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Flashcards in 39. Heart Failure (HF) Deck (69):
1

A patient with systolic heart failure has been given a prescription for BiDil. Which of the following side effects is most common with BiDil therapy?

A. Rash
B. Headache
C. Hair growth
D. Sore, painful joints
E. Increased appetite

B. Headache is a common side effect of any nitrate therapy, including BiDil. Some patients find benefit by pre-treating with acetaminophen.

isosorbide dinitrate/hydralazine (BiDil): indicated in black patients with NYHA FC III-IV who are symptomatic despite optimal therapy with ACE-Is and beta blockers. CI with PDE-5 inhibitors. Warning: DILE. SE: headache, dizziness, hypotension, tachycardia, weakness. does not need nitrate-free interval. target dose 40/75mg TID

2

Max is hospitalized with a MRSA infection and is receiving vancomycin. This antibiotic carries a risk of ototoxicity. The physician is trying to adjust his other medications and asks the pharmacist which loop diuretic has the highest risk of ototoxicity. Which of the loop diuretics has the highest risk for ototoxicity?

A. Lasix
B. Bumex
C. Demadex
D. Edecrin
E. All loops have equal risk of ototoxicity

D. All of the loop diuretics can cause ototoxicity (especially with IV dosing) but ethacrynic acid has the highest risk among the loops. Additional risk is present if the patient is using other ototoxic drugs, such as vancomycin or aminoglycosides.

Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).

furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature

bumetanide (Bumex): IV:PO is 1:1

torsemide (Demadex): IV:PO is 1:1

ethacrynic acid (Edecrin): IV:PO is 1:1

3

Select the correct generic name for Natrecor:

A. Nitroprusside
B. Nebivolol
C. Eplerenone
D. Naloxone
E. Nesiritide

E. The generic name for Natrecor is nesiritide.

4

Select the correct mechanism of action for Diovan:

A. Binds to the Na+/K+ ATPase pump and decreases its action
B. Aldosterone receptor antagonist
C. Binds to beta-adrenergic receptors and blocks epinephrine and norepinephrine
D. Blocks angiotensin II by binding directly to the AT1 receptor
E. Blocks the conversion of angiotensin I to angiotensin II

D. Angiotensin receptor blockers (ARBs) such as Diovan block AT II directly at a receptor site on the smooth muscle wall of the vessel.

Diovan (valsartan)

5

A patient gave the pharmacist a prescription for Edecrin 25 mg daily. Which of the following is an appropriate generic substitution for Edecrin?

A. Ethacrynic acid
B. Torsemide
C. Bumetanide
D. Nesiritide
E. Furosemide

A. The generic name of Edecrin is ethacrynic acid.

furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature

bumetanide (Bumex): IV:PO is 1:1

torsemide (Demadex): IV:PO is 1:1

ethacrynic acid (Edecrin): IV:PO is 1:1

6

GT is a systolic heart failure patient on carvedilol 12.5 mg twice daily. To improve medication adherence, the primary physician wants to convert him to the once daily Coreg CR. What is the equivalent daily dose of Coreg CR for GT?

A. 10 mg
B. 20 mg
C. 40 mg
D. 80 mg
E. 160 mg

C. The conversion of immediate release carvedilol to Coreg CR is not on a direct mg per mg basis due to the formulation. Immediate release carvedilol 12.5 mg BID = Coreg CR 40 mg daily.

7

A 71 year-old male patient with heart failure was receiving standard therapy, however, he remained symptomatic. He has an appointment with the cardiologist in six weeks. To try and help him out, his primary care physician initiated digoxin 0.25 mg once daily and increased his carvedilol dose from 3.125 mg BID to 6.25 mg BID. Recent lab work includes an ALT 78 units/L, BUN 40 mg/dL, SCr 2.1 mg/dL, and K+ 4.5 mEq/L. The patient took the new medications for a couple of weeks and began to notice nausea and a reduced appetite. He felt confused and disoriented. He went back to the physician for help. What is the likely cause of the patient's symptoms?

A. Digoxin toxicity
B. The increased carvedilol dose
C. Liver failure
D. Decompensated heart failure
E. The potassium level

A. The patient is likely experiencing digoxin toxicity. The patient is prescribed a dose that requires good renal function, however he has very poor renal function and digoxin is primarily (~85%) renally cleared.

digoxin (Digox, Lanoxin): inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR). Does not improve survival, but does improve QoL and reduce hospitalizations. CI: ventricullar fibrillation. Warning: vesicant, avoid in 2nd or 3rd degree heart block with a functional pacemaker. SE: dizziness mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

8

A patient with New York Heart Association (NYHA) functional class III heart failure is diagnosed with rheumatoid arthritis (RA). The physician must choose an agent to treat the RA. Which of the following medications would be most appropriate in this patient?

A. Certolizumab
B. Infliximab
C. Methotrexate
D. Etanercept
E. Rituximab

C. TNF-blockers have a warning regarding worsening or new onset heart failure; therefore, they are generally avoided in heart failure patients. Methotrexate is the (relatively) safest agent for this patient.

9

An elderly patient with NYHA functional class IV heart failure is using 120 mg of furosemide twice daily. He takes his furosemide at 8 am and 12 noon. He has several conditions and takes a lot of pills. The prescriber requests that you calculate the dose of bumetanide that would be equivalent to the patient’s furosemide therapy. Choose the correct equivalent bumetanide dose:

A. Bumetanide 2 mg daily
B. Bumetanide 4 mg daily
C. Bumetanide 6 mg daily
D. Bumetanide 8 mg daily
E. Bumetanide 10 mg daily

C. The conversion ratio is 40 mg furosemide to 1 mg bumetanide. The patient is using a total daily dose of 240 mg, and the equivalent dose of bumetanide would be 6 mg daily.

bumetanide = 1

torsemide = 20

furosemide = 40

ethacrynic acid = 50

"Because They Fuck Everything"

10

Which of the following statements is correct regarding digoxin?

A. Digoxin is a positive inotrope and a negative chronotrope.
B. Digoxin is a positive inotrope and a positive chronotrope.
C. Digoxin is a negative inotrope and a negative chronotrope.
D. Digoxin is a negative inotrope and a positive chronotrope.
E. Digoxin has no effects on these hemodynamic parameters.

A. Digoxin is a positive inotrope, which means it increases the force of the heart's contractions, and is a negative chronotrope, which means it decreases heart rate.

digoxin (Digox, Lanoxin): inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR). Does not improve survival, but does improve QoL and reduce hospitalizations. CI: ventricullar fibrillation. Warning: vesicant, avoid in 2nd or 3rd degree heart block with a functional pacemaker. SE: dizziness mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

11

A patient gave the pharmacist a prescription for Aldactone 25 mg daily. Which of the following is an appropriate generic substitution for Aldactone?

