1/2- HF/angina/arrythmia drugs
What medication is recommended in all patients with HFrEF? (1) - what additional med if/when stable? (1)
- ACEi - BB (if stable)
Which drug classes improve survival in HF? (4/5)
- ACEi (maybe ARBs but not stated anywhere) - Aldosterone Antagonists - BB - ARNI
DRUGS for HF: ACEi Decrease ____________ (vascular resistance) and therefore ____________ (venous tone), resulting in increased CO. - this is also true for what other type of medications?
- Afterload - Preload - ARBs * they also blunt epi and aldosterone increase
Which medications slow conduction through the AV node? (3/4)
- Beta blockers (metoprolol) - non-DHPs (verapamil/diltiazem) - digoxin
What medications are commonly used to treat stable atrial fibrillation? (3/4) * what is an alternative? (2)
- Metoprolol - Amiodarone - Diltiazem - (anticoagulant therapy) *digoxin, dofetilide
What medications are commonly used to treat stable atrial flutter? (2) * what is an alternative? (1)
- Metoprolol - Verapamil *digoxin (Same as AVNRT)
What medications are commonly used to treat AVNRT? (2) * what is an alternative? (1)
- Metoprolol - Verapamil *digoxin (Same as atrial flutter)
What medications are commonly used to treat acute SVT? (1) * what is an alternative? (1)
- adenosine *diltiazem
What medications are commonly used to treat acute V-tach? (1) * what is an alternative? (1)
- amiodarone *lidocaine
What medications are commonly used to treat V- fib? (2) * what is an alternative? (1)
- amiodarone - epinephrine *lidocaine
What drugs classes mentioned below are commonly used in the treatment of angina with the following concomitant diseases? (each dz has 2/3 drug classes) * If no concomitant dz, can use all 3 1. Long-acting nitrates 2. BBs 3. CCBs - Recent MI - Asthma/COPD - HTN - DM - Chronic renal dz
1. Long-acting nitrates 2. BBs 3. CCBs - Recent MI---------> 1 & 2 - Asthma/COPD ---> 1 & 3 - HTN --------------> 2 & 3 (1 less effective) - DM ---------------> 1 & 3 - Chronic renal dz-> 1 & 3 (2 less effective)
What is the progression of treatments (meds) added for various stages of HF? 1st step: (1) 2nd step: (2) 3rd step: (1) *4th step: (2/3) - added *5th step: (1) - may replace *6th step: (2) - added for symptomatic benefit only * if still symptomatic after first 3
1st med: Diuretics 2nd med: ACEi or ARBs (if ACE not tolerated) 3rd med: BB 4th med: Spironolactone, hydralazine, and isosorbide dinitrate 5th med: sacubitril/valsartan 6th med: digoxin and ivabradine
HF with a reduced EF is < ______ % HF with a presevered EF is > ______ %
< 40 % > 50 %
How do β-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. Although it seems counterintuitive to decrease heart rate in HF, β-blockers improve cardiac functioning by slowing heart rate, decreasing renin release, and preventing the direct effects of norepinephrine on cardiac muscle to decrease remodeling.
All of the following are adverse effects of amiodarone except: A. Cinchonism. B. Hypothyroidism. C. Hyperthyroidism. D. Pulmonary fibrosis. E. Blue skin discoloration.
A. Cinchonism. - this was just so we could recognize the a/e it does cause. *Cinchonism is a constellation of symptoms (blurred vision, tinnitus, headache, psychosis) that is known to occur with quinidine. All other options are adverse effects with amiodarone that require close monitoring.
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 administration of isosorbide mononitrate but advise the patient to take this medication in the evening. B. Advise continuation of isosorbide mononitrate twice daily for full 24-hour coverage of anginal symptoms. C. Switch to isosorbide dinitrate, as this has a longer duration of action than the mononitrate. D. Switch to nitroglycerin patch for consistent drug delivery and advise him to wear the patch around the clock. *Bonusish (from book)
A. Continue once-daily administration of isosorbide mononitrate but advise the patient to take this medication in the evening. * It is important to maintain a nitrate-free period to prevent the development of tolerance to nitrate therapy. The mononitrate formulation has the longer half- life. The nitroglycerin patch should be taken off for 10 to 12 hours daily to allow for nitrate-free interval.
