Hospital Operations II Rotation

Franciscan Health Lafayette ANSWERS

Question Packet #2

1. Name 4 classes of drugs that reduce morbidity/mortality in patients with heart failure.
Medications that Reduce Morbidity/Mortality
ACEIs
 Lisinopril
 Reduces the risk of and reduces hospitalizations in HFrEF
 Quinapril
 No differences among those available and effects on symptoms/survival
 Ramipril
 Initiate at low doses and gradually increase as lower doses are tolerated
ARBs
 ARBs are utilized when patients are intolerant to ACEIs
 Losartan
 If a patient is being switched from an ACEI to an ARNI, the patient must have a 36-
 Valsartan
hour washout period from the ACEI prior to starting the ARNI
ARNI
 ALL patients should receive an ACEI, ARB, or ARNI for HFrEF
 Sacubitril/
Valsartan
 Only 3 recommended for use in HF (positive effects are not considered a class effect)
 Long-term use can lessen symptoms of HF, improve the patient’s clinical status, and
enhance overall well being
Beta-Blockers
 Initiate as soon as HFrEF diagnosis even if symptoms are mild and/or improve with
 Metoprolol
other therapies
Succinate
 Patients do not need a higher dose of an ACEI before initiating a BB
 Carvedilol
o Addition of the BB will produce greater improvement of symptoms and
 Bisoprolol
reduction of risk of death that increasing the ACEI dose
 If the patient has current or a history of fluid retention, ensure that a diuretic is also
prescribed to maintain sodium and fluid restriction
 Recommended in patients with NYHA class 2-4 HF with LVEF ≤ 35%
o History of prior cardiovascular hospitalizations or elevated plasma natriuretic
Aldosterone peptide levels
Antagonists o Serum creatinine ≤ 2.5 mg/dL in men or ≤ 2 mg/dL in women; Potassium < 5
 Spironolactone mEq/L
 Eplerenone  Recommended following acute MI in patients with LVEF ≤ 40% who develop
symptoms of HF or have DM history
 Initial and maintenance doses depend on GFR
 Combination of hydralazine + isosorbide dinitrate recommended for African
Americans with NYHA class 3-4 HFrEF receiving optimal therapy with an ACEI + BB
Hydralazine/Nitrate  Can be useful for patients with current or prior symptomatic HFrEF who cannot be
given an ACEI or ARB because of intolerance, hypotension, renal insufficiency, or
contraindication
Other Medications – These do NOT reduce morbidity/mortality
Loop Diuretics Used for fluid retention in HFrEF and HFpEF, but provides no mortality benefit
Added to standard therapy if a patient has an EF ≤ 35%has a resting HR ≥ 70 bpm despite
Ivabradine
being on a maximally tolerated BB (or if there is a contraindication to beta-blocker use)
Digoxin Reduces hospitalizations, but not mortality
Chronic Utilized in patients with chronic heart failure with permanent Afib and/or additional risk
Anticoagulation factors for stroke
Ometa-3 Fatty Acids Adjunctive with NYHA 2-4, HFrEF or HFrEF to reduce mortality and cardiovascular
CCBs Not routinely recommended due to a myocardial depressant activity
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Franciscan Health Lafayette
Question Packet #2

2. Which beta-blockers are indicated for heart failure? Explain.

Beta-Blocker Initial and Max Doses

Metoprolol Succinate (TOPROL) Initial Dose: 12.5 – 25 mg daily
Beta-1 selective blocker Max Dose: 200 mg daily
Initial Dose:
 IR = 3.125 mg BID
Carvedilol  CR = 10 mg daily
Alpha-1, Beta-1, and Beta-2 receptor blocker Max Dose
 IR = 50 mg BID
 CR = 80 mg daily
Bisoprolol Initial Dose: 1.25 mg daily
Beta-1 selective blocker Max Dose: 10 mg daily

3. A patient begins taking warfarin for the treatment of a pulmonary embolism. How long (approximately) will it take
the patient to become anticoagulated? What should you recommend to the physician in the meantime before the
patient is therapeutic?
 Time to full therapeutic effect = 3-5 days
o INR may begin to increase in 36-72 hours
 Recommendation: Bridge warfarin with LMWH (Enoxaparin)
o Enoxaparin Dose = 1 mg/kg every 12 hours
o Bridge until INR is ≥ 2 for at least 2 measurements ~24 hours apart

4. A 72-year-old female is admitted with a hip fracture following a fall at home. She has a history of atrial fibrillation
and is taking apixaban 5 mg BID. She is 65 inches, 148 pounds, and has a serum creatinine of 0.9 mg/dl. The
orthopedic surgeon calls the pharmacy and asks how soon he can take this patient to surgery. What do you
recommend?
 The pharmacodynamic effect of Eliquis can persist for at least 24 hours after the last dose.
 Recommendation:
o Eliquis should be discontinued for at least 48 hours prior to elective surgery or invasive procedures
with moderate or high risk of bleeding
 Bridging during the 24 hours after stopping Eliquis is generally not required
o Urgent Reversal = PCC 4-Factor (KCENTRA): Factors 2, 7, 9, 10 and Proteins C and Protein S
 50 units/kg for non-vitamin K antagonist anticoagulation reversal
 Significant decline in INR within 10 minutes, duration ~6 – 8 hours
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Franciscan Health Lafayette
Question Packet #2

5. The nurse states they are giving potassium replacement riders multiple times during the day and still can’t get the
potassium to be normal. You recommend to check X (a lab value). What is X and why did you recommend checking
this lab?
 Magnesium lab should be checked
o Patients with hypokalemia may have low magnesium due to concurrent loss with diarrhea or
diuretics or renal potassium wasting
 This causes patients to be refractory to potassium replacement alone
o Renal potassium wasting in patients with hypomagnesemia
 Increased potassium secretion in the connecting tubule and cortical collecting tubule
 Potassium secretion from the cell into the lumen by cells of the connecting tubule and
cortical collecting tubule is mediated by luminal potassium ROMK channels, which is a
process inhibited by intracellular potassium
 Hypomagnesemia is associated with reduction in intracellular magnesium
concentrations, which releases this inhibitory effect on potassium efflux
 There is high cell potassium concentration so this would promote potassium
secretion from the cell into the lumen and enhance urinary losses
 The hypokalemia in this setting is relatively refractory to potassium
supplementation and requires correction of magnesium
 If the patient is experiencing hypokalemia and hypomagnesemia, the magnesium must be corrected prior
to the potassium

6. Describe the following insulins as rapid-acting, intermediate-acting, or long-acting:

Insulin Aspart Insulin Detemir Insulin NPH Insulin Glargine Insulin Lispro Insulin Regular
Intermediate
Onset Rapid acting Long acting Long acting Rapid acting Short acting
acting
Basaglar
Humulin N Humulin R
Brands Novolog Levemir Lantus Humalog
Novolin N Novolin R
Toujeo