# Antihypertensives, Heart Failure and Angina Drugs for NEET PG Pharmacology: ICMR 2026 Protocols, ACE Inhibitors, ARNI, Nitrates

Source: https://tracknation.in/story/antihypertensives-heart-failure-and-angina-drugs-for-neet-pg-pharmacology-icmr-2026-protocols-ace-inhibitors-arni-nitrates (TrackNation — free UPSC notes with PYQs)

> NEET PG Pharmacology: India's ICMR 2026 workflows for hypertension (grades, targets, first-line combinations, the step-up protocol), heart failure (furosemide, ARNI, spironolactone, beta-blockers, SGLT2 inhibitors) and stable angina (metoprolol, amlodipine, nitrates, aspirin, statins), plus the drug warnings examiners love — ACE-inhibitor cough and angioedema, RAAS drugs in pregnancy, nitrates with sildenafil, hydralazine lupus, nitroprusside cyanide — with a diagram, hooks, vignette MCQs and ca

## Start Here

🎯 **Exam priority: High.** *Cardiovascular drugs are the biggest block in Pharmacology. Expect: first-line choice for
a new hypertensive, a cough on enalapril, a pregnant woman on an ARB, a man on sildenafil with chest pain, and the heart-failure drug that
saves lives.*

CBME mapping: **PH 4.1–4.5**. Protocols follow India's **ICMR Standard Treatment Workflows (2026)**.

## Hypertension: Diagnosis and Targets (ICMR 2026)

| **Category (ICMR 2026)**

 | **Systolic**

 | **Diastolic**

 | **Action**

 |
| Normal

 | < 120

 | and < 80

 | Healthy lifestyle

 |
| Elevated

 | 120–139

 | and/or 80–89

 | Lifestyle change

 |
| Grade 1

 | 140–159

 | and/or 90–99

 | Drugs + lifestyle

 |
| Grade 2

 | 160–179

 | and/or 100–109

 | Drugs + lifestyle

 |
| Grade 3

 | ≥ 180

 | and/or ≥ 110

 | Drugs + lifestyle

 |

- **Diagnosis**: ≥ 140/90 on **two different visits**; a single visit is enough if ≥ 160/100.

- **Targets**: < 140/90 for all adults; < 130/80 with diabetes, CKD or established CVD if tolerated; < 150/90 at age
≥ 80.

- **Lifestyle**: salt < 5 g a day, no tobacco or alcohol, 30 minutes of activity daily, BMI < 23.

## Hypertension: Drug Choice

- **Two drugs from two classes** can be the default first step for most adults, preferably as a single pill. Monotherapy only
for low-risk grade 1, age ≥ 80 or frailty.

- Pair a **CCB or thiazide-like diuretic** with a RAAS blocker (ACE inhibitor or ARB). Never combine two RAAS blockers (kidney
injury).

- Beta-blockers are for hypertension with angina, after MI or with heart failure.

*ICMR hypertension step-up protocol 1: amlodipine 5 mg, add telmisartan 40 mg, raise telmisartan to 80 mg, raise amlodipine to 10 mg, add chlorthalidone 12.5 mg, then consider spironolactone, each step after 4 weeks. Drawn by TrackNation.*

| **Class (ICMR doses)**

 | **Contraindications**

 | **Side effects**

 | **Label points**

 |
| CCB: amlodipine 2.5–10 mg

 | Heart failure

 | Pedal oedema (dose-related), constipation

 | —

 |
| ACE inhibitor: enalapril 5–40 mg, ramipril 2.5–10 mg

 | Pregnancy, planning pregnancy, prior ACE-inhibitor angioedema, bilateral renal artery stenosis

