Pharm questions - heart faailuuure, angina

What are the two mechanisms by which HF activates RAAS?

1. Increased renin release by cells in renal afferent arterioles d/t diminished renal perfusion pressure 2. Increased renin release via sympathetic stimulation and activation of B-receptors. (ATII production —> vasoconstriction. ^^aldosterone release —> salt and water retention. Increase in preload and afteroad)

What are the four compensatory physiological responses to heart failure?

1. Increased sympathetic nervous system activity 2. Activation of the RAAS system 3. Activation of natriuretic peptides 4. Myocardial hypertrophy

What are the three kinds of heart failure and what do they indicate?

1. Systolic failure with reduced ejection fraction (HFrEF) - ventricle is unable to pump efficiently 2. Diastolic dysfunction - structural changes cause impairment of the ventricles to relax and accept blood 3. Diastolic HF with preserved ejection fraction - thickening of ventricular wall decreases ventricular volume and the ability of the heart to relax, so the ventricle can't fill adequately

A 25 y/o man is admitted to the ED with a brownish cyanotic appearance, marked SOB, and hypotension. He has needle marks in both of his arms. Which of the following is most likely to cause methemoglobinemia? A. Amyl nitrite B. Isosorbide dinitrate C. Isosorbide mononitrate D. NTG E. Sodium cyanide

A. Amyl nitrite Nitrites cause methemoglobinemia in adults. Obtained as street drugs, commonly used as sex enhancers.

(Q3) (Q2) A 57 y/o F presents to her PCP with a complaint of severe chest pain when she walks uphill in cold weather. The pain disappears when she rests. She has a 40-pack-year history of smoking but her plasma lipids are within normal range. After evaluation and discussion of tx options, a decision is made to treat her with NTG. If a B-blocker were to be used for prophylaxis in this patient, what is the most probable mechanism of action in angina? A. Block of exercise-induced tachycardia B. Decreased end-diastolic ventricular volume C. Increased double product D. Increased cardiac force E. Decreased ventricular ejection time

A. Block of exercise-induced tachycardia

How do B-blockers improve cardiac function in HF? A. By decreasing cardiac remodeling B. By increasing heart rate C. By increasing renin release D. By activating norepinephrine

A. By decreasing cardiac remodeling

Which of the following has been shown to prolong life in patients with chronic CHF in spite of having a negative inotropic effect on cardiac contractility? A. Carvedilol B. Digoxin C. Dobutamine D. Enalapril E. Furosemide

A. Carvedilol

A patient whose angina was previously well-controlled with once-daily isosorbide mononitrate states that recently he has been taking isosorbide mononitrate twice a day to control angina symptoms that are occurring more frequently during early morning hours. Which of the following is the best option for this patient? A. Continue once-daily admin of isosorbide mononitrate but advise pt to take his meds in the evening. B. Advise continuation of isosorbide mononitrate twice-daily for full 24hr coverage of anginal symptoms C. Switch to isosorbide dinitrate, as this has longer DOA. D. Switch to NTG patch for consistent drug delivery and advise him to wear patch around the clock.

A. Continue once-daily admin of isosorbide mononitrate but advise pt to take his meds in the evening. Important to maintain nitrate-free period to prevent tolerance buldup.

5 y/o child was vomiting and brought to the ER with sinus arrest and ventricular rate of 35bpm. An empty bottle of digoxin was found where he was playing. Which of the following is the drug of choice in treating a severe digoxin overdose? A. Digoxin antibodies B. Lidocaine infusion C. Magnesium infusion D. Phenytoin by mouth E. Potassium by mouth

A. Digoxin antibodies

What is a notable therapeutic difference between ACEIs and ARBs?

ARBs do not increase bradykinin levels. They also result in a more complete blockade of ATII activity than ACEIs because they are competitive antagonists of ATII type 1 receptors, where ACEIs block the enzyme that turns ATI to ATII.

What are some underlying causes of heart failure?

Arteriosclerotic heart disease, MI, HTN, valvular heart disease, dilated cardiomyopathy, congenital heart disease

What drugs are administered IV for short-term tx of acute HF?