A. Traimterene/Hydrochlorothiazide
B. Spironolactone
C. Eplerenone
D. Alendronate
E. Alfuzosin

B. The generic name of Aldactone is spironolactone.

K-Sparing Diuretics: For patients with NYHA FC II-IV. Compete with aldosterone at the distal convoluted tubule and collecting ducts, increasing Na and water excretion while conserving K and H+. Not effective as monotherapy and are commonly used in combination. Boxed warning: tumor risk (spironolactone). CI: anuria, significant renal impairment, hyperkalemia. SE: hyperkalemia, increase SCr, dizziness, pregnancy (C). Do not use when: CrCl <30, SCr >2 (females), SCr >2.5 (males), K >5 or diseases such as Addison's

spironolactone (Aldactone): for HTN and HF. blocks androgen (SE: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea), remember "A" for androgen block. target dose 25mg daily or BID

eplerenone (Inspra): for HTN and HF. selective aldosterone blocker, SE: increase TGs, 3A4 substrate (use with 3A4 inhibitors is CI). target dose 50mg daily

12

Which of the following beta-adrenergic blocking agents has been shown to reduce mortality in patients with systolic heart failure?

A. Carvedilol
B. Metoprolol tartrate
C. Atenolol
D. Propranolol
E. Labetalol

A. The only beta-blockers which have been shown in prospective, randomized trials to reduce mortality in systolic heart failure are metoprolol succinate, carvedilol, and bisoprolol.

13

Jamal has systolic heart failure with an ejection fraction of 33%. He gets short of breath while reaching down to tie his shoes and getting dressed. Which of the following ACC/AHA stages and NYHA functional class for heart failure best describe this patient?

A. ACC/AHA Stage A
B. ACC/AHA Stage B, NYHA Class I
C. ACC/AHA Stage C, NYHA Class II
D. ACC/AHA Stage C, NYHA Class III
E. ACC/AHA Stage D, NYHA Class IV

D. Jamal is classified as an ACC/AHA Stage C which indicates structural heart disease with prior or current heart failure symptoms. He is also NYHA Class III since he has symptoms with minimal exertion.

14

A patient with systolic heart failure and atrial fibrillation uses lisinopril, carvedilol, spironolactone, amiodarone, furosemide, clopidogrel, digoxin, cholestyramine and potassium. Which drug is likely to lower the digoxin level via a gut binding interaction?

A. Amiodarone
B. Clopidogrel
C. Lisinopril
D. Carvedilol
E. Cholestyramine

E. Bile acid sequestrants such as cholestyramine can inhibit digoxin absorption and lower digoxin concentration levels if the dosing is not separated.

15

Esther has NYHA functional class III systolic heart failure. She needs to use an additional drug to lower her blood pressure. She is currently taking Altace and hydrochlorothiazide. Which of the following medications should be added for her blood pressure?

A. Diltiazem
B. Monopril
C. Carvedilol
D. Amlodipine
E. Candesartan

C. Beta-blockers are considered a first-line option in heart failure patients.

Drugs used in HF:

1st line: beta-blockers and ACE-Is (both agents decrease mortality, start low and titrate up)

2nd line: loop diuretics (+/- benefit), ARBs (+/- benefit), aldosterone antagonists (decrease mortality, most likely to be added on 1st as 2nd line), digoxin (no mortality benefit, but does improve QoL, and decrease hospitalizations), BiDiL (decrease mortality in African American)

16

Choose the correct mechanism of action for carvedilol:

A. Beta-1 and beta-2 blocker and dopamine blocker
B. Beta-1 and beta-2 blocker and norepinephrine reuptake inhibitor
C. Beta-1 and beta-2 blocker and alpha-1 blocker
D. Beta-2 and alpha-2 selective blocker
E. Beta-1 and alpha-1 selective blocker

C. Carvedilol is a beta non-selective blocker that also blocks alpha-1 receptors in arterial walls.

Non-selective alpha and beta blocker

carvedilol (Coreg): PO. take with food. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels. Coreg IR target dose is weight dependent (<85kg = 25mg BID; >85kg = 50mg BID). Coreg CR target dose 80mg daily

17

A patient with systolic heart failure on digoxin has developed an upper respiratory tract infection. He has been prescribed clarithromycin. Choose the correct statement:

A. The digoxin level will decrease; it is best not to use a P450 3A4 enzyme inducer such as clarithromycin.
B. The digoxin level will increase; it is best not to use a P-glycoprotein and 3A4 inhibitor such as clarithromycin.
C. Digoxin levels are not affected by hepatic inducers or inhibitors.
D. Clarithromycin will bind to digoxin in the gut and reduce absorption.
E. Digoxin will cause the clarithromycin level to increase.

B. The interaction between digoxin and clarithromycin is mainly due to the inhibition of P-glycoprotein and (to a lesser extent) 3A4 inhibition.

18

A patient gave the pharmacist a prescription for BiDil 20 mg TID. Which of the following is an appropriate generic substitution for BiDil?

A. Isosorbide dinitrate/hydralazine
B. Spironolactone
C. Isosorbide mononitrate/hydralazine
D. Digoxin
E. Triamterene/Hydrochlorothiazide

A. The generic name of BiDil is isosorbide dinitrate + hydralazine.

19

Select the correct mechanism of action for Zestril:

A. Binds to the Na+/K+ ATPase pump and decreases its action
B. Aldosterone receptor antagonist
C. Blocks the conversion of angiotensin I to angiotensin II
D. Blocks angiotensin II by binding directly to the AT1 receptor
E. Binds to beta-adrenergic receptors and blocks epinephrine and norepinephrine

C. Zestril is an ACE inhibitor which blocks the conversion of angiotensin I to angiotensin II.

Renin-Angiotensin Aldosterone System (RAAS) Inhibitors: ACE-I & ARB. For ALL heart failure patients regardless of symptoms.

First line in CKD, slow progression of kidney disease, HF, stroke. Do not use ACE-I and ARB together. Avoid in pregnancy (D), angioedema, bilateral renal artery stenosis, or with aliskiren in patients with DM or GFR <60. SE: hyperkalemia, hypotension, cough (ACE-I only), dizziness, headache. Can decrease lithium's renal clearance and increase risk of toxicity.

20

Hamid has been prescribed Lasix. The following may occur from the use of this drug: (Select ALL that apply.)

A. Increased magnesium
B. Increased blood glucose
C. Increased potassium
D. Increased chloride
E. Increased triglycerides

B, E. Loop diuretics decrease sodium, magnesium, chloride, calcium and potassium and increase blood glucose and triglycerides.

Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).

21

John went to see a cardiologist at his doctor’s request. John does not understand why he should see a heart doctor. He has no heart failure symptoms or signs that the doctor has noticed, but his primary care physician wants a specialist to look at his heart. His past medical history is significant for high cholesterol, hypertension and type 2 diabetes. Which of the following ACC/AHA categories for heart failure best describe this patient?

A. ACC/AHA Stage A
B. ACC/AHA Stage B
C. ACC/AHA Stage C
D. ACC/AHA Stage D
EJohn does not match any of ACC/AHA staging categories

A. John is classified as ACC/AHA Stage A since he is high risk for heart failure but without evidence of structural heart disease or heart failure symptoms.

22

A heart failure patient is receiving furosemide 80 mg intravenously twice daily for the treatment of acute pulmonary edema. After two days, the patient is negative 5 liters of urine output. The patient is noted to have an increasing serum bicarbonate concentration of 36 mEq/L. Which of the following agents can be prescribed to prevent development of a metabolic alkalosis?

