39. Heart Failure (HF) Flashcards
A patient with systolic heart failure has been given a prescription for BiDil. Which of the following side effects is most common with BiDil therapy?
A. Rash
B. Headache
C. Hair growth
D. Sore, painful joints
E. Increased appetite
B. Headache is a common side effect of any nitrate therapy, including BiDil. Some patients find benefit by pre-treating with acetaminophen.
isosorbide dinitrate/hydralazine (BiDil): indicated in black patients with NYHA FC III-IV who are symptomatic despite optimal therapy with ACE-Is and beta blockers. CI with PDE-5 inhibitors. Warning: DILE. SE: headache, dizziness, hypotension, tachycardia, weakness. does not need nitrate-free interval. target dose 40/75mg TID
Max is hospitalized with a MRSA infection and is receiving vancomycin. This antibiotic carries a risk of ototoxicity. The physician is trying to adjust his other medications and asks the pharmacist which loop diuretic has the highest risk of ototoxicity. Which of the loop diuretics has the highest risk for ototoxicity?
A. Lasix
B. Bumex
C. Demadex
D. Edecrin
E. All loops have equal risk of ototoxicity
D. All of the loop diuretics can cause ototoxicity (especially with IV dosing) but ethacrynic acid has the highest risk among the loops. Additional risk is present if the patient is using other ototoxic drugs, such as vancomycin or aminoglycosides.
Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).
furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature
bumetanide (Bumex): IV:PO is 1:1
torsemide (Demadex): IV:PO is 1:1
ethacrynic acid (Edecrin): IV:PO is 1:1
Select the correct generic name for Natrecor:
A. Nitroprusside
B. Nebivolol
C. Eplerenone
D. Naloxone
E. Nesiritide
E. The generic name for Natrecor is nesiritide.
Select the correct mechanism of action for Diovan:
A. Binds to the Na+/K+ ATPase pump and decreases its action
B. Aldosterone receptor antagonist
C. Binds to beta-adrenergic receptors and blocks epinephrine and norepinephrine
D. Blocks angiotensin II by binding directly to the AT1 receptor
E. Blocks the conversion of angiotensin I to angiotensin II
D. Angiotensin receptor blockers (ARBs) such as Diovan block AT II directly at a receptor site on the smooth muscle wall of the vessel.
Diovan (valsartan)
A patient gave the pharmacist a prescription for Edecrin 25 mg daily. Which of the following is an appropriate generic substitution for Edecrin?
A. Ethacrynic acid
B. Torsemide
C. Bumetanide
D. Nesiritide
E. Furosemide
A. The generic name of Edecrin is ethacrynic acid.
furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature
bumetanide (Bumex): IV:PO is 1:1
torsemide (Demadex): IV:PO is 1:1
ethacrynic acid (Edecrin): IV:PO is 1:1
GT is a systolic heart failure patient on carvedilol 12.5 mg twice daily. To improve medication adherence, the primary physician wants to convert him to the once daily Coreg CR. What is the equivalent daily dose of Coreg CR for GT?
A. 10 mg
B. 20 mg
C. 40 mg
D. 80 mg
E. 160 mg
C. The conversion of immediate release carvedilol to Coreg CR is not on a direct mg per mg basis due to the formulation. Immediate release carvedilol 12.5 mg BID = Coreg CR 40 mg daily.
A 71 year-old male patient with heart failure was receiving standard therapy, however, he remained symptomatic. He has an appointment with the cardiologist in six weeks. To try and help him out, his primary care physician initiated digoxin 0.25 mg once daily and increased his carvedilol dose from 3.125 mg BID to 6.25 mg BID. Recent lab work includes an ALT 78 units/L, BUN 40 mg/dL, SCr 2.1 mg/dL, and K+ 4.5 mEq/L. The patient took the new medications for a couple of weeks and began to notice nausea and a reduced appetite. He felt confused and disoriented. He went back to the physician for help. What is the likely cause of the patient’s symptoms?
