Heart Failure 2

Question 1

Which drug?

• Competitively blocks B1 receptors and alpha 1 receptors
• Slows HR
• Reduces HF mortality
• Used in Chronic HF (to slow progression)
• Should be taken w/ food
• HTN and CHF med

Answer 1

Carvedilol (beta blocker)

Question 2

Which BB is effective in both systolic and diastolic HF?

(HFrEF & HFpEF)

Answer 2

Nebivolol

Question 3

Which drug?***

• MOA: releases nitric oxide (NO)
• Effects: Venodilation - reduces preload and ventricular stretch
• Used in: acute and chronic HF (angina)
• Toxicity: postural hypotension, tachycardia, HA
• Synergistic w/ phosphodiesterase type 5 inhibitors

Answer 3

Isosorbide dinitrate

Question 4

Which drug?***

• Used for chronic HF in African Americans
• Indicated in conjunction w/ standard HF therapy to improve survival/reduce hospitalizations in self identified African American pts

Answer 4

Hydralazine Isosorbide Dinitrate (Bidil)

Question 5

***Which drug?*****

• MOA: probably increases Nitric Oxide (NO) synthesis in endothelium
• Reduces BP and afterload
• Results in increased CO
• W/ nitrates has reduced mortality
• Toxicity: tachycardia, fluid retention, lupus like syndrome

Answer 5

Hydralazine (arteriolar dilator)

Question 6

Which drug?

• Rapid, powerful vasodilation which reduces preload/afterload
• Used in acute severe decompensated HF
• Toxicity: excessive hypotension, thiocyanate and cyanide toxicity

Answer 6

Nitroprusside (vasodilator)

Question 7

Which drug?

• Cardiac glycoside
• MOA: Na/K ATPase inhibition results in reduced Ca expulsion and increased Ca stored in sarcoplasmic reticulum
• Effects: increases contractility, cardiac parasympathomimetic effect (slowed sinus HR, slowed atrioventricular conduction)
• Used in: chronic symptomatic HF and rapid ventricular rate in atrial fibrillation
• REDUCE dose in elderly
• Nausea, vomiting, diarrhea
• Cardiac arrhythmias

Answer 7

Digoxin

(not show to reduce mortality w/ HFrEF)

(Digibind: dig antibodies)

Question 8

Diuretics used in acute or chronic HF?

Answer 8

Both

Question 9

Beta Blockers used in acute or chronic HF?

Answer 9

Chronic HF

Question 10

Vasodilators used in acute or chronic HF?

Answer 10

Both

Question 11

Used in acute or chronic HF?

• Cardiac glycosides
• Angiotensin receptor blockers
• Angiotensin-converting enzyme inhibitors
• Aldosterone receptor antagonists

Answer 11

Chronic HF

Question 12

**Used in acute or chronic HF?****

• Bipyridines
• Natriuretic peptide
• HCN, /f current inhibitor

Answer 12

Acute HF

Question 13

Which drug?***

• MOA: Beta-selective agonist (increases cAMP synthesis)
• Increases cardiac contractility, output
• Used in acute decompensated HF
• Intermittent therapy in chronic failure reduces sxs
• IV only!!!

Answer 13

Dobutamine

(Beta adrenoceptor agonists)

Question 14

Which drug?***

• MOA: Dopamine receptor agonist
• Higher doses activate Beta and alpha adrenoceptors
• Increases renal blood flow
• Higher doses increase cardiac force and BP
• Used in acute decompensated HF and shock
• IV only!!
• no renin release

Answer 14

Dopamine

(Beta adrenoceptor agonists)

Question 15

Which drug?

• MOA: Phosphodiesterase type 3 inhibitors (decrease breakdown of cAMP)
• Vasodilators; lower periph vasc resistance
• Increase contractility
• Used in acute decompensated HF
• Increase mortality in chronic HF
• IV only!!
• Toxicity: arrhythmias

Answer 15

• Inamrinone
• Milrinone

(Bipyridines)

Question 16

Which drug?

• MOA: activates BNP receptors, increases cGMP
• Vasodilation (diuresis)
• Used in acute decomp failure
• NOT shown to reuce mortality
• IV only!!
• Toxicity: renal damage***

Answer 16

Nesiritide

(Naturiuretic Peptide)

Question 17

Which drug?

• MOA: prolongs diastolic time by inhibiting f current within HCN channel (reducing HR)
• Indication: sxs of HF that are stable
• **Hopefully reduces risk of being hospitalized for worsening HF***

Answer 17

Ivabradine

(HCN f Current Inhibitor)

Question 18

What are the 4 SE of Ivabradine?

Answer 18

• Dizziness
• Fatigue
• Less common: increased BP and A. fib

Question 19

• Ivabradine can be used in people w/ HR of at least ___ BPM.
• Only used for stable HF
• Don’t use in people w/ HR

Answer 19

• at least 70
• Not under 60

Question 20

3 toxicities of Ivabradine

Answer 20

• SSS (sick sinus syndrome)
• 3rd degree AV block
• Severe hepatic impairment

Question 21

In patients w/ NYHA class 2 and 3 heart failure and iron deficiency, what might be reasonable to give for improvement of functional status?

Answer 21

IV iron replacement

Question 22

In patients w/ HF, the optimal BP in those with HTN should be less than ____ mmHg

Answer 22

130 / 80

Question 23

In patients w/ CVD and obstructive sleep apnea, what may be reasonable to improve sleep quality and daytime sleepiness?

Answer 23

CPAP (Continuous positive airway pressure)

Question 24

Case:

• 65 yr male, w/ SOB on exertion several weeks after viral illness
• Swelling of feet/ankles and increasing fatigue
• PE: mild SOB lying down, better upright
  
  • Pulse 105/regular
  • BP: 90/60
  • Crackles bilateral bases
  • JVP elevated
  • Liver enlarged
  • 3+ edema of anles/feet
• Echo: dilated, poorly contracting, Left EF reduced
• Dx: cardiomyopathy secondary to viral infection (stage C class 3 HF)
• Do you tx HF or HTN first?
• Steps of therapy?

Answer 24

• Tx HF first! Then carefully control HTN
• Initially tx w/ diuretic: Furosemide
  
  • this improved SOB on exertion/orthopnea
• ACE-I was added
  
  • felt better
• Digoxin added to improve exercise tolerance
• BP stabilized at 150/90
• Educate pt on HTN and HF and BP control
• Consider adding BB (metoprolol)
• Monitor blood lipids