Treatments in Specific Patient Populations for Cardiology

The majority of the questions on cardiology medical board exams are focused on treatment since the reason patients see a cardiologist is to obtain appropriate treatment. The aspects of treatment tested by the specialty board exams include:

• Details of particular treatment options
• Treatment interventions by disease variant and in specific patient populations
• Treatment algorithms

This post aims to understand how to choose the correct treatment for a specific patient population or disease form. The writer of the cardiovascular disease board exams tests your ability to know the right treatment option that applies to a specific patient population or disease variant. Such questions are reserved for diseases that have well-established guidelines or treatment recommendations.

For example, in hypertensive patients with chronic kidney disease (CKD), treatment should be able to maintain a blood pressure of less than 130/80 mm Hg to prevent the progression of CKD.

Another example: For a woman with hypertension, the use of combined oral contraceptive pills should be limited, and an alternative method of contraception should be provided to decrease the risk of thromboembolic events.

Example Exam Question from Cardiology

A 32-year-old woman visits the outpatient clinic. The patient has a positive pregnancy test after missing her last menstrual cycle. She had a four-year-old girl that was delivered via spontaneous vaginal delivery. The patient has had chronic hypertension for the past ten years and is currently on losartan. There is no other significant past medical or surgical history. On examination, her blood pressure is 125/84 mmHg. Which of the following is the appropriate management of this patient’s hypertension?

1. Stop losartan and continue to monitor BP
2. Switch to spironolactone
3. Continue losartan
4. Switch to captopril
5. Switch to atenolol

The above patient should be advised to stop losartan because angiotensin II receptor blockers (ARBs) are contraindicated in pregnancy, as they can cause renal malformations, oligohydramnios, and abnormal bone ossification in the fetus. The patient should also be advised to monitor her blood pressure. According to the National High Blood Pressure Education Program (NHBPEP) guidelines, anti-hypertensive medicines can be safely withheld in pregnant females with chronic hypertension and recommends restarting treatment at systolic BP of > 150–160 mmHg and/or diastolic BP of 100–110 mmHg, or in the presence of LVH or renal insufficiency. The guidelines also recommend methyldopa as the first line of treatment when restarting anti-hypertensives in pregnant females with chronic hypertension. Other drugs that can be safely used during pregnancy to control hypertension include labetalol, beta-blockers (except for atenolol), verapamil, clonidine, slow-release nifedipine, and hydrochlorothiazide. Spironolactone is contraindicated, as it can cause potential fetal antiandrogen effects. Captopril, an angiotensin-converting-enzyme inhibitor (ACE inhibitor), is also contraindicated because similar to ARBs, it can cause intrauterine growth restriction, oligohydramnios, renal failure, and abnormal bone ossification in the fetus. Atenolol is not recommended, as it increases the risk of growth restriction.

References

Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E. Braunwald’s Heart Disease A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia: Elsevier; 2018.

Brown CM, Garovic VD. Drug treatment of hypertension in pregnancy. Drugs. 2014; 74(3):283-96. DOI: 10.1007/s40265-014-0187-7.

 

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