A 64-year-old woman comes to the hospital due to sudden-onset right arm weakness and difficulty speaking, which completely resolved within 20 minutes. The patient has had no shaking movements, headache, nausea, photophobia, or anxiety. She has a history of hypertension and hypercholesterolemia and takes amlodipine and rosuvastatin, respectively. Her blood pressure is 125/70 mm Hg and pulse is 78/min and regular. Neurologic examination is unremarkable. Fingerstick glucose is within normal limits. ECG shows normal sinus rhythm. Carotid Doppler reveals mild left common carotid artery stenosis. MRI of the brain and echocardiogram are unremarkable. If the patient is started on an additional medication that is indicated for her condition, which of the following adverse effects is most likely to occur?

Question

A 64-year-old woman comes to the hospital due to sudden-onset right arm weakness and difficulty speaking, which completely resolved within 20 minutes.  The patient has had no shaking movements, headache, nausea, photophobia, or anxiety.  She has a history of hypertension and hypercholesterolemia and takes amlodipine and rosuvastatin, respectively.  Her blood pressure is 125/70 mm Hg and pulse is 78/min and regular.  Neurologic examination is unremarkable.  Fingerstick glucose is within normal limits.  ECG shows normal sinus rhythm.  Carotid Doppler reveals mild left common carotid artery stenosis.  MRI of the brain and echocardiogram are unremarkable.  If the patient is started on an additional medication that is indicated for her condition, which of the following adverse effects is most likely to occur?

Quizplus · Accepted Answer

11ec160b_3c28_0687_9249_7d7077294931_MD0001_00 This patient, with hypertension, hypercholesterolemia, and sudden-onset neurologic deficits (eg, right arm weakness, difficulty speaking) that fully resolved within minutes, most likely had a transient ischemic attack (TIA). In addition to optimal blood pressure control and statin therapy, low-dose aspirin is commonly used to prevent ischemic stroke in patients with TIA. It works by irreversibly acetylating/inhibiting the cyclooxygenase (COX) enzymes. At low doses, aspirin predominantly inhibits COX-1, preventing platelet synthesis of thromboxane A2, which impairs platelet aggregation and reduces vasoconstriction. At least 2 distinct COX-1-dependent mechanisms contribute to the increased risk of upper gastrointestinal (GI) bleeding associated with aspirin therapy: Inhibition of platelet aggregation and impairment of prostaglandin-dependent GI mucosal protection. The risk of upper GI bleeding increases with higher doses but is increased 2- to 3-fold even with low-dose aspirin. Proton pump inhibitors can help reduce the risk of upper GI bleeding in patients taking aspirin. (Choice A) Central nervous system depression is commonly seen with benzodiazepine use as these agents potentiate the effect of GABA (a major inhibitory neurotransmitter) on GABA-A receptors. (Choice C) Very high doses of aspirin can cause salicylism (eg, vertigo, tinnitus, hearing loss) and hyperpnea (stimulates respiratory drive). Hyperpnea may result in respiratory alkalosis, whereas systemic salicylate accumulation often leads to a concurrent metabolic acidosis. (Choice D) Orthostatic hypotension may occur with use of antihypertensive medications due to vasodilation (eg, nitrates, calcium channel blockers) and volume depletion (eg, loop and thiazide diuretics). (Choice E) Sexual dysfunction is a common side effect of antidepressants (eg, selective serotonin inhibitors, tricyclics) and some antihypertensives (eg, thiazide diuretics, spironolactone, clonidine). (Choice F) Pioglitazone (a thiazolidinedione) increases insulin sensitivity in patients with type II diabetes mellitus by binding to peroxisome proliferator-activated receptors. Long-term use may be associated with urinary bladder cancer. Educational objective: Gastrointestinal (GI) mucosal injury and bleeding are the most common side effects of aspirin. These are due primarily to cyclooxygenase-1 inhibition, which results in impaired prostaglandin-dependent GI mucosal defense and decreased platelet aggregation. __________ References: Long-term use of aspirin and the risk of gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/21531232) Systematic review and meta-analysis of adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/16887404)

A 64-Year-Old Woman Comes to the Hospital Due to Sudden-Onset