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PHRM 845 Therapeutics > Exam 2 - Heart Failure > Flashcards

Exam 2 - Heart Failure Flashcards

1
Q

what is stage A heart failure?

A

high risk: HTN, CAD, diabetes, family history

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1
Q

what is stage B heart failure?

A

asymptomatic LVD (pre-heart failure): includes previous MI, LV systolic dysfunction asymptomatic valvular disease

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2
Q

what is stage C heart failure?

A

symptomatic HF

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3
Q

what is stage D heart failure?

A

refractory end-stage HF: marked symptoms at rest despite maximal medical therapy

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4
Q

NYHA class I

A

cardiac disease with no symptoms

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5
Q

NYHA class II

A

symptoms with moderate exertion

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6
Q

NYHA class III

A

symptoms with minimal exertion (limitations of physical activity)

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7
Q

NYHA class IV

A

symptoms at rest

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8
Q

what is JVD?

A

jugular vein distention -> jugular vein is swollen/bulging (usually a sign of HF)

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9
Q

true or false: HF is the most common hospital discharge for pts > 65 yo

A

true

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10
Q

CAD, HTN, cardiomyopathy, and valvular disease all lead to _____ _____ _____

A

left ventricular dysfunction (LVD)

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11
Q

how does LVD eventually lead to death?

A

LVD -> remodeling -> reduced EF -> death

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12
Q

which HF is due to systolic dysfunction: decreased contractility?

a. HFrEF
b. HFpEF

A

a. HFrEF

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13
Q

which HF is due to diastolic dysfunction: impairment in ventricular relaxation/filling?

a. HFrEF
b. HFpEF

A

b. HFpEF

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14
Q

cause of HFrEF

A

dilated ventricle (there is more, look at slide 9)

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15
Q

most common cause of HFpEF (> 60%)

A

HTN

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16
Q

what is EF of 41-49% called?

A

HFmrEF (mildly reduced EF)

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17
Q

what is HFimpEF?

A

EF > 40%, previously had HFrEF

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18
Q

3 determinants of left-ventricular performance (stroke volume)

A

preload, myocardial contractility, afterload

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19
Q

what are the 3 classes of drugs we talked about for drug-induced HF?

A

-drugs that reduce contractility (negative inotropes)
-direct cardiac toxins
-drugs that lead to sodium/water retention

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20
Q

how do antiarrhythmics, beta blockers, CCBs, and itraconazole lead to drug-induced HF?

a. they reduce contractility
b. they are direct cardiac toxins
c. they lead to sodium/water retention

A

a. they reduce contractility

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21
Q

which of the following is a direct cardiac toxin?

a. itraconazole
b. glucocorticoids
c. doxorubicin
d. flecainide

A

c. doxorubicin

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22
Q

the clinical presentation of right ventricular failure is primarily

a. pulmonary congestion
b. systemic venous congestion

A

b. systemic venous congestion

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23
Q

the clinical presentation of left ventricular failure is primarily

a. pulmonary congestion
b. systemic venous congestion

A

a. pulmonary congestion

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24
Q

peripheral edema, JVD, HJR, hepatomegaly, and ascites are signs of

a. right ventricular failure
b. left ventricular failure

A

a. right ventricular failure

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25
Q

what is orthopnea?

A

SOB when lying down (how many pillows do patients need to sleep?)

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26
Q

what is paroxysmal nocturnal dyspnea?

A

sudden SOB at night

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27
Q

DOE, orthopnea, PND, rales, pulmonary edema, and bendopnea are major signs/symptoms of

a. systemic venous congestion
b. pulmonary congestion

A

b. pulmonary congestion

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28
Q

Low cardiac output results in the activation of compensatory neurohormonal pathways. Activation of the SNS results in which one of the following effects?

A. Peripheral vasodilation
B. Fluid retention
C. Decreased cardiac contractility
D. Increased heart rate
E. Diuresis

A

D. Increased heart rate

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29
Q

Which one of the following medications may
exacerbate HFrEF?

