Chronic Heart Failure
JB 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 quinapril 20 mg BID, 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 BPM. 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 Amlodipine (a dihydropyridine calcium channel blocker) 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 duplications of therapy.
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, such as doxorubicin and daunorubicin 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. Specific detail about the lifetime maximum dose of anthracyclines can be reviewed in the Oncology II chapter.
Which of the following signs/symptoms would not be expected in a patient with untreated NYHA Class IV heart failure? A) Asterixis B) Dyspnea C) Jugular venous distention D) Peripheral edema E) Rales
A) Asterixis Patients with severe heart failure will have symptoms related to fluid build up in the lungs and elsewhere. Rales can be heard with a stethoscope when examining the lungs. BNP levels (if checked) will usually be high. Asterixis is a "flapping tremor" associated with hepatic encephalopathy.
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 Q10. Which of the following statements is correct? A) BiDil is contraindicated with sildenafil. 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) BiDil increases risk of hyperkalemia when taken with ramipril.
A) BiDil is contraindicated with sildenafil. BiDil is contraindicated with phosphodiesterase inhibitors, such as sildenafil.
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) Carvedilol 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.
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 and a negative chronotrope. 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.
The labeling for each of these medications includes a warning regarding cross-sensitivity with sulfa allergy EXCEPT: A) Ethacrynic acid B) Torsemide C) Bumetanide D) Glipizide E) Furosemide
A) Ethacrynic acid Ethacrynic acid (Edecrin) is the only loop diuertic that does not carry a warning regarding sulfa allergy. Furosemide, torsemide, bumetanide and glipizide (a sulfonylurea) are "non-arylamine" sulfonamides that usually do not cross react in patients with a "sulfa" allergy, but the warning exists. Refer to the Drug Allergies and Adverse Drug Reactions chapter for additional information.
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) Flecainide B) Mexiletine C) Propafenone D) Procainamide E) Quinidine Class I antiarrhythmics (refer to the Arrhythmias chapter) should be avoided in heart failure patients. Amiodarone and dofetilide have less risk of worsening heart failure. Amiodarone is considered the antiarrhythmic of choice for patients with heart failure and atrial fibrillation (which are common comorbidities).
FL 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 the dose as soon as you remember, unless it is time to take the next dose. Do not double the dose. B) Do not drive a car, use machinery, or do anything that requires being alert until the medication is adjusted and the symptoms subside. C) This medication may cause you to feel more tired and dizzy at first. These effects will go away in a few days. Call a healthcare provider if the symptoms feel severe or if you experience weight gain or increased shortness of breath. D) This medication must be taken 1 hour before meals on an empty stomach. E) This medication should not be stopped abruptly.
A) If you miss a dose, take the dose as soon as you remember, unless it is time to take the next dose. Do not double the dose. B) Do not drive a car, use machinery, or do anything that requires being alert until the medication is adjusted and the symptoms subside. C) This medication may cause you to feel more tired and dizzy at first. These effects will go away in a few days. Call a healthcare provider if the symptoms feel severe or if you experience weight gain or increased shortness of breath. E) This medication should not be stopped abruptly. 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.
HA has been prescribed Lasix. The following may occur from the use of this drug: (Select ALL that apply.) A) Increased uric acid B) Increased blood glucose C) Increased potassium D) Increased calcium E) Increased triglycerides
A) Increased uric acid B) Increased blood glucose E) Increased triglycerides Loop diuretics decrease sodium, magnesium, chloride, calcium and potassium. They increase blood glucose, triglycerides and uric acid.
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) Valsartan/sacubitril
A) Isosorbide dinitrate/hydralazine
JC has systolic heart failure with an ejection fraction of 33%. Which of the following medications could possibly worsen JC's heart failure? (Select ALL that apply.) A) Itraconazole B) Verapamil C) Ramipril D) Prednisone E) Carbamazepine
A) Itraconazole B) Verapamil D) Prednisone Itraconazole, verapamil and prednisone can worsen heart failure and should be avoided, if possible. Avoid medications that antagonize diuretics (cause Na and water retention), have negative inotropic effect, cause direct cardiotoxicity or increase cardiac workload (stimulants) in patients with heart failure.
