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Update on Heart Failure Management: A Primer for Pharmacists Upon completion of this activity, participants should be better able to: 1. Describe the prevalence, pathophysiology, and etiologies of heart failure (HF). 2. Review recent changes in recommendations for the treatment of HF, particularly involving current research findings and newer/investigational approaches to HF. 3. Discuss approaches to decreasing hospital readmission rates for HF through discharge planning and patient education. 4. Address individual patient and disease characteristics to educate patients about appropriate care for HF. 5. Describe the rationale for individualizing the approach to HF management, taking into account newer management approaches. POST-TEST/Rationale 1. Hospitalizations account for what percentage of the direct medical care costs for patients with heart failure in the United States? A. 25% B. 40% C. 50% D. 80%*** Correct Answer: D Hospitalizations account for 80% of the direct medical care costs associated with heart failure. 2. The most common cause of heart failure in the Unites States is: A. Valvular heart disease B. Alcoholism C. Coronary artery disease*** D. Obesity Correct Answer: C In the United States, coronary artery disease and myocardial infarction are the most common causes of heart failure. 3. Patients with ACC/AHA Stage D heart failure (HF) are characterized by: A. The presence of structural heart disease but no current symptoms B. Being at high risk for heart disease but without structural heart disease or symptoms of HF C. The presence of structural heart disease with prior symptoms D. Refractory HF requiring specialized interventions*** Correct Answer: D Patients with refractory HF requiring specialized interventions are classified as ACC/AHA Stage D. 4. Which of the following drugs has not been shown to reduce mortality in patients with heart failure with reduced ejection fraction? A. Digoxin*** B. Angiotensin-converting enzyme inhibitors C. Beta-blockers D. Aldosterone receptor antagonists Correct Answer: A Digoxin was evaluated in a large outcomes trial; the results indicated that the drug had a neutral effect on mortality in heart failure patients. 5. In a patient receiving an angiotensin-converting enzyme inhibitor (ACEI), which of the following washout periods is required prior to initiation of sacubitril/valsartan? A. 24 hours B. 48 hours C. 36 hours*** D. The washout period depends on the dose of the ACEI Correct Answer: C In patients already taking an ACEI, ACEI therapy needs to be discontinued for 36 hours prior to initiation of sacubitril/valsartan. 6. The adverse event that led to a significantly greater rate of drug discontinuation with ivabradine compared to placebo in the SHIFT study was: A. Hypotension B. Bradycardia*** C. Phosphenes D. Atrial fibrillation Correct Answer: B Bradycardia was the only adverse event that was associated with a significantly greater rate of treatment discontinuation with ivabradine than with placebo. 7. Patients with HF should be able to demonstrate an understanding of the content of their education concerning heart failure treatment using: A. A post-interview quiz B. The Morisky scale C. The “teach back” technique*** D. Adherence on the basis of refill records Correct Answer: C Patients should be able to demonstrate an understanding of their education about diet, exercise, medications, and disease processes using the “teach back” technique. 8. Guideline-directed medical therapy for a patients with ACC/AHA Stage A heart failure should include: A. Angiotensin converting enzyme inhibitor and beta-blocker*** B. Ivabradine C. Sacubitril/valsartan D. Aldosterone receptor antagonist Correct Answer: A For patients with Stage A HF, therapy is directed at reducing the risk factors for the development of HF. 9. Factors associated with improved medication adherence in patients with heart failure (HF) include: A. Cognitive decline and/or depression B. High education level*** C. High baseline heart rate D. Increased severity of HF Correct Answer: B Factors that improve adherence to HF treatment include age older than 65 years, more years of education, current use of other cardiovascular medications, patient knowledge of correct medication use, prior use of HF medications, adequate heath literacy, satisfactory reading ability, and being married. 10. According to the Heart Failure Society of America, patients who should be referred to a heart failure (HF) disease management program include: A. Patients with poor adherence to guideline-directed medical therapy B. Patients discharged after a HF hospitalization*** C. Patients with atrial fibrillation requiring warfarin monitoring D. Patients with low health literacy Correct Answer: B The HFSA recommends that referral to an HF disease management program (DMP) should be considered in patients who have been hospitalized for HF. Although many patients would benefit from enrollment in an education or medication management program, including those with poor adherence, those who require substantial medication therapy monitoring, or those with low literacy, the HFSA does not specifically note that these patients have specific risk factors that necessitate enrollment in a DMP.