Heart failure

Question 1

Difference between Systolic (HFrEF) and diastolic (HFpEF) heart failure

Answer 1

• If you have systolic heart failure (reduced EF), it means your heart does not contract effectively with each heartbeat. LVEF <40%
• If you have diastolic heart failure (preserved EF), it means your heart isn’t able to relax normally between beats. Both types of left-sided heart failure can lead to right-sided heart failure. LVEF >50%

Question 2

Rationale for drug use
Heart failure

Answer 2

Provide symptom relief and improve exercise tolerance.

Prevent hospitalisation and deterioration in left ventricular function.

Reduce mortality.

Question 3

Non pharmacological treatment
Heart failure

Answer 3

Exercise
diet

Question 4

Drugs for heart failure management

Answer 4

Standard treatment of HFrEF consists of quadruple therapy with:

ACE inhibitor (or sartan or sacubitril with valsartan)
beta-blocker
aldosterone antagonist (Eplerenone, Spironolactone)
sodium-glucose co‑transporter 2 inhibitor.
Doubutamine
Digoxin

Loop diuretics can be used to relieve symptoms of heart failure

Question 5

Indication
Dobutamine

Answer 5

Inotropic support in acute heart failure, cardiogenic and septic shock

Pharmacological stress testing of myocardial function

Question 6

Indication
Digoxin

Answer 6

AF and atrial flutter
Heart failure

Question 7

ACE inhibitor means …

Answer 7

Angiotensin converting enzyme inhibitor

Question 8

MOA
ACE inhibitor

Answer 8

• block angiotensin I conversion to angiotensin II
• inhibit breakdown of bradykinin (contribute to vasodilation)
• reduce sodium retention
• reduced aldosterone (hormone that controls sodium and water retension and therefore controls BP)

ACE inhibitors block conversion of angiotensin I to angiotensin II and also inhibit the breakdown of bradykinin. They reduce the effects of angiotensin II-induced vasoconstriction, sodium retention and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.
## water follows salt … increased salt = increased BP, decreased salt = decreased BP

Question 9

Indication
ACE inhibitors

Answer 9

Hypertension

Chronic heart failure with reduced ejection fraction as part of standard treatment

Diabetic nephropathy

Prevention of progressive renal failure in patients with persistent proteinuria (>1 g daily)

Post MI

Question 10

Adverse reactions
ACE inhibitors

Answer 10

• hypotension
• headache
• dizziness
• cough (dry / non productive)
• hyperkalaemia
• fatigue
• nausea
• renal impairment

Question 11

Practice points

Answer 11

*You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.

Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.*

When starting an ACE inhibitor:
* stop potassium supplements and potassium-sparing diuretics
* in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting an ACE inhibitor
* review use of NSAIDs (including selective COX‑2 inhibitors)
* start with a low dose
* check renal function and electrolytes before starting an ACE inhibitor and review after 1–2 weeks
* encourage patients to continue ACE inhibitors during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment

Question 12

Drug class and indication

Captopril

Answer 12

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI in patients with left ventricular dysfunction
* Diabetic nephropathy (type 1 diabetes)

Question 13

Drug Class and indication

Enalapril

Answer 13

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Asymptomatic left ventricular dysfunction

Question 14

Drug class and indication

Enalapril with hydrochlorothiazide

Answer 14

ACE inhibitor + Thiazide diuretic
* Hypertension

Question 15

Drug class and indication

Fosinopril

Answer 15

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

Question 16

Drug class and indication

Fosinopril with hydrochlorothiazide

Answer 16

ACE inhibitor + Thiazide diuretic
* Hypertension

Question 17

Drug class and indication

Lisinopril

Answer 17

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI, acute treatment

Question 18

Drug class and indication

Perindopril

Answer 18

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Reduction of risk of MI or cardiac arrest in people with established coronary heart disease without heart failure

Question 19

Drug class and indication

Perindopril with amlodipine

Answer 19

ACE inhibitor + Dihydropyridine Calcium channel blocker
* Hypertension
* Stable coronary heart disease

Question 20

Drug class and indication

Perindopril with indapamide

Answer 20

ACE inhibitor + Thiazide diuretic
* Hypertension

Question 21

Drug class and indication

Quinapril

Answer 21

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

Question 22

Drug class and indication

Quinapril with hydrochlorothiazide

Answer 22

ACE inhibitor + Thiazide diuretic
* hypertension

Question 23

Drug class and indication

Ramipril

Answer 23

ACE inhibitor
* Hypertension
* Post MI
* Prevention of MI, stroke, cardiovascular death in patients >55 years with: cardio risk factors

