Self-Assessment Exam – ANSWER KEY 1. Which of the following are classic sign(s) of heart failure (HF): A. B. C. D. Dyspnea at rest or with exertion Orthopnea Edema All of the above*** Correct Answer: D Classic symptoms of HF, including dyspnea at rest or with exertion, orthopnea, paroxysmal nocturnal dyspnea (PND), exercise intolerance, congestion, edema, and fatigue. 2. Which of the following clinical decisions is evidence-based: A. Addition of combination hydralazine (HYD) and isosorbide dinitrate (ISDN) to standard therapy in an African-American patient with asymptomatic HF to prevent progression of disease B. Addition of combination HYD-ISDN to standard therapy in a Caucasian patient with moderate symptoms and systolic HF to reduce the risk of morbidity and mortality C. Addition of digoxin 0.250 mg daily for a Caucasian patient with mild-to-moderate symptoms and diastolic HF to reduce the risk of mortality D. Addition of combination HYD-ISDN to standard therapy in an African-American patient with severe dyspnea with mild activity and systolic HF to reduce the risk of morbidity and mortality*** Correct Answer: D The addition of combination hydralazine (HYD) and isosorbide dinitrate (ISDN) to standard therapy in African-American patients with systolic heart failure (HF) who remain symptomatic despite being on standard therapy is strongly recommended by current guidelines to reduce the risks of mortality and rehospitalization, based on the outcomes benefit seen in the African American Heart Failure Trial (AHeFT). Guidelines do not recommend the use of HYD-ISDN in patients with HF who are asymptomatic, so choice A is incorrect. Choice B is incorrect because combination HYD-ISDN is not indicated for Caucasian patients with HF to improve outcomes, based on evidence from clinical trials. Choice C is incorrect because data for digoxin have not shown outcomes benefit in patients with diastolic HF, especially not at a daily dose of 0.250 mg. 3. Risk factors for developing HF in African-American patients include which of the following: A. B. C. D. Uncontrolled and/or resistant hypertension High prevalence and severity of risk factors for diabetes and chronic kidney disease Lower socioeconomic status and educational level that may decrease access to care All of the above*** Correct Answer: D All of the factors listed are risk factors for the development of HF in African-American patients. Questions 4 to 7 pertain to the following patient (HM) case: HM is a 63-year-old Hispanic male who presents to the Emergency Department with increased shortness of breath, 3 pillow orthopnea, and weight gain of 6 pounds in the past week. He was diagnosed with ischemic cardiomyopathy after a non-ST segment elevation myocardial infarction five years ago. His left ventricular ejection fraction (LVEF) was 30% to 35% according to echocardiogram during his last hospitalization, which was 13 months ago. Medications on record include the following: aspirin 81 mg daily, metoprolol succinate 200 mg daily (increased from 150 mg daily 5 months ago), enalapril 10 mg daily, digoxin 0.125 mg daily, rosuvastatin 10 mg daily, furosemide 20 mg daily, metformin 1000 mg daily, and acetaminophen as needed for osteoarthritis and hip pain, which the patient says does not work well. Vital signs on exam: Labs on admission: BP 120/76, HR 60, RR 22, O 2 sat 98%, Weight 93 kg Na 140 SCr 1.6 Gluc 234 K 5.1 BUN 20 WBC 6.3 4. Which of the following is an appropriate laboratory or therapeutic intervention at this time: A. Check serum digoxin level for therapeutic goal of 1.2 to 2.0 ng/mL B. Order N-terminal pro-BNP to correlate biomarker for congestion with clinical signs of increased congestion and fluid/volume overload*** C. Order cardiac troponin T to correlate biomarker with clinical signs of congestion D. None of the above interventions are clinically indicated Correct Answer: B It is appropriate to order B-type natriuretic peptide (BNP) or N-terminal pro-BNP to correlate biomarkers for congestion with clinical signs of increased congestion and fluid/volume overload. Choice A is incorrect because the serum digoxin goal for HF is < 1.0 ng/mL, preferably 0.7 to 0.9 ng/mL. Choice C is incorrect because cardiac troponin T is a biomarker of cardiac injury; it will not be helpful in distinguishing between dyspnea secondary to HF versus a pulmonary cause. 5. HM’s physical exam shows positive jugular venous pressure, 1+ pitting edema, normal S1 and S2 heart sounds, and mild crackles at the bases in the lungs, bilaterally. Which of the following is the best pharmacologic intervention for HM at this time: A. Hold angiotensin-converting enzyme (ACE) inhibitor since blood pressure is controlled and serum creatinine is elevated B. Add spironolactone 25 mg daily for added outcomes benefit since he has systolic HF and is symptomatic C. Give intravenous (IV) Lasix to alleviate congestive symptoms and evidence of fluid retention*** D. Add HYD-ISDN to alleviate symptoms and to reduce the risks of rehospitalization and mortality Correct Answer: C Since the patient has signs and symptoms of congestion and appears volume overloaded on physical exam, an intravenous loop diuretic is recommended to alleviate congestive symptoms and evidence of fluid retention. The angiotensin-converting enzyme (ACE) inhibitor should not be held in this patient at this time, given its benefits in neurohormonal blockade for those with HF. Choice B is incorrect because this patient’s serum potassium is > 5 mEq/L at this time. Choice D is incorrect in this particular situation. If the patient is Hispanic-black, HYD-ISDN may be recommended after hemodynamic stabilization to improve outcomes. Enalapril would likely be optimized to 10 mg, twice daily before consideration of adding HYD/ISDN. The addition of HYD-ISDN is not indicated in non-African-American patients because of the lack of data and evidence. 