Hypertension, heart failure and dyslipidaemia

38 Gulf Prometric Pharmacist (DHA, DOH, MOH, SCFHS, QCHP) practice questions on Hypertension, heart failure and dyslipidaemia, part of Clinical Pharmacy and Therapeutics. 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.

1. Question 1 · Medium

   A patient with asymptomatic hypertension has a BP of 210/120 mmHg and normal examination. What is the best management?

   1. AIV labetalol bolus and ICU admission
   2. BSodium nitroprusside infusion in a high-dependency unit
   3. CSublingual short-acting nifedipine capsule
   4. DOptimise oral therapy and lower BP over 24-48 hours

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   Answer: D · Optimise oral therapy and lower BP over 24-48 hours

   Asymptomatic severe hypertension without target organ damage is hypertensive urgency, not emergency, and it is treated with oral agents and outpatient follow-up. Rapid lowering risks cerebral and renal hypoperfusion. IV infusions are reserved for hypertensive emergencies with organ damage.

   • A: ICU-level IV therapy is not needed without organ damage.
   • B: Nitroprusside is for emergencies with organ damage.
   • C: Sublingual short-acting nifedipine can cause precipitous falls.

   Remember this

   Asymptomatic severe hypertension needs oral therapy and gradual reduction, not IV drugs.

2. Question 2 · Easy

   Sacubitril/valsartan must not be started within how long of the last dose of an ACE inhibitor?

   1. A7 days
   2. B72 hours
   3. C36 hours
   4. D12 hours

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   Answer: C · 36 hours

   Both ACE inhibitors and neprilysin inhibitors reduce bradykinin breakdown, so giving them together can cause serious angioedema. A washout of at least 36 hours is required when switching from an ACE inhibitor to sacubitril/valsartan. No washout is needed from an ARB.

   • A: 7 days is longer than needed.
   • B: 72 hours is longer than the labelled 36-hour washout.
   • D: 12 hours is too short to clear the ACE inhibitor effect.

   Remember this

   Wait 36 hours after the last ACE inhibitor dose before starting sacubitril/valsartan.

3. Question 3 · Easy

   Ezetimibe lowers LDL cholesterol by:

   1. ABlocking intestinal cholesterol absorption through NPC1L1
   2. BIncreasing lipoprotein lipase activity
   3. CInhibiting PCSK9 binding to LDL receptors
   4. DInhibiting HMG-CoA reductase in the liver

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   Answer: A · Blocking intestinal cholesterol absorption through NPC1L1

   Ezetimibe inhibits the NPC1L1 transporter on the brush border of the small intestine, reducing cholesterol absorption and lowering LDL-C by about 18-20%. It is added to a statin when LDL targets are not met, or used alone in statin intolerance.

   • B: Fibrates act mainly through PPAR-alpha and lipoprotein lipase.
   • C: That is the mechanism of evolocumab and alirocumab.
   • D: That is the mechanism of statins.

   Remember this

   Ezetimibe blocks NPC1L1 cholesterol absorption and is the usual add-on to a statin.

4. Question 4 · Medium

   A patient has a fasting triglyceride of 11 mmol/L and abdominal pain. What drug is most appropriate to lower the pancreatitis risk?

   1. AFenofibrate
   2. BCholestyramine
   3. CRosuvastatin alone
   4. DEzetimibe

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   Answer: A · Fenofibrate

   Severe hypertriglyceridaemia (above 10 mmol/L) carries a risk of acute pancreatitis, and fibrates lower triglycerides by about 30-50% through PPAR-alpha activation. Ezetimibe has little triglyceride effect, and bile acid sequestrants can raise triglycerides.

   • B: Bile acid resins increase triglycerides.
   • C: A statin alone reduces triglycerides modestly.
   • D: Ezetimibe mainly lowers LDL-C.

   Remember this

   Triglycerides above 10 mmol/L: use a fibrate to lower pancreatitis risk.