Which of the following medications can cause phosphenes? A) Ivabradine B) Entresto C) Hydralazine D) Potassium chloride E) Spironolactone
A) Ivabradine Ivabradine (Corlanor) can cause phosphenes or seeing enhanced brightness of light (or flashes of light).
Which of the following statements is/are correct regarding treatment with Lasix? (Select ALL that apply.) A) Lasix should be taken in the morning or early afternoon to avoid getting up at night to go to the bathroom. B) Potassium supplementation is often required when loop diuretics are taken. C) Loop diuretics decrease mortality in patients with heart failure. D) Patient taking Lasix must have their renal function monitored. E) Patients taking oral Lasix can be converted to IV Lasix in a 1:1 ratio.
A) Lasix should be taken in the morning or early afternoon to avoid getting up at night to go to the bathroom. B) Potassium supplementation is often required when loop diuretics are taken. D) Patient taking Lasix must have their renal function monitored. Loop diuretics should be taken in the morning (or, if divided, the second dose is taken in early afternoon) to avoid nocturia. Many patients (but not all) require potassium supplementation during therapy. Most patients with heart failure will require a loop diuretic for symptom control, but this class of medications does not reduce mortality. Renal function montoring is critical to avoid over-diuresis and renal impairment.
Which of the following agents have been shown to improve survival in systolic heart failure? (Select ALL that apply.) A) Lisinopril B) Digoxin C) Ivabradine D) Metoprolol succinate E) Spironolactone
A) Lisinopril D) Metoprolol succinate E) Spironolactone ACE inhibitors, beta blockers and aldosterone antagonists have been shown to reduce mortality in patients with systolic HF. With ACE inhibitors and ARAs, this is thought to be a class effect (all agents in the class reduce mortality). Mortality reduction with beta blockers is not thought to be a class effect. Only certain beta blockers should be selected when treating patients with HF. Additional medications/classes reduce mortality in certain groups of patients.
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 Micro-K capsules can be opened and sprinkled on food and immediately swallowed.
A patient with heart failure comes to the community pharmacy asking for help choosing a medicine to treat her mild pain. Which of the following is a safe, over-the-counter analgesic to recommend for this patient? A) Tylenol B) Aleve C) Advil D) Celebrex E) Indomethacin
A) Tylenol NSAIDs are not recommended in heart failure since they can increase sodium and water retention, which can worsen heart failure. NSAIDs should also be avoided in advanced renal disease.
What is the therapeutic range for digoxin in patients with heart failure? A) < 0.5 ng/mL B) 0.5 - 0.9 ng/mL C) 0.8 - 1.2 ng/mL D) 1.5 - 2 ng/mL E) 0.5 - 3 ng/mL
B) 0.5 - 0.9 ng/mL In the largest, prospective study of digoxin therapy in patients with heart failure, serum digoxin concentrations ≥ 1 ng/mL were associated with increased mortality. Higher digoxin levels are often required for rate control in atrial fibrillation.
KG has been diagnosed with heart failure and is beginning carvedilol immediate-release. He 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 KG should be given? A) 12.5 mg BID B) 25 mg BID C) 50 mg BID D) 75 mg BID E) 100 mg BID
B) 25 mg BID The target dose of carvedilol for patients who weigh ≤ 85 kg is 25 mg BID (slow titration would be required to reach this dose). Target dose for patients who weigh >85 kg is 50 mg BID
JC went to see a cardiologist and was diagnosed with systolic heart failure. He had an ECG 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, NYHA Class I 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.
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) Fish oils C) Hawthorn E) Coenzyme Q10 Fish oils, hawthorn, and coenzyme Q10 may have beneficial effects in heart failure patients. Ma huang (ephedra) should be avoided.
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 Headache is a common side effect of any nitrate therapy, including BiDil. Some patients find benefit by pre-treating with acetaminophen.
AP 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) Hyperglycemia D) Orthostatic hypotension E) Hypouricemia
B) Hypokalemia C) Hyperglycemia D) Orthostatic hypotension Loop diuretics are commonly used in clinical practice and have numerous potential side effects that must be monitored. Loop diuretics can be expected to reduce serum levels of most electrolytes (e.g., Na, K, Mg, Cl and Ca). Additional side effects from loop diuretics include hyperglycemia, photosensitivity, hyperuricemia and an increased TG and total cholesterol. Orthostatic hypotension can be caused by volume depletion, so it is a possible side effect from any diuretic (loop, thiazides, etc.).
