Heart Failure

Question 1

Do you use Nitrates and ISMN for HF?

Answer 1

Yes

Question 2

Name of Beta blockers?

Answer 2

Non-Selective blocker: Carvedilol

Beta-1 blocker: Bisoprolol, Metoprolol

Mixed 3rd Gen: Nebivolol

Question 3

Carvedilol MOA?

Answer 3

Block Alpha-1 receptors, lower peripheral vascular resistance

Has antioxidative and anti-ischaemic properties

Question 4

Nebivolol MOA?

Answer 4

Beta-1 selective in low dose/fast metabolizers

Non-selective in high dose/slow metabolizers

Has vasodilatory effects through higher NO release

Question 5

Name of Loop diuretics?

Answer 5

Sulfonamide derivatives:

Furosemide
Bumetanide

Question 6

MOA of Loop diuretics?

Answer 6

Selectively inhibit luminal Na/K/Cl transporter in thick ascending limb of Loop of Henle

Raise Mg and Ca excretion

Induce renal PGs synthesis.

Furosemide raises renal blood flow.

Question 7

Uses of Loop diuretics?

Answer 7

1. Acute Pulmonary edema and other edema
2. Acute Hyperkalemia
3. Acute renal failure
4. Anion overdose: Toxic ingestions of bromide, fluoride, iodide

Question 8

ADR of loop diuretics?

Answer 8

1. Hypokalemic metabolic alkalosis
2. Ototoxicity
3. Hyperuricemia
4. Hypomagnesemia
5. Avoid using with NSAIDs

Question 9

Name of Potassium-sparing diuretics?

Answer 9

Spironolactone
Eplerenone
Triamterene
Amiloride

Question 10

MOA of K-sparing diuretics?

Answer 10

Spironolactone and Eplerenone - Block aldosterone receptor
Triamterene and Amiloride - block Na channel

Question 11

Use of K-sparing diuretics?

Answer 11

Hyperaldosteronism

Question 12

ADR of K-sparing diuretics?

Answer 12

Hyperkalemia
Metabolic acidosis
Gynaecomastia - except eplerenone

Triamterene can cause kidney stones and acute renal failure

Question 13

Hydralazine MOA?

Answer 13

1. Direct Arteriole vasodilator
2. Inhibit IP3-induced release of Ca from smooth muscle cells sarcoplasmic reticulum
3. Reduces peripheral resistance - compensatory release of epinephrine - higher venous return and CO

Question 14

Use of Hydralazine?

Answer 14

“1. HF with low Ejection Fraction. Combine with Isosorbide Dinitrate. (Oral)

2. Essential Hypertension (2nd line, Oral)
3. Acute peripartum or post-partum hypertension >15min. (IV)”

Question 15

ADR of Hydralazine/

Answer 15

1. Baroreflex associated sympathetic activation - flushing, hypotension, tachycardia
2. Hydralazine - Induced Lupus Syndrome:
   - Athralgia, myalgia, serositis, fever
   - Can become dose-dependent with >6 months use
   - Can be resolved with Hydralazine discontinuation
3. Banned in Coronary Artery disease due to stimulation of Symph NS - higher CO + Oxygen demand. This can cause myocardial ischemia

Question 16

Sacubitril-Valsartan MOA?

Answer 16

“1. Natriuretic Peptide System is activated under HF. Brain Natriuretic Peptide and NT-proBNP rises.
2. BNP promotes vasodilation, natriuresis, diuresis
3. BNP antagonizes RAAS - favourable effects on HF pathogenesis.
4. BNP is broken down by neprilysin.

1. Sacubitril-Valsartan is an ARNi (Ang2 receptor/Neprilysin inhibitor)
2. Sacubitril prolongs BNP beneficial effects and Valsartan avoids negative effects of Ang2

Question 17

Use of Sacubitril-Valsartan?

Answer 17

Chronic HFrEF
Used to replace ARB/ACE inhibitors

Question 18

ADR of Sacubitril-Valsartan

Answer 18

Hypotension
Hypokalemia
Renal failure
Cough
Angioedema

Question 19

Ivabradine MOA?

Answer 19

Inhibit cardiac pacemaker I current, lower cardiac workload

Question 20

Use of Ivabradine?

Answer 20

Stable angina pectoris

“pure”” HR-lowering agent, indicated for chronic HF with systolic dysfunction

Question 21

ADR of Ivabradine?

Answer 21

Visual effects: Luminous phenomena, transient enhanced brightness in limited area of visual field.

Dizziness

Other bradycardia associated symptoms e.g. hypotension, fatigue, malaise