patient case studies. jr is a 72 yo male with chf, lvef=32%. t2dm, htn his meds include carvedilol...
TRANSCRIPT
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
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
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 furosemideB. Increase the dose of LisinoprilC. No changes need take placeD. Add diltiazem CD 120mg q day.
CASE 2
Answer: Lisinopril dose should be increased.
When implementing Beta-blockers and Ace-Inhibitors.. Start low and titrate up. 1st the Beta-blocker for most effect, then the Ace-Inhibitor.
CASE 2-ANSWER
The previous patient JR, comes in for a visitHis lungs sound congested. His BNP= 4099He is admitted and given IV furosemide, uponDischarge, 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
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
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
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
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
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
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
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
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
Stop cilostazol and ibupofen
NSAID promote sodium and water retention.
Cilostazol (an inhibitor of phosphodiesterase) is contraindicated in heart
Failure.
CASE #7 - ANSWER
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
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
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
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
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