Download Exam A 2009 - Pharm D Notes

PHA 5592 Pharmaceutical Care for Patients with Cardiac Disorders
Fall 2009
Exam 1
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This is a 2 hour open book exam. Please document your answer as directed to each question/issue in
a brief and clear response. Your responses must by unambiguous and answer the question presented.
This exam is worth 100 points. Point values for each specific question are indicated.
Please note that laptops or handhelds (e.g. Palm Pilot®, Handspring®, Blackberry®) are permitted
during the exam. However, none of these devices should be connected to the internet during the
exam (this includes cell phones with internet capabilities). Also, it is the student’s responsibility to
ensure that they have adequate battery power for their laptop during the exam as there may not be
enough power outlets available at each examination site.
Cardiac Anatomy, Physiology and Assessment (12 points total)
1. Where is the Aortic Valve located? (4 points)
a. Between the aorta and the left ventricle
b. Between the aorta and the right ventricle
c. Between the left atria and left ventricle
d. Between the pulmonary artery and left ventricle
2. JA is a 55 yo wm with evidence of coronary artery disease in 1 vessel by angiography.
His RCA has a 90% stenosis. Which area of his heart is MOST affected by this
stenosis? (4 points)
a. Left ventricle
b. Right ventricle
c. Left atria
d. Septum
3. In an ECG tracing, what does the p wave represent? (4 points)
a. Atrial depolarization
b. Atrial repolarization
c. Depolarization of the left and right ventricles
d. Ventricular repolarization
Acute Decompensated Heart Failure (24 points total)
RB is a 76 year old man admitted for acute heart failure after poor dietary discretion around the
holidays. His current medications include amiodarone, lisinopril, digoxin, carvedilol,
furosemide, potassium and ibuprofen. He has a history of ischemic cardiomyopathy (ejection
fraction 19% by echo) and non‐sustained ventricular tachycardia. Today his weight is increased
15 lbs over his baseline, he has significant symptoms at rest, and his chest radiograph shows
moderate pulmonary edema. The team has changed his furosemide to IV and increased the
dose and gave IV morphine. Three hours later his respiratory symptoms have improved only
mildly. His extremities remain warm and he is maintaining adequate urine output. A pulmonary
artery catheter (Swan‐Ganz) was then placed which revealed a cardiac index of 2.5 L/min/m2,
and a pulmonary artery occlusion pressure (PAOP) of 32 mm Hg. Vitals are stable, BP = 124/79,
P=80.
4. Does this patient have symptoms of volume overload or hypoperfusion? Give three
examples in the history and findings to support your answer. (6 points)
Volume overload (1.5 points). 1.5 points each for supporting findings such as
pulmonary edema, dyspnea, shortness of breatah at rest, weight gain, warm
extremities, increased PAOP, CI of 2.5.
5. What IV therapy is the most appropriate to recommend at this time? (4 points)
a. Normal saline bolus
b. Dopamine
c. Dobutamine
d. Nitroglycerin
Explanation: Nitroglycerin – This patient falls into subset II. These patients are fluid
overloaded, but maintain normal perfusion (contractility). Nitroglycerin (Choice C) is the best
answer. This will decrease preload by increasing venous capacitance and thus less pulmonary
vascular congestion. Choice A makes little sense, because the patient is already volume
overloaded. Choice B and C would not be correct as this is an inotrope and this patient has
maintained adequate perfusion. Although increased contractility may increase GFR and thus
diuresis, the additional risk of arrhythmias does not warranted any benefits.
6. List four specific parameters you would monitor for the above therapy. (6 points)
1.5 points for any four of the following, UOP, BUN/Cr, BP, HR, ECG, improvement in
dyspnea or shortness of breath.
The following day, RB’s urine output has decreased dramatically, creatinine is up to 2.4mg/dL
and his extremities are cool on exam. The physician has stopped lisinopril and renally adjusted
digoxin. He remains on IV furosemide and maximum doses of therapy recommended earlier
(#5). He now has a cardiac index of 1.7 L/min/m2 and a pulmonary artery occlusion pressure
(PAOP) of 23 mm Hg. Vitals are BP 112/70 P 89 bpm.
7. What is the most appropriate therapy at this time? (4 points)
a. Add valsartan and change furosemide to bumetanide at equivalent dose
b. Stop furosemide and add nesiritide
c. Continue furosemide and add milrinone
d. Start hemofiltration.
This patient continues to be volume overloaded and thus we want to continue with the furosemide. His
heart has begun to fail and he has become cool and clammy. He is now in Subset IV. Patient in subset IV
are diuretics and inotropes. Choice B – although a partial intervention, does not address his failing heart
and thus is not the best choice. Choice A – changes will not improve outcome as mechanisms are the
same. Choice D is held as a last resort.
