Quiz 5 Heart Failure scores (n=163)

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1 Quiz 5 Heart Failure summary statistics The correct answers to questions are indicated by *. Students were awarded 2 points for question #3 for either selecting spironolactone or eplerenone. However, the correct answer was listed as c. Add eplerenone 25 mg po daily. Patient fits the inclusion criteria of the EPHESUS trial. Quiz 5 score stats all students (n=163). 7.7±2.1,mean±sd 8.0, median , range n=163 (TC: 109, Duluth: 54) Frequency Quiz 5 Heart Failure scores (n=163)

2 Case 1. JD is a 62 year old white female recently admitted to the coronary intensive care unit with an acute exacerbation of congestive heart failure and currently experiencing some chest discomfort. Past medical history: acute myocardial infarction in 1992 and 1995 congestive heart failure renal insufficiency Type 2 DM obesity Vital signs include: BP: 125/80 mmhg HR: 60 bpm RR: 20 bpm temp: 98.6 F Weight: 95 kg Height: 5'2" BMI: 35.9 kg/m2 BSA: 1.95 m2 ECG: RRR with mild (0.5mm) ST-segment depression Medications prior to admission include: Enalapril (Vasotec ) 10mg po bid Lovastatin (Mevacor ) 20mg po daily Glipizide (Glucotrol ) 10mg bid for Type 2 Dm Nitroglycerin 0.4mg SL prn chest pain Aspirin 162 mg po daily Furosemide (Lasix ) 40mg po bid Digoxin 0.25 po daily A Swan-Ganz catheter is placed and the following hemodynamic parameters (normal values) are obtained: CO: 5.0 (4-7 L/min) CI: 2.56 ( L/min/m2) PCWP: 20 (5-12 mm Hg) CVP: 8 (2-6 mm Hg) BP: 120/75 (90-140/60-90 mm Hg) MAP: 90 ( mm Hg) SVR: 1312 ( dyn.sec.cm-5) SVRI: 2562 ( dyn.sec.cm-5) 1. Given the data provided in Case 1, JD is now in which of the hemodynamic subsets described by the Forrester Classification? a. Subset I *b. Subset II c. Subset III d. Subset IV e. None of the above 2. What would be the most appropriate initial therapy for improving this JD's hemodynamic parameters? a. IV fluid bolus of 250 ml b. Dopamine c. Dobutamine d. IV furosemide *e. Nitroglycerin infusion

3 3. A 59 year old male with hight 5'8" and weight of 230 pound is being evaluated today in the hospital from a MI he had 5 days ago after which he had drug coated eluting stent placed in his LAD. His chart today indicates pulmonary rales and an echocardiography determines EF of 33%. Medical history: AMI 5 days ago hypertension dyslipidemia smoking a pack of cigarettes per day for the past 25 years Vitals (today) blood pressure: 138/85 mmhg heart rate: 78 bpm. No known drug allergies atrovastatin (Lipitor ) 20mg daily metoprolol tartrate (Lopressor ) 50mg po bid lisinopril (Zestril ) 20mg po daily aspirin 162 mg po daily furosemide (Lasix ) 20mg po bid nitroglycerin 0.4mg sl prn for chest pain Nicotine 21 mg apply 1 patch every day for smoking cessation Labs (today): Potassium: 4.0 meq/l (normal range: meq/l) creatinine 1.1 mg/dl (normal range: mg/dl) Based on a specific study, which of the following drug therapy recommendations could be justified for this patient to reduce morbidity and mortality? a. Change lisinopril to candesartan 4 mg daily. *b. Add spironolactone 25 mg po daily. *c. Add eplerenone 25 mg po daily. d. Add hydrochlorothiazide 12.5 mg daily. e. None of the above are justified choices based on a specific study.

4 4. During a scheduled clinic visit a 65 year old female complains of increasing shortness of breath when walking up one flight of stairs (NYHA III). She is a non-smoker. Past medical history: hypertension hyperlipidemia Congestive heart failure with left ventricular systolic dysfunction (EF 25%) Chest X-ray (today): enlarged left ventricle and clear lung fields Physical exam: Weight (today): 78 kg Weight (3 months ago): 79 kg Vitals (today): blood pressure 121/72 mmhg heart rate: 65 bpm respiratory rate: 12 breaths per minute No known drug allergies pravastatin 40mg po every evening lisinopril 20mg po daily furosemide 40mg po bid potassium chloride 20mEq daily metoprolol succinate (Toprol-XL ) 100mg po daily Current medications have not changed in the last 6 months. Which of the following recommendations would optimize patient's drug therapy for heart failure? a. Change metoprolol succinate (Toprol-XL ) to metoprolol tartrate (IR) to lower risk of mortality as confirmed by the COMET trial. b. Add digoxin to reduce hospitalizations (morbidity) as established by the DIG study. c. Add spironolactone to existing therapy to improve survival and prevent hospitalization with the consideration of lowering potassium supplement and a follow-up serum potassium level. d. Change lisinopril to ramipril due to the SOLVD trial demonstrating a reduction in mortality and morbidity for heart failure patients. *e. Both b and c are reasonable considerations.

5 5. A 76 year male with height 5'8" and weight of 195 pounds presents to the clinic today with complaints of 4 pound weight gain in the past 7 days. medical history: hypertension (10 years) Physical exam (today): peripheral edema +1 bilateral rales Vitals (today: blood pressure: 132/83 mmhg heart rate: 74 bpm temperature: 98.9F No know drug allergies HCTZ 50 mg po daily metoprolol tartrate (Lopressor ) 12.5 mg po bid multivitamin 1 tab po daily aspirin 162 mg po daily chest x-ray (today): lower half of each lung has a cloudy appearance. What would be the most appropriate treatment option at this time? a. Hold metoprolol and decrease dose of HCTZ to 25 mg daily. b. Increase metoprolol tartrate (Lopressor ) 25 mg po bid. *c. Discontinue HCTZ then start furosemide 40 mg now and 20 mg po bid. d. Start lisinopril 10 mg po daily. e. None of the above are justified choices.

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