 | Dry cough, angioedema, hyperkalaemia, rise in creatinine

 | Cough from bradykinin; boxed fetal toxicity

 |
| ARB: losartan 50–100 mg, telmisartan 40–80 mg

 | Pregnancy, bilateral renal artery stenosis

 | Hyperkalaemia, hypotension, acute renal failure

 | Boxed fetal toxicity

 |
| Thiazide-like: chlorthalidone 12.5–25 mg

 | Pregnancy, gout

 | Glucose intolerance, low sodium and potassium, high calcium

 | —

 |
| Beta-blockers: metoprolol, carvedilol, labetalol, nebivolol

 | Asthma, severe bradycardia, 2nd/3rd-degree AV block, uncontrolled HF

 | Fatigue, hyperglycaemia, sexual dysfunction

 | For angina, post-MI, heart failure

 |
| MRA: spironolactone 25 mg

 | Hyperkalaemia

 | Gynaecomastia, mastalgia

 | —

 |

**Hypertensive urgency** (≥ 180/120 without acute organ damage): start **oral** drugs, lower BP gradually over 24–48 hours,
**no IV drugs**; review within a week. With red-flag symptoms, stabilise and refer.

## Other Antihypertensives: Label Warnings

- **Hydralazine**: a lupus-like syndrome (including glomerulonephritis).

- **Methyldopa**: positive Coombs test, haemolytic anaemia, liver disorders.

- **Sodium nitroprusside**: releases **cyanide**; never run at the maximum rate for more than 10 minutes.

- **Verapamil**: avoid in 2nd/3rd-degree AV block; with beta-blockers ventricular function can deteriorate.

- **Furosemide**: ototoxicity (tinnitus, deafness), especially with rapid injection, renal failure, high doses or aminoglycosides.

## Heart Failure (ICMR 2026)

- **Decongest first** with IV furosemide (and oxygen if saturation < 90%).

- Then start an **ARNI** (sacubitril-valsartan) and **spironolactone**; add a **beta-blocker after
decongestion** (carvedilol 3.125–25 mg twice daily, metoprolol or bisoprolol, started low and uptitrated every 1–2 weeks); add an
**SGLT2 inhibitor** (dapagliflozin reduces CV death and heart-failure hospitalisation). Consider ivabradine, vericiguat and digoxin at
tertiary level.

- HFrEF = ejection fraction < 35% (ICMR). Give pneumococcal and influenza vaccines.

- **ARNI**: allow a **36-hour washout** when switching from or to an ACE inhibitor (angioedema risk).

- **Spironolactone**: hyperkalaemia (watch potassium and creatinine), gynaecomastia. **Ivabradine**: blocks the HCN
channel (the pacemaker If current) and slows the heart.

## Stable Angina (ICMR 2026)

- Stable angina: effort-related pain relieved by rest or nitroglycerin within 1–2 minutes.

- **Control symptoms**: metoprolol with or without a dihydropyridine CCB; add nitrates if needed; then trimetazidine,
nicorandil or ranolazine.

- **Prevent events**: aspirin 75 mg (clopidogrel 75 mg if aspirin is not tolerated) and high-intensity statins (atorvastatin
40–80 mg or rosuvastatin 20–40 mg); ACE inhibitor. Prefer CABG over PCI in diabetes with multivessel or left-main disease.

- **Sublingual nitroglycerin**: one tablet every 5 minutes, no more than three in 15 minutes; then seek help.
**Never with PDE-5 inhibitors** (sildenafil, tadalafil): severe hypotension, syncope, ischaemia.

- **Nitrate tolerance**: efficacy returns only after nitrates have been absent for several hours (nitrate-free interval).

## Traps the Examiner Sets

- ACE-inhibitor cough is from bradykinin and resolves when the drug is stopped.

- ACE inhibitors and ARBs are contraindicated in pregnancy and in bilateral renal artery stenosis.

- Amlodipine is contraindicated in heart failure (ICMR) and causes ankle oedema.

- Never ACE inhibitor + ARB; ARNI needs 36 hours off an ACE inhibitor.

- Beta-blockers in heart failure only after decongestion, started low.

- Nitrates + sildenafil = dangerous hypotension.

- Hypertensive urgency: oral drugs, slow lowering, no IV.