A. Hydrochlorothiazide
B. Triamterene
C. Acetazolamide
D. Mannitol
E. Metolazone

C. Acetazolamide inhibits carbonic anhydrase, the enzyme responsible for catalyzing the conversion of carbonic acid (H2CO3) to H2O + CO2 in the renal tubule which leaves more HCO3- available for reabsorption. When carbonic anhydrase in inhibited, the reaction favors maintenance of H2CO3 which results in greater elimination of bicarbonate.

23

Frank has been diagnosed with heart failure and was told to begin Toprol XL 12.5 mg daily. The pharmacist dispensed a 25 mg tablet with instructions to the patient to cut at the score line. Which of the following statements are true regarding Toprol XL? (Select ALL that apply.)

A. This is an extended-release formulation and cannot be cut.
B. This medication can be taken without regard to food.
C. The dose is likely to be titrated every 2 weeks, if tolerated.
D. This medication should be stored in the refrigerator.
E. Toprol XL can be cut at the score line; they should use a tablet cutter.

B, C, E. Toprol XL tablets have a score line and can be cut. They remain long-acting if cut only at the score line. They cannot be crushed or chewed.

metoprolol succinate (Toprol XL): PO, IV. IV:PO ratio 1:2.5. target dose 200mg daily

24

Esther has NYHA functional class III systolic heart failure. The cardiologist is considering beginning Inspra, in addition to her other medications. He checks her lab values and finds the following: Na+ 151 mEq/L, K+ 5.6 mEq/L, Cl 99 mEq/L, C02 mEq/L 20, BUN 39 mg/dL and serum creatinine 1.8 mg/dL. Can Inspra be initiated?

A. Yes, once she is classified as NYHA IV.
B. Yes, once she has trouble breathing without exertion.
C. No, Inspra is contraindicated.
D. Yes, but it will require sodium monitoring.
E. Yes, but it will require potassium monitoring.

C. The aldosterone blockers like Inspra should not be started if the potassium is greater than 5 mEq/L. If a patient is using one of these agents and the potassium reaches 5.5 mEq/L the aldosterone blocker is stopped.

K-Sparing Diuretics: For patients with NYHA FC II-IV. Compete with aldosterone at the distal convoluted tubule and collecting ducts, increasing Na and water excretion while conserving K and H+. Not effective as monotherapy and are commonly used in combination. Boxed warning: tumor risk (spironolactone). CI: anuria, significant renal impairment, hyperkalemia. SE: hyperkalemia, increase SCr, dizziness, pregnancy (C). Do not use when: CrCl <30, SCr >2 (females), SCr >2.5 (males), K >5 or diseases such as Addison's

spironolactone (Aldactone): for HTN and HF. blocks androgen (SE: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea), remember "A" for androgen block. target dose 25mg daily or BID

eplerenone (Inspra): for HTN and HF. selective aldosterone blocker, SE: increase TGs, 3A4 substrate (use with 3A4 inhibitors is CI). target dose 50mg daily

25

Which of the following agents is associated with a risk of cyanide toxicity?

A. Nitrogylcerin
B. Nitroprusside
C. Nesiritide
D. Eplerenone
E. Enalaprilat

B. Nitroprusside has a risk of cyanide and thiocyanate toxicity.

Vasodilators

nesiritide (Natrecor): provides both arterial and venous vasodilation. long half life. recombinant B-type natriuretic peptide. CI: persistent SBP <100 prior to therapy, cardiogenic shock. SE: hypotension, SCr

nitroglycerin: venous vasodilator at low dose, arterial vasodilator at higher doses. CI: SBP <90, concurrent use with PDE-5 inhibitors, increase intracranial pressure. SE: hypotension, headache, lightheadedness, tachycardia, tachyphylaxis. No PVC due to adsorption

nitroprusside (Nitropress): equal arterial and venous vasodilator at all doses. metabolism results in the formation of thiocynanate and cyanide which can cause toxicity. Boxed warning: rise in cyanide quantities at high infusion rates, can cause excessive hypotension, solution must be further diluted with D5W. CI: SBP <90, PDE-5 inhibitors, increase intracranial pressure. SE: hypotension, headache, tachycardia, thiocynanate/cyanide toxicity (especially in renal and hepatic impairment). requires protection from light during administration.

26

A patient presents to the hospital with increasing shortness of breath, fatigue, and lower extremity edema. The patient is diagnosed with acute decompensated heart failure. His blood pressure is 105/60 mmHg and his heart rate is 80 beats/minute. His serum creatinine is 1.4 mg/dL. In addition to furosemide, which of the following intravenous vasodilators are appropriate for this patient? (Select ALL that apply.)

A. Nitrogylcerin
B. Nesiritide
C. Milrinone
D. Dopamine
E. Phenylephrine

A, B. Milrinone, dopamine and phenylephrine are not vasodilators.

27

The most effective diuretics for controlling fluid volume in patients with heart failure are:

A. Carbonic anhydrase inhibitors
B. Thiazide-type diuretics
C. Loop diuretics
D. Potassium-sparing diuretics
E. Osmotic diuretics

C. Loop diuretics are the preferred diuretics in heart failure patients.

Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).

furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature

bumetanide (Bumex): IV:PO is 1:1

torsemide (Demadex): IV:PO is 1:1

ethacrynic acid (Edecrin): IV:PO is 1:1

28

A patient with heart failure has been given a prescription for BiDil. He has been using ramipril, metoprolol, furosemide and potassium extended-release for heart failure, ferrous sulfate for anemia, methotrexate for rheumatoid arthritis, a multivitamin complex, sildenafil for erectile dysfunction and coenzyme Q 10. Which of the following statements is correct?

A. Do not fill the new prescription; the physician must be contacted.
B. BiDil must be separated from the dosing of the ferrous sulfate and the multivitamin complex.
C. BiDil is contraindicated in patients with rheumatoid arthritis.
D. The patient is at heightened risk for rhabdomyolysis.
E. The drugs prescribed are fine to use together if taken as-directed.

A. BiDil is contraindicated with phosphodiesterase inhibitors, such as sildenafil.

Hydralazine/Nitrate: hydralazine is a direct arterial vasodilator which decreases afterload. Nitrates are venous vasodilators and decrease preload. The combination improves survival of heart failure patients and is used as alternative in patients who cannot tolerate ACE-Is or ARBs. Also can be added to standard therapy in black patients.

isosorbide dinitrate/hydralazine (BiDil): indicated in black patients with NYHA FC III-IV who are symptomatic despite optimal therapy with ACE-Is and beta blockers. CI with PDE-5 inhibitors. Warning: DILE. SE: headache, dizziness, hypotension, tachycardia, weakness. does not need nitrate-free interval. target dose 40/75mg TID

29

Which of the following chemotherapeutic agents have lifetime maximum doses due to risk of cardiotoxicity?

A. Anthracyclines, such as doxorubicin and daunorubicin
B. Vinca alkaloids, such as vincristine and vinblastine
C. Antimetabolites, such as fluorouracil
D. Taxanes, such as paclitaxel
E. Topoisomerase inhibitors, such as irinotecan

A. Anthracyclines require monitoring of cardiac output at baseline and with high doses due to the risk of cardiotoxicity. Clinicians cannot exceed the maximum lifetime doses of these medications or heart failure is likely to occur.