A. Metformin
B. Amlodipine
C. Atorvastatin
D. Ibuprofen

A

D. Ibuprofen

(any NSAIDs except 81 mg aspirin)

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30
Q

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

A. Bipolar Disorder
B. Asthma
C. MI
D. HTN
E. Gout

A

C. MI
D. HTN

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31
Q

via what 4 methods can we use to evaluate LV function and measure EF in clinic?

A

-echocardiogram
-nuclear testing
-cardiac cath
-MRI and CT

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32
Q

sodium restriction per day for HF pts

A

2-3 grams/day

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33
Q

fluid intake restriction for HF pts

A

< 2 L/day in pts with hyponatremia (< 130 mEq/L) or if Tx with diuretics is difficult in maintaining fluid volume

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34
Q

diuretics and SGLT2s reduce _____ _____

A

intravascular volume

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35
Q

positive inotropes increase _____ _____

A

myocardial contractility

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36
Q

ACEi’s, vasodilators, and SGLT2s decrease _____ _____

A

ventricular afterload

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37
Q

what 2 drug classes should be used in stage B pt if previous MI or asymptomatic rEF?

A

ACE/ARB and beta blocker

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38
Q

true or false: diuretics reduce mortality in HF

A

false (reduce hospitalizations but not mortality or disease progression)

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39
Q

true or false: pts without symptoms of volume overload should still receive a diuretic

A

false (only those with symptoms should; slide 50)

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40
Q

loop diuretics block ___ and ___ reabsorption in the _____ limb of the loop of Henle

A

Na, Cl, ascending

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41
Q

initial oral dose for furosemide

A

20-40 mg QD or BID

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42
Q

initial oral dose for bumetanide

A

0.5-1 mg QD or BID

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43
Q

initial oral dose for torsemide

A

10-20 mg QD

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44
Q

initial oral dose for ethacrynic acid

A

25-50 mg QD or BID

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45
Q

what are the IV equivalent doses for the loop diuretics?

A

furosemide 40 = bumetanide 1 = torsemide 20 = ethacrynic acid 50

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46
Q

usual dose range for furosemide

a. 20-160 mg QD or BID
b. 1-2 mg QD or BID
c. 10-80 mg QD

A

a. 20-160 mg QD or BID

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47
Q

usual dose range for bumetanide

a. 20-160 mg QD or BID
b. 1-2 mg QD or BID
c. 10-80 mg QD

A

b. 1-2 mg QD or BID

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48
Q

usual dose range for torsemide

a. 20-160 mg QD or BID
b. 1-2 mg QD or BID
c. 10-80 mg QD

A

c. 10-80 mg QD

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49
Q

torsemide dose for Cr-Cl 20-50 mL/min

A

40 mg QD

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50
Q

Which one of the following doses would be
considered “equivalent” to 1 mg PO bumetanide?

A. Furosemide PO 80 mg
B. Furosemide IV 20 mg
C. Torsemide PO 10 mg
D. Bumetanide IV 0.5 mg

A

a. Furosemide PO 80 mg

(B. is furosemide IV 40; C. is torsemide 20 mg; not sure about D)

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51
Q

thiazides block Na and Cl reabsorption in which part of the nephron?

A

DCT

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52
Q

HCTZ’s initial and max doses for HF

a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day

A

a. initial: 25 mg/day; max: 100 mg/day

53
Q

metolazone’s initial and max doses for HF

a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day

A

b. initial: 2.5 mg/day; max: 10 mg/day

54
Q

chlorthalidone initial and max doses for HF

a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day

A

c. initial: 12.5-25 mg/day; max: 50 mg/day

55
Q

CTZ’s initial and max doses for HF

a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day

A

d. initial: 250-500 mg/day; max: 2000 mg/day

56
Q

indapamide’s initial and max doses for HF

a. initial: 25 mg/day; max: 100 mg/day
b. initial: 2.5 mg/day; max: 10 mg/day
c. initial: 12.5-25 mg/day; max: 50 mg/day
d. initial: 250-500 mg/day; max: 2000 mg/day
e. initial: 2.5 mg/day; max: 5 mg/day

