CVS Pharmacology 3: Heart Failure.

Question 1

Definition: a state which the heart is unable to pump blood at a rate sufficient to meet the body’s requirement or can do so only at elevated filling pressure?

Answer 1

Heart failure.

Question 2

List 4 causes of HF?

Answer 2

1- MI.
2- cardiomyopathies.
3- viral infections.
4- excessive alcohol.

Question 3

List the symptoms of left-sided heart failure?

Answer 3

1- low cardiac output.
2- elevated pulmonary venous pressure.
3- dyspnea.

Question 4

List the symptoms of right-sided heart failure?

Answer 4

Symptoms of fluid retention; usually RV failure is secondary to LV failure.

Question 5

List the 4 symptoms of low output (forward failure)?

Answer 5

1- fatigue.
2- dizziness.
3- SOB.
4- aggravated by physical exercise.

Question 6

Increased filling pressure leads to what?

Answer 6

Congestions of the organs upstream of the heart (backward failure).

Question 7

Backward failure leads to what?

Answer 7

Edema, maldigestion, and ascites.

Question 8

Definition: an emergency condition in which the patient was asymptomatic before the onset of heart failure?

Answer 8

Acute HF.

Question 9

Acute HF is seen in which conditions?

Answer 9

Acute injury such as MI.

Question 10

Definition: long term syndrome in which the patient exhibits symptoms over a long period of time?

Answer 10

Chronic HF.

Question 11

Chronic Hf is usually as a result of what?

Answer 11

A result of pre-existing cardiac condition.

Question 12

List the 9 factors precipitating HF?

Answer 12

1- myocardial ischemia or infract.
2- dietary sodium excess.
3- excess fluid intake.
4- medication noncompliance.
5- arrhythmias.
6- intercurrent illness (e.g. infection).
7- conditions associated with increased metabolic demand (e.g. pregnancy, thyrotoxicosis).
8- administration of drug with negative inotropic property of fluid retaining properties (e.g. NSAIDs, corticosteroids).
9- alcohol.

Question 13

Patients with HF are often categorized by the ____ classification.

Answer 13

NYHA.

Question 14

List the 4 HF classes of NYHA? And what do they mean?

Answer 14

1- class I: asymptomatic.
2- class II: symptomatic with moderate activity.
3- class III: symptomatic with mild activity.
4- class IV: symptomatic at rest.

Question 15

HF is often preventable by what?

Answer 15

By early detection of patients at risk and by early intervention.

Question 16

List the 3 stages of HF?

Answer 16

1- stage A.
2- stage B.
3- stage C&D.

Question 17

What is stage A HF?

Answer 17

Risk of developing HF (eg. HTN) aggressive t/t of HTN, modification of coronary risk factors, reduction of alcohol intake.

Question 18

What is stage B HF?

Answer 18

Structural heart disease but no symptoms of HF (eg. Previous MI, LVH, valvular ds), ACE-I and BB, more aggressive t/t of HTN, surgical intervention.

Question 19

What is stage C&D HF?

Answer 19

• Clinical HF.
• Patients refractory to therapy.

Question 20

Which NYHA class is stage C HF?

Answer 20

NYHA II/III.

Question 21

Stage D HF may need which type of management?

Answer 21

May need heart transplantation.

Question 22

List the 4 compensatory physiological responses in HF?

Answer 22

1- increased sympathetic activity.
2- activation of the RAAS.
3- activation of natriuretic peptides.
4- myocardial dysfunction.

Question 23

The pathophysiology of HF is complex and involves which four major interrelated systems?

Answer 23

1- the heart itself.
2- the vasculature.
3- the kidney.
4- neurohumoral regulatory circuits.

Question 24

List the 7 drugs used in HF?

Answer 24

1- ACE-I.
2- ARBs.
3- aldosterone antagonist.
4- diuretics.
5- beta blockers.
6- direct vaso- and venodilators.
7- inotropic agents.

Question 25

List the 3 new drugs used in HF?

Answer 25

1- HCN channel blocker. 2- B-type natriuretic peptide. 3- ARNI.