## Memory Hooks & Shortcuts

*Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.*

- 🧠 **140/90 twice, 160/100 once** — ICMR diagnosis of hypertension

- 🧠 **A + T, then T↑, A↑, add C, then S** — ICMR protocol: amlodipine, telmisartan, chlorthalidone, spironolactone

- 🧠 **Two RAAS = Renal disaster** — never combine ACE inhibitor and ARB

- 🧠 **ACE = Always Coughs Eventually** — bradykinin cough with ACE inhibitors

- 🧠 **Pregnant? Pull the pril and sartan** — RAAS drugs are fetotoxic

- 🧠 **Drain, then Defend** — heart failure: decongest with furosemide, then ARNI, spironolactone, beta-blocker, SGLT2 inhibitor

- 🧠 **Nitrate + Viagra = Floor** — PDE-5 inhibitors with nitrates cause severe hypotension

## Rapid-Revision Cards

- G1 140–159/90–99 · G2 160–179/100–109 · G3 ≥ 180/110.

- ≥ 140/90 on 2 visits, or ≥ 160/100 at one.

- < 140/90; < 130/80 DM/CKD/CVD; < 150/90 at ≥ 80.

- Two classes, single pill: CCB or thiazide-like + ACEi/ARB.

- Amlo 5 → +Telmi 40 → Telmi 80 → Amlo 10 → +Chlorthalidone 12.5 → MRA; 4-weekly.

- ACEi + ARB together.

- Avoid in heart failure; pedal oedema.

- Dry cough (bradykinin), angioedema, hyperkalaemia; not in pregnancy or bilateral RAS.

- Boxed fetal toxicity: stop when pregnancy found.

- Avoid in gout, pregnancy; low K and Na, high Ca and glucose.

- ≥ 180/120, no organ damage: oral drugs, lower over 24–48 h, no IV.

- Drug-induced lupus.

- Coombs-positive haemolytic anaemia.

- Cyanide; max rate ≤ 10 min.

- IV furosemide to decongest.

- ARNI + spironolactone; beta-blocker after decongestion; SGLT2 inhibitor.

- 36-hour gap from ACEi.

- Hyperkalaemia, gynaecomastia.

- Blocks HCN (If) current.

- Metoprolol ± DHP CCB; add nitrates.

- Aspirin 75 (clopidogrel if intolerant) + high-intensity statin + ACEi.

- Every 5 min, max 3 in 15 min.

- Contraindicated: severe hypotension.

- Needs a nitrate-free interval.

- Ventricular depression, AV block.

- Ototoxicity, worse with aminoglycosides.

## Sources

*Facts in this article were checked against these documents.*

- Standard Treatment Workflow: Hypertension in Adults — Indian Council of Medical Research / Department of Health Research, MoHFW, May 2026

- Standard Treatment Workflows: Heart Failure; Stable Angina — Indian Council of Medical Research / Department of Health Research, MoHFW, January 2026

- Prescribing labels: Vasotec, Cozaar, Entresto, Aldactone, Farxiga, Nitrostat, isosorbide mononitrate ER, Corlanor, hydralazine, methyldopa, sodium nitroprusside, verapamil ER, amlodipine, furosemide — DailyMed, US National Library of Medicine, current labels, accessed November 2026 (link)

- Competency Based Undergraduate Curriculum, Pharmacology (PH 4.1–4.5) — National Medical Commission, 2024

## Test Yourself: Practice Questions

Twenty-five questions in NEET PG style, most of them clinical vignettes.

## Practice Questions (NEET PG pattern)

*Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer
was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.*

**Q1.** A 45-year-old has BP 150/95 on two visits; no other illness. Under ICMR 2026, the usual starting treatment is

- (a) clonidine

- (b) furosemide

- (c) two drugs from different classes (e.g. amlodipine with an ARB), preferably as a single pill

- (d) a beta-blocker alone

**Answer: (c)** — Two-drug combination can be the default for most adults; a CCB or thiazide-like diuretic is paired with an ACE inhibitor or ARB.