A. Digoxin toxicity
B. The increased carvedilol dose
C. Liver failure
D. Decompensated heart failure
E. The potassium level
A. The patient is likely experiencing digoxin toxicity. The patient is prescribed a dose that requires good renal function, however he has very poor renal function and digoxin is primarily (~85%) renally cleared.
digoxin (Digox, Lanoxin): inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR). Does not improve survival, but does improve QoL and reduce hospitalizations. CI: ventricullar fibrillation. Warning: vesicant, avoid in 2nd or 3rd degree heart block with a functional pacemaker. SE: dizziness mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.
A patient with New York Heart Association (NYHA) functional class III heart failure is diagnosed with rheumatoid arthritis (RA). The physician must choose an agent to treat the RA. Which of the following medications would be most appropriate in this patient?
A. Certolizumab
B. Infliximab
C. Methotrexate
D. Etanercept
E. Rituximab
C. TNF-blockers have a warning regarding worsening or new onset heart failure; therefore, they are generally avoided in heart failure patients. Methotrexate is the (relatively) safest agent for this patient.
An elderly patient with NYHA functional class IV heart failure is using 120 mg of furosemide twice daily. He takes his furosemide at 8 am and 12 noon. He has several conditions and takes a lot of pills. The prescriber requests that you calculate the dose of bumetanide that would be equivalent to the patient’s furosemide therapy. Choose the correct equivalent bumetanide dose:
A. Bumetanide 2 mg daily
B. Bumetanide 4 mg daily
C. Bumetanide 6 mg daily
D. Bumetanide 8 mg daily
E. Bumetanide 10 mg daily
C. The conversion ratio is 40 mg furosemide to 1 mg bumetanide. The patient is using a total daily dose of 240 mg, and the equivalent dose of bumetanide would be 6 mg daily.
bumetanide = 1
torsemide = 20
furosemide = 40
ethacrynic acid = 50
“Because They Fuck Everything”
Which of the following statements is correct regarding digoxin?
A. Digoxin is a positive inotrope and a negative chronotrope.
B. Digoxin is a positive inotrope and a positive chronotrope.
C. Digoxin is a negative inotrope and a negative chronotrope.
D. Digoxin is a negative inotrope and a positive chronotrope.
E. Digoxin has no effects on these hemodynamic parameters.
A. Digoxin is a positive inotrope, which means it increases the force of the heart’s contractions, and is a negative chronotrope, which means it decreases heart rate.
digoxin (Digox, Lanoxin): inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR). Does not improve survival, but does improve QoL and reduce hospitalizations. CI: ventricullar fibrillation. Warning: vesicant, avoid in 2nd or 3rd degree heart block with a functional pacemaker. SE: dizziness mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.
A patient gave the pharmacist a prescription for Aldactone 25 mg daily. Which of the following is an appropriate generic substitution for Aldactone?
A. Traimterene/Hydrochlorothiazide
B. Spironolactone
C. Eplerenone
D. Alendronate
E. Alfuzosin
B. The generic name of Aldactone is spironolactone.
K-Sparing Diuretics: For patients with NYHA FC II-IV. Compete with aldosterone at the distal convoluted tubule and collecting ducts, increasing Na and water excretion while conserving K and H+. Not effective as monotherapy and are commonly used in combination. Boxed warning: tumor risk (spironolactone). CI: anuria, significant renal impairment, hyperkalemia. SE: hyperkalemia, increase SCr, dizziness, pregnancy (C). Do not use when: CrCl <30, SCr >2 (females), SCr >2.5 (males), K >5 or diseases such as Addison’s
spironolactone (Aldactone): for HTN and HF. blocks androgen (SE: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea), remember “A” for androgen block. target dose 25mg daily or BID
eplerenone (Inspra): for HTN and HF. selective aldosterone blocker, SE: increase TGs, 3A4 substrate (use with 3A4 inhibitors is CI). target dose 50mg daily
Which of the following beta-adrenergic blocking agents has been shown to reduce mortality in patients with systolic heart failure?