A

e. initial: 2.5 mg/day; max: 5 mg/day

57
Q

which of the following is NOT a mechanism of ACE inhibitor benefit in HF?

a. increased aldosterone
b. inhibition of cardiac hypertrophy
c. reduced vasoconstriction
d. decreased endothelin-1

A

a. increased aldosterone (it is decreased)

58
Q

which of the following is a mechanism of ACE inhibitor benefit in HF?

a. increased NE
b. increased Na and water retention
c. decreased endothelial function
d. decreased arginine vasopressin

A

d. decreased arginine vasopressin

(a. and d. are decreased; c. is increased)

59
Q

enalapril initial dose for HF

A

2.5-5 mg BID

60
Q

captopril initial dose for HF

A

6.25-12.5 mg TID

61
Q

lisinopril initial dose for HF

a. 2.5-5 mg QD
b. 5-10 mg BID
c. 1.25-2.5 mg QD

A

a. 2.5-5 mg QD

62
Q

quinapril initial dose for HF

A

5-10 mg BID

63
Q

ramipril initial dose for HF

a. 2.5-5 mg QD
b. 5-10 mg BID
c. 1.25-2.5 mg QD

A

c. 1.25-2.5 mg QD

64
Q

fosinopril initial dose for HF

a. 1.25-2.5 mg QD
a. 2.5-5 mg BID
b. 5-10 mg QD
c. 5-10 mg BID

A

c. 5-10 mg QD

65
Q

what are the dose equivalents for enalapril, captopril, and lisinopril?

A

20 mg enalapril = 150 mg captopril = 20 mg lisinopril

66
Q

enalapril target dose for HF

A

10 mg BID

67
Q

captopril target dose for HF

A

50 mg TID

68
Q

lisinopril target dose for HF

A

20-40 mg QD

69
Q

quinapril target dose for HF

a. 20-40 mg QD
b. 20-40 mg BID
c. 10 mg BID
d. 40 mg QD

A

b. 20-40 mg BID

70
Q

fosinopril target dose for HF

a. 20-40 mg QD
b. 20-40 mg BID
c. 10 mg BID
d. 40 mg QD

A

d. 40 mg QD

71
Q

ramipril target dose for HF

A

5 mg BID-10 mg QD

72
Q

true or false: SCr goes down in almost every pt upon initiation of an ACE inhibitor

A

false (goes up)

73
Q

losartan initial and target doses for HF

a. initial: 25-50 mg daily; target: 150 mg daily
b. initial: 20-40 mg BID; target: 160 mg BID
c. initial: 4 mg daily; target: 32 mg daily

A

a. initial: 25-50 mg daily; target: 150 mg daily

74
Q

valsartan initial and target doses for HF

a. initial: 25-50 mg daily; target: 150 mg daily
b. initial: 20-40 mg BID; target: 160 mg BID
c. initial: 4 mg daily; target: 32 mg daily

A

b. initial: 20-40 mg BID; target: 160 mg BID

75
Q

candesartan initial and target doses for HF

a. initial: 25-50 mg daily; target: 150 mg daily
b. initial: 20-40 mg BID; target: 160 mg BID
c. initial: 4 mg daily; target: 32 mg daily

A

c. initial: 4 mg daily; target: 32 mg daily

76
Q

sacubitril inhibits the degradation of ___ and ultimately leads to __________

A

BNP; vasodilation

77
Q

entresto indication

A

reduce risk of CV death/hospitalization for HFrEF pts with NYHA class II-IV

78
Q

is hypotension more common in entresto or enalapril?

A

entresto

79
Q

is elevations in SCr and potassium more common in entresto or enalapril?