8. RB has improved and is now ready for discharge home. Renal function has returned
to baseline, lisinopril has been restarted and other cardiac medications continued.
Which of the following recommendations would you make regarding his discharge
medications? (4 points)
a. Discontinue ibuprofen and replace with meloxicam.
b. Advise patient to take only OTC ibuprofen as it is safer for heart failure
patients.
c. Discontinue ibuprofen and recommend acetaminophen for arthritis pain.
d. Continue ibuprofen, add omeprazole and increase furosemide to
compensate for sodium retention caused by NSAID.
Chronic Heart Failure (32 points total)
Mr. F is a 59 yo WM who presented to the ED with left‐sided chest pain and nausea x 2 hours.
ECG revealed ST‐elevation in leads V2‐V4. He has a past medical history of HTN,
hyperlipidemia, and GERD. Consistent with symptoms and ECG, the patient was diagnosed with
an anterior STEMI and sent for heart catheterization. Catheterization revealed 95% occlusion of
LAD and 20‐40% occlusion of the other coronary arteries. PCI was performed on the LAD lesion
with deployment of a drug‐eluting stent with grade 3 TIMI flow. Catheterization also showed EF
25% and an LVEDP 22 mm Hg. Two days post‐procedure the patient is doing well with no
complaints. He does have 1+ edema in the lower extremities, lungs clear to auscultation, and +
JVD. Chest X‐ray is clear. Baseline or dry weight is approximately 188 lbs. Echocardiogram
done today reveals EF of 25‐29% with no valvular abnormalities. Vitals and medications are
shown below.
Vitals: HR 79 bpm, RR 16, T 98 F, BP 138/70 mm Hg, Wt 192 lbs, Ht. 69 in
Medications:
Metoprolol tartrate 25 mg po bid
Atorvastatin 80 mg po daily
ASA 325 mg po daily
Clopidogrel 75 mg po daily
Ranitidine 150 mg po daily
HCTZ 12.5 mg po daily
Labs:
Na 138 mmol/l; K 4.8 mmol/l; Mg 2.1 mg/dl; SCr 1.0 mg/dl; BUN 19 mg/dl
Liver panel, CBC WNLs
NT‐proBNP on admission 12,093 pg/ml
9. What medication would be appropriate to initiate at this time for stage B HF, post‐
ACS? (2 points)
ACE‐inhibitor outlined on slide 34. The evidence‐based choice would be captopril, ramipril,
or trandolapril due to a recent history of ACS. Since patient is taking a diuretic,
recommendations are to start with the lowest possible dose to avoid hypotension.
10. What evidence‐ or guideline‐based medication changes would you consider based
on catheterization and echocardiogram results? (4 points)
Since echo and cath results indicate reduced EF, it would be appropriate to change metoprolol
tartrate (Lopressor) to carvedilol based on CAPRICORN data. Change to carvedilol 6.25 or
12.5 mg bid since patient is already on a beta‐blocker. Change to metoprolol succinate is OK,
too.(2 points)
Mr. F is volume overloaded as indicated by LVEDP 22 mm Hg and signs of congestion (lower
extremity edema and rales). HCTZ is not likely a potent enough diuretic to reduce volume
overload. Change to furosemide 40 mg qam and monitor weight, signs, renal function, and
electrolytes daily until discharge. Discontinue HCTZ. (2 points)
Mr. F returns 14 days after discharge in the post‐MI outpatient clinic. He has SOB with
ordinary activity, but denies orthopnea, PND, palpitations, angina, dizziness, or syncope.
He is still fatigued, but this is improving. Physical exam shows 2+ lower extremity
edema and + JVD. Lungs clear to auscultation. Current vitals, medications and labs are
shown below
Vitals: HR 75 bpm, RR 15, T 98.1 F, BP 128/72 mm Hg, Wt 198 lbs, Ht. 69 in
Medications:
Metoprolol succinate 100 mg po daily
Atorvastatin 80 mg po daily
ASA 325 mg po daily
Clopidogrel 75 mg po daily
Ranitidine 150 mg po daily
Lisinopril 10 mg po daily
HCTZ 25 mg po daily
Labs:
Na 139 mmol/l; K 5.0 mmol/l; Mg 2.1 mg/dl; SCr 1.3 mg/dl; BUN 20 mg/dl
CBC WNLs
NT‐proBNP 6,621 pg/ml
11. What NYHA classification does Mr. F fall into? What lifestyle factors would you want
to counsel this patient on? (4 points)
NYHA Class II (2 pts). (1 pt for each correct counseling point up to 2 pts)Counsel on salt (< 2000
mg daily) and fluid restriction (< 1.5 L daily), monitoring daily weight and blood pressure, and
smoking cessation if appropriate. Limit alcohol use and may stop altogether if responsible for
cardiomyopathy.