6. HM was given furosemide 40 mg IV in the Emergency Department and admitted to the Cardiology service. The resident ordered an echocardiogram and a chest X-ray and will continue diuresis with furosemide 40 mg IV q12h. Medications to be continued on the floor include the following: aspirin 81 mg daily, metoprolol succinate ER 200 mg daily, enalapril 10 mg daily, digoxin 0.125 mg daily, atorvastatin 80 mg daily, and insulin sliding scale. Vital signs: BP 116/78, HR 62, RR 22, Weight 91.5 kg Labs: Na 141 SCr 1.9 Gluc 134 K 4.8 BUN 19 WBC 6.5 Which of the following is an appropriate clinical intervention at this time? A. Add eplerenone 25 mg daily and increase to 50 mg daily after 4 weeks if K+ remains < 5 mEq/L and renal function is stable B. Add eplerenone 25 mg every other day and increase to 25 mg daily after 4 weeks if K+ remains < 5 mEq/L and renal function is stable*** C. Discontinue furosemide at discharge since patient will be at dry weight D. None of the above are appropriate clinical measures at this time Correct Answer: B At this time, it is important to discharge the patient on an oral diuretic to help maintain him at dry weight and to prevent him from having congestive symptoms again. It is appropriate to add a mineralocorticoid antagonist in HM given that he is mild to moderately symptomatic with reduced LVEF. Given HM’s renal impairment, it is safer to add eplerenone 25 mg every other day and increase to 25 mg daily after 4 weeks if K+ remains < 5 mEq/L. 7. Two days later, HM’s dyspnea is relieved and he has no clinical evidence of fluid retention. He is sleeping on 2 pillows and experiences only mild shortness of breath with exertion. HM’s LVEF is 35% on echocardiogram and he is planned for discharge. Vital signs at discharge: BP 110/76 HR 58 RR 22 Weight 88.5 kg Labs at discharge: Na 142 SCr 1.9 Gluc 120 K 4.7 BUN 20 WBC 6.5 Which of the following are appropriate considerations for the pharmacist at discharge? A. Decrease metoprolol succinate ER dose from 200 mg daily to 150 mg daily because of concerns for hypotension and bradycardia in this patient B. Counsel about avoiding the use of non-steroidal anti-inflammatory drugs/COX-2 inhibitors for pain C. Ensure follow-up appointment and check renal function and serum potassium level within 2 to 3 days to follow the strict monitoring guideline recommendation D. B and C*** Correct Answer: D It is recommended that patients with HF receive proper discharge counseling and continuity of care. The health care team, particularly the pharmacist, should monitor for drug-drug interactions and discourage the use of non-steroidal anti-inflammatory drugs and herbal supplements that may increase cardiovascular risk. Patients should receive counseling on smoking cessation, alcohol restriction, and obtaining pneumococcal and influenza vaccinations. To ensure continuity of care after hospital discharge, patients should typically receive a followup appointment within 7 to 14 days and/or a telephone follow-up within 3 days of hospital discharge to reduce the risk of rehospitalization. Assuming HM was started on spironolactone, it is important to check his renal function and serum potassium level and titrate dose based on a strict monitoring guideline, so renal function and serum potassium level need to be checked within 2 to 3 days of initiation of spironolactone. 8. Which of the following is TRUE regarding the management of chronic HF in AfricanAmerican patients: A. The addition of HYD-ISDN was shown in a clinical trial to improve LVEF and all-cause mortality in self-identified African-American patients with mild-to-severe symptoms of HF B. The addition of HYD-ISDN was shown in a clinical trial to improve health-related quality of life and all-cause mortality in self-identified African-American patients with moderate-tosevere symptoms of HF*** C. Digoxin was shown in a clinical trial to improve LVEF, exercise tolerance, and all-cause mortality in self-identified African-American patients with moderate-to-severe symptoms of HF D. Based on evidence-based guidelines, ACE inhibitors are not recommended in self-identified African-American patients with symptomatic systolic HF because of lack of efficacy and increased risk in this population Correct Answer: B In the AHeFT trial, the addition of HYD-ISDN was shown to improve health-related quality of life, decrease all-cause mortality, and reduce hospitalizations in self-identified African-American patients with moderate to severe symptoms (New York Heart Association Functional Classification [NYHA] III to IV) and systolic HF. The AHeFT trial did not include patients with mild symptoms (NYHA II). Data for digoxin’s effect on outcomes are mixed; no large studies were conducted that were specific to efficacy in African-American patients with HF. Current evidencebased guidelines still recommend the use of ACE inhibitors and beta-blockers in self-identified African-American patients with symptomatic systolic HF. 9. Which of the following is NOT a challenge in the management of patients with HF, considering current trends and the costly disease burden of HF: A. Possible biological differences across racial/ethnic groups and an incomplete understanding of the different pathophysiology and etiology of HF among patient groups B. Lower incidence of HF in younger AA patients compared with similar aged white patients*** C. Underutilization of evidence-based medicines, especially in high-risk patient populations D. Inconsistent adoption of guideline recommendations by health care providers Correct Answer: B The relative incidence of HF is higher in African-American patients than the general population. However, HF in blacks has been shown to occur at a younger age. All of the other choices are current challenges that contribute to the complexities of HF management and disease burden. 10. Pharmacists’ roles in the management of HF include which of the following: A. Dose optimization and titration to the maximally tolerable doses that were shown to be effective in large clinical trials B. Early identification and prevention, screening, or risk factor modification in high-risk patient groups C. Promotion of adherence to diet and sodium restriction and smoking cessation, if applicable D. All of the above*** Correct Answer: D Pharmacists’ roles include dose optimization and titration to the maximally tolerable doses that were shown to be effective in the large clinical trials; early identification and prevention, screening, and risk factor modification in high-risk patient groups; and promotion of adherence to diet and sodium restriction and smoking cessation, if applicable.