A

enalapril

80
Q

which of the following pt populations get an initial dose of entresto 49/51 mg BID? SELECT ALL THAT APPLY

a. eGFR < 30
b. low to medium dose ACEi or ARB
c. high dose ACEi
d. high dose ARB
e. age > 75 yrs
f. ACEi/ARB naive

A

c. high dose ACEi
d. high dose ARB

81
Q

what is considered a high dose ACEi?

A

> 10 mg total daily enalapril (or therapeutic equiv)

82
Q

what is considered a high dose ARB?

A

> 160 mg total daily dose valsartan

83
Q

how long after an ACEi can we take an ARNI?

A

36 hours

84
Q

true or false: a stage B pt should be on an ARNI

A

false (not indicated for stage B)

85
Q

Sacubitril/valsartan is contraindicated in patients with HFrEF and with which one of the following?

A. Hypokalemia
B. Angioedema with ramipril
C. Concomitant therapy with furosemide
D. Heart rate <65 BPM

A

B. Angioedema with ramipril

86
Q

how long after starting entresto can we follow up to titrate?

A

2-4 weeks (I would say 2 weeks to assess tolerability)

87
Q

true or false: you can abruptly discontinue beta blockers for HF

A

false (slowly titrate due to rebound HTN)

88
Q

true or false: metoprolol tartrate can be used for HF

A

false

89
Q

bisoprolol initial dose for HF

A

1.25 mg daily

90
Q

bisoprolol target dose for HF

A

10 mg daily

91
Q

Coreg vs Coreg CR initial and target doses for HF

A

Coreg- initial: 3.125 mg BID; target: 25-50 mg BID

Coreg CR: initial: 10 mg daily; target: 80 mg daily

92
Q

metoprolol CR/XL initial and target doses for HF

A

initial: 12.5-25 mg daily; target: 200 mg daily

93
Q

true or false: beta blockers are negative inotropes

A

true

94
Q

carvedilol dose for < 85 kg pt

A

25 mg BID

95
Q

carvedilol dose for > 85 kg pt

A

50 mg BID

96
Q

dose conversion for carvedilol vs Coreg CR

A

carvedilol vs Coreg CR
3.125 mg BID = 10 mg QD
6.25 mg BID = 20 mg QD
12.5 mg BID = 40 mg QD
25 mg BID = 80 mg QD

97
Q

true or false; all stage B HF pts should be on a beta blocker

A

true

98
Q

GV was brought to the ED for difficulty breathing and notable swelling of the face, lips and tongue. His medical history is significant for diabetes and HFrEF. He currently takes rosuvastatin, metformin, spironolactone, carvedilol, fosinopril, bumetanide, and digoxin. Which med should be discontinued?

a. bumetanide
b. spironolactone
c. carvedilol
d. fosinopril
e. digoxin

A

d. fosinopril (due to angioedema)

99
Q

which BB reduces mortality in systolic HF?

a. labetalol
b. metoprolol tartrate
c. atenolol
d. nebivolol
e. bisoprolol

A

e. bisoprolol

(systolic HF = HFrEF)

100
Q

how long after stopping quinapril can a pt take their first dose of entresto?

A

36 hours

101
Q

KG has been diagnosed with HF and is beginning carvedilol IR. He is 5 ft 7 in and weighs 78 kg. Assuming he tolerates the dose titrations, what is the target dose of carvedilol IR for KG?

a. 12.5 mg BID
b. 25 mg BID
c. 50 mg BID
d. 75 mg BID
e. 100 mg BID

A

b. 25 mg BID

102
Q

which MRA is non-selective?

a. spironolactone
b. eplerenone

A

a. spironolactone

103
Q

which drug is a selective agent with 100- to 1000- fold lower affinity for androgen, glucocorticoid, and progesterone receptors than spironolactone?

A

eplerenone

104
Q

what CrCl and K levels should we avoid for spironolactone?

A

CrCl < 30 mL/min
K > 5 (due to hyperkalemia)

105
Q

when do we increase the dose for aldosterone antagonists?

A

every 2 weeks until max tolerated/target dose achieved

106
Q

how often should we monitor for aldosterone antagonists?