12. What evidence‐ or guideline‐based medication changes would you consider today
based on patient presentation today? (4 points)
Patient is now Stage C HF due to the presence of symptoms. Weight has increased since
discharge (most likely due to no loop diuretic on discharge) and patient has SOB. Heart rate is
elevated and patient is not at target dose of beta‐blocker or ACE inhibitor. With the results of
CIBIS III in mind, we can either titrate the beta‐blocker or ACE inhibitor. As HR is elevated and
SCr is 30%, it would be most appropriate to increase the dose of metoprolol succinate to 200
mg daily. (2 points for either choice)
Change to furosemide 40 mg daily due to congestive symptoms. Repeat labs to assess renal
function and electrolytes in 1 week. Phone call follow‐up in 1 week and 2 weeks to further
assess dose titration. Discontinue HCTZ. (2 points)
13. What common adverse effects may occur with titration of an ACE inhibitor or ARB?
(4 points)
Hyperkalemia, worsening renal function, hypotension, and cough. Less common adverse
effect to mention is angioedema. (1 point for each). May give full credit if two or three correct
answers are given as I did not specify the number of AEs.
Mr. F returns 4 months after hospital discharge to a new heart failure disease
management clinic. He gets SOB doing household chores and has to stop to “catch his
breath after walking 25 to 50 yards. He also sleeps on 2‐3 pillows to help him “breathe
better”. He denies PND, palpitations, angina, dizziness, or syncope. Tiredness is
minimal, but dyspnea is limiting his normal activity. He has minimal lower extremity
edema, lungs have minimal rales in the bases, and no JVD. ECG today revealed NSR, q‐
waves, QRS 116 ms, but no other significant changes. Echocardiogram performed
earlier today showed EF 25‐29% with global hypokinesis, moderately dilated LV and
normal size atria and right ventricle, normal pulmonary pressures, and no valvular
abnormalities. Current vitals, medications and labs are shown below
Vitals: HR 61 bpm, RR 17, T 97.9 F, BP 102/60 mm Hg, Wt 189 lbs, Ht. 69 in
Medications:
Metoprolol succinate 200 mg po daily
Atorvastatin 80 mg po daily
ASA 325 mg po daily
Clopidogrel 75 mg po daily
Ranitidine 150 mg po daily
Lisinopril 40 mg po daily
Bumetanide 1 mg po qam and prn for weight gain
Labs:
Na 132 mmol/l; K 4.6 mmol/l; Mg 1.9 mg/dl; SCr 1.5 mg/dl; BUN 25 mg/dl
CBC WNLs
NT‐proBNP 1,430 pg/ml
14. What HF stage and NYHA classifications does Mr. F fall into today? (4 points)
Stage C, NYHA Class III.
15. What evidence‐ or guideline‐based medication changes would you consider based
on patient presentation today? Identify proper follow‐up interval and laboratory
tests required for each possible medication change. (4 points)
A few different options are available, although one option is best. He is still symptomatic on
current regimen including target dose ACE inhibitor and beta‐blocker. As HR is perfect, digoxin
is not an option as it could precipitate bradycardia and would only help with symptoms. Adding
an ARB is not the best option as SCr is approximately 50% over baseline and BP is low‐normal.
Since patient is post‐MI and NYHA class III HF, eplerenone 25 mg would be the most
appropriate option based on the results of EPHESUS. He meets criteria for RALES as well, thus,
spironolactone would be an option and is cheaper. Recheck renal function and electrolytes
within 1 week and again in 1 month. Follow‐up in clinic in 4‐8 weeks to determine if dose
titration is necessary.
Patient is at or close to dry weight. Continue current diuretic regimen and counsel patient on
prn dosing. Also, remind patient on limiting sodium and fluids. (2 points for aldosterone
antagonist and 2 points for follow up and lab recommendations)
16. What specific recommendations would you give regarding diuretic dosing, alternate
regimens, or additional agents, if Mr. F continues to retain fluid and have worsening
symptoms on current diuretic dose? (6 points)
Diuretic resistance is common in HF patients taking loop diuretics long‐term. However, a clinician
must also suspect noncompliance with fluid and sodium restrictions and use of
medications known to cause fluid retention (NSAIDs, corticosteroids). Most patient take
furosemide once a day in the morning and all that is needed is an appropriate dose increase. If
the patient has CKD and higher SCr levels (> 2.0 mg/dl), it would be most appropriate to increase
the dose (i.e. furosemide 40 mg qam to 80 mg qam.) If the patient has preserved renal function,
increasing the doses per day is most appropriate (i.e. furosemide 40 mg qam to 40 mg bid).
Changing to a different loop diuretic is an option due to erratic absorption of furosemide.
