Management of chf

MANAGEMENT OF CHF

Q. 1 All are true about starting of b-Blocker therapy in a case of CHF except ‑
 A

They should be started with optimal doses

 B

They should be gradually increased over weeks

 C

Special precautions should be taken in cases of NYHA class III and IV

 D

Carvedilol and Metoprolol are the preferred drugs

Q. 1 All are true about starting of b-Blocker therapy in a case of CHF except ‑
 A

They should be started with optimal doses

 B

They should be gradually increased over weeks

 C

Special precautions should be taken in cases of NYHA class III and IV

 D

Carvedilol and Metoprolol are the preferred drugs

Ans. A

Explanation:

They should be started with optimal dose [Ref: Harrison I7/e p 1050-1051]

  • Beta blocker therapy represents a major advance in the treatment of patients with depressed ejection fraction.

– Although the negative inotropic effect of beta blocker resulted in their contraindication in left ventricular

dysfunction until very recently, there is now evidence that, not only are they tolerated, but they greatly improves

prognosis.

How does blockade of fi receptors help in heart failure??

  • Left ventricular dysfunction results in neurohormonal activation (renin angiotensin aldosterone system, sympathetic system, cytokine release) which, although beneficial in acute cases is reponsible for gradual deterioration in myocardial function.

For instance , in response to decrease in cardiac output, an increase in circulating norepinephrine (NE) can be seen which acts on the sympathetic myocardial receptors particularly beta-1 thus increasing tnyocardial contractility.

In addition, by stimulating peripheral alpha receptor, NE induces peripheral vasoconstriction, which helps to maintain blood pressure

– This effect is counter balanced by peripheral *to-2 stimulation and consequent vasodilation.

  • Prolonged exposure of heart to alpha and beta receptor stimulation unfortunately, promotes left ventricular modelling, cell death due to necrosis or apoptosis and water/ salt retention.
  • 8 blockers interfere with the harmful effect of sustained activation of the adrenergic nervous system by competitively antagonizing one or more adrenergic receptors.
  • When given along with ACE inhibitors beta blockers reverse the process of RV remodelling, improve patient symptoms, prevents hospitalisation and prolongs life.
  • Therefore II blockers are indicated for patients with symptomatic or asymptomatic HF and depressed Ejection Fraction < 40%.
  • There are three beta blockers that have been shown to be effective in reducing the risk of death in patients with chronic HE : – Bisoprolol – Metoprolol – Carvedilol

Current recommendation are to consider the addition of fl blockers in the case of patients presenting with  functional class II or Ill congestive heart failure if caused by systolic function.

Dose of 13eta blockers

  • First of all, treatment should be started at extremely low doses:?

– This dosage should be maintained for at least two to .four weeks and is increased only if the patient has tolerated it well.

– if the patient does not tolerate the increased dosage the medication should not be considered a failure and treatment should be maintained at the tolerated dose.

–  The dose of beta blocker should he increased, until, the dose, used are similar to those that have been reported to be effective in clinical trials.

  • Administering ,8 blockers may lead to worsening fluid retention consequent to the withdrawl of adrenergic support to the heart and the circulation.

–  Thus it is important to optimize the dose of diuretic before starting therapy with beta blockers.

– The increased, fluid retention can usually be managed by increasing the dose of diuretics.

Beta blockers in NYHA class IV  😕

  • Since most of the clinical trials of Beta blocking agents have been conducted in patients with heart failure NYHA .functional class 11/ HI, until recently, there was limited information regarding safety and efficacy of Beta blockers in patients with heart failure NYHA functional class IV.
  • Carvedilol prospective Randomized cumulative survival (COPER- NICUS)

– The COPERNICUS TRIAL was designed as multicentric multinational trial in patients with severe heart failure randomized to Carvedilol vs Placebo.

-The result of COPERNICUS demonstrates that even in patients with advanced heart .failure, Carvedilol exerts a beneficial effect.



Q. 2

Drugs used in CHF –

 A

Nesiritide

 B

Digoxin

 C

Spironolactone

 D

All

Q. 2

Drugs used in CHF –

 A

Nesiritide

 B

Digoxin

 C

Spironolactone

 D

All

Ans. D

Explanation:

Ans. is ‘a’ i.e., Nesiritide; ‘b’ i.e., Digoxin; ‘c’ i.e., Spironolactone


Q. 3

Which drug is not used in CHF –

 A

Spironolactone

 B

Trimetazidine

 C

Nitroglycerine

 D

Nesiritide

Q. 3

Which drug is not used in CHF –

 A

Spironolactone

 B

Trimetazidine

 C

Nitroglycerine

 D

Nesiritide

Ans. B

Explanation:

Ans. is ‘b’ i.e., Trimetazidine

o Trimetazidine is an antianginal drugs which act by inhibiting fatty acid oxidation.

Quiz In Between


Q. 4

Which of the following potassium sparing diuretic alters cardiac mortality-

 A

Spironolactone

 B

Amiloride

 C

Triamterene

 D

Epleronone

Q. 4

Which of the following potassium sparing diuretic alters cardiac mortality-

 A

Spironolactone

 B

Amiloride

 C

Triamterene

 D

Epleronone

Ans. A

Explanation:

Ans. is ‘a’ i.e., Spironolactone

o Among potassium sparing diuretics, aldosterone antagonists (Spironolactone, eplerenone) reduce mortality in CHF.


