Heart Failure Final Exam Questions And
Answers Verified 100% Correct
What are the monitoring parameters for Ivabradine? - ANSWER- For efficacy: HR
(between 50 and 60) and Decreased hospitalizations
For Safety: bradycardia, sinus arrest,heart block, phosphenes, blurred vision,A.Fib, fetal
toxicity
What are the dose adjustments for Ivabradine based on HR? - ANSWER- HR greater
than 60 increase dose by 2.5 mg PO BID until a max dose of 7.5 mg PO BID HR less
tan 50 or signs and symptoms of bradycardia decrease dose by 2.5 PO BID If current
dose is 2.5 PO BID then d/c
What is the dosing for ivabradine? - ANSWER- starting dose is 5 mg PO BID with food
and the goal HR is 50-60 BPM, undergoes significant first pass effect
What is the MOA of ivabradine? - ANSWER- selectively inhibits the funny current in the
SA nodes which slows the spontaneous depolarization by allowing sodium and
potassium to reenter the cell to reach threshold, decreases heart rate, does not affect
BP, myocardial contractility or AV conduction
Who is ivabradine indicated for? - ANSWER- beneficial to reduce HF hospitalization for
patients with NYHA class II-III, stable chronic HFrEF (LVEF <35%), receiving GDMT
(including a beta blocker at maximum tolerated dose), in sinus rhythm with a heart rate
of 70 BPM or greater at rest, or those in IIaB
What are the efficacy parameters for digoxin? - ANSWER- decreased hospitalizations
What are the safety parameters for digoxin? - ANSWER- cardiac arrhythmias, nausea,
vomiting, diarrhea, dizziness, headache, confusion but dosing for HF doesn't lead to
many ADRs but risk of toxicity increases with age, renal dysfunction, hypokalemia,
hypomagnesemia
What is the MOA for digoxin in HFrEF? - ANSWER- positive inotropic activity,
neurohormonal modulating activity, it causes inhibition of Na/K/ATPase by binding to the
enzyme following phosphorylation of a beta-aspartate residue and thereby stabilize this
conformation
What is the dosing for digoxin? - ANSWER- 0.125 mg PO QD or QOD for those over
70/impaired renal function/low lean bod mass
target concentration is 0.5-0.9 ng/ml and concentrations above 1.2 ng/ml associated
with increased mortality
,Who is indicated for digoxin? - ANSWER- current or prior symptoms of HF and reduced
LVEF to decrease hospitalizations for HF
What are the efficacy parameters for hydralazine- isosorbide? - ANSWER- decrease in
mortality and decreased exacerbations, *NOT HOSPITALIZATION
What are the safety parameters for hydralazine-isosorbide? - ANSWER- hypotension,
headache, dizziness, drug induced lupus
What is the MOA of hydralazine-isosorbide dinitrate? - ANSWER- hydralazine: arterial
vasodilator, increases effects of nitrates through antioxidant mechanism, acts in the
arteries and reduces afterload, may also mitigate tolerance to nitrates and dilates arterie
Isosorbide dinitrate: stimulates nitric oxide signaling by releasing NO in the endothelium,
venous vasodilator, works to dilate arteries and veins
How does hydrazaline work in the cell? - ANSWER- in the endothelium it causes
hyperpolarization by allowing calcium into the cell causing relaxation by increasing NO-
and increasing PGI-2 (prostacyclin to vasodilation)
in vascular muscle it blocks calcium from entering the cell also causing relaxation
What type of drug is isosorbide? - ANSWER- prodrug that is converted into two active
metabolites
How are nitrates processed? - ANSWER- organic nitrates are processed through
ALDH2 in mitochondria to release NO-
inorganic nitrates are processed through P450 in smooth muscle to produce NO-
Who is indicated for hydralazine-isosorbide dinitrate therapy? - ANSWER- patients
selfdescribed as African American with NYHA class III-IV HFrEF receiving optimal
therapy with ACEi and beta blockers OR patients with current or prior symptomatic
HFrEF who cannot be given an ACEi or ARB because of drug intolerance, hypotension
or renal insufficiency
What is the dosing of BiDil and what are the dosing of using hydralazine-isosorbide
dinitrate separately? - ANSWER- BiDil: start with 37.5/20mg TID then titrate up to max
of 75/40 TID
Separate products: Hydralazine 25-50mg TID-QID to a max of 300 mg in divided doses
and Isosorbide 20-30 mg TID-QID, to a max of 120 in divided doses
What are the goals of therapy? - ANSWER- improve quality of life, relieve or reduce
symptoms, prevent or minimize hospitalizations, slow disease progression of the
disease, decrease mortality