**Q2.** Hypertension can be diagnosed at a single clinic visit (ICMR) when BP is at least

- (a) 180/120 only

- (b) 130/80

- (c) 160/100

- (d) 140/90

**Answer: (c)** — ≥ 140/90 on two visits, or ≥ 160/100 at one visit.

**Q3.** The ICMR BP target for a 60-year-old with diabetes is

- (a) below 120/70 at any cost

- (b) below 160/100

- (c) below 150/90

- (d) below 130/80 if tolerated

**Answer: (d)** — Diabetes, CKD or established CVD: < 130/80 (optimal, if tolerated); ≥ 80 years: < 150/90.

**Q4.** A woman on enalapril develops a persistent dry cough. The mechanism and best switch are

- (a) bradykinin accumulation; it resolves when the ACE inhibitor is stopped

- (b) histamine release; add an antihistamine

- (c) beta-blockade; it is permanent

- (d) fluid overload; add furosemide

**Answer: (a)** — ACE inhibitors block bradykinin degradation; the cough always resolved after stopping therapy (label).

**Q5.** A hypertensive woman on losartan finds she is 8 weeks pregnant. The right action is to

- (a) add enalapril

- (b) double the dose

- (c) continue losartan

- (d) stop losartan as soon as possible (fetal toxicity)

**Answer: (d)** — Boxed warning: RAAS drugs injure and can kill the fetus; discontinue when pregnancy is detected.

**Q6.** ACE inhibitors and ARBs are contraindicated in

- (a) heart failure

- (b) type 2 diabetes

- (c) bilateral renal artery stenosis

- (d) post-MI patients

**Answer: (c)** — ICMR lists bilateral renal artery stenosis (and pregnancy, prior ACE-inhibitor angioedema) as contraindications.

**Q7.** A man with heart failure is started on amlodipine for hypertension. Under ICMR this is

- (a) inappropriate: heart failure is listed as a contraindication to the CCB

- (b) required with every ARNI

- (c) safe only with digoxin

- (d) the best choice

**Answer: (a)** — ICMR table: amlodipine — contraindication heart failure; side effects pedal oedema, constipation.

**Q8.** A patient's BP stays high on amlodipine and telmisartan. Under ICMR, a doctor should never add

- (a) chlorthalidone

- (b) spironolactone later

- (c) a lifestyle plan

- (d) an ACE inhibitor, because combining two RAAS blockers raises kidney-injury risk

**Answer: (d)** — Do not combine two RAAS blockers (AKI risk). Next steps are chlorthalidone, then an MRA.

**Q9.** A man with gout needs a third antihypertensive. ICMR advises against

- (a) telmisartan

- (b) amlodipine

- (c) metoprolol

- (d) chlorthalidone (thiazide-like diuretic)

**Answer: (d)** — Thiazide-like diuretics: contraindicated in pregnancy and gout; cause glucose intolerance, hypokalaemia, hyponatraemia, hypercalcaemia.

**Q10.** BP is 190/122 in an asymptomatic man with no signs of organ damage (hypertensive urgency). ICMR advises

- (a) IV labetalol bolus

- (b) no treatment

- (c) oral antihypertensives, lowering BP gradually over 24–48 hours, no IV drugs