JB, a 68 year old black male, has just been diagnosed with NYHA Class III heart failure. His past medical history is significant for bilateral renal artery stenosis and type 2 diabetes. 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. JB has symptoms of leg edema, bibasilar rales and shortness of breath. Which medications should be started to treat JB's heart failure? (Select ALL that apply.) A) Toprol XL B) Lasix C) Diovan D) BiDil E) Altace
B) Lasix D) BiDil ACE inhibitors and ARBs cannot be used in patients with bilateral renal artery stenosis. Beta-blockers should not be used in severe bradycardia (this patient's HR is 48 BPM). This patient is congested and needs a loop diuretic. BiDil was proven to reduce mortality in African American patients with NYHA Class III-IV HF in patients who cannot tolerate an ACEI/ARB (or when added to an ACEI/ARB on other patients).
EK 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 spironolactone E) Fatigue and dizziness from carvedilol
B) Lupus-like syndrome from hydralazine Isosorbide dinitrate/hydralazine (BiDil) can cause lupus-like syndrome. Instruct patients to report fever, joint/muscle aches and fatigue.
EG is a 67 year old white female with 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, HCO3 22 mEq/L, BUN 39 mg/dL and serum creatinine 1.8 mg/dL. Can Inspra be initiated? A) No, Inspra is contraindicated at this level of serum sodium. B) No, Inspra is contraindicated at this level of serum potassium. C) No, Inspra is recommended only for African American patients with heart failure. D) Yes, once her HF progresses to NYHA Class IV. E) Yes, but she will require potassium monitoring.
B) No, Inspra is contraindicated at this level of serum potassium. 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 should be stopped.
A patient gave the pharmacist a prescription for Aldactone 25 mg daily. Which of the following is an appropriate generic substitution for Aldactone? A) Triamterene/hydrochlorothiazide B) Spironolactone C) Eplerenone D) Alendronate E) Torsemide
B) Spironolactone
A patient with systolic heart failure is taking ramipril, digoxin, carvedilol and furosemide. He has been diagnosed with atrial fibrillation and prescribed amiodarone. Choose the correct statement: A) The digoxin level will decrease; it is best not to use a P450 3A4 enzyme inducer such as amiodarone. B) The digoxin level will increase; it is best not to use a P-glycoprotein and 3A4 inhibitor such as amiodarone. C) Digoxin levels are not affected by hepatic inducers or inhibitors. D) Amiodarone will bind to digoxin in the gut and reduce absorption. E) Digoxin will increase the serum levels of amiodarone which can cause QT prolongation.
B) The digoxin level will increase; it is best not to use a P-glycoprotein and 3A4 inhibitor such as amiodarone. The interaction between digoxin and amiodarone is mainly due to the inhibition of P-glycoprotein and (to a lesser extent) 3A4 inhibition. Digoxin is a P-gp substrate and amiodarone is a P-gp inhibitor. Most clinicians reduce the dogixin dose by ~50% when amiodarone is started. Drugs that interact with digoxin include dronedarone, verapamil, macrolides, itraconazole and others.
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 with eplerenone? A) Ranitidine B) Voriconazole C) Benazepril D) Diltiazem E) Pravastatin
B) Voriconazole 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.
Which of the following is the brand name for bisoprolol? A) Diabeta B) Zebeta C) Betapace D) Betaseron E) Brevibloc
B) Zebeta
GV 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 this patient? A) 10 mg once daily B) 25 mg once daily C) 40 mg once daily D) 80 mg once daily E) 160 mg once daily
C) 40 mg once daily 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. Coreg 3.125 mg BID = Coreg CR 10 mg QD Coreg 6.25 mg BID = Coreg CR 20 mg QD Coreg 12.5 mg BID = Coreg CR 40 mg QD Coreg 25 mg BID = Coreg CR 80 mg QD
What type of patient might benefit from eplerenone? A) A patient experiencing hyperkalemia with quinapril B) A patient experiencing bradycardia with Coreg C) A patient experiencing gynecomastia with Aldactone D) A patient experiencing hypertriglyceridemia with Toprol XL E) A patient experiencing flusing with BiDil
C) A patient experiencing gynecomastia with Aldactone Spironolactone (Aldactone) is a non-selective aldosterone antagonist, while eplerenone is selective. Eplerenone is much more expensive than spironolactone, but might be an alternative in a patient with gynecomastia, breast tenderness, impotence or other endocrine side effects from spironolactone.