A. Carvedilol
B. Metoprolol tartrate
C. Atenolol
D. Propranolol
E. Labetalol
A. The only beta-blockers which have been shown in prospective, randomized trials to reduce mortality in systolic heart failure are metoprolol succinate, carvedilol, and bisoprolol.
Jamal has systolic heart failure with an ejection fraction of 33%. He gets short of breath while reaching down to tie his shoes and getting dressed. Which of the following ACC/AHA stages and NYHA functional class for heart failure best describe this patient?
A. ACC/AHA Stage A
B. ACC/AHA Stage B, NYHA Class I
C. ACC/AHA Stage C, NYHA Class II
D. ACC/AHA Stage C, NYHA Class III
E. ACC/AHA Stage D, NYHA Class IV
D. Jamal is classified as an ACC/AHA Stage C which indicates structural heart disease with prior or current heart failure symptoms. He is also NYHA Class III since he has symptoms with minimal exertion.
A patient with systolic heart failure and atrial fibrillation uses lisinopril, carvedilol, spironolactone, amiodarone, furosemide, clopidogrel, digoxin, cholestyramine and potassium. Which drug is likely to lower the digoxin level via a gut binding interaction?
A. Amiodarone
B. Clopidogrel
C. Lisinopril
D. Carvedilol
E. Cholestyramine
E. Bile acid sequestrants such as cholestyramine can inhibit digoxin absorption and lower digoxin concentration levels if the dosing is not separated.
Esther has NYHA functional class III systolic heart failure. She needs to use an additional drug to lower her blood pressure. She is currently taking Altace and hydrochlorothiazide. Which of the following medications should be added for her blood pressure?
A. Diltiazem
B. Monopril
C. Carvedilol
D. Amlodipine
E. Candesartan
C. Beta-blockers are considered a first-line option in heart failure patients.
Drugs used in HF:
1st line: beta-blockers and ACE-Is (both agents decrease mortality, start low and titrate up)
2nd line: loop diuretics (+/- benefit), ARBs (+/- benefit), aldosterone antagonists (decrease mortality, most likely to be added on 1st as 2nd line), digoxin (no mortality benefit, but does improve QoL, and decrease hospitalizations), BiDiL (decrease mortality in African American)
Choose the correct mechanism of action for carvedilol:
A. Beta-1 and beta-2 blocker and dopamine blocker
B. Beta-1 and beta-2 blocker and norepinephrine reuptake inhibitor
C. Beta-1 and beta-2 blocker and alpha-1 blocker
D. Beta-2 and alpha-2 selective blocker
E. Beta-1 and alpha-1 selective blocker
C. Carvedilol is a beta non-selective blocker that also blocks alpha-1 receptors in arterial walls.
Non-selective alpha and beta blocker
carvedilol (Coreg): PO. take with food. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels. Coreg IR target dose is weight dependent (<85kg = 25mg BID; >85kg = 50mg BID). Coreg CR target dose 80mg daily
A patient with systolic heart failure on digoxin has developed an upper respiratory tract infection. He has been prescribed clarithromycin. Choose the correct statement:
A. The digoxin level will decrease; it is best not to use a P450 3A4 enzyme inducer such as clarithromycin.
B. The digoxin level will increase; it is best not to use a P-glycoprotein and 3A4 inhibitor such as clarithromycin.
C. Digoxin levels are not affected by hepatic inducers or inhibitors.
D. Clarithromycin will bind to digoxin in the gut and reduce absorption.
E. Digoxin will cause the clarithromycin level to increase.
B. The interaction between digoxin and clarithromycin is mainly due to the inhibition of P-glycoprotein and (to a lesser extent) 3A4 inhibition.
A patient gave the pharmacist a prescription for BiDil 20 mg TID. Which of the following is an appropriate generic substitution for BiDil?