B-agonists, i.e. dobutamine and dopamine

A 62 y/o pt with hx of asthma and vasospastic angina states that he gets chest pain both with exertion and at rest, about 10x per week. One SL NTG tablet always relieves his sx, but this med gives him an awful headache every time he uses it. Which is the best option for improving his angina? A. Change to SL NTG spray. B. Add amlodipine C. Add propanolol D. Replace NTG with ranolazine

B. Add amlodipine. CCBs preferred for vasospastic angina. Spray would still cause headache, B-blockers can worsen, and non-selective B-blockers should be avoided in pts with asthma. Ranolazine is not indicated for immediate relief

Which of the following drugs is associated with clinically useful or physiologically important positive inotropic effect? A. Captopril B. Dobutamine C. Enalapril D. Losartan E. Nesiritide

B. Dobutamine

A 65 y/o F has been admitted to the coronary care unit with a left ventricular myocardial infarction. She develops severe acute heart failure with marked pulmonary edema, but no evidence of peripheral edema. Which one of the following drugs would be most useful? A. Digoxin B. Furosemide C. Minoxidil D. Propanolol E. Spironolactone

B. Furosemide

What IS effected when using an HCN blocker? A. Contractility B. Heart rate C. Blood pressure D. AV conduction

B. Heart rate

Which of the following drugs can cause a lupus-like syndrome? A. Isosorbide mononitrate B. Hydralazine C. Methyldopa D. Isosorbide dinitrate

B. Hydralazine

Which describes the mechanism of action in milrinone in HF? A. Decreases intracellular calcium B. Increases cardiac contractility C. Decreases cAMP D. Activates phosphodiesterase

B. Increases cardiac contractility

What makes losartan different from other ARBs? A. Losartan is renally eliminated B. Losartan has an active metabolite C. Losartan has the shortest 1/2 life D. Losartan has a small volume of distribution

B. Losartan has an active metabolite.

Which organic nitrate works the fastest? A. Isosorbide mononitrate B. Nitroglycerin C. Isosorbide dinitrate

B. Nitroglycerin. Onset of action is 1 minute. Iso mono onset is 30 minutes, iso di is longer than that.

Which of the following is NOT indicated in treating silent ischemia? A. B-blockers B. Organic nitrates C. CCBs

B. Organic nitrates. Although CCBs are less effective than B-blockers, organic nitrates aren't indicated at all for silent ischemia.

Which is important to monitor in patients taking digoxin? A. Chloride B. Potassium C. Sodium D. Zinc

B. Potassium

Which three beta blockers reduce morbidity and mortality in HFrEF?

Bisoprolol, metoprolol succinate (ER form), and carvedilol

Which best describes the action of ACE inhibitors on the failing heart? A. ACE inhibitors increase vascular resistance B. ACE inhibitors decrease cardiac output C. ACE inhibitors reduce preload D. ACE inhibitors increase aldosterone

C. ACE inhibitors reduce preload

Which type of angina is ranolazine indicated in? A. Silent ischemia B. Prinzmetal angina C. Chronic stable angina

C. Chronic stable angina

Which side effect is associated with amlodipine? A. Bradycardia B. Cough C. Edema D. QT prolongation

C. Edema

Which of the following meds would be safe to use in a patient taking ranolazine? A. Carbamazepine B. Clarithromycin C. Enalapril D. Quetiapine

C. Enalapril

What is the most common adverse effect associated with fixed-dose hydralazine/isosorbide dinitrate? A. Diarrhea B. Drug-induced lupus C. Headache D. Heartburn

C. Headache

All of the following meds can be useful for managing stable angina in a patient with CAD except: A. Amlodipine B. Atenolol C. Immediate-release nifedipine D. Isosorbide dinitrate

C. Immediate-release nifedipine Short acting should be avoided, as it can worsen angina. ER is fine.

Which med should be prescribed to all anginal patients to treat an acute attack? A. Isosorbide dinitrate B. Ntg patch C. Ntg SL tablet or spray D. Ranolazine

C. Ntg SL tablet or spray

How is spironolactone beneficial in HF? A. Promotes potassium secretion B. Agonizes aldosterone C. Prevents cardiac hypertrophy D. Decreases blood glucose

C. Prevents cardiac hypertrophy

What is the clinical term for angina caused by coronary vasospasm? A. Classic angina B. Myocardial infarction C. Prinzmetal angina D. Unstable angina

C. Prinzmetal angina The others refer to angina caused by atherosclerosis (with varying levels of severity)

A 65 y/o M experiences uncontrolled angina attacks that limit his ability to do household chores. He is adherent to a max dose of B-blocker with a low HR and low BP. He was unable to tolerate an increase in isosorbide mononitrate d/t headache. Which is the most appropriate addition to his antianginal therapy? A. Amlodipine B. Aspirin C. Ranolazine D. Verapamil