Question 24

Drug class and indication

Ramipril with felodipine

Answer 24

ACE inhibitor + Dihydropyridine calcium channel blocker
* Hypertension

Question 25

# Drug class and indication Trandolapril

Answer 25

**ACE inhibitor** * Hypertension * Post MI in patients with left ventricular dysfunction

Question 26

Generic names of ACE inhibitors

Answer 26

Captopril Enalapril Enalapril with hydrochlorothiazide Fosinopril Fosinopril with hydrochlorothiazide Lisinopril Perindopril Perindopril with amlodipine Perindopril with indapamide Quinapril Quinapril with hydrochlorothiazide Ramipril Ramipril with felodipine Trandolapril

Question 27

**Drug interactions** ACE inhibitor

Answer 27

**Triple threat = ACE inhibitor + NSAID + loop or thiazide diuretic** **Lithium + ACE inhibitors Loop diuretics + ACE inhibitors NSAIDs + ACE inhibitors** NSAIDs (including selective COX‑2 inhibitors) may reduce antihypertensive effect of ACE inhibitor and may increase risk of renal impairment and hyperkalaemia (risk is further increased if a thiazide or loop diuretic is also taken). Avoid combination in the elderly or if renal hypoperfusion or impairment exists; monitor BP, weight, serum creatinine and potassium concentration. Use no more than 100–150 mg aspirin daily. sartans + ACE inhibitors **Sartans** given with ACE inhibitors increase the risk of hypotension, hyperkalaemia and renal impairment without additional benefit; avoid combinations (see Treatment with an ACE inhibitor and a sartan). ## Footnote Members of this class are captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril and trandolapril. ACE inhibitors can cause potassium retention, which may lead to hyperkalaemia, especially in people with renal impairment or diabetes, or if taken with potassium supplements or with other drugs* that can also cause potassium retention. Avoid combinations if possible or monitor potassium concentration. Note that aldosterone antagonists are used with ACE inhibitors in patients with heart failure, with routine potassium concentration monitoring. Monitor potassium concentration if an ACE inhibitor is given with drugs* that can reduce potassium concentration, as hypokalaemia may still occur. ACE inhibitors also reduce BP; administration with other drugs* that lower BP may result in additional hypotensive effects (which may be intended); avoid combinations or use carefully and monitor BP.

Question 28

SARTANs a.k.a. ...

Answer 28

angiotensin receptor agonists (ARA)

Question 29

**MOA** sartans / ARA

Answer 29

Competitively **block binding of angiotensin II to type 1 angiotensin** (AT1) receptors. They **reduce** angiotensin II-induced **vasoconstriction, sodium reabsorption and aldosterone release**. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.

Question 30

**Indication** sartans / ARAs

Answer 30

* Hypertension * Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors

Question 31

**Adverse effects** sartans

Answer 31

dizziness, headache, hyperkalaemia

Question 32

**Precautions / contradictions** sartans / ARAs

Answer 32

**Peripheral vascular disease or atherosclerosis**—patients may be more likely to have renal artery stenosis. **Volume or sodium depletion**—Monitor combination w/ diuretics (both affect sodium and BP) **Black African or Caribbean descent** **Treatment with drugs that can increase potassium concentration**,

Question 33

**Practice points** sartans / ARAs

Answer 33

* stop K+ and K+ sparing diuretics * review use of NSAIDs * check renal function * used when ACE inhibitors are not tolerated for HTN and chronic heart failure ## Footnote You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed. Do not take potassium supplements while you are taking this medicine unless your doctor tells you to. when starting a sartan: stop potassium supplements and potassium-sparing diuretics in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting a sartan review use of NSAIDs (including selective COX‑2 inhibitors) start with a low dose check renal function and electrolytes before starting a sartan and review after 1–2 weeks unlike ACE inhibitors, sartans do not inhibit the breakdown of bradykinin and may be useful if an ACE inhibitor is not tolerated because they: cause less cough than ACE inhibitors may be used if there is a history of angioedema caused by an ACE inhibitor (with close monitoring as there is a small risk of recurrence) maximum antihypertensive effect occurs about 4–6 weeks after starting treatment encourage patients to continue sartans during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment

Question 34

# Drug class and indication Candesartan

Answer 34

**sartan / ARA** * Hypertension * Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors

Question 35

# Drug class and indication Candesartan with hydrochlorothiazide

Answer 35

**sartan / ARA + thiazide diuretic** Hypertension

Question 36

# Drug class and indication Eprosartan

Answer 36

**sartan / ARA** Hypertension

Question 37

# Drug class and indication Eprosartan with hydrochlorothiazide

Answer 37

**sartan / ARA + thiazide diuretic** Hypertension

Question 38

# Drug class and indication Irbesartan

Answer 38

**sartan / ARA** * Hypertension * Reduction of renal disease progression in patients with type 2 diabetes, hypertension and microalbuminuria (>30 mg/24 hours) or proteinuria (>900 mg/24 hours)