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) A reduction in HF hospitalizations The DIG study and others clearly show a reduction in HF hospitalizations in patients with systolic heart failure. Digoxin has not been proven to reduce mortality in heart failure.
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) Beta-1 and beta-2 blocker and alpha-1 blocker Carvedilol is a non-selective beta blocker that also blocks alpha-1 receptors in arterial walls.
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) Blocks the conversion of angiotensin I to angiotensin II Zestril is an ACE inhibitor which blocks the conversion of angiotensin I to angiotensin II.
An elderly patient with NYHA functional class IV heart failure is taking furosemide 120 mg PO twice daily. He takes his furosemide at 8 am and 12 noon. He has several conditions and takes many medications. The prescriber requests that the pharmacist calculate the dose of oral bumetanide that would be equivalent to the patient's current 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) Bumetanide 6 mg daily The oral conversion ratio is 40 mg furosemide to 1 mg bumetanide. The patient is using a total daily dose of 240 mg of furosemide, and the equivalent dose of bumetanide would be 6 mg daily.
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) Monorail C) Captopril D) Lisinopril E) Accupril
C) Captopril Captopril has the shortest half-life and is dosed TID.
WR has been using digoxin 0.125 mg daily for several years. During this time his renal function has declined from an estimated 55 mL/min to 24 mL/min. WR is unable to stand and has vomited and his heart rate is found to be 45 BPM with an abnormal heart rhythm. 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? A) Dextrose B) Fabior C) DigiFab D) Digox E) Ferriprox
C) DigiFab DigiFab (Digoxin Immune Fab) is the antidote for digoxin used in overdose situations. DigiFab is very expensive and is generally reserved for acute digoxin ingestions or life-threatening manifestations of toxicity (e.g., arrhythmias). In many cases, digoxin can be held until the level falls.
ST has a past medical history significant for systolic heart failure and hypertension. She is being seen in clinic for routine follow up. Medications: lisinopril 10 mg daily, Toprol XL 100 mg daily, furosemide 20 mg twice daily, and spironolactone 25 mg daily Vitals: BP 134/84 mmHg, HR 75 BPM, RR 25 BPM Labs: Na (mEq/L) = 135 (135 - 145) K (mEq/L) = 5.6 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 26 (24 - 30) BUN (mg/dL) = 39 (7 - 20) SCr (mg/dL) = 1.5 (0.6 - 1.3) Glucose (mg/dL) = 126 (100 - 125) Human chorionic gonadotropin + Question: Which of the following recommendations should be made to the prescriber regarding ST's current regimen? A) Discontinue Toprol XL B) Increase furosemide dose C) Discontinue lisinopril D) Discontinue spironolactone E) Start valsartan 80 mg BID
C) Discontinue lisinopril D) Discontinue spironolactone Human chorionic gonadotropin (hCG) is positive in pregnancy. ACE inhibitors and ARBs are contraindicated in pregnancy. SCr and potassium must be monitored carefully in patients taking spironolactone. The FDA-approved labeling for spironolactone suggests discontinuing or interrupting therapy if potassium is > 5 mEq/L. Heart failure guidelines recommend holding therapy if potassium is > 5.5 mEq/L and holding until K < 5 mEq/L.
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) Titrate the Vasotec to the target dose for heart failure. Cough will subside when the target dose is reached. 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) Discontinue the Vasotec (Enalapril) and begin valsartan 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.
