Cardiovascular Drugs USMLE Step 1 Practice Question
A 68-year-old man with a history of ischemic cardiomyopathy (ejection fraction 28%) and stage 3 chronic kidney disease presents to clinic with progressive dyspnea on exertion over the past 2 weeks. He reports orthopnea and lower extremity swelling. Current medications include lisinopril 10 mg daily, metoprolol succinate 95 mg daily, and furosemide 40 mg daily. Vital signs: BP 142/88 mmHg, HR 98/min, RR 20/min, SpO2 96% on room air. Laboratory values show: serum potassium 6.1 mmol/L (normal 3.5-5.0), creatinine 2.2 mg/dL (baseline 2.0), BUN 48 mg/dL, and LVEF remains 28% on transthoracic echocardiogram. Physical examination confirms bilateral lower extremity pitting edema and elevated jugular venous pressure. Which of the following is the most appropriate next step in management?
Answer choices
- ADiscontinue lisinopril immediately and initiate sodium polystyrene sulfonate therapy
- BIncrease furosemide dose and reduce lisinopril dose from 10 mg to 5 mg dailyCorrect answer
- CAdd spironolactone 12.5 mg daily to improve heart failure outcomes while monitoring potassium
- DDiscontinue lisinopril and metoprolol, and initiate hydralazine/isosorbide dinitrate instead
- EContinue all current medications and add patiromer to allow continuation of renin-angiotensin-aldosterone system inhibition
- FIncrease lisinopril to 20 mg daily to optimize heart failure therapy despite hyperkalemia
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