Question 39

# Drug class and indication Irbesartan with hydrochlorothiazide

Answer 39

**sartan /ARA + thiazide diuretic** Hypertension

Question 40

# Drug class and indication Losartan

Answer 40

**sartan / ARA** * Hypertension * Reduction of renal disease progression in patients with type 2 diabetes, hypertension and proteinuria (urinary albumin to creatinine ratio greater than or equal to 300 mg/g or proteinuria >500 mg per 24 hours)

Question 41

# Drug class and indication Olmesartan

Answer 41

**sartan / ARA** Hypertension

Question 42

# Drug class and indication Olmesartan with amlodipine

Answer 42

**sartan / ARA + Dihydropyridine calcium channel blocker** Hypertension

Question 43

# Drug class and interaction Olmesartan with amlodipine and hydrochlorothiazide

Answer 43

**sartan / ARA + Dihydropyridine calcium channel blocker + thiazide diuretic** Hypertension

Question 44

# Drug class and interaction Olmesartan with hydrochlorothiazide

Answer 44

**sartan / ARA + thiazide diuretic** Hypertension

Question 45

# Drug class and indication Telmisartan

Answer 45

**sartan / ARA** * Hypertension * Prevention of cardiovascular morbidity and mortality in patients with coronary artery disease, peripheral artery disease, high-risk diabetes, previous stroke or TIA

Question 46

# Drug class and indication Telmisartan with amlodipine

Answer 46

**sartan / ARA + Dihydropyridine calcium channel blocker** Hypertension

Question 47

# Drug class and indication Telmisartan with hydrochlorothiazide

Answer 47

**sartan / ARA + thiazide diuretic** Hypertension

Question 48

# Drug class and indication Valsartan

Answer 48

**Sartan / ARA** * Hypertension * Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors * Left ventricular failure/dysfunction after MI, when clinically stable

Question 49

# Drug class and indication Valsartan with hydrochlorothiazide

Answer 49

**Sartan / ARA + Thiazide diuretic** Hypertension

Question 50

Generic names of Sartans / ARA

Answer 50

Candesartan Candesartan with hydrochlorothiazide Eprosartan Eprosartan with hydrochlorothiazide Irbesartan Irbesartan with hydrochlorothiazide Losartan Olmesartan Olmesartan with amlodipine Olmesartan with amlodipine and hydrochlorothiazide Olmesartan with hydrochlorothiazide Telmisartan Telmisartan with amlodipine Telmisartan with hydrochlorothiazide Valsartan Valsartan with hydrochlorothiazide

Question 51

**Tripple Whammy**

Answer 51

NSAID + Sartan + ACE | Sounds like satan ate enough said

Question 52

# Suffix: Beta-blocker

Answer 52

lol

Question 53

# Drug class lol

Answer 53

Beta-blockers

Question 54

**Indication** Beta-blocker

Answer 54

Hypertension Angina Tachyarrhythmias MI Chronic heart failure with reduced ejection fraction as part of standard treatment Prevention of migraine

Question 55

**MOA** Beta-blocker

Answer 55

Competitively **block beta receptors** in heart, peripheral vasculature, bronchi, pancreas, uterus, kidney, brain and liver. **Beta-blockers reduce heart rate, BP and cardiac contractility**; also depress sinus node rate and slow conduction through the atrioventricular (AV) node, and prolong atrial refractory periods.

Question 56

**Precautions / adverse effects** Beta-blockers

Answer 56

**Shock** (cardiogenic and hypovolaemic)—contraindicated. **Hyperthyroidism**—beta-blockers may mask clinical signs, eg tachycardia. **Phaeochromocytoma**—beta-blockers may aggravate hypertension; an alpha-blocker should be given first. **History of anaphylactic reactions**—beta-blockers may reduce the response to usual doses of adrenaline (epinephrine) for anaphylaxis. **Myasthenic symptoms**—may worsen. **CARDIAC**Contraindicated in bradycardia (45–50 beats/minute), second‑ or third-degree AV block, sick sinus syndrome (without pacemaker), severe hypotension or uncontrolled heart failure. **Respiratory** contraindicated in asthma, alpha 1 selective drugs may be used in controlled asthma and COPD | Myasthenic symptoms (muscle weakness)

Question 57

**Adverse effects** Beta-blockers

Answer 57

* bradycardia, * hypotension, * orthostatic hypotension * bronchospasm, * dyspnoea, * fatigue, dizziness * Mask Hypoglycemia ## Footnote Can mask signs of hypoglycemia in diabetics

