Heart failure

Question 1

What should all patients with left ventricular systolic dysfunction receive

Answer 1

ACEi and a beta blocker

Question 2

What should all patiets with oedema get

Answer 2

diuretics

Question 3

Which drugs can worsen heart failure

Answer 3

Rate limiting calcium channel inhibitors

NSAIDS

Pioglitazone (anti diabetic)

(Dihydropyridines safe)

Question 4

Which CCI are safe in HF

Answer 4

Dihydropyridines

Question 5

Mode of action of ACEi

Answer 5

Reduce arterial and venous vasoconstriction (reduce after and pre-load)

Reduce salt/water retention hence reduce circulating volume

Question 6

How to prescribe and monitor ACEI

Answer 6

Low dose then titrate up

Monitor eGFR and K+ before and during treatment

Question 7

What may ACEi cause

Answer 7

Severe hypotension (give at night)

Cause deterioration of renal function in pre-existing renal disease

Cough

Question 8

When should ACEi be avoided

Answer 8

Renovascular disease

Question 9

Mode of action of AT1 receptor antagonists

Answer 9

Angiotensin 2 acts at AT1 receptors. AT1 receptor antagonists block the action of a2

Question 10

when are ATRA used

Answer 10

Alternative to ACEi

Question 11

Why are beta blockers used

Answer 11

Reduce disease progression, symptoms and mortality

Question 12

What selectivity do beta blockers have

Answer 12

Beta1 selective

Question 13

Mode of action of beta blockers

Answer 13

Oppose the neurohormonal activation which leads to myocyte dysfunction

Question 14

What other roles do beta blockers have

Answer 14

Control HR in atrial fib

Useful in failure associated with ischaemia

Question 15

How should you prescribe beta blockers

Answer 15

Start with a low dose
Symptoms may get worse at 1st
Monitor BP

Question 16

What may thiazides and loop diuretics cause and how to monitor

Answer 16

hypokalaemia nd renal function

K+ before and during treatment

Question 17

What to use for emergency relief of pulmonary oedema

Answer 17

I.V furosemide

Question 18

Mode of action of eplerenone

Answer 18

Aldosterone (mineralocorticoid) receptor antagonist

Opposes cardiac fibrosis

Question 19

Risk of using eplerenone

Answer 19

Hyperkalaemia (increased with ACEi/AT1 receptor antagonist

Question 20

Mode of action of digoxin

Answer 20

+ve inotrope (increase force of contraction) by inhibiting Na-k+ ATPase, Na+ accumulates in myocytes, exchanged with Ca2+ leading to increased contractility

Question 21

How is digoxin used in AF

Answer 21

Impairs AV conduction and increases vagal activity

The heart block and bradycardia is beneficial in HF with AF

-Slowing the heart improves cardiac filling

Question 22

Action of sacubitril

Answer 22

Neprilysin (NEP) inhibitor

• Endopeptidase inhibitor
• Enzyme breaks down natriuretic peptides and bradykinin

(therefore its aim is to prevent breakdown of ANP, BNP and bradykinin)

Question 23

Mode of action of valsartan

Answer 23

AT1 receptor antagonist

Question 24

When is the risk of hyperkalaemia increased if

Answer 24

ACEi used with a K+ sparing diuretic

Question 25

What should the pulse be maintained at if using digoxin

Answer 25

> 60bpm

Question 26

First line treatment

Answer 26

ACEi/ B blocker

Or ATRA if cough

Question 27

Second line treatment

Answer 27

Aldosterone antagonist or ARB or Hydralazine plus nitrate

Question 28

Fourth line treatment

Answer 28

if AF- digoxin

If sinus rhythm- ivabradine