**Question:** Drug contraindicated in patient with rheumatic heart disease in PPH is

A. Nitroglycerin
B. Nifedipine
C. Verapamil
D. Amiodarone

**Core Concept:**
Rheumatic heart disease is a condition caused by past streptococcal infection that leads to inflammation and damage to heart valves, causing valvular dysfunction. Poorly controlled hypertension (PPH) in a patient with rheumatic heart disease may further compromise cardiac output and worsen the condition, making the patient more prone to complications.

**Why the Correct Answer is Right:**
Nitroglycerin is a vasodilator that increases blood flow and decreases blood pressure by relaxing blood vessels. In a patient with rheumatic heart disease and PPH, nitroglycerin could worsen their cardiovascular instability, leading to a decrease in cardiac output and worsening of valvular dysfunction.

**Why Each Wrong Option is Incorrect:**
B. Nifedipine (calcium channel blocker) might also decrease blood pressure and heart rate, but it is less likely to cause significant cardiovascular instability compared to nitroglycerin.
C. Verapamil (calcium channel blocker) is also contraindicated in patients with rheumatic heart disease due to its potential to cause bradycardia and hypotension, worsening their cardiovascular instability.
D. Amiodarone (antiarrhythmic drug) is contraindicated in patients with rheumatic heart disease due to its potential to cause hypotension, bradycardia, and worsening of valvular dysfunction.

**Clinical Pearl:**
In patients with rheumatic heart disease and PPH, a careful selection of antihypertensive medication is crucial to avoid worsening cardiovascular instability and further compromising the already impaired cardiac output. Optimal management involves judicious use of medication that does not significantly affect blood pressure and heart rate, such as a beta-blocker or ACE inhibitor, with close monitoring of cardiovascular status and potential side effects.

**Correct Answer:**
D. Amiodarone

**Explanation:** Amiodarone, an antiarrhythmic drug, is contraindicated in patients with rheumatic heart disease due to its potential to cause hypotension, bradycardia, and worsening of valvular dysfunction. In contrast, the other options (nitroglycerin, verapamil, and nifedipine) are more likely to cause significant cardiovascular instability in patients with rheumatic heart disease and PPH, making them the correct answer.