Beta Blockers, Ranolazine, Digoxin, and Ivabradine

Question 1

What are the Contraindications for ALL Beta Blockers?

Answer 1

1. Decompensated HF
2. Cardiogenic Shock
3. Severe Bradycardia
4. AV Block
5. Sick Sinus Syndrome
6. Asthma/Bronchospastic Disease

Question 2

Can you initiate a NEW beta blocker in decompensated HF?

Answer 2

NO

Question 3

Can you use a beta blocker in asthma/bronchospatic diseases?

Answer 3

Yes, it they are NOT nonselective, aka the cardioselective ones

Question 4

How does DM affect beta blockers?

Answer 4

They mask hypoglycemia, patients will not be sweating in a hypoglycemic situation

Question 5

What is the titration and taper rule of beta blockers?

Answer 5

Titrate and Taper every 1-2 weeks

Question 6

Can you use Nondihydropyridine CCBs with BB?

Answer 6

NO = additive bradycardia

Question 7

Can you used Clonidine with BB?

Answer 7

NO = enhanced AV blocking, SA node dysfunction, and rebound HTN

Question 8

Can you used NSAIDs with BB?

Answer 8

EH = cause decreased effect on BP

Question 9

What are the common A/Es of BB?

Answer 9

1. Dizzy
2. Drowsy
3. Fatigue
4. Bradycardia

Question 10

What are the beta blockers?

Answer 10

1. Bisoprolol
2. Atenolol
3. Metoprolol
4. Nebivolol
5. Propranolol
6. Carvedilol
7. Labetalol

Question 11

What is the indication for Propranolol?

Answer 11

FDA: Stable Angina, HTN, Migraine HA, portal HTN

Off Label: thyroid storm

Question 12

What is the specific class of BB for Propranolol?

Answer 12

Non-Selective
Lipophilic

Question 13

What is the concern with Propranolol?

Answer 13

CI: asthma
Counseling: take on an empty stomach

Question 14

What is the indication for Atenolol?

Answer 14

FDA: HTN and Angina

Question 15

What is the specific class of BB for Atenolol?

Answer 15

Relatively Cardioselective
NOT Lipophilic

Question 16

What is the indication for Metoprolol Tartrate?

Answer 16

FDA: HTN, Post MI, AFib, and Angina

Question 17

What is the specific class of BB for Metoprolol Tartrate?

Answer 17

Relative Cardioselective
Lipophilic

Question 18

What is the concern with Metoprolol Tartrate?

Answer 18

Take with food to increase absorption

Question 19

What is the indication for Metoprolol Succinate?

Answer 19

FDA: HTN, Angina, HFrEF, Post MI

Question 20

What is the specific class of BB for Metoprolol Succinate?

Answer 20

Relatively Cardioselective
Lipophilic

Question 21

What are the concerns with Metoprolol Succinate?

Answer 21

Take without regard to food
Tablet is scored and may divide in half BUT do NOT crush or chew

Question 22

What is the indication for Bisoprolol?

Answer 22

FDA: HTN
Off: HFrEF

Question 23

What is the specific class of BB for Bisoprolol?

Answer 23

Relatively Cardioselective
Lipophilic

Question 24

What is the indication for Nebivolol?

Answer 24

FDA: HTN

Question 25

What is the specific class of BB for Nebivolol?

Answer 25

Relatively Cardioselective

Question 26

What is the indication for Carvedilol?

Answer 26

FDA: HTN, HFrEF

Question 27

What is the specific class of BB for Carvedilol?

Answer 27

Nonselective Beta + Alpha Blocker

Question 28

What are the concerns with Carvedilol?

Answer 28

AE = hypotension/syncope Take with food to decrease absorption and limit orthostatic BP changes Capsules can be opened and sprinkled in applesauce

Question 29

What is the indication of Ranolazine?

Answer 29

Chronic Angina

Question 30

What is CI'd with Ranolazine?

Answer 30

Strong 3A4 inhibitors/inducers and Liver Cirrhosis

Question 31

What are the AEs of Ranolazine?

Answer 31

1. Dizzy 2. HA 3. Constipation 4. QTc Prolongation

Question 32

What do you counsel with Ranolazine?

Answer 32

1. Avoid Grapefruit 2. Do NOT crush/chew

Question 33

What is the indication for Digoxin?

Answer 33

FDA: HFrEF, AFib

Question 34

What are the lipophilic BBs?

Answer 34

Metoprolol, Bisoprolol, Carvedilol, and Propranolol

Question 35

What are the hydrophilic BBs?

Answer 35

Atenolol and Labetalol

Question 36

What are the AEs of Digoxin?

Answer 36

1. Dizzy 2. GI Upset 3. Bradycardia

Question 37

When is Digoxin preferred and not preferred for treatment?

Answer 37

Useful in patient sixth HFrEF and AF CI: Ventricular Fibrillation

Question 38

What weight do you use when calculating CrCl for Digoxin?

Answer 38

IBW

Question 39

What is considered Digoxin Toxicity? What are the S/S?

Answer 39

AV Node Suppression Anorexa, N/V, VISUAL CHANGES GREEN YELLOW HALO, Arrhythmias

Question 40

What increases the risk of Digoxin Toxicity?

Answer 40

Low Potassium/Low Magnesium and High Calcium

Question 41

What are DDIs to be of concern when using Digoxin?

Answer 41

1. Diuretics 2. BAS 3. Amiodarone 4. Verpamil 5. Diltazem

Question 42

What is the indication for Ivabradine?

Answer 42

HFrEF with EF <35% and HR >70 bpm already on max GDMT/BB or CI'd

Question 43

What are the AEs and Warnings for Ivabradine?

Answer 43

Warning: increase risk of Afib A/E: Brightness or Halo

Question 44

What are the CIs for use of Ivabradine?

Answer 44

1. Acute decompensated CHF 2. Sinus bradycardia 3. SA Node disorders 4. Low BP <90/50

Question 45

What are the patient counseling points of Ivabradine?

Answer 45

Take with food to increase bioavailability AVOID grapefruit