A. Isosorbide dinitrate/hydralazine
B. Spironolactone
C. Isosorbide mononitrate/hydralazine
D. Digoxin
E. Triamterene/Hydrochlorothiazide
A. The generic name of BiDil is isosorbide dinitrate + hydralazine.
Select the correct mechanism of action for Zestril:
A. Binds to the Na+/K+ ATPase pump and decreases its action
B. Aldosterone receptor antagonist
C. Blocks the conversion of angiotensin I to angiotensin II
D. Blocks angiotensin II by binding directly to the AT1 receptor
E. Binds to beta-adrenergic receptors and blocks epinephrine and norepinephrine
C. Zestril is an ACE inhibitor which blocks the conversion of angiotensin I to angiotensin II.
Renin-Angiotensin Aldosterone System (RAAS) Inhibitors: ACE-I & ARB. For ALL heart failure patients regardless of symptoms.
First line in CKD, slow progression of kidney disease, HF, stroke. Do not use ACE-I and ARB together. Avoid in pregnancy (D), angioedema, bilateral renal artery stenosis, or with aliskiren in patients with DM or GFR <60. SE: hyperkalemia, hypotension, cough (ACE-I only), dizziness, headache. Can decrease lithium’s renal clearance and increase risk of toxicity.
Hamid has been prescribed Lasix. The following may occur from the use of this drug: (Select ALL that apply.)
A. Increased magnesium
B. Increased blood glucose
C. Increased potassium
D. Increased chloride
E. Increased triglycerides
B, E. Loop diuretics decrease sodium, magnesium, chloride, calcium and potassium and increase blood glucose and triglycerides.
Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).
John went to see a cardiologist at his doctor’s request. John does not understand why he should see a heart doctor. He has no heart failure symptoms or signs that the doctor has noticed, but his primary care physician wants a specialist to look at his heart. His past medical history is significant for high cholesterol, hypertension and type 2 diabetes. Which of the following ACC/AHA categories for heart failure best describe this patient?
A. ACC/AHA Stage A
B. ACC/AHA Stage B
C. ACC/AHA Stage C
D. ACC/AHA Stage D
EJohn does not match any of ACC/AHA staging categories
A. John is classified as ACC/AHA Stage A since he is high risk for heart failure but without evidence of structural heart disease or heart failure symptoms.
A heart failure patient is receiving furosemide 80 mg intravenously twice daily for the treatment of acute pulmonary edema. After two days, the patient is negative 5 liters of urine output. The patient is noted to have an increasing serum bicarbonate concentration of 36 mEq/L. Which of the following agents can be prescribed to prevent development of a metabolic alkalosis?
A. Hydrochlorothiazide
B. Triamterene
C. Acetazolamide
D. Mannitol
E. Metolazone
C. Acetazolamide inhibits carbonic anhydrase, the enzyme responsible for catalyzing the conversion of carbonic acid (H2CO3) to H2O + CO2 in the renal tubule which leaves more HCO3- available for reabsorption. When carbonic anhydrase in inhibited, the reaction favors maintenance of H2CO3 which results in greater elimination of bicarbonate.
Frank has been diagnosed with heart failure and was told to begin Toprol XL 12.5 mg daily. The pharmacist dispensed a 25 mg tablet with instructions to the patient to cut at the score line. Which of the following statements are true regarding Toprol XL? (Select ALL that apply.)
A. This is an extended-release formulation and cannot be cut.
B. This medication can be taken without regard to food.
C. The dose is likely to be titrated every 2 weeks, if tolerated.
D. This medication should be stored in the refrigerator.
E. Toprol XL can be cut at the score line; they should use a tablet cutter.
B, C, E. Toprol XL tablets have a score line and can be cut. They remain long-acting if cut only at the score line. They cannot be crushed or chewed.
metoprolol succinate (Toprol XL): PO, IV. IV:PO ratio 1:2.5. target dose 200mg daily
Esther has NYHA functional class III systolic heart failure. The cardiologist is considering beginning Inspra, in addition to her other medications. He checks her lab values and finds the following: Na+ 151 mEq/L, K+ 5.6 mEq/L, Cl 99 mEq/L, C02 mEq/L 20, BUN 39 mg/dL and serum creatinine 1.8 mg/dL. Can Inspra be initiated?