, What is the MOA of sacubitril/valsartan? - ANSWER- neprilysin inhibition, neprilysin
degrades b-type natriuretic pepides and bradykinin, natriuretic peptides cause
vasodilation, increase glomerular filtration, increase natriuresis and diuresis
What are the efficacy parameters for sacubitril/valsartan? - ANSWER- decreased
mortality, decreased hospitalizations, reduction in symptoms, reduction in exacerbations
What are the safety parameters for sacubitril/valsartan? - ANSWER- increased SCr,
hyperkalemia, hypotension, angioedema`
What kind of drug is sacubitril? - ANSWER- prodrug that is activated by esterases to
produce sacubitrilat which is an inhibitor of the enzyme neprilysin
Why does sacubitril have to be administered with an ARB? - ANSWER- neprilysin is
responsible for breaking down angiotensin II
What are the contraindications for sacubitril/valsartan? - ANSWER- history of
angioedema, combination with an ACEi or another ARB, use within 36 hours of ACEi,
avoid if pregnant or trying to conceive, avoid if diabetic and taking aliskiren
What is the role of nitric oxide? - ANSWER- the endothelium releases nitric oxide which
is a potent vasodilator responsible for protecting the heart and has been shown to
increase cardiac output and inhibit the RAAS and the SNS, neurohormonal activation
influences hemodynamic abnormalities which lead to endothelial dysfunction
Why are African Americans impacted more strongly by nitric oxide inducers? -
ANSWER- less renin and less activation of the RAAS and less basal nitric oxide as well
as an increase in the oxidative species that metabolizes nitric oxide
What is the dosing for sacubitril/valsartan? - ANSWER- if not taking an ACEi or ARB:
start 24/26mg BID
low dose ACEi or ARB: 24/26 BID
moderate to high dose ACEi or ARB: 49/51 mg BID
target dose is 97/103 mg
*must stop ACEi for 36 hours before starting can schedule with next scheduled dose
after stopping ARB
What is NYHA functional classification I? - ANSWER- Stage B or C patients with no
limitation of physical activity. Ordinary physical activity does not cause symptoms of HF
What is NYHA functional classification II? - ANSWER- Stage C patients with slight
limitation of physical activity. Comfortable at rest, but ordinary physical activity results in
symptoms of HF
Answers Verified 100% Correct
What are the monitoring parameters for Ivabradine? - ANSWER- For efficacy: HR
(between 50 and 60) and Decreased hospitalizations
For Safety: bradycardia, sinus arrest,heart block, phosphenes, blurred vision,A.Fib, fetal
toxicity
What are the dose adjustments for Ivabradine based on HR? - ANSWER- HR greater
than 60 increase dose by 2.5 mg PO BID until a max dose of 7.5 mg PO BID HR less
tan 50 or signs and symptoms of bradycardia decrease dose by 2.5 PO BID If current
dose is 2.5 PO BID then d/c
What is the dosing for ivabradine? - ANSWER- starting dose is 5 mg PO BID with food
and the goal HR is 50-60 BPM, undergoes significant first pass effect
What is the MOA of ivabradine? - ANSWER- selectively inhibits the funny current in the
SA nodes which slows the spontaneous depolarization by allowing sodium and
potassium to reenter the cell to reach threshold, decreases heart rate, does not affect
BP, myocardial contractility or AV conduction
Who is ivabradine indicated for? - ANSWER- beneficial to reduce HF hospitalization for
patients with NYHA class II-III, stable chronic HFrEF (LVEF <35%), receiving GDMT
(including a beta blocker at maximum tolerated dose), in sinus rhythm with a heart rate
of 70 BPM or greater at rest, or those in IIaB
What are the efficacy parameters for digoxin? - ANSWER- decreased hospitalizations
What are the safety parameters for digoxin? - ANSWER- cardiac arrhythmias, nausea,
vomiting, diarrhea, dizziness, headache, confusion but dosing for HF doesn't lead to
many ADRs but risk of toxicity increases with age, renal dysfunction, hypokalemia,
hypomagnesemia
What is the MOA for digoxin in HFrEF? - ANSWER- positive inotropic activity,
neurohormonal modulating activity, it causes inhibition of Na/K/ATPase by binding to the
enzyme following phosphorylation of a beta-aspartate residue and thereby stabilize this
conformation
What is the dosing for digoxin? - ANSWER- 0.125 mg PO QD or QOD for those over
70/impaired renal function/low lean bod mass
target concentration is 0.5-0.9 ng/ml and concentrations above 1.2 ng/ml associated
with increased mortality
,Who is indicated for digoxin? - ANSWER- current or prior symptoms of HF and reduced