5. Question 5 · Medium

   A man with HFrEF has taken sacubitril/valsartan for 3 months, and the clinic wants a natriuretic peptide to follow his heart failure. Which test reflects his status most reliably?

   1. ABNP
   2. BC-type natriuretic peptide
   3. CNT-proBNP
   4. DAtrial natriuretic peptide

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   Answer: C · NT-proBNP

   Neprilysin breaks down BNP, so sacubitril raises BNP levels even when heart failure is improving, which makes BNP hard to interpret. NT-proBNP is not a neprilysin substrate, so its level still tracks wall stress and falls when treatment works.

   • A: BNP is a neprilysin substrate and rises with sacubitril.
   • B: C-type natriuretic peptide is not used to monitor heart failure.
   • D: ANP is also broken down by neprilysin and is not a routine heart failure test.

   Remember this

   On sacubitril/valsartan, monitor NT-proBNP rather than BNP, because neprilysin inhibition raises BNP.

6. Question 6 · Hard

   A patient with HFrEF taking ramipril and spironolactone 25 mg has potassium 6.2 mmol/L, eGFR 40 mL/min and no ECG changes. What is the most appropriate step?

   1. AStop spironolactone and treat the hyperkalaemia
   2. BSwitch spironolactone to the potassium-sparing amiloride
   3. CContinue both drugs and advise dietary potassium restriction
   4. DHalve the spironolactone dose and continue

   Answer and explanation in LearnFree account

7. Question 7 · Medium

   A patient with HFrEF starts ramipril. Baseline creatinine is 90 umol/L; at 10 days it is 112 umol/L with potassium 4.8 mmol/L and BP 108/66 mmHg. What is the best action?

   1. AReplace it with a thiazide diuretic as monotherapy
   2. BContinue ramipril and recheck bloods in 1-2 weeks
   3. CStop ramipril permanently and avoid ACE inhibitors
   4. DHalve the dose and add a potassium supplement

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8. Question 8 · Medium

   A patient with heterozygous familial hypercholesterolaemia has an LDL-C of 6.0 mmol/L despite maximum statin plus ezetimibe. Which drug class is the next addition?

   1. ANicotinic acid
   2. BFibrate
   3. CPCSK9 inhibitor
   4. DOmega-3 ethyl esters

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9. Question 9 · Medium

   An elderly woman on hydrochlorothiazide develops confusion and a sodium of 122 mmol/L. Which statement fits best?

   1. AIt is unrelated to the drug and needs no review
   2. BThiazide hyponatraemia is likely; stop the drug
   3. CThe diuretic has caused hypernatraemia and needs a dose cut
   4. DA higher thiazide dose will correct the sodium

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10. Question 10 · Medium

    A man with hypertension and recurrent gout flares is starting a new antihypertensive. Which choice is most suitable?

    1. ALosartan
    2. BChlorthalidone
    3. CFurosemide
    4. DHydrochlorothiazide

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11. Question 11 · Hard

    A man with stable heart failure takes furosemide 80 mg orally daily. He is nil by mouth for 2 days after surgery and is euvolaemic. Which IV daily dose matches his usual oral dose?

    1. A80 mg
    2. B20 mg
    3. C40 mg
    4. D160 mg

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12. Question 12 · Medium

    A 55-year-old Black man with newly diagnosed hypertension has a clinic BP of 158/96 mmHg, a normal creatinine and no diabetes. Which drug is the best initial choice?

    1. AAtenolol
    2. BLisinopril
    3. CAmlodipine
    4. DLosartan

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13. Question 13 · Easy

    The dry persistent cough caused by ACE inhibitors results mainly from accumulation of:

    1. ARenin
    2. BBradykinin
    3. CAngiotensin II
    4. DAldosterone

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14. Question 14 · Medium

    Ivabradine is added to heart failure therapy only when the patient has:

    1. ASinus rhythm, rate 70 or more, on a beta-blocker
    2. BAtrial fibrillation with a fast ventricular response
    3. CSinus bradycardia with a rate below 50 bpm
    4. DCardiogenic shock requiring vasopressor support

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15. Question 15 · Medium

    A patient on atorvastatin 40 mg reports severe muscle pain. CK is 12 times the upper limit of normal. What is the best action?