C. Ranolazine. Verapamil and Amlodipine may drop BP further. Verapamil may also drop HR further.

SC is a 75 y/o white male who has HF. He is seen in clinic today, reporting SOB, increased pitting edema, and a 5-lb weight gain over the last 2 days. His current medication regimen includes losartan and metoprolol succinate. SC has no chest pain and is deemed stable for outpatient treatment. Which of the following is the best recommendation? A. Increase dose of metoprolol succinate. B. Start HCTZ C. Start furosemide D. Discontinue losartan

C. Start furosemide.

a 73 y/o M with an inadequate response to other drugs is to receive digoxin for chronic HF. He is in NSR with HR of 88 and BP of 135/85. Which of the following is the best documented mechanism of beneficial of cardiac glycosides? A. A decrease in calcium uptake by the sarcoplasmic reticulum B. An increase in a late transmembrane sodium current C. A modification of the actin molecule D. An increase in systolic cytoplasmic calcium levels E. A block in cardiac B-adrenoceptors

D. An increase in systolic cytoplasmic calcium levels

When nitrates are used in combination with other drugs for the treatment of angina, which one of the following combinations results in additive effects on the variable specified? A. Beta blockers and nitrates on end-diastolic cardiac size B. Beta blockers and nitrates on heart rate C. Beta blockers and nitrates on venous tone D. Calcium channel blockers and B-blockers on cardiac force E. Calcium channel blockers and nitrates on heart rate

D. Calcium channel blockers and B-blockers on cardiac force. B-blockers and nitrates effects on heart size, force, venous tone, and HR are opposite. The effects of B-blockers and CCBs on heart size, force, and rate, are the same.

BC is a 70 y/o female who is diagnosed with HFrEF. Her PMHx is significant for HTN and AFib. She is taking hydrochlorothiazide, lisinopril, metoprolol tartrate, and warfarin. BC says she's feeling "good," and has no cough, shortness of breath, or edema. Which is the most appropriate med change to make? A. D/c HCTZ B. Change lisinopril to losartan C. Decrease warfarin dose D. Change metoprolol tartrate to metoprolol succinate

D. Change metoprolol tartrate to metoprolol succinate

When might we consider using a phosphodiesterase inhibitor? A. For long term use of pts with HFrEF B. For long term use in patients with HF without history of CAD C. For short term use of pts with HFrEF D. For short term use of pts with HF without history of CAD

D. For short term use of pts with HF without history of CAD Typically it's only for symptomatic benefit for patients with refractory HF. Long term use is associated with an increased risk of mortality.

(Q1) A 57 y/o F presents to her PCP with a complaint of severe chest pain when she walks uphill in cold weather. The pain disappears when she rests. She has a 40-pack-year history of smoking but her plasma lipids are within normal range. After evaluation and discussion of tx options, a decision is made to treat her with NTG. In advising the pt about side effects, you point out that NTG in moderate doses often produces certain symptoms. Which of the following might occur due to the mechanism listed? A. Constipation due to reduced colonic activity B. Dizziness due to reduced cardiac force of contraction C. Diuresis due to sympathetic discharge D. Headache due to meningeal vasodilation E. Hypertension due to reflex tachycardia

D. Headache due to meningeal vasodilation

Which drug may exacerbate HF? A. Acetaminophen B. Cetrizine C. Chlorthalidone D. Ibuprofen

D. Ibuprofen

Patient who has been taking digoxin for several years for AFib and CHF is about to receive atropine for another condition. A common effect of digoxin that can be almost entirely blocked by atropine is A. Decreased appetite B. Headaches C. Increased atrial contractility D. Increased PR interval on ECG E. Tachycardia

D. Increased PR interval on ECG

(Q2) A 57 y/o F presents to her PCP with a complaint of severe chest pain when she walks uphill in cold weather. The pain disappears when she rests. She has a 40-pack-year history of smoking but her plasma lipids are within normal range. After evaluation and discussion of tx options, a decision is made to treat her with NTG. Which of the following is a common direct or reflex effect of NTG? A. Decreased HR B. Decreased venous capacitance C. Increased afterload D. Increased cardiac force E. Increased diastolic myocardial fiber tension