LVEF to decrease hospitalizations for HF
What are the efficacy parameters for hydralazine- isosorbide? - ANSWER- decrease in
mortality and decreased exacerbations, *NOT HOSPITALIZATION
What are the safety parameters for hydralazine-isosorbide? - ANSWER- hypotension,
headache, dizziness, drug induced lupus
What is the MOA of hydralazine-isosorbide dinitrate? - ANSWER- hydralazine: arterial
vasodilator, increases effects of nitrates through antioxidant mechanism, acts in the
arteries and reduces afterload, may also mitigate tolerance to nitrates and dilates arterie
Isosorbide dinitrate: stimulates nitric oxide signaling by releasing NO in the endothelium,
venous vasodilator, works to dilate arteries and veins
How does hydrazaline work in the cell? - ANSWER- in the endothelium it causes
hyperpolarization by allowing calcium into the cell causing relaxation by increasing NO-
and increasing PGI-2 (prostacyclin to vasodilation)
in vascular muscle it blocks calcium from entering the cell also causing relaxation
What type of drug is isosorbide? - ANSWER- prodrug that is converted into two active
metabolites
How are nitrates processed? - ANSWER- organic nitrates are processed through
ALDH2 in mitochondria to release NO-
inorganic nitrates are processed through P450 in smooth muscle to produce NO-
Who is indicated for hydralazine-isosorbide dinitrate therapy? - ANSWER- patients
selfdescribed as African American with NYHA class III-IV HFrEF receiving optimal
therapy with ACEi and beta blockers OR patients with current or prior symptomatic
HFrEF who cannot be given an ACEi or ARB because of drug intolerance, hypotension
or renal insufficiency
What is the dosing of BiDil and what are the dosing of using hydralazine-isosorbide
dinitrate separately? - ANSWER- BiDil: start with 37.5/20mg TID then titrate up to max
of 75/40 TID
Separate products: Hydralazine 25-50mg TID-QID to a max of 300 mg in divided doses
and Isosorbide 20-30 mg TID-QID, to a max of 120 in divided doses
What are the goals of therapy? - ANSWER- improve quality of life, relieve or reduce
symptoms, prevent or minimize hospitalizations, slow disease progression of the
disease, decrease mortality
, What is the MOA of sacubitril/valsartan? - ANSWER- neprilysin inhibition, neprilysin
degrades b-type natriuretic pepides and bradykinin, natriuretic peptides cause
vasodilation, increase glomerular filtration, increase natriuresis and diuresis
What are the efficacy parameters for sacubitril/valsartan? - ANSWER- decreased
mortality, decreased hospitalizations, reduction in symptoms, reduction in exacerbations
What are the safety parameters for sacubitril/valsartan? - ANSWER- increased SCr,
hyperkalemia, hypotension, angioedema`
What kind of drug is sacubitril? - ANSWER- prodrug that is activated by esterases to
produce sacubitrilat which is an inhibitor of the enzyme neprilysin
Why does sacubitril have to be administered with an ARB? - ANSWER- neprilysin is
responsible for breaking down angiotensin II
What are the contraindications for sacubitril/valsartan? - ANSWER- history of
angioedema, combination with an ACEi or another ARB, use within 36 hours of ACEi,
avoid if pregnant or trying to conceive, avoid if diabetic and taking aliskiren
What is the role of nitric oxide? - ANSWER- the endothelium releases nitric oxide which
is a potent vasodilator responsible for protecting the heart and has been shown to
increase cardiac output and inhibit the RAAS and the SNS, neurohormonal activation
influences hemodynamic abnormalities which lead to endothelial dysfunction
Why are African Americans impacted more strongly by nitric oxide inducers? -
ANSWER- less renin and less activation of the RAAS and less basal nitric oxide as well
as an increase in the oxidative species that metabolizes nitric oxide
What is the dosing for sacubitril/valsartan? - ANSWER- if not taking an ACEi or ARB:
start 24/26mg BID
low dose ACEi or ARB: 24/26 BID
moderate to high dose ACEi or ARB: 49/51 mg BID
target dose is 97/103 mg
*must stop ACEi for 36 hours before starting can schedule with next scheduled dose
after stopping ARB
What is NYHA functional classification I? - ANSWER- Stage B or C patients with no
limitation of physical activity. Ordinary physical activity does not cause symptoms of HF
What is NYHA functional classification II? - ANSWER- Stage C patients with slight
limitation of physical activity. Comfortable at rest, but ordinary physical activity results in
symptoms of HF