30

Select the correct indication for BiDil:

A. For the treatment of heart failure as initial therapy in self-identified black patients.
B. For the treatment of heart failure as an adjunct to standard therapy in self-identified black patients.
C. For the treatment of hypertension as an adjunct to standard therapy in self-identified black patients.
D. For the treatment of hypertension as initial therapy in self-identified black patients.
E. For the treatment of benign prostatic hyperplasia in self-identified black patients.

B. BiDil is indicated for the treatment of heart failure as an adjunct to standard therapy in self-identified black patients.

ACE-Is and beta-blockers are always 1st line.

Hydralazine/Nitrate: hydralazine is a direct arterial vasodilator which decreases afterload. Nitrates are venous vasodilators and decrease preload. The combination improves survival of heart failure patients and is used as alternative in patients who cannot tolerate ACE-Is or ARBs. Also can be added to standard therapy in black patients.

isosorbide dinitrate/hydralazine (BiDil): indicated in black patients with NYHA FC III-IV who are symptomatic despite optimal therapy with ACE-Is and beta blockers. CI with PDE-5 inhibitors. Warning: DILE. SE: headache, dizziness, hypotension, tachycardia, weakness. does not need nitrate-free interval. target dose 40/75mg TID

31

Select the correct generic name for Demadex:

A. Dolasetron
B. Torsemide
C. Dexamethasone
D. Meperidine
E. Docetaxel

B. The generic name for Demadex is torsemide.

Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).

furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature

bumetanide (Bumex): IV:PO is 1:1

torsemide (Demadex): IV:PO is 1:1

ethacrynic acid (Edecrin): IV:PO is 1:1

 

bumetanide = 1

torsemide = 20

furosemide = 40

ethacrynic acid = 50

"Because They Fuck Everything"

32

A patient gave the pharmacist a prescription for Lasix 20 mg daily in the morning. Which of the following is an appropriate generic substitution for Lasix?

A. Ethacrynic acid
B. Torsemide
C. Bumetanide
D. Nesiritide
E. Furosemide

33

Albert has been prescribed Lasix. He should be counseled regarding the following side effects from the use of this drug: (Select ALL that apply.)

A. Hypercalcemia
B. Hypokalemia
C. Photosensitivity
D. Orthostatic hypotension
E. Hypouricemia

B, C, D. Hypokalemia, photosensitivity and orthostatic hypoetension are all side effects of Lasix.

Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).

furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature

bumetanide (Bumex): IV:PO is 1:1

torsemide (Demadex): IV:PO is 1:1

ethacrynic acid (Edecrin): IV:PO is 1:1

 

bumetanide = 1

torsemide = 20

furosemide = 40

ethacrynic acid = 50

"Because They Fuck Everything"

34

JY has a past medical history significant for systolic heart failure and hypertension. He is being seen in clinic for routine follow up. He is on lisinopril 20 mg daily, Toprol XL 200 mg daily, furosemide 20 mg twice daily, and spironolactone 25 mg daily. His blood pressure has been averaging 154/94 mmHg and his heart rate is averaging 65 beats/minute. Which of the following agents would be best to add to provide better control of his blood pressure?

A. Amlodipine
B. Diltiazem
C. Losartan
D. Eplerenone
E. Carvedilol

A. Amlodipine has been shown to have a neutral effect on outcomes in patients with systolic heart failure. Diltiazem is associated with worse outcomes in systolic heart failure. Losartan cannot be added since triple combination therapy of an ACE inhibitor, aldosterone receptor antagonist and an ARB is not recommended due to an increased risk of hyperkalemia. The other agents would be duplication of therapy.

Drugs that cause or worsen HF: some chemotherapeutic agents, amphetamines, sympathomimetics, non-DHP CCB, antiarrhythmics (do not use Class I agents: mexiletine, tocainide, procainamide, quiniduine, disopyramide, flecainide, propafenone), itraconazole, interferons, TNF inhibitors, rituximab, NSAIDs, glucocorticoids, triptans, thiazolidinediones, excessive alcohol

35

A patient has NYHA functional class II heart failure. All patients with heart failure should follow these recommendations: (Select ALL that apply.)

A. Exercise 30 minutes/day, 3-5 days/week as tolerated.
B. Do not use NSAIDs or COX-2 inhibitors without the doctor's authorization.
C. Monitor body weight daily, in the morning before eating and after using the restroom. Weight should be documented.
D. Get a hepatitis vaccine and annual flu shot.
E. Fluid restriction of < 2 L/day is recommended.

A, B, C. Pneumococcal vaccine and an annual influenza vaccination is recommended. Fluid restriction is beneficial in selects patients with NYHA Class IV heart failure.

Non-drug therapy for HF patients:

Monitor and document body weight daily before eating and after voiding. Notify their provider if heart failure symptoms worsen or when weight increases (2-4 lbs/day or 3-5+ lbs/wk, increase SOB, increase cough/wheezing, increase swelling ankles, increase # of pillows). Restrict Na (<1500mg) in Stage A and B (not enough evidence in Stage C/D). Fluid restriction (1.5-2L/day) in Stage D HF to reduce congestion. Stop smoking, weight reduction BMI<30, exercise, vaccines, fish oil, avoid stimulants, avoid NSAIDs, hawthorn and coenzyme Q10 may be beneficial.

36

Which of the following antiarrhythmics should be avoided in patients with systolic heart failure? (Select ALL that apply.)

A. Flecainide
B. Mexiletine
C. Propafenone
D. Procainamide
E. Quinidine

A, B, C, D, E. Class I agents should not be used in heart failure patients.

Drugs that cause or worsen HF: some chemotherapeutic agents, amphetamines, sympathomimetics, non-DHP CCB, antiarrhythmics (do not use Class I agents: mexiletine, tocainide, procainamide, quiniduine, disopyramide, flecainide, propafenone), itraconazole, interferons, TNF inhibitors, rituximab, NSAIDs, glucocorticoids, triptans, thiazolidinediones, excessive alcohol

37

A patient gave the pharmacist a prescription for Inspra 25 mg daily. Which of the following is the generic name for Inspra?

A. Isosorbide Dinitrate/Hydralazine
B. Spironolactone
C. Eplerenone
D. Nesiritide
E. Furosemide

C. The generic name for Inspra is eplerenone.

K-Sparing Diuretics: For patients with NYHA FC II-IV. Compete with aldosterone at the distal convoluted tubule and collecting ducts, increasing Na and water excretion while conserving K and H+. Not effective as monotherapy and are commonly used in combination. Boxed warning: tumor risk (spironolactone). CI: anuria, significant renal impairment, hyperkalemia. SE: hyperkalemia, increase SCr, dizziness, pregnancy (C). Do not use when: CrCl <30, SCr >2 (females), SCr >2.5 (males), K >5 or diseases such as Addison's

spironolactone (Aldactone): for HTN and HF. blocks androgen (SE: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea), remember "A" for androgen block. target dose 25mg daily or BID

eplerenone (Inspra): for HTN and HF. selective aldosterone blocker, SE: increase TGs, 3A4 substrate (use with 3A4 inhibitors is CI). target dose 50mg daily

38

A patient is using furosemide 20 mg QHS and has a reported potassium level of 2.8 mEq/L. The patient reports she has to get up at night more often to use the bathroom. Which of the following statements are correct? (Select ALL that apply.)