Question 58

**Counselling / practice points** Beta-blockers

Answer 58

Counselling This medicine **may cause dizziness or tiredness** **Do not stop** taking this medicine suddenly **Practice points** **beta-blockers are not usually recommended first line for uncomplicated essential hypertension**; they are associated with reduced protection against stroke in the elderly **when stopping treatment, reduce dosage gradually

Question 59

# Drug class and indication Atenolol

Answer 59

**Beta-blocker** Hypertension Angina Tachyarrhythmias MI

Question 60

# Drug class and indication Bisoprolol

Answer 60

**Beta-blocker** Chronic heart failure with reduced ejection fraction as part of standard treatment

Question 61

# Drug class and Indication Carvedilol

Answer 61

**Beta-blocker** Hypertension Chronic heart failure with reduced ejection fraction as part of standard treatment

Question 62

# Drug class and indication Labetalol

Answer 62

**Beta-blocker** Hypertension Hypertensive emergency

Question 63

# Drug class and Indication Metoprolol

Answer 63

**Beta-blocker** Hypertension Angina Tachyarrhythmias MI Prevention of migraine Chronic heart failure with reduced ejection fraction as part of standard treatment

Question 64

# Drug class and Indication Nebivolol

Answer 64

**Beta-blocker** Hypertension Chronic heart failure with reduced ejection fraction as part of standard treatment

Question 65

# Drug class and indication Propranolol

Answer 65

**Beta-blocker** Hypertension Angina Tachyarrhythmias Tetralogy of Fallot, seek specialist advice MI Prevention of migraine Essential tremor Phaeochromocytoma (with an alpha-blocker)

Question 66

**Generic drug names** Beta-blockers

Answer 66

Atenolol Bisoprolol Carvedilol Esmolol Labetalol Metoprolol Nebivolol Propranolol Sotalol

Question 67

**Indication** Loop diuretic

Answer 67

Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome

Question 68

**MOA** Loop diuretic

Answer 68

Inhibit reabsorption of sodium and chloride in the ascending limb of the loop of Henle. This site accounts for retention of approximately 20% of filtered sodium; therefore, these are potent diuretics. Produce a rapid and intense diuresis and have a short duration of action (4–6 hours). They are effective over a wide dose range with a dose-related response.

Question 69

**Precautions** Loop Diuretics

Answer 69

**Allergy** to the specific loop diuretic—contraindicated (see Comparative information below). **Prostatic obstruction**—loop diuretics may precipitate acute urinary retention. **Gout**—may be aggravated by diuretic-induced hyperuricaemia. If a regular loop diuretic is started after the target serum urate level has been reached, measure serum urate levels every 2–5 weeks and adjust dose of urate-lowering drugs if necessary. **Treatment with ototoxic drugs**—increases risk of ototoxicity with loop diuretics; use combinations carefully, especially in renal impairment.

Question 70

**Adverse effects** Loop diuretics

Answer 70

electrolyte disturbances (eg hyponatraemia, hypokalaemia, hypomagnesaemia, hypochloraemia, hypocalcaemia), dehydration, metabolic alkalosis, increased creatinine concentration, hyperuricaemia, gout, dizziness, orthostatic hypotension, fainting

Question 71

**Nursing considerations** Loop diuretic

Answer 71

Furosemide is the only loop diuretic available in oral and IV formulations. Bumetanide may be used in patients allergic to furosemide (eg rash) but risk of cross-reactivity cannot be excluded. Can cause hypotension which can cause dizziness in case of heart failure: 1. Start with low dose 2. combine with ACE inhibitor ## Footnote This medicine is usually taken once daily in the morning. If you are taking it twice a day, take the first dose in the morning and the second dose at lunchtime. You may feel dizzy on standing when taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy. role of loop diuretics in hypertension is limited to management of excess salt and water retention inadequately controlled by other antihypertensive treatment **Heart failure **start with a low dose then adjust according to clinical response; use the lowest effective maintenance dose combine with an ACE inhibitor if hypotension occurs decrease dose of diuretic before that of the ACE inhibitor usually given once daily in the morning although there may be a better clinical response if the drug is given twice daily (second dose is usually given at midday; diuresis may interfere with sleep if given after 6 pm) higher doses are necessary in refractory heart failure: a trial of IV furosemide may be more effective than increasing oral doses increase diuretic effect by adding a thiazide diuretic; use small, intermittent thiazide doses with careful monitoring, seek specialist advice monitor weight and electrolytes hypokalaemia is less likely when diuretics are used with ACE inhibitors or sartans than when used alone

Question 72

# Drug class and indication Bumetanide

Answer 72

**Loop diuretic** Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome Given if furosemide is not tolerated

Question 73

# Drug class and indication Furosemide

Answer 73

**Loop diuretic** Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome