)

(H) Propranolol

(I) Terburaline

(J) Verapamil

11. Nimodipine, a dihydropyridine calcium channel

blocker, is approved only for the treatment of hem-

orrhagic stroke. The answer is E.

12. Which of the following drugs interacts with nitroglycerin by inhibiting

the metabolism of cGMP?

(E) Propranolol (A) Amyl nitrite

(F) Sildenafil (B) Hydralazine

(G) Terburaline (C) Isosorbide rnononitrare

(0) Nifedipine

12. Sildenafil inhibits phosphodiesterase 5, an enzyme that inactivates cGMP.

The answer is F.