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NBME 22 Answers

nbme22/Block 3/Question#39 (36.8 difficulty score)
A 52-year-old man with stable angina pectoris ...
Headache🔍
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 +3 
submitted by nwinkelmann(285),
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I dnfuo itsh ewhn iyntgr ot addnrtsune wyh ceisradne ON adcuse :cahesehda eiasstre/itNirttn rae a veyr noocmm aedahehc dan eimarign dofo rteigrgs (WD)Mbe dna arise nictri dieox sevlle. hHig vleles of nritci oiedx rea eistdaasco iwht gmeaiirn d)u(Syt. adHesahce and iineasmgr are lsoa eryv mcmnoo in adcmiteoisn ahtt osbot tnciri dox,ie hcus a igaavr ds,y(tu) tub ti is lcrnuae hyw tihs p.hapesn eTh rgonliia ehtihossyp aws htat irinct idxeo seaicsern lbodo evessl ezis and irtergsg a r,gaieimn tub het iagrav yudst adn ethrso idsrvpdoe sh.ti Nrwee itedssu no intrci oxied hsows tath ti acersisne teh pdtiepe )(CGRP ttha si dnicoreeds peirelsnosb for ierrgnggti imangries y)u(Std aftre eseicnsra ni iimnal.mafont ueaesBc riicnt idxoe si tsoaiedcas grceuioenn ailnifmaomtn ,seesiads i'st eyklil atht aadeehcsh nda iiengamrs mrfo tniric eiodx aer a nrgwain nsgi fo itsh tnmlomiaaifn t.(dyu)S

The arherecs is alybsialc nttsiag that ensiattr aisre niirtc eoixd veesll nad hgih irtcni dioxe evslel icarnsee finlntoamiam nda heeahascd dan rmsiegnia. eoHwe,rv teh cxeta oasnre wyh tish pehpnsa si nk.uownn

-irhcdh:s-ph/tae.ys/na/aedo.oW-wstrhatct-muqcouseeaww

taediggity  Goljan and FA mentioned this as Monday Disease for people who worked in industries that heavily used nitrates, where they would build tolerance during the week and then get a headache when they went back to work on Monday +3  
nootnootpenguinn  Just to add to this- one of the side effect of NG when given to patients with MI is "massive headache"! That's how I the question right! +  
mumenrider4ever  This is similar in how triptans induce vasoconstriction which is used to treat migraines +  



 +2 
submitted by amphotericin(8),
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I utp nsionticpoat besauec I thguoth hte oinmeatdic igenb eeibddscr igmth be CB:C cna enmseoo iaelnxp why rsetinta roev CB?C

seracen  Wouldn't nitrates be a faster acting drug here? That was my take-away anyway. One is more acute, the other for long term maintenance. +4  
suckitnbme  I also believe it's because CCBs have minimal effect on venous beds and would not cause a significant decrease on preload. +2  
beto  decrease of cardiac preload is another word of Venodilation, so Nitrates primarly venodilators. CCB dilate arteria more than veins +  
zevvyt  also, verapamil is the one that causes constipation. But Verampamil is non-dyhydropiridine, so it works more on the heart than the vessels +2  



 +1 
submitted by mdmikek89(1),

The most common adverse effect of nitrates is headache. (60% of patients)




 +0 
submitted by marbledoc(0),
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ahtW si tsih odmeantici inbge rsiecdbed re?he Cna moosene hmeci i.n

thatyummyslice  Nitrates i believe! NO --> increased cGMP in vessel smooth muscle --> myosin light chain dephosphorylate --> vascular smooth muscle RELAX --> Dilate (primarily in venous) AKA more venous capacitance --> LOWER preload and workload for heart. +25  
marbledoc  Thanks! Thought it was nitrates too from the Q stem. But had no clue it was notorious for headaches (only thought of hypotension, dizziness, etc) so doubted it all together. But you’re absolutely right apparently it’s the most common side effect! +  
dr.xx  Previously, Ferid Murad et al. described that organic nitrates, such as nitroglycerine, induce vasodilation by release of nitric oxide, activating soluble guanylyl cyclase and subsequent cyclic guanosine monophosphate formation.7 These discoveries rendered Robert Furchgott, Louis Ignarro, and Ferid Murad the Nobel Prize in Physiology or Medicine in 1998. https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2085806 +