BCACP Hypertension and Dyslipidemia Therapy 4 — Questions and Answers
Question 1: Which fibrate carries the lowest risk of myopathy when used in combination with a statin?
- Gemfibrozil
- Fenofibrate (Correct answer)
- Clofibrate
- All fibrates carry equal risk
Correct answer: Fenofibrate
Fenofibrate does not inhibit glucuronidation of statins (unlike gemfibrozil) and therefore carries a significantly lower risk of statin-associated myopathy.
Question 2: A patient on lisinopril develops a dry cough. The pharmacist recommends switching to which medication?
- Captopril
- Enalapril
- Losartan (Correct answer)
- Ramipril
Correct answer: Losartan
ACE inhibitor–induced cough (due to bradykinin accumulation) is a class effect; ARBs such as losartan do not affect bradykinin and are the preferred switch.
Question 3: What is the primary mechanism by which spironolactone lowers blood pressure in resistant hypertension?
- Beta-1 receptor blockade reducing cardiac output
- Aldosterone receptor antagonism promoting sodium excretion (Correct answer)
- Direct arterial vasodilation
- Inhibition of angiotensin-converting enzyme
Correct answer: Aldosterone receptor antagonism promoting sodium excretion
Spironolactone blocks mineralocorticoid receptors, preventing aldosterone-mediated sodium and water retention, which is particularly effective in patients with elevated aldosterone levels.
Question 4: Colesevelam (a bile acid sequestrant) is unique among lipid-lowering agents because it also reduces which other cardiovascular risk marker?
- Triglycerides
- Hemoglobin A1c in type 2 diabetes (Correct answer)
- C-reactive protein
- Lipoprotein(a)
Correct answer: Hemoglobin A1c in type 2 diabetes
Colesevelam has FDA approval for improving glycemic control in type 2 diabetes, making it a dual-benefit agent in diabetic patients with dyslipidemia.
Question 5: A patient with hypertension and a history of angioedema on enalapril is started on sacubitril/valsartan for HFrEF. What important counseling point applies?
- Sacubitril/valsartan is safe because it is not an ACE inhibitor
- There must be a 36-hour washout period after stopping the ACE inhibitor before starting sacubitril/valsartan
- Sacubitril/valsartan is contraindicated in patients with prior ACE inhibitor angioedema (Correct answer)
- The patient should take a 24-hour break before transitioning
Correct answer: Sacubitril/valsartan is contraindicated in patients with prior ACE inhibitor angioedema
A history of ACE inhibitor–induced angioedema is a contraindication to sacubitril/valsartan because neprilysin inhibition further raises bradykinin levels, increasing angioedema risk.
Question 6: Which of the following best describes the mechanism of action of bempedoic acid?
- Inhibits HMG-CoA reductase in hepatocytes
- Inhibits ATP-citrate lyase upstream of HMG-CoA reductase (Correct answer)
- Blocks intestinal cholesterol absorption at NPC1L1
- Activates LDL receptor expression via PCSK9 degradation
Correct answer: Inhibits ATP-citrate lyase upstream of HMG-CoA reductase
Bempedoic acid inhibits ATP-citrate lyase, a step upstream of HMG-CoA reductase in the hepatic cholesterol synthesis pathway, and is a prodrug activated only in the liver.
Question 7: An African American patient with hypertension has a BP of 148/92 mmHg. Which initial therapy is preferred based on clinical trial data and guidelines?
- ACE inhibitor monotherapy
- ARB monotherapy
- Thiazide diuretic or calcium channel blocker (Correct answer)
- Beta-blocker monotherapy
Correct answer: Thiazide diuretic or calcium channel blocker
Clinical trials (ALLHAT) show thiazide diuretics and calcium channel blockers are more effective antihypertensives in African American patients compared to ACE inhibitors or ARBs as monotherapy.
BCACP Hypertension and Dyslipidemia Therapy 4
Which fibrate carries the lowest risk of myopathy when used in combination with a statin?