Question 26

Give an example of HCN channel blocker?

Answer 26

Ivabradine.

Question 27

Give an example of B-type natriuretic peptide?

Answer 27

Nesirtide.

Question 28

List the 5 treatment principles of HF?

Answer 28

1- neurohumoral modulation. 2- preload reduction. 3- afterload reduction. 4- increased cardiac contractility. 5- heart rate reduction.

Question 29

List the 3 goals of HF treatment?

Answer 29

1- decrease symptoms. 2- slow disease progression. 3- improve survival.

Question 30

Which drugs improve mortality, morbidity, exercise tolerance, and left ventricular ejaction fraction?

Answer 30

ACE-I.

Question 31

List 4 examples of ACE-I?

Answer 31

1- capropril. 2- lisinopril. 3- enalapril. 4- ramipril.

Question 32

List 3 examples of ARBs?

Answer 32

1- losartan. 2- valsartan. 3- candesartan.

Question 33

Beta blockers protect the heart from which adverse long-term consequences of sympathetic overstimulation?

Answer 33

1- increased energy consumption. 2- arrhythmias. 3- cell death. 4- improve perfusion of the myocardium by prolonging diastole.

Question 34

List 4 BBs in HF?

Answer 34

1- bisoprolol. 2- carvedilol. 3- metoprolol. 4- nebivolol.

Question 35

Which patients should be treated with a beta blocker?

Answer 35

All patients with symptomatic HF (stage C, NYHA II-IV) and all patients with left ventricular dysfunction (stage B, NYHA I) after MI.

Question 36

Beta blockers should be initiated only in which patients and at what doses?

Answer 36

Only in clinically stable patients at very low doses.

Question 37

Beta blockers should not be used in which type of HF?

Answer 37

New-onset or acutely decompensated heart failure.

Question 38

Diuretics are useful in reducing the symptoms of volume overload by what?

Answer 38

1- decreasing the extracellular volume. 2- decreasing the venous return.

Question 39

Which type of diuretics are the most effective in severe HF?

Answer 39

Loop diuretics like furosemide and bumetanide.

Question 40

List the 2 AE of diuretics?

Answer 40

1- loop diuretics and thiazides cause hypokalemia. 2- potassium sparing diuretics help in reducing the hypokalemia due to these diuretics.

Question 41

List 2 examples of potassium sparing diuretics?

Answer 41

Spironolactone or eplerenone.

Question 42

Which effects does aldosterone inhibition has?

Answer 42

Minimize potassium loss, prevent sodium and water retention, endothelial dysfunction and myocardial fibrosis.

Question 43

What is the AE of spironolactone?

Answer 43

Gynecomastia.

Question 44

Combination of potassium supplements of ACE-I can increase the risk of what?

Answer 44

Hyperkalemia.

Question 45

Which drugs can be used specially in patients who cannot tolerate ACE-I?

Answer 45

Isosorbide dinitrate and hydralazine.

Question 46

Nitrates and hydralazine improve outcomes in which race of patients?

Answer 46

African-Americans.

Question 47

List the MOA of digoxin?

Answer 47

1- inhibition of Na/K ATPase pump increase intracellular sodium concentration - eventually increase cytosolic calcium. 2- increases force of cardiac contraction. 3- restores the vagal tone (HR and oxygen demand decreases). 4- abolishes the sympathetic over activity.

Question 48

Digoxin comes from which plant?

Answer 48

Obtained from digitalis plant (foxglove).

Question 49

Which AE does digoxin has?

Answer 49

1- initial indicators of toxicity: anorexia, nausea, vomiting. 2- blurred vision, yellowish vision (xanthopsia). 3- cardiac arrhythmias: almost every type of arrhythmia can be produced.

Question 50

What is the treatment of digoxin toxicity?

Answer 50

1- stop digoxin. 2- digoxin antibody (digibind).

Question 51

What is the treatment for digoxin induced tachyarrhythmias?

Answer 51

When caused by chronic use of digitalis and diuretics - infuse KCI.