- (d) IV nitroprusside at once

**Answer: (c)** — Urgency: start oral drugs, reduce gradually, do not use IV medicines; follow up within a week.

**Q11.** A woman on hydralazine develops arthralgia, rash and a positive ANA. The likely cause is

- (a) rheumatoid arthritis

- (b) drug-induced lupus from hydralazine

- (c) ACE-inhibitor angioedema

- (d) methyldopa haemolysis

**Answer: (b)** — Hydralazine can cause a syndrome simulating SLE, including glomerulonephritis.

**Q12.** Long-term methyldopa can cause

- (a) lupus

- (b) a positive Coombs test and haemolytic anaemia

- (c) gynaecomastia

- (d) cough

**Answer: (b)** — Methyldopa label: positive Coombs test, haemolytic anaemia and liver disorders.

**Q13.** A patient on a high-dose nitroprusside infusion for 2 days develops metabolic acidosis and confusion. Suspect

- (a) cyanide toxicity

- (b) beta-blocker overdose

- (c) thiazide hyponatraemia

- (d) digoxin toxicity

**Answer: (a)** — Nitroprusside releases cyanide; maximum-rate infusion should never exceed 10 minutes.

**Q14.** In acute decompensated heart failure, ICMR's first step is to

- (a) decongest with IV furosemide

- (b) start ivabradine

- (c) give verapamil

- (d) start a beta-blocker at full dose

**Answer: (a)** — Decongest with IV furosemide; beta-blockers only after decongestion.

**Q15.** In heart failure with reduced EF, a beta-blocker should be started

- (a) never

- (b) at full dose during acute pulmonary oedema

- (c) after decongestion, at a low dose, titrated every 1–2 weeks

- (d) only with verapamil

**Answer: (c)** — Consider beta-blockers after decongestion; start low and uptitrate 1–2 weekly.

**Q16.** A patient on enalapril is to switch to sacubitril-valsartan. The required gap is

- (a) 7 days

- (b) no gap

- (c) 36 hours

- (d) 2 hours

**Answer: (c)** — Entresto: 36-hour washout between ACE inhibitor and ARNI (angioedema risk).

**Q17.** Which drug, originally for diabetes, reduces CV death and heart-failure hospitalisation in heart failure?

- (a) Pioglitazone

- (b) Insulin

- (c) Dapagliflozin (SGLT2 inhibitor)

- (d) Glibenclamide

**Answer: (c)** — Farxiga is indicated to reduce CV death, HF hospitalisation and urgent HF visits; ICMR includes SGLT2 inhibitors.

**Q18.** A man on spironolactone for heart failure develops painful breast enlargement and a potassium of 6.0. Both are

- (a) unrelated

- (b) signs of digoxin toxicity

- (c) known adverse effects of spironolactone

- (d) due to furosemide

**Answer: (c)** — Aldactone causes gynaecomastia and hyperkalaemia; ICMR advises watching potassium and creatinine.

**Q19.** Ivabradine lowers heart rate by blocking

- (a) the HCN channel carrying the pacemaker If current

- (b) L-type calcium channels

- (c) Na-K ATPase

- (d) beta-1 receptors

**Answer: (a)** — Corlanor blocks the hyperpolarization-activated cyclic nucleotide-gated channel (If).

**Q20.** A man with stable angina took sildenafil last night and now has chest pain. Sublingual nitroglycerin is

- (a) first-line

- (b) safe at half dose

- (c) safe with aspirin

- (d) contraindicated: severe hypotension, syncope or ischaemia

**Answer: (d)** — Nitrostat is contraindicated with PDE-5 inhibitors.

**Q21.** During an angina attack, sublingual nitroglycerin may be taken

- (a) only after aspirin fails

- (b) every hour without limit

- (c) every 5 minutes, up to 3 tablets in 15 minutes, then seek help

- (d) once a day only

**Answer: (c)** — One tablet every 5 minutes until relief; no more than three in 15 minutes.

**Q22.** A patient on round-the-clock isosorbide mononitrate finds it stops working. The remedy is

- (a) switching to IV nitrates continuously

- (b) adding sildenafil

- (c) a daily nitrate-free interval

- (d) doubling the dose repeatedly

**Answer: (c)** — Tolerance: efficacy is restored only after nitrates have been absent for several hours; dose escalation fails.

**Q23.** For symptom control in stable angina, ICMR starts with

- (a) ranolazine alone

- (b) digoxin

- (c) metoprolol with or without a dihydropyridine CCB

- (d) furosemide

**Answer: (c)** — Metoprolol ± DHP CCB, add nitrates; then trimetazidine, nicorandil or ranolazine.

**Q24.** A man with stable angina cannot tolerate aspirin. ICMR's alternative antiplatelet is

- (a) warfarin

- (b) heparin

- (c) no antiplatelet

- (d) clopidogrel 75 mg daily

**Answer: (d)** — Clopidogrel 75 mg OD if intolerant to aspirin; plus high-intensity statin.

**Q25.** A patient on metoprolol for angina is given verapamil. The risk is

- (a) hypertension

- (b) cough

- (c) hyperkalaemia

- (d) worsening ventricular function and AV block

**Answer: (d)** — Verapamil with beta-blockers can depress ventricular function; avoid in 2nd/3rd-degree AV block.

### Active Recall

From memory: give the ICMR 2026 hypertension grades, diagnosis rule, targets, first-line strategy and step-up protocol; list each class with its contraindications and side effects; outline heart-failure and stable-angina treatment under ICMR; and recall the label warnings for ACE inhibitors, ARNI, nitrates, hydralazine, methyldopa and nitroprusside.