A clinician would like to initiate a drug for rhythm control of atrial fibrillation. Which of the following coexisting conditions would allow for initiation of flecainide? A. Hypertension. B. Left ventricular hypertrophy. C. Coronary artery disease. D. Heart failure.
A. Hypertension. *Since flecainide can increase the risk of sudden cardiac death in those with a history of structural heart disease, only A will allow for flecainide initiation. Structural heart disease includes left ventricular hypertrophy, heart failure, and atherosclerotic heart disease.
What are the tx for each in CAD tx? A= (2) B= (2) C= (2) D= (2) E= (2)
A= antiplatelet/antianginal B= BB and BP C= Cigarettes and cholesterol D= Diet and DM E= Education and exercise
If a pt with HFrEF is still symptomatic on optimal doses of an ACEi/ARB and BB, what class of medication would be indicated to replace the ACEi/ARB? - does this class improve survival a. ARNI b. HCN channel blocker c. Digitalis glycoside
ARNI - Angiotensin Receptor-Neprilysin Inhibitor *Improves survival Lecture said: ACEi/ARB needs to be replaced because they all increase bradykinin levels, so increased risk of angioedema etc. Book said: ARB and neprilysin are combined to reduce angioedema
A 62-year-old patient with a history of asthma and vasospastic angina states that he gets chest pain both with exertion and at rest, about ten times per week. One sublingual nitroglycerin tablet always relieves his symptoms, but this medication gives him an awful headache every time he takes it. Which is the best option for improving his angina? A. Change to sublingual nitroglycerin spray. B. Add amlodipine. C. Add propranolol. D. Replace nitroglycerin with ranolazine.
B. Add amlodipine. *Calcium channel blockers are preferred for vasospastic angina. β-Blockers can actually worsen vasospastic angina; furthermore, nonselective β-blockers should be avoided in patients with asthma. The nitroglycerin spray would also be expected to cause headache, so this is not the best choice. Ranolazine is not indicated for immediate relief of an angina attack, nor is it a first-line option.
An elderly patient with a history of heart disease is brought to the emergency room with difficulty breathing. Examination reveals that she has pulmonary edema. Which treatment is indicated? A. Chlorthalidone. B. Furosemide. C. Hydrochlorothiazide. D. Spironolactone.
B. Furosemide. This is a potentially fatal situation. It is important to administer a diuretic that will reduce fluid accumulation in the lungs and, thus, improve oxygenation and heart function. The loop diuretics are most effective in removing large fluid volumes from the body and are the treatment of choice in this situation. In this situation, furosemide should be administered intravenously. The other choices are inappropriate.
What makes losartan different from other ARBs? A. Losartan is renally eliminated. B. Losartan has an active metabolite. C. Losartan has the shortest half-life. D. Losartan has a small volume of distribution.
B. Losartan has an active metabolite. Losartan is the only ARB that under- goes first-pass metabolism to convert to its active metabolite. Most ARBs have once-daily dosing, and all (except candesartan) have large volumes of distribution.
Which is important to monitor in patients taking digoxin? A. Chloride. B. Potassium. C. Sodium. D. Zinc.
B. Potassium. *Hypokalemia can lead to life-threatening arrhythmias and increases the potential of cardiac toxicity with digoxin.
What is the only antianginal drug class proven to prevent reinfarction and to improve survival in pts who have sustained an MI?
Beta blockers - metoprolol tartrate - propanolol - carvedilol
What class of medication is used in a-fib, because they decrease HR and promote conversion to sinus rhythm?
Beta-blockers
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. ACE inhibitors decrease vascular resistance, decrease preload, decrease afterload, and increase cardiac output. In addition, ACE inhibitors blunt aldosterone release.
Which side effect is associated with amlodipine? A. Bradycardia. B. Cough. C. Edema. D. QT prolongation.
C. Edema. * This is a book question, but our lecture also stated QT prolongation so either/or
Which of the following medications would be safe to use in a patient taking ranolazine? A. Carbamazepine. B. Clarithromycin. C. Enalapril. D. Quetiapine. *bonusish (from book)
C. Enalapril. *All other medications should be avoided due to potential drug-drug interactions.
All of the following medications can be useful for managing stable angina in a patient with coronary artery disease except: A. Amlodipine. B. Atenolol. C. Immediate-release nifedipine. D. Metoprolol
C. Immediate-release nifedipine. *The short-acting DHP CCB nifedipine should be avoided in CAD patients as this can worsen angina; however, the extended- release formulation can be used (amlodipine)
A 60-year-old woman had a myocardial infarction. Which of the following should be used to prevent life-threatening arrhythmias that can occur post- myocardial infarction in this patient? A. Digoxin. B. Flecainide. C. Metoprolol. D. Procainamide
C. Metoprolol. *β-Blockers such as metoprolol prevent arrhythmias that occur subsequent to a myocardial infarction. None of the other drugs has been shown to be effective in preventing postinfarct arrhythmias. Flecainide should be avoided in patients with structural heart disease.