    1. AAdd gemfibrozil to improve the lipid profile
    2. BContinue the statin and add coenzyme Q10 for the pain
    3. CDouble the dose to overcome the muscle symptoms
    4. DStop the statin, check renal function, rechallenge later

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16. Question 16 · Hard

    A patient on enalapril 5 mg twice daily (BP 104/64 mmHg, eGFR 55 mL/min) is moved to sacubitril/valsartan after the washout. What is the appropriate starting dose?

    1. A49/51 mg once daily
    2. B49/51 mg three times daily
    3. C24/26 mg twice daily
    4. D97/103 mg twice daily

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17. Question 17 · Medium

    Which drug is contraindicated in a patient with HFrEF who has a documented history of ACE inhibitor-induced angioedema?

    1. ASpironolactone
    2. BBisoprolol
    3. CSacubitril/valsartan
    4. DDapagliflozin

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18. Question 18 · Medium

    A patient on amlodipine complains of bilateral ankle swelling. Which statement is correct?

    1. ADose-related arteriolar vasodilation; diuretics work poorly
    2. BIt indicates heart failure and needs the ACE inhibitor stopped
    3. CSodium retention that responds well to loop diuretics
    4. DAn allergic reaction that requires withdrawal of amlodipine

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19. Question 19 · Medium

    Six weeks after an MI, a patient on atorvastatin 80 mg has an LDL-C of 2.1 mmol/L. The ESC target is below 1.4 mmol/L. What is the most appropriate next step?

    1. AAdd ezetimibe 10 mg
    2. BAdd fenofibrate
    3. CSwitch to pravastatin
    4. DAdd niacin

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20. Question 20 · Hard

    A patient taking simvastatin 40 mg daily is started on amlodipine 10 mg. What is the best advice?

    1. AIncrease simvastatin to 80 mg for effect
    2. BStop amlodipine and use verapamil instead
    3. CNo action is required, as the effect is minor
    4. DCap simvastatin at 20 mg or switch statin

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21. Question 21 · Medium

    In which situation is the combination of hydralazine and isosorbide dinitrate specifically recommended in HFrEF?

    1. AIn patients with severe symptomatic aortic stenosis
    2. BRenin-angiotensin inhibitors are not tolerated
    3. CAs first-line therapy in all patients with HFrEF
    4. DOnly in patients with preserved ejection fraction

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22. Question 22 · Easy

    The most important adverse effect to monitor when spironolactone is added to an ACE inhibitor is:

    1. AHypokalaemia
    2. BHypernatraemia
    3. CHypercalcaemia
    4. DHyperkalaemia

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23. Question 23 · Easy

    Which of these statins is classed as high-intensity at its usual maximum dose?

    1. ASimvastatin 20 mg
    2. BAtorvastatin 40-80 mg
    3. CPravastatin 40 mg
    4. DFluvastatin 80 mg

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24. Question 24 · Medium

    Which monitoring plan is appropriate after starting an ACE inhibitor in a patient with chronic kidney disease?

    1. AFull blood count every month for a year
    2. BCreatinine and potassium in 1-2 weeks
    3. CLiver enzymes and bilirubin every 6 weeks
    4. DThyroid function tests every 3 months

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25. Question 25 · Hard

    A patient on lisinopril, furosemide and ibuprofen develops vomiting and diarrhoea for 2 days. What advice minimises the risk of acute kidney injury?

    1. APause all three drugs until normal intake returns
    2. BIncrease furosemide to clear the toxins faster
    3. CTake extra ibuprofen to relieve the abdominal pain
    4. DContinue all three drugs unchanged until symptoms stop

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