A

monitor electrolytes (especially K) and renal function 2-3 days after starting, then 7 days after. Then check monthly for 3 months and every 3 months after.

107
Q

true or false: aldosterone antagonists are recommended for stage B HF patients

A

false

108
Q

which pts are aldosterone antagonists recommended for?

A

pts with NYHA II-IV and HFrEF, eGFR > 30 and K < 5

109
Q

EG is a 67 yo white female with NYHA functional class III HFrEF. The cardiologist wants to start spironolactone. Which finding would prohibit the use of this medication?

a. CrCl = 60 mL/min
b. sulfa allergy
c. history of angioedema
d. K = 5.6 mEq/L
e. hemoglobin = 10.2 mg/dL

A

d. K = 5.6 mEq/L

(need K < 5)

110
Q

SGLT2 inhibitors causes _______ arteriolar constriction

a. afferent
b. efferent

A

a. afferent

111
Q

true or false: SGLT2s reduce preload and afterload and cause diuresis

A

true

112
Q

what is dose for either SGLT2 inhibitor for HF?

A

10 mg once daily

113
Q

true or false: SGLT2s reduce hospitalizations and mortality

A

true

114
Q

what are the eGFR cutoffs for dapagliflozin vs empagliflozin?

A

dapa -> 30 or greater
empa -> 20 or greater

115
Q

true or false: digoxin and ivabradine reduce mortality

A

false

116
Q

which drug is indicated for treatment of HF in black pts as adjunct to standard therapy?

A

BiDil (ISDN/Hydralazine)

(first drug combo with reduction in mortality)

117
Q

what is the initial and target dose for ISDN/Hydralazine?

A

initial: 20/37.5 mg TID
target: 40/75 mg TID

(titrate after 2 weeks)

118
Q

does ISDN/Hydralazine reduce preload, afterload, or both?

A

both

119
Q

JG is a 59 yo black male with stage C HFrEF. He is on bumetanide, dapagliflozin, enalapril, toprol XL, and prilosec. Which medication would be best to recommend adding to JG’s regimen?

a. Cozaar
b. Entresto
c. Hydralazine and isosorbide dinitrate
d. furosemide
e. carvedilol

A

c. Hydralazine and isosorbide dinitrate

120
Q

which drug is an additional therapy for NYHA II-III pts in normal sinus rhythm with HR of 70 or more on max tolerated beta blocker?

a. ivabradine
b. vericiguat
c. digoxin
d. PUFA
e. potassium binders

A

a. ivabradine

121
Q

digoxin MOA (2 things)

A

-inhibits Na+/K+ ATPase pump, which leads to inc calcium, enhancing force of contraction
-inc PNS -> inc vagal activity -> dec AV conduction -> dec HR

122
Q

therapeutic range for digoxin when used to treat HF

A

0.5-0.9 ng/mL

123
Q

which drug is used as add-on for pts with symptomatic HFrEF despite max GDMT to dec hospitalization for HF?

a. ivabradine
b. vericiguat
c. digoxin
d. PUFA
e. potassium binders

A

c. digoxin

124
Q

digoxin dose range

A

0.125-0.25 mg daily

125
Q

digoxin drug interactions (4 of them; part 3 slide 47)

A

amiodarone
quinidine
verapamil
itra/KTZ

126
Q

A pt with systolic HF is taking ramipril, digoxin, carvedilol, spironolactone, and furosemide. He is diagnosed with A Fib and prescribed amiodarone. Which medication dose should be reduced by 50% when starting amiodarone?

a. carvedilol
b. digoxin
c. furosemide
d. ramipril
e. spironolactone

A

b. digoxin

127
Q

true or false: vericiguat does NOT reduce mortality and hospitalization

A

false (it reduces both)

128
Q

true or false: PUFA (omega 3 polyunsat FAs) have been shown to reduce risk in HF II-IV when used as adjunct

A

true

129
Q

what drug should be used as needed for pt with HPpEF?

A

diuretic

PHRM 845 Therapeutics (34 decks)

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