D. Increased cardiac force NTG increases HR and venous capacitance and decreases afterload and diastolic myocardial fiber tension

A 45 y/o F with hyperlipidemia and frequent migraine headaches develops angina of effort. Which of the following is relatively contraindicated because of her migraines? A. Amlodipine B. Diltiazem C. Metoprolol D. NTG E. Verapamil

D. NTG

A new 60 y/o M pt presents to the medical clinic with HTN and angina. He is 1.8m tall with a waist measurement of 1.1m. Weight is 97kg, BP 150/95, and pulse is 85. In considering side effects of possible drugs for these conditions, you note that a common side effect of NTG and prazosin is: A. Bradycardia B. Impaired sexual function C. Lupus erythematous syndrome D. Orthostatic hypotension E. Weight gain

D. Orthostatic hypotension

When are HCN blockers NOT contraindicated? A. AFib patients B. Pregnant/breastfeeding patients C. Advanced HB patients D. Patients who cannot take beta-blockers E. Potent 3A4 inhibitors

D. Patients who cannot take beta-blockers

A 72 y/o M presents to the primary care clinic complaining of chest tightness that is increasing in severity and frequency. His current meds include atenolol, lisinopril, and NTG. Which intervention is most appropriate at this time? A. Add amlodipine B. Initiate isosorbide mononitrate C. Initiate ranolazine D. Refer the pt to the nearest ER for evaluation

D. Refer the pt to the nearest ER for evaluation

Which of the following drugs increases the plasma levels of endogenous BNP and also blocks angiotensin receptors? A. Furosemide B. Losartan C. Nesiritide D. Sacubitril E. Spironolactone

D. Sacubitril

68 y/o M with hx of angina had an MI last month, and an echo reveals HFrEF. He was continued on his prior home meds (diltiazem, enalapril, NTG) and atenolol was added at discharge. He has only had a few sporadic episodes of stable angina that are relieved with ntg or rest. What are eventual goals for optimizing this med regimen? A. Add isosorbide mononitrate B. Increase atenolol C. Stop atenolol and increase diltiazem D. Stop diltiazem and change atenolol to bisoprolol

D. Stop diltiazem and change atenolol to bisoprolol Nondihydropyridine CCBs (like diltiazem) should be avoided in pts with HFrEF. Adding isosorbide mononitrate wouldnt be necessary.

Which drugs do we use with caution when prescribing digoxin?

Drugs that slow AV nodal conductance (BB, verapamil, diltiazem)

Which of the following are indications to use ACE inhibitors? A. Asymptomatic and symptomatic HFrEF B. All stages of L ventricular failure C. HTN D. Patients with recent MI E. All of the above

E. All of the above

72 y/o F has long-standing HF. Which of the following has been shown to reduce mortality in chronic heart failure? A. Atenolol B. Digoxin C. Furosemide D. Nitroprusside E. Spironolactone

E. Spironolactone

(Q4) (Q2) A 57 y/o F presents to her PCP with a complaint of severe chest pain when she walks uphill in cold weather. The pain disappears when she rests. She has a 40-pack-year history of smoking but her plasma lipids are within normal range. After evaluation and discussion of tx options, a decision is made to treat her with NTG. One year later, she returns complaining that her NTG works well when she takes it for an acute attack but that she is now having more frequent attacks and would like something to prevent them. Useful drugs for the prophylaxis of angina of effort include A. Amyl nitrite B. Esmolol C. SL isosorbide dinitrate D. SL NTG E. Verapamil

E. Verapamil

Another patient is admitted to the emergency department after a drug overdose. He is noted to have hypotension and severe bradycardia. He has been receiving therapy for hypertension and angina. Which of the following drugs in high doses causes bradycardia? A. Amlodipine B. Isosorbide dinitrate C. Nitroglycerin D. Prazosin E. Verapamil

E. Verapamil Isosorbide dinitrate and prazosin cause reflex tachy. Amlodipine causes more vasodilation than cardiac depression and may also cause reflex tachycardia.

Certain drugs can cause severe hypotension when combined with nitrates. Which of the following interacts with NTG by inhibiting the metabolism of cGMP? A. Atenolol B. Hydralazine C. Isosorbide mononitrate D. Nifedipine E. Ranolazine F. Sildenafil G. Terbutaline

F. Sildenafil

What are non-pharmacologic interventions someone can take to manage their HF?

