11 HF 2

Question 1

HF drugs by indication

mortality or mortality and hospitalization
- chronic HFrEF (18)

Answer 1

metoprolol succinate, carvedilol, captopril, enalapril, ramipril, trandolapril, quinapril, fosinopril, lisinopril, candesartan, valsartan, sacubitril/valsartan, spironolactone, eplerenone, isosorbide/hydralazine
bisoprolol (not US), empagliflozin, dapagliflozin

BB, ACEi, ARBs, ARNi, MRA, SGLT2, ISDN/hydralazine

Question 2

HF drugs by indication

hospitalization
- chronic HFrEF (2)

Answer 2

digoxin, ivabradine

Question 3

HF drugs by indication

hemodynamic or physical function
- chronic HFrEF (2)
- AHF (4)

Answer 3

• digoxin, isosorbide/hydralazine
• inotropes, milrinone, sodium nitroprusside, nesiritide

Question 4

HF drugs by indication

QOL or symptoms
- chronic HFrEF (2)
- AHF: (2)

Answer 4

• digoxin, diuretics
• nesiritide, diuretics

Question 5

Neurohormonal Blockers

RAS Inhibitors
- angiotensin receptor ___ inhibitors (ARNi)
- ACEi
- ARB

BB
SGLT2
MRA
___ / ___

Answer 5

neprilysin
hydralazine/ISDN

Question 6

ACEi

T or F: benefit occurs regardless of etiology or severity of disease, must be used in all without contraindications

Answer 6

T

Question 7

ACEi MOA and benefit in HF

MOA: inhibition of ___ formation, enhancement of ___
- improved endothelial function
- ___ NE
- inhibition of cardiac ___
- improved cardiac ___
- ___ aldosterone
- decreased endothelin-1
- decreased arginine ___
- ___ vasoconstriction
- reduced ___ and ___ retention

Answer 7

angiotensin II, bradykinin
- decreased
- hypertrophy
- hemodynamics
- reduced
- vasopressin
- reduced
- Na, Cl

Question 8

Clinical use of ACEi - dosing

enalapril ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___

Answer 8

Vasotec
2.5-5, BID
10 BID

Question 9

Clinical use of ACEi - dosing

captopril ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___

Answer 9

Capoten
6.25-12.5, TID
50, TID

Question 10

Clinical use of ACEi - dosing

lisinopril ( ___ , ___ )
initial: ___ - ___ mg ___
target: ___ - ___mg ___

Answer 10

Prinivil, Zestril
2.5-5, QD
20-40, QD

Question 11

Clinical use of ACEi - dosing

quinapril ( ___ )
initial: ___ - ___ mg ___
target: ___ - ___ mg ___

Answer 11

Accupril
5-10, BID
20-40, BID

Question 12

Clinical use of ACEi - dosing

ramipril ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___ - ___ mg ___

Answer 12

Altace
1.25-2.5, QD
5, BID, 10, QD

Question 13

Clinical use of ACEi - dosing

fosinopril ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___

Answer 13

Monopril
5-10, QD
40, QD

Question 14

enalapril___ mg = capropril ___ mg = lisinopril ___ mg

total daily amounts

Answer 14

20
150
20

total daily amounts

Question 15

Dosing ACEi

titrate slowly to target dose used in clinical trials
- start low and double dose every ___ - ___ weeks

Caution if: ___ depleted, SBP < ___ , K > ___ , SCr > ___
- lower doses and more monitoring are required with SCr > ___ and/or CrCl < ___ mL/min
- can do ___ of the inital/survival

Answer 15

1-4
volume, 80, 5, 3
3, 30
half

Question 16

absolute ACEi CI

• pregnancy
• history of ___ or hypersensitivty
• ___ renal artery ___
• history of well documented intolerance due to symptomatic ___ , decline in ___ function, ___ kalemia, or cough

Answer 16

• angioedema
• bilateral, stenosis
• hypotension, renal, hyperkalemia

Question 17

Monitoring

volume status (normalize prior to initiation)

regular maintenance of ___ function and ___
- prior to therapy, ___ - ___ weeks after each increase in dose and ___ - ___ month intervals
- SCr may rise after initiation ( < ___ % acceptable)