A. Yes, once she is classified as NYHA IV.
B. Yes, once she has trouble breathing without exertion.
C. No, Inspra is contraindicated.
D. Yes, but it will require sodium monitoring.
E. Yes, but it will require potassium monitoring.
C. The aldosterone blockers like Inspra should not be started if the potassium is greater than 5 mEq/L. If a patient is using one of these agents and the potassium reaches 5.5 mEq/L the aldosterone blocker is stopped.
K-Sparing Diuretics: For patients with NYHA FC II-IV. Compete with aldosterone at the distal convoluted tubule and collecting ducts, increasing Na and water excretion while conserving K and H+. Not effective as monotherapy and are commonly used in combination. Boxed warning: tumor risk (spironolactone). CI: anuria, significant renal impairment, hyperkalemia. SE: hyperkalemia, increase SCr, dizziness, pregnancy (C). Do not use when: CrCl <30, SCr >2 (females), SCr >2.5 (males), K >5 or diseases such as Addison’s
spironolactone (Aldactone): for HTN and HF. blocks androgen (SE: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea), remember “A” for androgen block. target dose 25mg daily or BID
eplerenone (Inspra): for HTN and HF. selective aldosterone blocker, SE: increase TGs, 3A4 substrate (use with 3A4 inhibitors is CI). target dose 50mg daily
Which of the following agents is associated with a risk of cyanide toxicity?
A. Nitrogylcerin
B. Nitroprusside
C. Nesiritide
D. Eplerenone
E. Enalaprilat
B. Nitroprusside has a risk of cyanide and thiocyanate toxicity.
Vasodilators
nesiritide (Natrecor): provides both arterial and venous vasodilation. long half life. recombinant B-type natriuretic peptide. CI: persistent SBP <100 prior to therapy, cardiogenic shock. SE: hypotension, SCr
nitroglycerin: venous vasodilator at low dose, arterial vasodilator at higher doses. CI: SBP <90, concurrent use with PDE-5 inhibitors, increase intracranial pressure. SE: hypotension, headache, lightheadedness, tachycardia, tachyphylaxis. No PVC due to adsorption
nitroprusside (Nitropress): equal arterial and venous vasodilator at all doses. metabolism results in the formation of thiocynanate and cyanide which can cause toxicity. Boxed warning: rise in cyanide quantities at high infusion rates, can cause excessive hypotension, solution must be further diluted with D5W. CI: SBP <90, PDE-5 inhibitors, increase intracranial pressure. SE: hypotension, headache, tachycardia, thiocynanate/cyanide toxicity (especially in renal and hepatic impairment). requires protection from light during administration.
A patient presents to the hospital with increasing shortness of breath, fatigue, and lower extremity edema. The patient is diagnosed with acute decompensated heart failure. His blood pressure is 105/60 mmHg and his heart rate is 80 beats/minute. His serum creatinine is 1.4 mg/dL. In addition to furosemide, which of the following intravenous vasodilators are appropriate for this patient? (Select ALL that apply.)
A. Nitrogylcerin
B. Nesiritide
C. Milrinone
D. Dopamine
E. Phenylephrine
A, B. Milrinone, dopamine and phenylephrine are not vasodilators.
The most effective diuretics for controlling fluid volume in patients with heart failure are:
A. Carbonic anhydrase inhibitors
B. Thiazide-type diuretics
C. Loop diuretics
D. Potassium-sparing diuretics
E. Osmotic diuretics
C. Loop diuretics are the preferred diuretics in heart failure patients.
Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).
furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature
bumetanide (Bumex): IV:PO is 1:1
torsemide (Demadex): IV:PO is 1:1
ethacrynic acid (Edecrin): IV:PO is 1:1