A patient gave the pharmacist a prescription for Inspra 25 mg daily. Which of the following is the generic name for Inspra? A) Isosorbide Mononitrate/Hydralazine B) Spironolactone C) Eplerenone D) Nesiritide E) Ivabradine
C) Eplerenone
JG is a 59 year-old white male with Stage C Heart Failure. He is willing to start additional therapy for this condition because he realizes his symptoms are becoming worse. PMHx Heart Failure, Stage C Hypertension PUD Allergies ACE inhibitors (angioedema) Medications Bumetanide 1 mg daily Toprol XL 100 mg daily Prilosec 20 mg daily Norvasc 10 mg daily Aspirin 81 mg daily Which of the following medications would be best to recommend for addition to JG's regimen? A) Lisinopril B) Entresto C) Hydralazine and isosorbide dinitrate D) Furosemide E) Avapro
C) Hydralazine and isosorbide dinitrate Patients with a history of angioedema cannot be rechallenged with an ACE inhibitor, ARB or Entresto. Hydralazine and isosorbide dinitrate should be used when ACE inhibitor or ARB therapy cannot be tolerated (in this case, due to angioedema). The patient is already taking a loop diuretic. BiDil is also indicated (as an addition to ACE inhibitor/ARB) in self-identified Afrincan American patients with NHYA Class III-IV heart failure to reduce mortality.
ML has just been discharged from the hospital after a heart failure exacerbation. Which of the following steps is unlikely to prevent ML from being readmitted for another heart failure exacerbation? A) Provide regular and frequent follow up appointments to assess symptoms and address any questions. B) Do medication reconciliation from inpatient to outpatient therapy. C) Keep the patient on low doses of heart failure medications to avoid the chance of adverse reactions. D) Provide counseling on heart failure and offer strategies to improve medication adherence. E) Provide education on how to monitor for worsening symptoms and avoiding foods and medications that can worsen heart failure.
C) Keep the patient on low doses of heart failure medications to avoid the chance of adverse reactions. Heart failure medications should be titrated to target doses - the doses proven to provide benefit in clinical trials.
Which of the following potassium chloride formulations can be cut and/or dissolved in water? A) Micro-K B) Klor-Con C) Klor-Con M10 D) K-tab E) K-tab generic
C) Klor-Con M10
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 Loop diuretics are the most effective agents at reducing fluid volume in heart failure patients, while thiazide diuretics are the most effective diuertics for treating hypertension.
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) Methotrexate 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.
Which of the following are common causes of heart failure? (Select ALL that apply.) A) Bipolar disorder B) Stroke C) Myocardial infarction D) Long-standing hypertension E) MRSA infection
C) Myocardial infarction D) Long-standing hypertension Long-standing hypertension and myocardial infarction are the two primary causes of HF in the U.S. Less common causes include chronic/excessive alcohol intake, illicit drugs, valvular disease and others.
Which of the following statements are correct regarding the monitoring of serum potassium in patients with heart failure? (Select ALL that apply.) A) Potassium is expected to decrease when an ACE inhibitor or ARB is initiated. B) Potassium is expected to increase when a loop diuretic is initiated. C) Potassium should be monitored after the initiation or up-titration of an ACE inhibitor, ARB, aldosterone antagonist or diuretic D) Potassium should be monitored after the initiation or up-titration of a beta blocker. E) Potassium should be monitored when a patient's renal function changes
C) Potassium should be monitored after the initiation or up-titration of an ACE inhibitor, ARB, aldosterone antagonist or diuretic E) Potassium should be monitored when a patient's renal function changes Potassium levels should be assessed after any change in ACE inhibitor, ARB, aldosterone antagonist or diuretic therapy or when the renal function changes.
A patient with 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 Pioglitazone (Actos) is a thiazolidinedione (TZD). TZDs have a boxed warning against initiation in patients with NYHA Class III and IV heart failure.
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) Blocks angiotensin II by binding directly to the AT1 receptor Angiotensin receptor blockers (ARBs), such as Diovan (Valsartan), block AT II directly at a receptor site on the smooth muscle wall of the vessel.
Select the correct mechanism of action for Entresto: 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) Blocks neprilysin and the actions of angiotensin II at the receptor site E) Blocks hyperpolarization-activated cyclic nucleotide-gated channels in the sinus node
D) Blocks neprilysin and the actions of angiotensin II at the receptor site Entresto (Sacubitril/Valsartan) works by inhibiting neprilysin and blocking the AT1 receptor, hence the actions of angiotensin II.