A. Loop diuretics should be taken in the morning (or, if divided, the second dose is taken at noon or early afternoon).
B. Potassium supplementation is often required when loop diuretics are taken.
C. The potassium level is within normal range.
D. The dose of furosemide is too high for a patient with heart failure.
E. The patient should have her serum magnesium level checked.

A, B, E. Loop diuretics should be taken in the morning (or, if divided, the second dose is taken at noon or early afternoon).

Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).

furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature

bumetanide (Bumex): IV:PO is 1:1

torsemide (Demadex): IV:PO is 1:1

ethacrynic acid (Edecrin): IV:PO is 1:1

 

bumetanide = 1

torsemide = 20

furosemide = 40

ethacrynic acid = 50

"Because They Fuck Everything"

39

Select the correct mechanism of action for Aldactone:

A. Binds to beta-adrenergic receptors and blocks epinephrine and norepinephrine
B. Blocks angiotensin II by binding directly to the AT1 receptor
C. Blocks the conversion of angiotensin I to angiotensin II
D. Binds to the Na+/K+ ATPase pump and decreases its action
E. Aldosterone receptor antagonist

E. Spironolactone and eplerenone block aldosterone, a hormone which causes sodium and water retention and increases blood pressure. Aldosterone increases potassium secretion into the urine; drugs that block aldosterone such as spironolactone will cause an increase in serum potassium.

K-Sparing Diuretics: For patients with NYHA FC II-IV. Compete with aldosterone at the distal convoluted tubule and collecting ducts, increasing Na and water excretion while conserving K and H+. Not effective as monotherapy and are commonly used in combination. Boxed warning: tumor risk (spironolactone). CI: anuria, significant renal impairment, hyperkalemia. SE: hyperkalemia, increase SCr, dizziness, pregnancy (C). Do not use when: CrCl <30, SCr >2 (females), SCr >2.5 (males), K >5 or diseases such as Addison's

spironolactone (Aldactone): for HTN and HF. blocks androgen (SE: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea), remember "A" for androgen block. target dose 25mg daily or BID

eplerenone (Inspra): for HTN and HF. selective aldosterone blocker, SE: increase TGs, 3A4 substrate (use with 3A4 inhibitors is CI). target dose 50mg daily

40

A patient with heart failure comes to the community pharmacy asking for help choosing a medicine to treat her mild pain. Which agent is the safest over-the-counter oral analgesic to treat mild pain in this patient?

A. Acetaminophen
B. Naproxen
C. Ibuprofen
D. Hydrocortisone ointment
E. Flector patch

A. NSAIDs are not recommended in heart failure since they can worsen heart failure. NSAIDs should also be avoided in advanced renal disease.

Drugs that cause or worsen HF: some chemotherapeutic agents, amphetamines, sympathomimetics, non-DHP CCB, antiarrhythmics (do not use Class I agents: mexiletine, tocainide, procainamide, quiniduine, disopyramide, flecainide, propafenone), itraconazole, interferons, TNF inhibitors, rituximab, NSAIDs, glucocorticoids, triptans, thiazolidinediones, excessive alcohol

41

Which of the following statements are correct regarding the monitoring of potassium levels in heart failure patients? (SelectALL that apply.)

A. Potassium should be monitored at baseline
B. Potassium should be monitored quarterly
C. Potassium should be monitored a few days after the initiation of an ACE inhibitor, ARB, aldosterone antagonist or diuretic
D. Potassium should be monitored a few days after the up titration of an ACE inhibitor, ARB, aldosterone antagonist or diuretic
E. Potassium should be monitored when a patient's renal function changes

A, C, D, E. Potassium levels should be assessed after any change in ACE inhibitor, ARA, aldosterone antagonist or diuretic therapy or when the renal function changes.

42

A patient with systolic heart failure and paroxysmal atrial fibrillation is prescribed lisinopril, carvedilol, spironolactone, amiodarone, furosemide, clopidogrel, digoxin, cholestyramine and potassium. The patient forgot to refill his potassium tablets. His potassium level decreased to 2.1 mEq/L. Hypokalemia could potentiate which of the following in this patient? (Select ALL that apply.)

A. Cholestyramine toxicity
B. Increased risk of recurrent atrial fibrillation
C. Bleeding
D. Digoxin toxicity
E. Diarrhea

B, D. Hypokalemia can increase the risk of digoxin toxicity. This is important because patients on digoxin may be using a loop diuretic which lowers potassium.

digoxin (Digox, Lanoxin): inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR). Does not improve survival, but does improve QoL and reduce hospitalizations. CI: ventricullar fibrillation. Warning: vesicant, avoid in 2nd or 3rd degree heart block with a functional pacemaker. SE: dizziness mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

43

A patient with New York Heart Association (NYHA) functional class III heart failure is diagnosed with diabetes. She is started on metformin but has diarrhea and discontinues the drug. The physician must choose an alternative agent for treatment of her diabetes. Which of the following diabetes medications is contraindicated in this patient?

A. Amaryl
B. Glucotrol XL
C. Invokana
D. Actos
E. Januvia

D. Actos has a boxed warning against initiation in patients with NYHA Class III and IV heart failure.

Drugs that cause or worsen HF: some chemotherapeutic agents, amphetamines, sympathomimetics, non-DHP CCB, antiarrhythmics (do not use Class I agents: mexiletine, tocainide, procainamide, quiniduine, disopyramide, flecainide, propafenone), itraconazole, interferons, TNF inhibitors, rituximab, NSAIDs, glucocorticoids, triptans, thiazolidinediones, excessive alcohol

44

Karl has been diagnosed with heart failure and is beginning carvedilol immediate-release. Karl is 5 feet, 7 inches and weighs 78 kg. Assuming he tolerates the dose titrations, what is the maximum dose of carvedilol immediate-release that Karl may be given?

A. 12.5 mg BID
B. 25 mg BID
C. 50 mg BID
D. 75 mg BID
E. 100 mg BID

B. Carvedilol can be increased to 25 mg BID if the patient's weight is < 85 kg. If the weight is > 85 kg, the maximum dose is 50 mg BID. With the CR formulation, patients of any weight can be titrated from 10 to 20 to 40 to 80 over intervals of at least two weeks as tolerated.

carvedilol (Coreg): PO. take with food. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels. Coreg IR target dose is weight dependent (<85kg = 25mg BID; >85kg = 50mg BID). Coreg CR target dose 80mg daily

45

Frank has been diagnosed with heart failure and is beginning metoprolol extended-release. The pharmacist should provide the following counseling points: (Select ALL that apply.)

A. If you miss a dose, take your dose as soon as you remember, unless it is time to take your next dose. Do not double the dose.
B. Do not drive a car, use machinery, or do anything that requires you to be alert until you adjust to the medication and the symptoms subside.
C. This medication may make your feel more tired and dizzy at first. These effects will go away in a few days. However, call your doctor if the symptoms feel severe or you have weight gain or increased shortness of breath.
D. This medication must be taken with food.
E. This medication should not be stopped abruptly.

A, B, C, E. Beta blockers can worsen heart failure symptoms initially and the patient should be counseled that it may be several days before they start to feel better. This counseling should be offered when starting beta blocker therapy, and with each dose titration.

Beta Blocking Agents: Recommended for all, but especially those with NYHA FC II-IV. Inhibit effects of catecholamines at beta-1 & beta-2 receptors to reduce BP and HR. Beta blockers with intrinsic sympathomimetic activity (ISA) partially stimulate beta receptors while blocking additional stimulation and are contraindicated in S/P MI patients. ISA agents are carteolol, acebutolol, penbutolol, pindolol (CAPP). Boxed warning: avoid abrupt withdrawal, must taper. CI: sinus bradycardia, 2nd or 3rd degree heart block, sick sinus syndrome, cardiogenic shock, active asthma exacerbation. Warning: caution in diabetes (hypoglycemia), asthma, severe COPD, Raynaud's disease, may mask hyperthryoidism, aggravate psychiatric conditions. SE: decrease HR, hypotension, fatigue, dizziness, depression, decrease libido, impotence, hyperglycemia, hypoglycemia, hypertriglyceridemia, decrease HDL, most pregnancy (C)

46

Which of the following are common causes of heart failure? (Select ALL that apply.)

A. Bipolar disease
B. Stroke
C. Myocardial Infarction
D. Hypertension
E. Use of levothyroxine therapy

C, D. Hypothyroidism, if not treated for a long time, can cause or worsen heart failure. Treating hypothyroidism with a drug such as levothyroxine reduces this risk. Hypertension and myocardial infarction are the 2 primary causes of HF in the U.S.

Pathophysiology: ischemia (due to MI), long-standing HTN

47

Which of the following potassium chloride formulations can be opened and sprinkled on food?

A. Micro-K
B. Klor-Con
C. Klor-Con M10
D. K-tab
E. Klor-Con M15

A. Micro-K capsules can be opened and sprinkled on food and immediately swallowed.

potassium chloride (Klor-Con): any Klor-Con with an "M" can be cut or dissolved in water. any Klor-Con with "glass coating" should not be cut and must be swallowed whole. Klor-Con K capsules can be opened but not chewed.

48

A patient has been using digoxin 0.125 mg daily for several years. During this time the renal function has declined from an estimated 55 mL/min to 24 mL/min. The patient is unable to stand and has vomited. The heart rate is taken and found to be 45 BPM and the heart rhythm is unstable. The cardiologist is paged, but in the meantime the attending physician asks if there are any products that can lower the digoxin level quickly. What is the antidote for digoxin toxicity?

A. Phenytek
B. Fabior
C. DigiFab
D. Lanoxin
E. Ferriprox

C. DigiFab (Digoxin Immune Fab) is the antidote for digoxin toxicity.

digoxin (Digox, Lanoxin): inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR). Does not improve survival, but does improve QoL and reduce hospitalizations. CI: ventricullar fibrillation. Warning: vesicant, avoid in 2nd or 3rd degree heart block with a functional pacemaker. SE: dizziness mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

49

Anne has a past medical history significant for systolic heart failure and hypertension. She complains of being short of breath and states that it is the same as when she was originally told she had heart failure.  She asks if she is going to get better. She is currently taking lisinopril 10 mg daily, Toprol XL 100 mg daily, furosemide 20 mg twice daily, and spironolactone 25 mg daily. Today's vitals are: BP 134/84 mmHg, HR 75 beats/minute, RR 25 BPM. Current labs are: SCr 1.5 mg/dL, BUN 39 mg/dL, K+ 4.8 mEq/L and Cl- 101 mEq/L. No evidence of pitting edema. Which of the following changes should be made to Anne's current regimen? (Select ALL that apply.)

A. Increase the dose of furosemide
B. Increase the dose of lisinopril
C. Increase the dose of Toprol XL
D. Increase the dose of spironolactone
E. Decrease the dose of spironolactone

B, C. Anne is not at the target dose of Toprol XL or lisinopril. She has no contraindications to increasing the doses therefore, these medications should be up titrated.

50

A patient has been prescribed digoxin for systolic heart failure. What clinical benefit has digoxin shown in systolic heart failure?

A. A reduction in mortality
B. A reduction in strokes
C. A reduction in HF hospitalizations
D. A reduction in myocardial infarctions
E. A reduction in pulmonary edema

C. The DIG study and others clearly show a reduction in HF hospitalizations in patients with systolic heart failure.

digoxin (Digox, Lanoxin): inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR). Does not improve survival, but does improve QoL and reduce hospitalizations. CI: ventricullar fibrillation. Warning: vesicant, avoid in 2nd or 3rd degree heart block with a functional pacemaker. SE: dizziness mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

51

Which of the following positive inotropes acts via phosphodiesterase-3 inhibition?

A. Digoxin
B. Dobutamine
C. Dopamine
D. Epinephrine
E. Milrinone

E.

52

MT was recently admitted for an acute myocardial infarction and is found to have depressed left ventricular function. The patient is currently on aspirin, benazepril, diltiazem, pravastatin, voriconazole and ranitidine. The patient is to be started on eplerenone. Which of the following drugs is contraindicated for co-administration with eplerenone?

A. Ranitidine
B. Voriconazole
C. Benazepril
D. Diltiazem
E. Pravastatin

B. Eplerenone is contraindicated in patients receiving strong CYP3A4 inhibitors, such as voriconazole. Eplerenone dosing should not exceed 25 mg daily in patients receiving moderate 3A4 inhibitors, such as diltiazem.

K-Sparing Diuretics: For patients with NYHA FC II-IV. Compete with aldosterone at the distal convoluted tubule and collecting ducts, increasing Na and water excretion while conserving K and H+. Not effective as monotherapy and are commonly used in combination. Boxed warning: tumor risk (spironolactone). CI: anuria, significant renal impairment, hyperkalemia. SE: hyperkalemia, increase SCr, dizziness, pregnancy (C). Do not use when: CrCl <30, SCr >2 (females), SCr >2.5 (males), K >5 or diseases such as Addison's

spironolactone (Aldactone): for HTN and HF. blocks androgen (SE: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea), remember "A" for androgen block. target dose 25mg daily or BID

eplerenone (Inspra): for HTN and HF. selective aldosterone blocker, SE: increase TGs, 3A4 substrate (use with 3A4 inhibitors is CI). target dose 50mg daily

53

James went to see a cardiologist and was diagnosed with systolic heart failure. He had an echocardiogram and was told his left ventricle is enlarged. He has no symptoms during ordinary physical activity except if he is doing strenuous activity. Which of the following ACC/AHA stages and NYHA functional class for heart failure best describe this patient?

A. ACC/AHA Stage A
B. ACC/AHA Stage C, NYHA Class I
C. ACC/AHA Stage C, NYHA Class II
D. ACC/AHA Stage C, NYHA Class III
E. ACC/AHA Stage D, NYHA Class IV

B. ACC/AHA Stage C is designated to structural heart disease with prior or current symptoms. NYHA Class I is defined as having cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.

54

Which of the following loop diuretics is the least potent?

A. Furosemide
B. Torsemide
C. Bumetanide
D. Chlorthalidone
E. All loop diuretics have similar oral bioavailability

A. Furosemide is the least potent loop diuretic listed here.

Loop diuretics: block sodium and chloride reabsorption in the thick ascending limb of the loop of Henle resulting in excretion of sodium, chloride, magnesium, calcium, and water. Boxed warning: can lead to profound diuresis resulting in fluid and electrolyte depletion. CI in anuria. Warning: Sulfa allergy (not likely, does not apply to ethacrynic acid). SE: hypokalemia, orthostatic hypotension, decrease Na/Mg/Cl/Ca (bad for bones), increase HCO3/metabolic alkalosis, hyperuricemia, increase BG/TG/TC, photosensitivity, ototoxicity (more with ethacrynic acid), hearing loss, tinnitus, vertigo. All IV forms are light sensitive (all comes as IV and PO).

furosemide (Lasix): IV:PO ratio 1:2. Store at room temperature

bumetanide (Bumex): IV:PO is 1:1

torsemide (Demadex): IV:PO is 1:1

ethacrynic acid (Edecrin): IV:PO is 1:1

 

bumetanide = 1

torsemide = 20

furosemide = 40

ethacrynic acid = 50

"Because They Fuck Everything"

55

Which of the following statements regarding the use of beta-blockers in patients with systolic heart failure are correct? (Select ALL that apply.)

A. They are contraindicated in NYHA functional class IV patients.
B. The benefit of beta-blockers is considered a class effect.
C. When initiating therapy, low doses should be used.
D. The benefit of beta-blockers in heart failure is dose-dependent.
E. Beta-blockers with intrinsic sympathomimetic activity should be used.

C, D. Beta-blockers are indicated in all severities of heart failure, including patients with symptoms at rest. The benefit of beta-blockers is not considered a class effect; use only those that have shown clinical benefit.

Beta Blocking Agents: Recommended for all, but especially those with NYHA FC II-IV. Inhibit effects of catecholamines at beta-1 & beta-2 receptors to reduce BP and HR. Beta blockers with intrinsic sympathomimetic activity (ISA) partially stimulate beta receptors while blocking additional stimulation and are contraindicated in S/P MI patients. ISA agents are carteolol, acebutolol, penbutolol, pindolol (CAPP). Boxed warning: avoid abrupt withdrawal, must taper. CI: sinus bradycardia, 2nd or 3rd degree heart block, sick sinus syndrome, cardiogenic shock, active asthma exacerbation. Warning: caution in diabetes (hypoglycemia), asthma, severe COPD, Raynaud's disease, may mask hyperthryoidism, aggravate psychiatric conditions. SE: decrease HR, hypotension, fatigue, dizziness, depression, decrease libido, impotence, hyperglycemia, hypoglycemia, hypertriglyceridemia, decrease HDL, most pregnancy (C)

Beta-1 selective blockers: AMEBBA.

bisoprolol (Zebeta): PO. target dose 10mg daily

metoprolol succinate (Toprol XL): PO, IV. IV:PO ratio 1:2.5. target dose 200mg daily

Non-selective alpha and beta blocker

carvedilol (Coreg): PO. take with food. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels. Coreg IR target dose is weight dependent (<85kg = 25mg BID; >85kg = 50mg BID). Coreg CR target dose 80mg daily

56

James has systolic heart failure with an ejection fraction of 33%. Which of the following medications could possibly worsen James' heart failure? (Select ALL that apply.)

A. Itraconazole
B. Verapamil
C. Ramipril
D. Prednisone
E. Carbamazepine

A, B, D. These agents should not be used in heart failure patients.

Drugs that cause or worsen HF: some chemotherapeutic agents, amphetamines, sympathomimetics, non-DHP CCB, antiarrhythmics (do not use Class I agents: mexiletine, tocainide, procainamide, quiniduine, disopyramide, flecainide, propafenone), itraconazole, interferons, TNF inhibitors, rituximab, NSAIDs, glucocorticoids, triptans, thiazolidinediones, excessive alcohol

57

Anne has a past medical history significant for systolic heart failure and hypertension. She is being seen in clinic for routine follow up. She is currently taking lisinopril 10 mg daily, Toprol XL 100 mg daily, furosemide 20 mg twice daily, and spironolactone 25 mg daily. Today's vitals are: BP 134/84 mmHg, HR 75 beats/minute, RR 25 BPM. Current labs are: SCr 1.5 mg/dL, BUN 39 mg/dL, K+ 5.6 mEq/L and Cl- 101 mEq/L. Which of the following recommendations should be made to the physician regarding Anne's current regimen?

A. Discontinue the Toprol XL
B. Discontinue the furosemide
C. Discontinue the lisinopril
D. Discontinue the spironolactone
E. Start valsartan 80 mg BID

D. Spironolactone needs to be discontinued due to the elevated potassium level.

58

Which of the following agents have been shown to improve survival in heart failure? (Select ALL that apply.)

A. Lisinopril
B. Digoxin
C. Furosemide
D. Metoprolol succinate
E. Spironolactone

A, D, E.

Drugs used in HF:

1st line: beta-blockers and ACE-Is (both agents decrease mortality, start low and titrate up)

2nd line: loop diuretics (+/- benefit), ARBs (+/- benefit), aldosterone antagonists (decrease mortality, most likely to be added on 1st as 2nd line), digoxin (no mortality benefit, but does improve QoL, and decrease hospitalizations), BiDiL (decrease mortality in African American)

59

Which of the following natural products may be beneficial in heart failure patients? (Select ALL that apply.)

A. Ginkgo
B. Fish oils
C. Hawthorn
D. Ma huang
E. Coenzyme Q10

B, C, E. Fish oils, hawthorn, and coenzyme Q10 may have beneficial effects in heart failure patients. Ma huang (ephedra) should be avoided.

60

Jerrod, a 68 year old black male, has just been diagnosed with heart failure NYHA Class III. His past medical history is significant for bilateral renal artery stenosis and diabetes type 2. His allergies include codeine (nausea) and penicillin (hives). Today's vitals are: BP 165/95 mmHg, HR 48 BPM, RR 26 BPM, Temp. 37.8 °C. Jerrod has symptoms of leg edema, bibasilar rales and shortness of breath. Which medications should be started in Jerrod to treat his heart failure? (Select ALLthat apply.)

A. Toprol XL
B. Lasix
C. Diovan
D. BiDil
E. Altace

B, D. ACE inhibitors and ARBs cannot be used in patients with bilateral renal artery stenosis. Beta-blockers should not be used in sinus bradycardia (HR = 48 BPM). Jerrod is congested and needs a loop diuretic. BiDil will also provide benefit.

Drugs used in HF:

1st line: beta-blockers and ACE-Is (both agents decrease mortality, start low and titrate up)

2nd line: loop diuretics (+/- benefit), ARBs (+/- benefit), aldosterone antagonists (decrease mortality, most likely to be added on 1st as 2nd line), digoxin (no mortality benefit, but does improve QoL, and decrease hospitalizations), BiDiL (decrease mortality in African American)

 

61

Digoxin serum concentrations above what level are associated with increased mortality in patients with systolic heart failure?

A. 0.5 ng/mL
B. 1.0 ng/mL
C. 1.5 ng/mL
D. 2.0 ng/mL
E. 2.5 ng/mL

B. In the largest, prospective study of digoxin therapy in patients with heart failure, serum digoxin concentrations 1.0 ng/mL and greater were associated with increased mortality. Hence, it is recommended for digoxin doses to be adjusted to maintain concentrations below this threshold.

digoxin (Digox, Lanoxin): inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR). Does not improve survival, but does improve QoL and reduce hospitalizations. CI: ventricullar fibrillation. Warning: vesicant, avoid in 2nd or 3rd degree heart block with a functional pacemaker. SE: dizziness mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

62

A systolic heart failure patient is seen by his primary care physician after one month of starting on Vasotec 5 mg twice daily and Toprol XL 50 mg daily. The patient's blood pressure is 130/80 mmHg and heart rate is 78 BPM. The patient overall feels well but has noticed a tickle in his throat that causes him to have a constant, dry cough. Drinking water does not help. Which of the following medication changes is most appropriate for this patient?

A. Have the patient take an over-the-counter antitussive
B. Discontinue the Toprol XL and begin carvedilol
C. Discontinue the Vasotec and begin valsartan
D. Decrease the dose of Toprol XL
E. Decrease the dose of Vasotec

C. A dry cough is a common adverse effect of angiotensin converting enzyme inhibitors. The mechanism is thought to be due to an accumulation of bradykinin secondary to the inhibition of ACE which is responsible for the breakdown of bradykinin. Angiotensin receptor blockers do not affect the breakdown of bradykinin and thus are not associated with dry cough.

63

Which of the following potassium chloride formulations can be cut or dissolved in water? 

A. Micro-K
B. Klor-Con
C. Klor-Con M10
D. K-tab
E. K-tab generic

C. Klor-Con M tablets can be cut and or can be dissolved in water and taken immediately.

potassium chloride (Klor-Con): any Klor-Con with an "M" can be cut or dissolved in water. any Klor-Con with "glass coating" should not be cut and must be swallowed whole. Klor-Con K capsules can be opened but not chewed.

64

Miguel has just been discharged from the hospital after a heart failure exacerbation. Which of the following steps can be taken to prevent Miguel from being readmitted for another heart failure exacerbation? (Select ALL that apply.)

A. Provide regular and frequent follow up appointments to ask about medication adherence, assess symptoms and address any questions
B. Do medication reconciliation from inpatient to outpatient therapy
C. Keep patients on low doses of heart failure medications to avoid side effects
D. Provide a bulk of medical literature for the patient to read and comprehend
E. Provide education on how to monitor for worsening symptoms and avoiding foods and medications that can worsen heart failure

A, B, E. Heart failure medications should be titrated to higher doses as these are the doses proven to provide benefit in clinical trials. Many patients do not read or understand literature that is provided to them. It is best to explain how to manage this condition and serve as a resource for patient questions.

65

Which of the following is the brand name for bisoprolol?

A. Diabeta
B. Zebeta
C. Betapace
D. Betaseron
E. Brevibloc

B. The brand name for bisoprolol is Zebeta.

Beta Blocking Agents: Recommended for all, but especially those with NYHA FC II-IV. Inhibit effects of catecholamines at beta-1 & beta-2 receptors to reduce BP and HR. Beta blockers with intrinsic sympathomimetic activity (ISA) partially stimulate beta receptors while blocking additional stimulation and are contraindicated in S/P MI patients. ISA agents are carteolol, acebutolol, penbutolol, pindolol (CAPP). Boxed warning: avoid abrupt withdrawal, must taper. CI: sinus bradycardia, 2nd or 3rd degree heart block, sick sinus syndrome, cardiogenic shock, active asthma exacerbation. Warning: caution in diabetes (hypoglycemia), asthma, severe COPD, Raynaud's disease, may mask hyperthryoidism, aggravate psychiatric conditions. SE: decrease HR, hypotension, fatigue, dizziness, depression, decrease libido, impotence, hyperglycemia, hypoglycemia, hypertriglyceridemia, decrease HDL, most pregnancy (C)

Beta-1 selective blockers: AMEBBA.

bisoprolol (Zebeta): PO. target dose 10mg daily

metoprolol succinate (Toprol XL): PO, IV. IV:PO ratio 1:2.5. target dose 200mg daily

Non-selective alpha and beta blocker

carvedilol (Coreg): PO. take with food. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels. Coreg IR target dose is weight dependent (<85kg = 25mg BID; >85kg = 50mg BID). Coreg CR target dose 80mg daily

66

Eleanor has systolic heart failure and is taking quinapril, carvedilol, torsemide, spironolactone and BiDil. She presents to the clinic with a mild fever and sore finger and arm joints and muscle aches. She reports she is more tired than usual and feels miserable. The patient is likely experiencing this drug adverse effect:

A. Angioedema from quinapril
B. Lupus-like syndrome from hydralazine
C. Hypokalemia from torsemide
D. Hyperkalemia from the spironolactone
E. Fatigue and dizziness from carvedilol

B. Isosorbide dinitrate/hydralazine (BiDil) can cause lupus-like syndrome. Instruct patients to report fever, joint/muscle aches and fatigue.

Hydralazine/Nitrate: hydralazine is a direct arterial vasodilator which decreases afterload. Nitrates are venous vasodilators and decrease preload. The combination improves survival of heart failure patients and is used as alternative in patients who cannot tolerate ACE-Is or ARBs. Also can be added to standard therapy in black patients.

isosorbide dinitrate/hydralazine (BiDil): indicated in black patients with NYHA FC III-IV who are symptomatic despite optimal therapy with ACE-Is and beta blockers. CI with PDE-5 inhibitors. Warning: DILE. SE: headache, dizziness, hypotension, tachycardia, weakness. does not need nitrate-free interval. target dose 40/75mg TID

hydralazine (Apresoline): CI: mitral valve rheumatic heart disease. Warning: DILE. SE: headache, reflex tachycardia, palpitations. target dose 7300mg daily

isosorbide mononitrate (Monoket): CI with PDE-5 inhibitors. SE: headache, dizziness, lightheadedness, flushing, hypotension, tachyphylaxis (need 10-12 hour nitrate free period), syncope. dosed QD-BID. target dose 120mg daily

isosorbide dinitrate (Isordil): same as mononitrate but dosed TID-QID. Guidelines recommend dinitrate over mononitrate

67

A physician wants to initiate an angiotensin converting enzyme inhibitor in a heart failure patient with a blood pressure of 95/60 mmHg. He would like to use the shortest acting agent just in case the patient becomes hypotensive. Which angiotensin converting enzyme inhibitor has the shortest half-life?

A. Enalapril
B. Monopril
C. Captopril
D. Lisinopril
E. Accupril

C. Captopril has the shortest half-life.

68

Ronald has been diagnosed with systolic heart failure and is beginning metoprolol immediate-release. His blood pressure averages 138/82 mmHg and his heart rate averages 122 BPM. What benefit might Ronald experience with the use of metoprolol IR?

A. Weight loss
B. Hair growth
C. Reduced mortality due to heart failure
D. Improved blood pressure
E. Lowered heart rate

E. Beta blockers lower heart rate and are useful in patients with tachycardia. Some beta-blockers have been shown to reduce mortality.

69

Rank the following oral diuretics in order of milligram potency (least potent = 1 to most potent = 4).  Drag and drop the choices into the correct order.

A. Edecrin
B. Lasix
C. Demadex
D. Bumetanide

A, B, C, D.

Potency:

bumetanide = 1

torsemide = 20

furosemide = 40

ethacrynic acid = 50

"Because They Fuck Everything"

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