Question 52

What is the treatment for digoxin induced ventricular arrhythmias?

Answer 52

Lidocaine i.v.

Question 53

What is the treatment for digoxin induced supraventricular arrhythmias?

Answer 53

Propranolol.

Question 54

What is the treatment for digoxin induced AV block and bradycardia?

Answer 54

Atropine.

Question 55

What is the treatment of dyspnoea and other symptoms in refractory CHF?

Answer 55

Nesiritide.

Question 56

Which actions does nesiritide has?

Answer 56

1- enhances salt and water retention. 2- potent vasodilator. 3– reduces ventricular filling pressure.

Question 57

The latest addition to standard combination therapy of HF is what?

Answer 57

Angiotensin receptor-neprilysin inhibitor (ARNI). Sacubitril and valsartan.

Question 58

Sacubitril has which type of effect?

Answer 58

Inhibits neprilysin.

Question 59

Valsartan has which type of effect?

Answer 59

ARB.

Question 60

ARNI combines which effects?

Answer 60

Inhibition of the RAAS with activation of a beneficial axis of neurohumoral activation, the natriuretic peptides.

Question 61

What is the ACC/AHA recommends for HF patients who remain symptomatic on an ACE-I, BB, aldosterone inhibitor?

Answer 61

Use of sacubitril/valsartan as a replacement for ACE-I.

Question 62

HCN channel blocker: ivabradine has which action?

Answer 62

Hyperpolarization-activated cyclic nucleotide-gated channel blocker.

Question 63

HCN channel blocker: ivabradine is responsible for which current?

Answer 63

I(f) current

Question 64

Inhibition of the HCN channel with ivabradine use results with which action on HR?

Answer 64

Results in a lower heart rate.

Question 65

List a use of HCN channel blocker: ivabradine?

Answer 65

Used in HFrEF to improve in patients with sinus rhythm above 70 bpm.

Question 66

Treatment of HF with reduced LVEF is aimed at what?

Answer 66

Relieving symptoms, improving functional status and preventing death and hospitalizations.

Question 67

Management of heart failure with reduced LVEF is based on correcting what?

Answer 67

Correction of reversible causes (eg. Valvular lesions, uncontrolled HTN, drugs with negative inotropy such as CCBs).

Question 68

What is the pharmacological treatment of HF with reduced LVEF?

Answer 68

A combination of a diuretic and an ACE-I should be the initial treatment in most symptomatic patients with early addition of BB.

Question 69

List the non-pharmacological management of HF with reduced LVEF?

Answer 69

Implantable cardioefibillators, diet and exercise training, coronary revascularaization, cardiac transplantation.

Question 70

Half of the patients with HF have which type of LVEF?

Answer 70

Normal LVEF, often with diastolic dysfunction.

Question 71

Which therapy has been shown to improve HF with normal LVEF?

Answer 71

No therapies have been shown to improve survival in this population.

Question 72

What is the management of acute HF and pulmonary edema?

Answer 72

1- oxygen (to maintain arterial PO2 greater than 60 mmHg). 2- morphine (increases vascular capacitance, lowering LA pressure, relieves anxiety). 3- iv diuretic therapy (furosemide is indicated even if the patient has not exhibited fluid retention). 4- nitrate therapy (reduces BP and LV filling pressure). 5- iv nesiritide (a recombinant form of human BNP, is a potent vasodilator that reduces ventricular filling pressures and improves cardiac output).

Question 73

List the 6 symptoms of acute HF and pulmonary edema?

Answer 73

1- acute onset or worsening of dyspnea at rest. 2- tachycardia, diaphoresis, cyanosis. 3- pulmonary rales, rhonchi; expiratory wheezing. 4- radiograph shows interstitial and alveolar oedema with or without cardiomegaly. 5- arterial hypoxemia.

Question 74

List the 6 causes of acute HF and pulmonary edema?

Answer 74

1- acute MI. 2- exacerbation of chronic HF. 3- acute severe HTN. 4- AKI. 5- acute volume overload. 6- high altitude.