Lab 2 - Heart Failure, Pulmonary Edema

Question 1

Furosemide - MoA

Answer 1

Loop diuretic. Inhibit sodium, potassium, chloride symporter.

Question 2

Furosemide - Dose and route

Answer 2

20 mg IV

Question 3

Furosemide - Adverse effects

Answer 3

Hypokalemia and metabolic alkalosis
Hypocalcemia
Hyponatremia
Hypomagnesemia
Hyperglycemia
Hyperlipidemia
Hyperuricemia

Question 4

Furosemide - Contraindications

Answer 4

Diabetes
Gout
Allergy to sulfonamides

Question 5

Furosemide - Interactions

Answer 5

• The diuretic effect will be decreased with NSAIDs.
• If administered with ACE inhibitors, it may cause excessive hypotension, but have opposite effects on potassium.
• Increases levels of lithium

Question 6

Captopril - MoA

Answer 6

ACE inhibitor. Blocks production of angiotensin II and reduces after load and mortality.

Question 7

Captopril - Dose and route

Answer 7

6.25mg orally every 8 hours (3x daily)

Question 8

Captopril - Adverse effects

Answer 8

Hypotension
Hyperkalemia
Azotemia
Dry cough

Question 9

Captopril - Contraindications

Answer 9

Pregnancy
Renal artery stenosis
Impaired renal function
Hypovolemia
K>5,5

Question 10

Captopril - Interactions

Answer 10

• Potentiate the hyperkalemia effects with potassium-sparing diuretics
• Opposite effect on potassium with diuretics
• NSAIDs and ACE inhibitors can cause renal failure because of effect on GFR
• Increase levels of lithium

Question 11

Digoxin - MoA

Answer 11

Positive inotropic agent. Inhibit Na+/K+ ATP-ase.

Question 12

Digoxin - Dose and route

Answer 12

0.125 mg orally

Question 13

Digoxin - Adverse effects

Answer 13

Nause
Vomiting
Diarrhea
Tachyarrhytmias and Bradyarryhtmias
AV block
Blurred vision
Yellow-green or blue chromatopsia

Question 14

Digoxin - Contraindications

Answer 14

Ventricular fibrillation
Rapid IV administration of potassium
AV block
Cardiomyopathies

Question 15

Digoxin - Interactions

Answer 15

• Antacids and cholestyramine reduce the absorption of digoxin
• Dilitiazem and quinidine increases the levels of digoxin which can lead to toxicity
• Diuretics cause hypokalemia which can precipitate digoxin toxicity

Question 16

Metoprolol - MoA

Answer 16

Selective B1 antagonist

Question 17

Metoprolol - Dose and route

Answer 17

12.5 mg orally every 12h (2xdaily)

Question 18

Metoprolol - Adverse effects

Answer 18

Dizziness
Drowsiness
Fatique

High doses:
Hypoglycemia (tachycardia sweating)
Bronchoconstriction

Question 19

Metoprolol - Contraindications

Answer 19

AV block
Bradycardia
Cardiogenic shock
Hypotension

High doses:
Asthma
Diabetes

Question 20

Metoprolol - Interactions

Answer 20

• Metabolized by cytochrome P450 enzymes so serum concentration can be increased with the use of antiarrhytmics, H2 blockers, COX2 inhibitors and decreased with use of rifampin
• Potentiate the hypoglycemic effects of insulin
• Negative ionotropic effect potentiated with dilitiazem and verapamil

Question 21

HF - Diagnosis

Answer 21

Laboratory testing to exclude other diseases (anemia, DM, thyroid disease, liver and renal disease): CBC, electrolytes, BUN, urinalysis, fasting glucose, OGTT, TSH, total cholesterol
Biomarkers: BNP and N-terminal pro-BNP
ECG: rhythm, LV hypertrophy, prior MI
CXR: cardiac size, shape, pulmonary vasculature –> ABCDE
Doppler Echo: LV size and function (EF), valvular/regional wall motion abnormalities
MRI: ventricular structure, mass, volume
Other: coronary angiography, stress testing, myocardial biopsy, Swan-Ganz catheterization

Question 22

HF - Treatment

Answer 22

Treat the underlying cause, Valve replacement CABG
Life style changes
HF confirmed –> Fluid retention –>: Furosemide (20 mg PO) —> Captopril (6,25 mg x3 PO). (If not fluid retention start directly with Captopril) –> Metoprolol (12,5 mg x4 PO) –> Persistent symptoms: Spironolactone (12,5 mg PO), Hydralazine (10mg) + Isosorbide (10 mg), Digoxin (0,125 mg PO, used if systolic HF + atrial fibrillation)

Class II-III: Implantable cardioverter defibrillator (ICD)
Class III-IV + qrs>120ms: Cardiac resynchronization therapy (CRT); pacemaker

Question 23

HF - Differential diagnosis

Answer 23

Pulmonary disease: chronic bronchitis, emphysema, asthma

Other causes of peripheral edema: obesity, varicose veins, venous insufficiency, renal dysfunction

Question 24

PE- Diagnosis

Answer 24

ABG: reduction of PaO2 and PaCO2; Hypercapnia and acidosis with progression of disease
CXR: ABCDE
Kerley A and B lines
Biomarkers: low/normal levels of BNP
Swan-Ganz catheter: measures pulmonary capillary wedge pressure; differentiate cardiogenic from noncardiogenic causes of PE
Troponins: to exclude MI
ECG: visualize ischemia, arrhythmia
Echo: check EF, wall motion abnormalities

Question 25

PE - Treatment

Answer 25

CPAP (continous positive airway pressure) - 100% O2
Reduce preload:
- sit upright, remove tight clothes
- Nitroglycerin (0,5 mg subl)
- Furosemide (20 mg IV)
- Morphine (10 mg IV) + Metoclopromide (10 mg IV)
- Anxiety - Diazepam (10 mg IV)
- ACE- inh if pt in hypertensive, acute MI with HF
- Ventricular tachycardia - Amiodarone (300 mg IV)

Question 26

PE - Differential diagnosis

Answer 26

Asthma, COPD, pneumonia (especially hard to distinguish in elderly –> may coexist)