Usually, the most effective option is to add a thiazide‐type diuretic to sequentially block the
renal tubule which corrects for distal tubule hypertrophy. This is most commonly done by
taking metolazone 30 minutes to 1 hour prior to a loop diuretic. Metolazone is often chosen
because it is partially, actively secreted into the tubule and relies less on renal function. ( 2
points for recommending dose increase of current diuretic, 2 points for changing to a different
loop diuretic and 2 points for recommending addition of metolazone)
Infective Endocarditis (16 points total)
SD is a 26 yo WM with no significant past medical history. He presents to the Doctor's Urgent
Care Clinic with a 5 day history of fevers (up to 103F per patient report), chills, sweats and
headache. Pertinent findings on physical exam include a new 2/6 systolic murmur and
petechiae on his soft palate and conjunctiva. His allergies include amoxicillin (rash) and codeine
(nausea). Vitals: Temp = 102.1F, BP 105/60, HR 100, R 24 Wt 66kg. Labs drawn at the clinic
include Chem‐7 WNL, WBC 18.3, Hg 15.6, Hct 45, Plt 110, and gram stain of initial blood culture
shows gram‐positive cocci. He is transported to the local hospital for further workup and
treatment. An echocardiogram is ordered and reveals vegetation on the aortic valve. A
presumptive diagnosis of infective endocarditis is made. Upon questioning, SD admits to IV
drug use.
17. What signs/symptoms are suggestive of infective endocarditis? (4 points)
a. Fever
b. Headache
c. Petechiae
d. A and B
e. A and C
18. What is the most appropriate empiric therapy for SD? (4 points)
a. Vancomycin
b. Ceftriaxone
c. Ampicillin/Sulbactam+Gentamicin
d. Vancomycin+Gentamicin+Ciprofloxacin
19. Blood cultures have returned with MSSA as the causative organism. The attending
physician wants to use vancomycin. What dose and monitoring parameters do you
recommend? (4 points)
a. Vancomycin 1.5 gram q12 hours with peak of 10‐15ug/ml
b. Vancomycin 1 gram q8 hours with a trough of 10‐15ug/ml
c. Vancomycin 1 gram q12 hours with a trough of 10‐15ug/ml
d. Vancomycin should never be used alone for infective endocarditis
20. SD is at high risk for several serious sequelae directly attributable to his current
infective endocarditis, including: (4 points)
a. Acute Coronary Syndrome
b. Heart Failure
c. Deep Vein Thrombosis
d. Hemorrhagic Stroke
There is only one answer for this question. The others do not apply. Some folks have stated
because it did not state “best answer” that it is misleading. However, when you review the
sequelae from the lecture, HF is the only clear choice. Embolic events can occur, but NOT DVTs
or ACS and the stroke listed is hemorrhagic, not thrombotic.
Congenital Heart Defects (16 points total, 4 points each)
Baby Girl Wood is a 3500‐gram female neonate who was born at 38‐weeks gestational age
approximately 72 hours ago. She has been in the Newborn Nursery for monitoring. The mother
is a 17‐year‐old female with a PMH of Type I Diabetes who smokes approximately 1‐½ packs of
cigarettes per day.
21. In the above case, which of the following characteristics present in the mother are
considered maternal risk factors for delivering a child with a congenital heart defect
(CHD)? (4 points)
a.
b.
c.
d.
e.
Maternal age less than 18 years of age at conception
Heavy cigarette smoking
Pregestational diabetes mellitus
Both B and C are maternal risk factors for delivering a child with a CHD
A, B, and C are all maternal risk factors for delivering a child with a CHD
Baby Girl Wood has been doing well and is planning to be discharged today. Upon examination
prior to discharge, the physician notices the neonate is becoming increasingly tachycardic (HR
180 bpm) and will not feed well per her mother. The physician also notices a continuous
murmur upon listening to her heart sounds and has an ordered an echocardiogram. The
echocardiogram shows a patent ductus arteriosus (PDA).
22. A patient ductus arteriosus (PDA) is a shunt connecting what two vessels? (4 points)
Pulmonary artery (2 pts)
Aorta (can receive 2 pts if student writes out any one of the following: aorta, descending
aorta, OR ascending aorta)
23. Name two pharmacologic agents other than diuretics and fluid restriction that are
available to close a PDA? (4 points)
Indomethacin (2 pts)
Ibuprofen lysine (can receive 2 pts if student writes out ibuprofen OR ibuprofen lysine)
24. After treatment with one of the pharmacologic agents you listed above, list two
monitoring parameters that should be followed in this patient? (4 points)
Renal function (can receive 2 points if student writes out any one of the following: renal
function, serum creatinine (SrCr) OR urine output)
Platelets (can receive 2 points if student writes out any one of the following: bleeding, GI
bleeding, OR platelets)