BP
- avoid symptomatic ___

Answer 17

renal, K
- 1-2, 3-6
- 30%
- hypotension

Question 18

ACEi AE

• hypo ___
• functional ___ insufficiency
• hyper ___
• skin rash and __
• ___ (20%)
• ___ (1%)

Answer 18

• hypotension
• renal
• hyperkalemia
• dysgeusia
• cough
• angioedema

dysgeusia = altered taste

Question 19

ARBs do not get the benefit of inhibiting that breakdown of ___

Answer 19

bradykinin

Question 20

ARBs dosing

losartan ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___

Answer 20

Cozaar
25-50, daily
150, daily

Question 21

ARBs dosing

valsartan ( ___ )
initial: ___ - ___ mg ___
target: ___ mg ___

Answer 21

Diovan
20-40, BID
160, BID

Question 22

ARBs dosing

candesartan ( ___ )
initial: ___ mg ___
target: ___ mg ___

Answer 22

Atacand
4, daily
32, daily

Question 23

ARBs vs ACEis

not superior to ACEi
alternative if:
- unable to take ACEi due to ___ or ___

monitoring: pretty much everything that you would monitor for ACEi (except ___ )

Answer 23

cough, angioedema
cough

Question 24

sacubitril/valsartan inhibits ___ from degrading ___ and blocks ___ receptor

Answer 24

neprilysin, BNP, AT1

Question 25

# sacubitril/valsartan BNP causes ___ - ___ BP - decreases ___ tone - ___ aldosterone - ___ fibrosis - ___ hypertrophy - natriuresis/diuresis

Answer 25

vasodilation - decreases - sympathetic - decreases - decreases - decreases

Question 26

# sacubitril/valsartan angiotensin II binding to the AT1 receptor causes ___ - ___ BP - increases ___ tone - increases ___ - ___ fibrosis - ___ hypertrophy

Answer 26

vasocontriction - increases - sympathetic - aldosterone - increases - increases

Question 27

# sacubitril/valsartan indications: reduce the risk of CV ___ / ___ for HFrEF patients with NYHA class ___ - ___ sacubitril ( ___ , ___ , ___ mg) valsartan ( ___ , ___ , ___ mg) - valsartan equivalents: = ___ , ___ , and ___ respecitively

Answer 27

death/hospitalization II-IV 24, 49, 97 26, 51, 103 - 40, 80, 160

Question 28

# sacubitril/valsartan T or F: the way that the drug is packaged makes valsartan more bioavailable

Answer 28

T 26 = 40, 51 = 80, 103 = 160

Question 29

# sacubitril/valsartan AEs same as ACEi/ARB - ___ rare PARADIGM-HF trials - hypotension ___ enalapril - elevation in SCr and K ___ enalapril

Answer 29

- angioedema - > - <

Question 30

# sacubutril/valsartan dosing population: - high dose ACEi ( > ___ mg total daily enalapril or equivalent) - high dose ARB ( > ___ mg total daily valsartan or equivalent) initial dose: ___ / ___ mg ___ max dose: ___ / ___ mg ___

Answer 30

- 10 - 160 - 49/51, BID - 97/103, BID

Question 31

# sacubutril/valsartan dosing population: - low-to medium dose ACEi or ARB - ACEi/ARB ___ - eGFR < ___ - moderate ___ impairment - age > ___ years initial dose: ___ / ___ mg ___ double the dose every ___ - ___ weeks to target ___ / ___ mg ___ as tolerated

Answer 31

- naive - 30 - hepatic - 75 24/26, BID 2-4, 97/103, BID

Question 32

enalapril ___ mg/day = captopril ___ mg/day = lisinopril ___ - ___ mg/day

Answer 32

20, 150, 20-40

Question 33

# sacubutril/valsartan CI - taking within ___ hours of ACEi use - angioedema/known hypersensitivity to ACEi/ARB - pregnancy/lactation - severe heaptic impairment - concomitant ___ use in patients with diabetes

Answer 33

36 aliskiren

Question 34

# recommendations for ARNi/ACEi/ARB Stage B - ACE or ARBs if not tolerant Stage C - ARNi: patients with current or previous ___ (replacing ACEi/ARB with ARNi further reduces ___ ) - ACEi: patients with current or previous symptoms when use of an ___ is not feasible $$$ - ARBs: if intolerant to ___ and ___ isn't feasible - ARBs are reasonable alternatives as first line agents, especially if taking an ARB for another indication | class = evidence

