1. Patient case studies

2. JR is a 72 YO male with CHF, LVEF=32%. T2DM, HTN His meds include carvedilol 12.5mg q12hr, furosemide 40mg q day, and kcl 20meq q day. BP= 122/85 HR= 72 Scr= 0.1 … What drug would benefit the patient’s survival rate? A. Addition of Digoxin 0.125mg q day B. Addition of Lisinopril 2.5 mg q day C. Addition of Hydralazine 25mg q 8hr D. Addition of HCTZ 25 mg q day CASE 1

3. Answer: Lisinopril 2.5 mg q day. Beta-blockers, Ace-Inhibitors, and Spironolactone-antagonist are the medications associated with decreased mortality rate in Left-sided CHF. CASE 1- ANSWER

4. The previous pt in case 1, JR was started on Lisinopril 2.5 mg q day.. He has come back for a followup visit. What action should be taken? A. Decrease the dose of furosemide B. Increase the dose of Lisinopril C. No changes need take place D. Add diltiazem CD 120mg q day. CASE 2

5. Answer: Lisinopril dose should be increased. When implementing Beta-blockers and Ace-Inhibitors.. Start low and titrate up. 1 st the Beta-blocker for most effect, then the Ace- Inhibitor. CASE 2-ANSWER

6. The previous patient JR, comes in for a visit His lungs sound congested. His BNP= 4099 He is admitted and given IV furosemide, upon Discharge, what changes would be good. A. Add HCTZ 25 mg q day B. Add Spironolactone 25mg q day C. Increase Furosemide to 160 mg q day D. Enforce fluid restriction CASE 3

7. Answer: Aldactone-antagonist is one of the 3 drugs to increase survival. None of the other answers have shown to increase survival. Beta-Blocker decreases mortality 30% relative risk reduction Ace-Inhibitors decreases mortality 25-50% (depending on severity) Spironolactone decreases mortality 30% in NYHA class III & IV CASE-3 ANSWER

8. HR has CHF with LVEF= 40% and is on Bisoprolol 10mg/day. Per Recommendation of the pharmacy, Ramipril 2.5mg/day has been ordered Initial scr= 1.0… upon followup in 1 week, the scr climbs to 1.18.. What action should take place? A.Stop the Ramipril B.Decrease the dose of Ramipril to 1.25 C.No change in ramipril D.Change ramipril to Lisinopril 2.5mg q day CASE 4

9. The answer is to do nothing.. Typically the scr may rise up to 20% and is acceptable. ARF is rare. If the scr rises above the 20%, may consider stopping the ace- inhibitor. CASE 4- ANSWER

10. JJ comes to the hospital with heart failure, LVEF= 30%. When questioned about his decreased in physical activity. He says, he has no symptoms when watching TV, but finds he can’t finish mowing his front yard without total exhaustion. Which level of NYHA does he fall into? A.NYHA I B.NYHA 2 C.NYHA 3 D.NYHA 4 CASE #5

11. The answer is NYHA 3 NYHA 1--- No limitation in physical activity by HF symptoms NYHA 2--- Symptoms of HF with normal level of activity NYHA 3--- Marked limitations in physical activity because of HF symptoms NYHA 4--- Symptoms at rest. CASE #5- ANSWER

12. JJ is a 67 yo male with LVEF of 37% with atrial fib. He has a prosthetic mitral valve. He weighs 80 kg. scr= 1.1 crcl= 100. Which therapy should he be on? A.Enoxaparin 80 mg q 12 hr B.Enoxaparin 80 mg q 24 hr C.Warfarin 2.5 mg q day D.Apixaban 5 mg bid CASE #6

13. Answer: Warfarin 2.5 mg q day Since the patient has a prosthetic heart valve, warfarin is the only choice. None of the others are indicated for prothetic hear CASE #6-ANSWER

14. BT is admitted into the ER with CHF exacerbation. She is on metoprolol, Lisinopril, bumex, aspirin 81mg, cilostazol, and ibuprofen 800mg tid prn What changes should occur? A.Add Solu Medrol 125 mg q 8hrs B.Stop cilostazol and ibuprofen C.Increase aspirin to 325 mg D.Add lovenox CASE # 7

15. Stop cilostazol and ibupofen NSAID promote sodium and water retention. Cilostazol (an inhibitor of phosphodiesterase) is contraindicated in heart Failure. CASE #7 - ANSWER

16. TJ has CHF, LVEF= 22%, scr= 1.4 crcl=25 BP= 90/55 HR= 44 His meds include: Diltiazem 180mg CD, lisinopril 5 mg q12hr, spironolactone 25 mg q day. What actions should be taken? A.Add furosemide 40 mg iv bid B.Change Diltiazem to amlodipine 10 mg q day C.Add Metformin 500 mg q day D.Add aspirin 81 mg q day CASE # 8

17. Change Diltiazem to amlodipine. Diltiazem and verapamil have significant negative inotropic activity. LVEF is already at 22%... The calcium channel blockers amlodipine and felodipine Are safe to use and have minimal effect on the heart. CASE #8 - ANSWER

18. AR is an 89 YO male with a crcl= 32, wt= 51 kg with atrial fibrillation. He has been on long term warfarin, but can’t make the trip for the inr and wishes to try a new agent. Which one would you suggest? A.Rivaroxoban20 mg qday B.Adoxaban 60 mg q day C.Apixaban 2.5 mg bid D.Apixaban 5 mg bid CASE #9

19. Answer: Apixiban 2.5 mg bid Apixiban 5mg bid is wrong because wt < 60 kg, Adoxaban requires a dosage decrease for weight <= 60kg (needs 30mg qday).. Rivaroxaban should be dosed 15mg q day for crcl =15-50ml/min CASE #9-ANSWER

20. Jp is a 92 YO male with HTN and Rapid ventricular rate. He is Amlodipine 10 mg q day and hydralazine 25 mg tid. His HR= 120 and blood pressure is 170/110.. What medication would be most appropriate to try? 1. Switch amlodipine to verapamil 2. Switch hydralazine to Labetalol 3. Add dronedarone. 4. No change. CASE # 10

21. The answer is change hydralazine to labetalol. Labetolol has both calcium channel blocker activity for the HTN and a beta-blocker component for the fast heart rate. CASE # 10-ANSWER