Fluid limitations, low sodium intake, low/no alcohol intake, low/no use of NSAIDs, and treat comorbid conditions

What is the best next-step for someone who presents to your clinic with unstable angina?

Go to the ER

68 y/o man with hx of chronic HF goes on vacation and abandons his low-salt diet. Three days later, he develops severe SOB and is admitted to the local hospital ER with significant pulmonary edema. The first-line drug of choice of acute decompensation in pts with CHF is A. Atenolol B. Captopril C. Carvedilol D. Digoxin E. Diltiazem F. Dobutamine G. Enalapril H. Furosemide I. Metoprolol J. Spironolactone

H. Furosemide

Why is there such a small target serum concentration for digoxin?

Higher levels can increase mortality. Within the serum concentration range, there are reduced HF admissions and improved survival

What are some *atypical* symptoms of angina pectoris?

Indigestion, nausea, vomiting, diaphoresis

How does an HCN channel blocker work?

Inhibits the HCN channel (which is responsible for the If current and sets the pace within the SA node), slowing depolarization and lowering HR.

What can high levels of ATII and aldosterone cause?

It can favor remodeling, fibrosis, and inflammatory changes

What drugs are commonly used in tx'ing angina for patients with chronic renal disease?

Long-acting nitrate, CCBs, and to a lesser extent, B-blockers. B-blockers are less effective.

What drugs are commonly used in treating angina for patients with asthma?

Long-acting nitrates and CCBs. No beta blockers

What drugs are commonly used in tx'ing angina for patients with a recent MI?

Long-acting nitrates, B-blockers. No CCBs

What can use of an ARNI result in?

Natriuresis, diuresis, vasodilation, inhibition of fibrosis. *Use in combo with an ARB and it can decrease afterload, preload, and myocardial fibrosis.

What side effects are common with high doses of organic nitrates?

Orthostatic HoTN, facial flushing, tachycardia

When do we use an HCN blocker?

Patients with HFrEF in sinus rhythm with a HR of >70bpm and are already optimized on pharmacologic therapy (*Pt should be on optimal dose of B-blocker, or have a CI to B-blockers)

What are the indications of aldosterone antagonists?

Patients with more severe stages of HFrEF or HFrEF and a recent MI, and advanced heart disease

When is an ARNI used?

Replaces an ACEI or ARB in patients with HFrEF who remain symptomatic despite optimal doses of B-Blocker and ACEI/ARB

What are the three kinds of myocardial necrosis?

ST elevation MI (STEMI), Non-ST elevated MI (NSTEMI), unstable angina

When is digoxin use indicated?

Severe HFrEF after initiation of ACEI, BB, and diuretic therapy

What are some non-pharmacologic management ideas for managing atherosclerotic disease?

Smoking cessation, exercise, weight reduction. Management of other risk factors, like HTN, DM, HLD.

Why might you use eplerenone over spironolactone?

Spironolactone often has endocrine related adverse effects, like gynecomastia or irregular periods

What is/are symptom(s) of *typical* angina pectoris?

Sudden and severe crushing chest pain that can radiate to neck, jaw, back, arms

Why should you avoid non-DHP CCBs in heart failure?

The negative inotropic effect can worsen heart failure as well as AV conduction abnormalities. Sx of HF may be precipitated

What are biomarkers of myocardial necrosis?

Troponin, creatine kinase

What is the indication for sodium channel blockers?

Tx of chronic angina as mono or combo therapy with B-blockers, CCBs, or nitrates.

What are contraindications for beta-blockers in treating angina?

Tx'ing vasospastic (prinzmetal) angina (it may worsen symptoms). Also, do not use blockers with intrinsic sympathomimetic activity in patients with angina and hx of MI.

What is the order of CCBs used to treat angina?

Verapamil > diltiazem > nifedipine Verapamil - best effect on myocardium Amlodipine (nifedipine for extended release) - best effect on smooth muscle in peripheral vasculature Diltiazem - intermediate actions on both

When should you use verapamil over amlodipine?

Verapamil will decrease contractility better than amlodipine. Amlodipine will vasodilate better than verapamil.

When could we use a recombinant B-type natriuretic peptide?

When IV diuretics are minimally effective. B-type natriuretic peptides decrease preload and afterload. During acute decompensated HF, reducing preload can improve symptoms.

What populations are atypical symptoms more common in?

Women, elderly, pts with DM