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. *Spironolactone antagonizes aldosterone, which in turn prevents salt/water retention, cardiac hypertrophy, and hypokalemia. Spironolactone has endocrine effects on hormones but not on glucose.
A 65-year-old male experiences uncontrolled angina attacks that limit his ability to do household chores. He is adherent to a maximized dose of β-blocker with a low heart rate and low blood pressure. He was unable to tolerate an increase in isosorbide mononitrate due to headache. Which is the most appropriate addition to his antianginal therapy? A. Amlodipine. B. Aspirin. C. Ranolazine. D. Verapamil.
C. Ranolazine. *Ranolazine is the best answer. The patient's blood pressure is low, so verapamil and amlodipine may drop blood pressure further. Verapamil may also decrease heart rate. Ranolazine can be used when other agents are maximized, especially when blood pressure is well controlled. The patient will need a baseline ECG and lab work to ensure safe use of this medication.
SC is a 75-year-old white male who has HF. He is seen in clinic today, reporting shortness of breath, increased pitting edema, and a 5-pound 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 the dose of metoprolol succinate. B. Start hydrochlorothiazide. C. Start furosemide. D. Discontinue losartan.
C. Start furosemide. *As it is possible that SC is having a HF exacerbation, increasing the dose of the β-blocker is not indicated at this time. There is no reason to stop losartan, based on the information we have. Loop diuretics are preferred over thiazide diuretics when patients require diuresis immediately.
Which drug class is 1st line in vasospastic angina?
CCBs - usually diltiazem or amlodipine
What is the adverse effect and recommended monitoring (w/intervals) for amiodarone for each organ/system possibly affected? *a/e, test, and interval for each - Cardiac (1/1/1) - Dermatologic (2/1/1) - Endocrine (1/1/1) - Hepatic (1/1/1) - Ophthalmologic (2/1/1) - Pulmonary (1/2/1)
Cardiac (1/1/1) - QT prolongation --> ECG- yearly Dermatologic (1/1/1) - Photosensitivity, blue/gray skin --> physical exam- prn Endocrine (1/1/1) - HYPO/hyper thyroidism --> TSH -every 6 months Hepatic (1/1/1) - Elevated AST/ALT --> LFTs - every 6 months Ophthalmologic (1/1/1) - corneal microdeposits, optic neuropathy- yearly/prn Pulmonary (1/1/1) - toxicity --> PFTs, CXRs - yearly/prn
BC is a 70-year-old female who is diagnosed with HFrEF. Her past medical history is significant for hypertension and atrial fibrillation. She is taking hydrochlorothiazide, lisinopril, metoprolol tartrate, and warfarin. BC says she is feeling "good" and has no cough, shortness of breath, or edema. Which is the most appropriate medication change to make? A. Discontinue hydrochlorothiazide. B. Change lisinopril to losartan. C. Decrease warfarin dose. D. Change metoprolol tartrate to metoprolol succinate. *Bonusish (from book)
D. Change metoprolol tartrate to metoprolol succinate. Metoprolol succinate should be used in HF, given that there is mortality benefit shown with metoprolol succinate in landmark HF trials. Hydrochlorothiazide and warfarin are appropriate based on the information given; there is no reason to change to an ARB since the patient has no cough or history of angioedema.
Which of the following is correct regarding digoxin when used for atrial fibrillation? A. Digoxin works by blocking voltage-sensitive calcium channels. B. Digoxin is used for rhythm control in patients with atrial fibrillation. C. Digoxin increases conduction velocity through the AV node. D. Digoxin levels of 1 to 2 ng/mL are desirable in the treatment of atrial fibrillation.