Answer 34

- symptoms, mortality - ARNi - ACEi, ARNi

Question 35

# ACE/AHA Guidelines - ARNi should not be administered concomitantly with ACEi or within ___ hours for the last dose - ARNi should not be administered to patients with Hx of ___ - inhibition of RAS with ARNi, ACEi, or ARB is recommended to reduce ____ - ___ is preferred and can be used rather than with pre-treatmnt with ACEi/ARBs

Answer 35

- 36 - angioedema - mortality/morbidity - ARNi

Question 36

# BB reverse ___ is proposed as one mechanism of benefit 3 approved BBs: ___ , ___ , ___

Answer 36

remodeling carvedilol, metoprolol XL, bisoprolol

Question 37

# rationale B-AR pathway in HF increased cardiac ___ 1) B-AR pathway ___ leads to impaired ___ tolerance resulting in HF 2) ___ toxicity leads to myocardial ___ resulting in HF

Answer 37

NE 1) desensitization, exercise 2) myocytes, dysfunction

Question 38

# rationale BB in HF decrease - ___ arrythmias - cardiac ___ and cell death - ___ and ___ - cardiac ___

Answer 38

- ventricular - hypertrophy - VC, HR - remodeling

Question 39

# BB Patinet Selection - Stable and ___ patients - symptomatic patients should receive ___ , especially with current or recent histroy of fluid retentiion - should be considered in patients with bronchospastic disease and asymptomatic bradycardia, but ___ - dont abruptly D/C - dont start initially in hospital, but if patients are already on them while being admitted, dont ___ | Sowinski wouldnt do if patient has hospitalized uncontrolled asthma

Answer 39

- euvolemic - diuretics - cautiously - D/C

Question 40

# BB Dosing bisoprolol ( ___ ) initial dose: ___ mg ___ target: ___ mg ___

Answer 40

Zebeta 1.25, daily 10, daily

Question 41

# BB Dosing carvedilol ( ___ ) initial: ___ mg ___ target: ___ - ___ mg ___

Answer 41

Coreg 3.125, BID 25-50, BID

Question 42

# BB Dosing carvedilol CR ( ___ ) initial: ___ mg ___ target: ___ mg ___

Answer 42

Coreg CR 10, daily 80, daily

Question 43

# BB Dosing metoprolol XL ( ___ ) initial: ___ - ___ mg ___ target: ___ mg ___

Answer 43

Toprol XL 12.5-25, daily 200, daily

Question 44

# BB ___ and ___ are FDA approved and ___ is a european thing

Answer 44

carvedilol, metoprol, bisoprolol

Question 45

# BB Dose titration Double the dose every ___ weeks and monitor vital signs and symptoms - planned dose increases can be slowed if necessary aim for target dose in ___ - ___ weeks or highest tolerated dose

Answer 45

2 8-12

Question 46

# NAPLEX weight and carvedilol < 85 kg = ___ mg ___ > 85 kg = ___ mg ___

Answer 46

25, BID 50, BID

Question 47

# dose conversion between Coreg and Coreg CR - 3.125 mg BID = __ mg QD - ___ mg BID = 20 mg QD - 12.5 mg BID = ___ mg QD - ___ mg BID = 80 mg QD

Answer 47

10 6.25 40 25

Question 48

# BB monitoring BP, symptomatic hypotension, HR ___ - ___ weeks - symp. hypotension, bradycardia, and dizziness are uncommon is slow ___ (reduce dose ~ ___ % if necessary) - if hypotension only, reduce other drugs first - Goal HR is not defined edema, fluid retention, signs of congestion ( ___ - ___ weeks) fatigue or weakness

Answer 48

1- 2 - titration, 50 1-2

Question 49

# Consensus panel recommendations for BB Stage B - in all patients with a recent or remote history of ___ and ___ should receive at least one of the agents shown to reduce ___ - all other patients should also receive at least one of the agents shown to reduce ___ Stage C - Use one of the agents shown to reduce ___ in all patients, with current or previous symptoms unless CI

Answer 49

ACS, rEF, mortality mortality mortality