Q. 5

Anti androgen used in heart failure ‑

 A

Carvedilol

 B

Sampatrilat

 C

Spironolactone

 D

Abiraterone

Q. 5

Anti androgen used in heart failure ‑

 A

Carvedilol

 B

Sampatrilat

 C

Spironolactone

 D

Abiraterone

Ans. C

Explanation:

Ans. is ‘c’ i.e., Spironolactone

o Spironolactone and eplerenone are the aldosterone antagonists. They are used as potassium sparing diuretics. Their diurectic effect is quite feeble, but in CHF these drugs reduce the mortality (at doses lower than diuretic doses) by antagonizing the effect of aldosterone (reversal of remodelling). Spironolactone also possesses anti- androgenic effects.


Q. 6

Which is true about calcium channel blockers –

 A

Verapamil causes reflex tachycardia

 B

Diltiazam causes reflex tachycardia

 C

Nifedipine causes reflex tachycardia

 D

Nifedipine has longer t1/2 than felodipine

Q. 6

Which is true about calcium channel blockers –

 A

Verapamil causes reflex tachycardia

 B

Diltiazam causes reflex tachycardia

 C

Nifedipine causes reflex tachycardia

 D

Nifedipine has longer t1/2 than felodipine

Ans. C

Explanation:

Ans. is ‘c’ i.e., Nifedipine causes reflex tachycardia

DHPs (nifedipine) cause reflex tachycardia.

o Felodipine – it differs from nifedipine in having greater vascular selectivity, large tissue distribution and longer t1/2.

Quiz In Between


Q. 7

One of the following statements about hydralazine is not true –

 A

It causes direct relaxation of blood vessels

 B

It causes dilatation of both arteries and veins

 C

Postural hypotension is not a common problem

 D

It increases plasma rennin activity

Q. 7

One of the following statements about hydralazine is not true –

 A

It causes direct relaxation of blood vessels

 B

It causes dilatation of both arteries and veins

 C

Postural hypotension is not a common problem

 D

It increases plasma rennin activity

Ans. B

Explanation:

Ans. is ‘b’ i.e., It causes dilatation of both arteries and veins

o Hydralation is a potent vasodilator

o It acts as a vasodilator by directly acting on arterioles. It has negligible effect on veins.

o There is also renin release with secondary salt and water retention.

o Postural hypotension is not a prominent action because of little action on veins; venous return and cardiac output are not reduced.


Q. 8

Nifedipine and beta-blocker are given together –

 A

To decrease pedal edema due to nifedipine

 B

To overcome increased sympathetic activity of nifedipine

 C

Anti CHF action of propranolol

 D

Antiarrhythmic effect of nifedipine

Q. 8

Nifedipine and beta-blocker are given together –

 A

To decrease pedal edema due to nifedipine

 B

To overcome increased sympathetic activity of nifedipine

 C

Anti CHF action of propranolol

 D

Antiarrhythmic effect of nifedipine

Ans. B

Explanation:

Ans. is ‘b’ i.e., To overcome increased sympathetic activity of Nifedipine

β-Blocker is given along with Nifedipine because

a)         Reflex tachycardia (Increased sympathetic activity) caused due to Nifedipine, is prevented by β-blocker.

b)         β-blockers cause dilatation of coronary arteries by unopposed a-mediated vasoconstriction. Nifedipine causes coronary vasodilatation and opposes the spasm caused by β-blockers.

The tendency of β-blocker to cause ventricular dilatation is counteracted by Nifedipine.


Q. 9

An increase in heart rate and renin release seen in patients of CHF can be overcome by which of the following drugs –

 A

Minoxidil

 B

Metoprolol

 C

Metolazone

 D

Milrinone

Q. 9

An increase in heart rate and renin release seen in patients of CHF can be overcome by which of the following drugs –

 A

Minoxidil

 B

Metoprolol

 C

Metolazone

 D

Milrinone

Ans. B

Explanation:

Ans. is ‘b’ i.e., Metoprolol

o Beta-blocker (metoprolol) prevent reflex tachycardia as well as renin release.


Q. 10

All of the following are true about starting beta­blocker therapy in cases of CHF, Except

 A

They should be initiated at the effective doses

 B

They should be gradually increased over weeks

 C

Special precautions should be taken in NYHA class III & IV

 D

Carvedilol and Metoprolol are the preferred drugs

Q. 10

All of the following are true about starting beta­blocker therapy in cases of CHF, Except

 A

They should be initiated at the effective doses

 B

They should be gradually increased over weeks

 C

Special precautions should be taken in NYHA class III & IV

 D

Carvedilol and Metoprolol are the preferred drugs

Ans. A

Explanation:

Answer is A (They should be initiated at the effective doses)

Beta blocker should be initiated at lower than effective doses in CHF

Beta blockers should be initiated at lower than effective doses in CHF and be

‘Beta blockers should be initiated at low doses followed by gradual increments in the dose if lower doses have been well tolerated. The dose of beta blockers should be increased until the doses used are similar to those that have been  reported effective in clinical trials. The titration of beta blockers should proceed no more rapidly than at 2 week intervals because the initiation and / or increased dosing of these agents may lead to worsening fluid retention’ — Harrison’s 17th/1450

Special precaution should be taken in NYHA class III & IV

‘Although data suggests that patients with NYHA class IHB and IV CHF may tolerate beta blockers and benefit from their use, this group of patients should be approached with considerable caution’

—Goodman & Gillman’s Manual of Pharmacology (2007)/570

Carvedilol and Metoprolol are the preferred beta blockers in CHF

`Non selective third generation beta blockers (Bucindolol, Carvedilol) as well a the Beta-I selective agent (Metoprolol) are generally well tolerated by patients with CHF’.

-‘Current Diagnosis & Treatment in Cardiology’ 3,1/217

Quiz In Between



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