D. Digoxin levels of 1 to 2 ng/mL are desirable in the treatment of atrial fibrillation. (narrow therapeutic window) *Digoxin works by inhibiting the Na+/K+- ATPase pump. It decreases conduction velocity through the AV node and is used for rate control in atrial fibrillation (not rhythm control). Digoxin levels between 1 and 2 ng/mL are more likely to exhibit negative chronotropic effects desired in atrial fibrillation or flutter. A serum drug concentration between 0.5 and 0.8 ng/mL is for symptomatic management of heart failure.
Which drug may exacerbate HF? A. Acetaminophen. B. Cetirizine. C. Chlorthalidone. D. Ibuprofen.
D. Ibuprofen. *NSAIDs, such as ibuprofen, lead to increased fluid retention and increased blood pressure. If possible, NSAIDs should be avoided in HF patients in order to avoid exacerbations of HF.
A 78-year-old woman has been newly diagnosed with atrial fibrillation. She is not currently having symptoms of palpitations or fatigue. Which is appropriate to initiate for rate control as an outpatient? A. Amiodarone. B. Sotalol. C. Flecainide. D. Metoprolol.
D. Metoprolol *Only is used to control rate. The other options are used for rhythm control in patients with atrial fibrillation.
A 72-year-old male presents to the primary care clinic complaining of chest tightness and pressure that is increasing in severity and frequency. His current medications include atenolol, lisinopril, and nitroglycerin. Which intervention is most appropriate at this time? A. Add amlodipine. B. Initiate isosorbide mononitrate. C. Initiate ranolazine. D. Refer the patient to the nearest emergency room for evaluation.
D. Refer the patient to the nearest emergency room for evaluation. *Crescendo angina is indicative of unstable angina that requires further workup.
A 68-year-old male with a history of angina had a MI last month, and an echocardiogram reveals heart failure with reduced ejection fraction. He was continued on his previous home medications (diltiazem, enalapril, and nitroglycerin), and atenolol was added at discharge. He has only had a few sporadic episodes of stable angina that are relieved with nitroglycerin or rest. What are eventual goals for optimizing this medication regimen? A. Add isosorbide mononitrate. B. Increase atenolol. C. Stop atenolol and increase diltiazem. D. Stop diltiazem and change atenolol to carvedilol.
D. Stop diltiazem and change atenolol to carvedilol. *Non-DHP CCBs such as diltiazem should be avoided in patients with heart failure with reduced ejection fraction. Patients should be treated with one of three β-blockers approved for heart failure with reduced ejection fraction (bisoprolol, metoprolol succinate, or carvedilol). It sounds like his angina symptoms are well managed with his current therapy so adding isosorbide mononitrate would not be necessary. These symptoms may become even less frequent as his new β-blocker is titrated.
Which arrhythmia can be treated with lidocaine? A. Paroxysmal SVT B. Atrial fibrillation. C. Atrial flutter. D. Ventricular tachycardia
D. Ventricular tachycardia *Lidocaine has little effect on atrial or AV nodal tissue; thus, it used for ventricular arrhythmias such as ventricular tachycardia.
CCBs can be used for angina, but when should they be avoided in each category? - DHPs - Non-DHPs
DHPs: short acting should be avoided in pts with CAD Non- DHPs: should be avoided in pts with HF
Pt presents with dyspnea, fatigue, and fluid retention. These are the cardinal symptoms of what condition?
Heart failure
What is a complex, progressive disorder in which the heart is unable to pump sufficient blood to meet the needs of the body?
Heart failure
Which type of heart failure can be due to either systolic or diastolic dysfunction, with the predominant symptoms d/t low cardiac output and congestion, including dyspnea? Left or Right-sided HF
Left-sided HF (orthopnea, DOE --> at rest, PND)
Which below has the predominate symptoms of fluid overload; ascites, peripheral edema, hepatomegaly? Left or Right-sided HF
Right-sided HF (edema, hepatic congestion, ascites)
Which drug is the least proarrhythmic? *but all can cause arrhythmias a. Amiodarone b. Sotalol c. Dofetilide d. Flecainide
a. Amiodarone
Which type of chest pain is usually precipitated by exertion and relieved rapidly w/rest or nitrates? a. Stable angina b. Unstable angina c. Vasospastic (variant/prinzmetal) angina
a. Stable angina
Which class of medication decreases plasma volume thereby decreasing venous return (preload), and therefore cardiac output? a. diuretics b. ACEi c. ARBs d. BB
a. diuretics
Which below is the 1st line treatment of HF? a. diuretics b. ACEi c. ARBs d. BB
a. diuretics ACEi/ARBs are second - BB introduced once stabilized (commonly 3rd)
Which medication aids in the tx of HF by dilating venous blood vessels leading to decreased preload, and is indicated in pts who can't tolerate ACE/ARB? a. isosorbide dinitrate b. hydralazine c. neprilysin d. losartan
a. isosorbide dinitrate
If a black pt with HFrEF is still symptomatic on optimal doses of an ACEi and BB, what class of medication might be added to help? a. isosorbide dinitrate b. hydralazine c. neprilysin d. losartan
a. isosorbide dinitrate b. hydralazine *shown to reduce mortality in black patients receiving optimal therapy with ACE and BB.