A physician calls the pharmacist to inquire about the current heart failure guidelines. She recalls reading that "some medication" can now replace ACE inhibitors and ARBs for mortality reduction. Which medication can be used in NYHA class II-III patients as a substitute for ACE inhibitor/ARB treatment for further mortality reduction? A) Aldactone B) Corlanor C) Neprilysin D) Entresto E) Zebeta
D) Entresto Entresto carries this indication and this recommendation is included in current heart failure guidelines.
MM is hospitalized and will require a lengthy course of therapy with gentamicin and vancomycin for endocarditis. MM also requires high doses of loop diuretics for heart failure and the prescriber is concerned about additive ototoxicity. Which of the loop diuretics has the highest risk for ototoxicity? A) Furosemide B) Bumetanide C) Torsemide D) Ethacrynic acid E) All loops have equal risk of ototoxicity
D) Ethacrynic acid All of the loop diuretics can cause ototoxicity (especially with IV dosing and high doses), 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.
Which of the following best describes why it is important that potassium levels be maintained in the range of 4-5 mEq/L when a patient is taking digoxin? A) Digoxin causes a reduction in potassium levels. B) Digoxin is an ineffective positive inotrope when potassium levels are lower than this range. C) Digoxin is displaced at the binding site when potassium levels are lower than this range. D) Potassium levels lower than this range allow more digoxin to act at the Na/K/ATPase pump. E) Potassium levels lower than this range inactivate the Na/K/ATPase pump.
D) Potassium levels lower than this range allow more digoxin to act at the Na/K/ATPase pump. Both digoxin and potassium compete for binding at the Na/K/ATPase pump. When serum potassium levels are low (hypokalemia), there is less competition at the site and the action (toxicity) of digoxin is potentiated. Patients with hypokalemia may exhibit signs/symptoms of digoxin toxicity with digoxin levels within the reference range Importantly, digoxin does not alter potassium levels and hypokalemia does not raise digoxin levels.
Which of the following statements is/are true regarding Toprol XL? (Select ALL that apply.) A) This is an extended-release formulation and cannot be cut. B) This medication must be taken with a high fat meal. C) The dose should be up-titrated every 2-3 days as tolerated. D) Toprol XL is a beta-1 selective beta blocker. E) Toprol XL can be cut at the score line with a tablet cutter.
D) Toprol XL is a beta-1 selective beta blocker. E) Toprol XL can be cut at the score line with a tablet cutter. Metoprolol succinate (Toprol XL) is a beta-1 selective beta blocker (sometimes called "cardioselective"). The tablets remain long-acting if cut at the score line. They cannot be crushed or chewed. Patients will usually remain on the same dose of beta blocker for 2 weeks (or longer) before up-titrating. This is a slower titration than used for many other medications.
RW 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 proven effect can be expected with the use of metoprolol IR? A) Weight loss B) Hair growth C) Reduced mortality due to heart failure D) Higher blood pressure E) Lowered heart rate
E) Lowered heart rate Beta blockers lower heart rate and are useful in patients with tachycardia. Metoprolol tartrate (immediate release metoprolol) has not been shown to reduce mortality in HF.
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) Inhibitor of the Na+/K+ ATPase pump E) Non-selective aldosterone receptor antagonist
E) Non-selective aldosterone receptor antagonist 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. Spironolactone is non-selective (also blocks androgen), which is why it is associated with more endocrine side effects than eplerenone.
A patient with systolic heart failure (NYHA Class III) has been taking the following medications for 8 months: Aldactone 25 mg daily Quinapril 20 mg BID Coreg CR 40 mg daily Lasix 40 mg daily The patient presents to the outpatient clinic pharmacy with a new prescription for Entresto 50 mg BID. The pharmacist will call the prescriber to make the following recommendation: A) The patient must be stabilized on valsartan for 2 weeks before starting Entresto. B) The patient must be stabilized on digoxin for 2 weeks before starting Entresto. C) The patient must stop Aldactone for 36 hours before Entresto can be started. D) The patient must stop Coreg for 36 hours before starting Entresto. E) The patient must stop quinapril for 36 hours before starting Entresto.
E) The patient must stop quinapril for 36 hours before starting Entresto. A washout period of 36 hours is required between any ACE inhibitor and Entresto. Entresto cannot be used with another ARB (it contains valsartan).
