more trials

Question 1

Sprinolactone and eplernone

Answer 1

• mineralocorticoid receptor antagonists (MRA)

AKA Aldosterone Antagonist

Question 2

Monitoring

Answer 2

• Renal function • K+
• Na+
• Weight
• Fluid balance
• Gynaecomastia

Question 3

Nitrates

Answer 3

• Vasodilators
• Give IV in acute exacerbations, short term only
• Monitor BP: AVOID HYPOTENSION
• Oral for maintenance therapy (+ hydralazine)

Question 4

Hydralazine

Answer 4

• Vasodilator
– May be used if poor renal function as alternative to ACEI
• Useful in patients of African/Caribbean (A-HeFT)
• Poorly tolerated
• Avoid after an acute event (can provoke angina)
• Can cause lupus like syndrome (auto-immune disease causing tissue damage) • Monitor Liver

Question 5

Digoxin

Answer 5

• Recommended for worsening or severe heart failure due to LVSD despite first- and second-line treatment
• Slows heart rate, better filling of ventricle, increases force of contraction
• Monitor
– K+
– Heart rate
• Used in sinus rhythm at low dose
• Does NOT improve mortality but reduces hospital admissions

Question 6

Ivrabradine

Answer 6

Class of medication - hyper polarisation- activated cyclic nucleotide- gated HCN Channel blockers.It works by slowing the heart rate so the heart can pump more blood through the body each time it beats

Question 7

Give sacubitril with angiotensin receptor blocker

Answer 7

instead of ACE-I because one of the side effects with ACE-I is angioedema
Combination tablet of sacubitril and valsartan

Question 8

Patient

Answer 8

• Symptoms – how does the pt feel?
• Daily weights – use same scales
• Fluid intake / salt intake
• Blood pressure
• Heart rate / rhythm
• Renal function / K+ / Na+
• LFT’S deranged - Right heart failure / drugs?
• MEDICINES TO AVOID such as NSAIDs
• Vaccination: annual flu + one-off pneumovax + COVID • Treatment is a balance of:
– BP, Heart Rate, renal function vs. symptoms

Question 9

In practice

Answer 9

• Implementing the evidence base is multifactorial and multi-disciplinary • Inpatient stay:
– Managing acute presentations and decompensated patients – Managing fluid overload
– Ensuring evidence base initiated (and up-titrated)
• Following hospital discharge
– Close follow-up in out-patient setting to complete titrations, diuretic management and
consideration of advanced therapies and devices
• HFrEF – new treatment option SGLT2 inhibitors
• New strategies for sequencing of therapy
• HFpEF – nothing yet licenced but some new data with the SGLT2 inhibitor
(empagliflozin)

Question 10

Therapeutics of heart failure

Answer 10

• ICD: a small device that is implanted under the skin with leads inserted into the heart. ICDs monitor the electrical activity of the heart and deliver electrical pulses or shocks to restore normal rhythm if ventricular arrhythmias are detected
• CRT-P: a pulse generator is implanted in the upper chest with three leads that connect it to the right atrium and each ventricle. The device resynchronises the contraction of the ventricles to improve the heart’s pumping efficiency
• CRT-D: combines the technology of the ICD and CRT- P devices
Heart transplant
• 126 (2009/10), increased to 181 (2014/15) in 7 UK hospitals • However, demand is greater than supply
• To qualify:
– End stage heart disease with life expectancy of 12-18/12
– Stage III-IV NYHA
– Condition unsuitable for further medical / surgical therapy
– Patient must be medically and surgically fit (usually this means age < 60)
• Paediatric: due to congenital heart disease

Question 11

Potential ADRs

Answer 11

Common side effects include:
dizziness, rash, back pain, UTI, vulvovaginitis/ balanitis, dysuria or polyuria, initial dip in CrCl, hypoglycaemia (with insulin or sulphonylureas)

Question 12

Salbutamol inhaler

Answer 12

Indicated for COPD

Question 13

Atenolol

Answer 13

Switch to BB licensed for secondary prevention AND heart failure
– Bisoprolol – Carvedilol – (Nebivolol)
• Titrate up

Question 14

Ramipril

Answer 14

• Indicated for secondary prevention AND heart failure reduced ejection fraction • Titrate up
• Monitor kidneys and electrolytes
• Monitor blood pressure

Question 15

Simvastatin

Answer 15

• Secondary prevention of coronary disease • Switch to atorvastatin at least 20mg od
o First line for secondary prevention
o Aim for > 40% reduction in non-HDL-cholesterol o Lower dose in CKD

Question 16

Omacor

Answer 16

• Fish oil, used to be recommended for secondary prevention of myocardial infarction • No longer recommended for secondary prevention CHD – this should be stopped

Question 17

Spironalactone

Answer 17

• Aldosterone antagonist used in the management of heart failure with reduced ejection fraction
• Indicated for chronic heart failure (HFrEF)
• Eplerenone licensed post ACS
• Monitor K+ and Renal function
• Monitor blood pressure
• May titrate to 50mg od (max dose in HFrEF)

Question 18

Metolazone

Answer 18

• Thiazide diuretic
• Indicated for heart failure – for congestion
• Close monitoring – giving with loop diuretic
• May not need to be continued if fluid retention reduced • Monitor renal function, elctrolytes,weight

Question 19

Furosemide

Answer 19

• Loop diuretic
• Indicated for symptomatic relief of heart failure (HFrEF or HFpEF) • Monitor renal function, electrolytes, weight
• Monitor blood pressure
• Symptoms
• Titrate dose – may need IV therapy?
• Second dose timing

Question 20

GTN S/L

Answer 20

• Indicated due to PMH of STEMI • Use on PRN basis

Question 21

Additions?

Answer 21

• Aspirin
– Indicated for secondary prevention • Digoxin ?
• Ivabradine?
• Switch to sacubitril valsartan?
• Add an SGLT2 inhibitor?
• Candidate for device

Question 22

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Answer 22

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