If a pt with HFrEF is still symptomatic on optimal doses of an ACEi and BB, what class of medication might be added to help? a. spironolactone b. enalapril c. neprilysin d. losartan * does this medication improve survival?
a. spironolactone - usually only added if still sxs after diuretic and ACE/ARB - Yes, it has been shown to decrease mortality
Which medication inhibits Na+/K+-ATPase leading to increased cardiac contractility and CO, and slows conduction through the AV node? - It also decreases sympathetic reflexes and vascular tone leading to a decrease in end-diastolic pressure. a. Ivarbradine b. Digoxin c. Losartan d. Carvedilol
b. Digoxin
Which medications should be initiated in the hospital setting to monitor the QT interval? (2) a. flecainamide b. sotalol c. amiodarone d. ranolazine e. dofetilide
b. Sotalol e. Dofetilide *also ibutilide (but not in obj.)
Which type of chest pain is new onset chest pain, CP at rest, or increasing in severity or duration? a. Stable angina b. Unstable angina c. Vasospastic (variant/prinzmetal) angina
b. Unstable angina
Which medication aids in the tx of HF by reducing systemic arteriolar resistance leading to decreased afterload? a. isosorbide dinitrate b. hydralazine c. neprilysin d. losartan
b. hydralazine
Which of the below can exacerbate HF? a. ARBs b. non-DHPs c. BB d. DHPS
b. non-DHPs - NSAIDs - Alcohol - Non-DHP CCBs
All of the below medications are positive inotropes EXCEPT: - increase contractility a. dobutamine b. verapamil c. digoxin d. epinephrine
b. verapamil *digoxine, dobutamine, and epi are all positive inotropes
Which receptors are mainly found in the heart? a. Alpha-1 b. Alpha-2 c. Beta-1 d. Beta-2
c. Beta-1
Which of the below can exacerbate HF? a. ACEi b. BB c. NSAIDS d. DHPs
c. NSAIDS - NSAIDs - Alcohol - Non-DHP CCBs
Which type of chest pain is angina at rest that promptly responds to short-acting nitrates and is attributable to coronary artery vasospasm? a. Stable angina b. Unstable angina c. Vasospastic (variant/prinzmetal) angina
c. Vasospastic (variant/prinzmetal) angina
All of the below medications are negative inotropes EXCEPT: - decrease contractility a. metoprolol b. verapamil c. digoxin d. dilatiazem
c. digoxin *metoprolol, verapamil, and diltiazem are all negative inotropes
Which of the below can exacerbate HF? a. Thiazide diuretic b. Ivabradine c. Digoxin d. Alcohol
d. Alcohol - NSAIDs - Alcohol - Non-DHP CCBs
Which medication improves systolic function, reverses remodeling, and decreases hypertrophy to reduce morbidity and mortality in patients with HFrEF? a. diuretics b. ACEi c. ARBs d. BB
d. BB - but DO NOT start if pt is not stable
Which of the following medications is an IC antiarrhythmic and works by suppressing phase 0 depolarization, slowing conduction in all cardiac tissue? a. Amiodarone b. Sotalol c. Digoxin d. Flecainide
d. Flecanide * it also: -Increases threshold potential decreasing automaticity -Blocks Na+ channels -Also blocks K+ channels→ increased action potential duration
Which medication prevents salt retention, myocardial hypertrophy, and hypokalemia to decrease mortality in pts with HFrEF? a. furosemide b. losartan c. carvedilol d. spironolactone
d. spironolactone *usually added if still sxs after adding diruetic and ACE/ARB or if recent MI