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12
PHARMACY PREP

CONGESTIVE HEART FAILURE


1-Which of the following drug in combination reduce preload and after load angiotensin
converting enzyme and might provide alternate to ACE inhibitors?
A-Hydralazine and methyldopa
B-diltiazem and verapamil
C-Hydralazine and isosorbide dinitrate
D-Prazosin and angiotensin II
E-Nitroglycerine and isosorbide dinitrate
Answer-C
Comments: Venous dilating properties of Isosorbide (preload) in conjunction with
arterial dilating hydralazine (after load) make this combination alternate to ACE
inhibitors. This is not used as initial therapy but can be used if patient is intolerant.
TC page 316 symptomatic systolic hear failure, hydralazine and nitrates are alternate
to ACEI and ARBs

Next 2 Questions refer to the following scenario
Mary 60 year old woman is hypertensive and is currently being treated with
Nitroglycerin, Carvedilol, Furosemide, Nifedipine, Ramipril, Aspirin and Digoxin. She is
admitted for HF:
2-Which agent most likely to be discontinued in this patient?
A-Furosemide
B-Digoxin
C-Carvedilol
D-Aspirin
E-Nifedipine
Answer-E
Comments: Nifedipine, CCB produce negative inotropic effect must be use cautiously in
CHF. Among CCB, Amlodipine has less effect.

3-Which of the following representative of the groups used as first choice for the above
patient?
A-HCTZ
B-Furosemide
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C-Carvedilol
D-Losartan
E-Lisinopril
Answer-E

4-At what dose dopamine functions as positive inotropic effect:
A- 40 mg/kg/min
B- 40 mcg/kg/min
C- 10-20 mcg/kg/min
D- 5-10 mcg/kg/min
E- 2.0 mcg/kg/min
Answer-D

5-Which of the following shows effectiveness in digitalis toxicity?
I-Potassium administration
II-Cholestyramine
III-Fab fragment antibody
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Answer-E

6-Which of the following will predispose a digitalis toxicity treated patient?
I-Hyper magnesia
II-Hyperkalemia
III-Hypercalcemia
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Answer-B

7-CORRECT statement about dobutamine include
I-Doses of 5-10 mcg/kg/min have been associated with positive inotropic effect in CHF
II-Patient receiving dobutamine should be monitored for increased peripheral resistance.
III-This is a non-glycoside, non-sympathomimetic inotropic drug.
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Answer-E
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Comments: Dobutamine lack effect peripheral resistance but is a non-glycoside
sympathomimetic.

Next 3 Questions refer to the following scenario
8-The following is the most common category of heart failure:
I-Systolic failure
II-Diastolic heart failure
III-Cardiac heart failure associated with other morbidities.
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Answer-A

9-Goal of treatment in CHF patients:
I-Improve quality of life
II-Prevent the factor that aggravate hear failing
III-Reduce morbidity and mortality
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Answer-E

10-A patient with class IIIb or IV heart failure, currently he is on ACE inhibitors and
digoxin. In order to reduce his severe heart failure conditions, the following drug can be
preferred:
I-Spironolactone
II-increase dose of digoxin from 0.25 mg to 0.5 mg
III-Consider b-blockers
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Answer-A
Tips: Spironolactone contraindicated when serum creatinine above 220 mole/L and
potassium above 5 mmol/L

11- New York heart Association has classified heart failure into classes. All of the
following are the patient symptoms of class III, except?
A-Marked limitation of physical activity
B-ordinary activity causes fatigue
C-ordinary activity causes palpitation or dyspnea
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D-No limitation on physical activity
E-None of the above
Ans-D

12-Which of the following are does not improve mortality however only produce
symptomatic benefit in CHF?
A-Digoxin
B-Captopril
C-Beta blockers
D-Lisinopril
E-Losartan
Ans-A

13-A patient with class III or IV heart failure, currently he is on ACE inhibitors and
digoxin. In order to reduce his severe heart failure conditions, the following drug can be
preferred:
I-Spironolactone
II-increase dose of digoxin from 0.25 mg to 0.5 mg
III-Consider b-blockers
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Answer-A
Tips: Spironolactone contraindicated when serum creatinine above 220 mole/L and
potassium above 5 mmol/L

14. Which medication cannot be used in CHF except?
a. rosiglitazone
b. meloxicam
c. diltiazem
d. verapamil
e. metoprolol
Ans: A

Next 4 Questions refer to the amlodipine
15-The following are CORRECT counseling points about Amlodipine:
I-Take drug with liquid
II-Avoid grape fruit juice
III-Can be taken concomitantly with nitroglycerin SL (dose titration needed)
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
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Next 5 Questions refer to the following scenario
16-A 55 year old patient who has CHF is taking digoxin and Furosemide. He was started
on Metoprolol recently. Pharmacist would monitor all except:
A. Fatigue
B. Weakness
C. Dry cough
D. Orthopnea
E. None of the above
Answer-D
Comments: ability to breathe only upright position

Next 6 Questions refer to the following scenario
17- A 60 year ol Patient has congestive heart failure (CHF), which is appropriate for low
ejection fraction
A. Carvedilol
B. Altace
C. Digoxin
D. Hydrochlorothiazide
E. Verapamil
Answer-B

Next 7 Questions refer to the following scenario
18. A 40-year patient is suffering from heart disease and he is under treatment of
Ramipril, propranolol and digoxin. Which medication causes sexual impotence?
A. Propranolol
B. Ramipril
C. Digoxin
D. Captopril
E. All of thea above
Answer: A

Next 8 Questions refer to the following scenario
91. Patient is on Furosemide and doctor prescribed him Ramipril. What should the
pharmacist suggest?
A. Decrease dose of Ramipril and maintain the dose of Furosemide
B. Ramipril should take full dose along with Furosemide
Answer: A

20-All of the following are correct about Spironolactone counseling EXCEPT:
A-Give drug with meals to enhance absorption
B-Protect drug from light
C-At doses 200 mg a day; it can be use for hirsutism
D-Avoid citrus fruits and tomatoes, bananas
E-Take potassium supplements
Answer-E
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Next 9 Questions refer to the spironolactone
21-When Spironolactone is used in-patient with cardiac heart failure, it works through
which of the following mechanism?
A-Aldosterone antagonist
B-Negative inotropic effect
C-Angiotensin II Inhibitors
D-Positive inotropic drugs
E-positive chronotropic effect
Answer-A

Next 10 Questions refer to the spironolactone
22-About digoxin, which of the following statement are true:
I-+ve chronotropic effects
II-+ve inotropic effects
III-Vagomimetic effects
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Ans-D

Next 11 Questions refer to the spironolactone
S.S is an 79 year-old female. Presents at your pharmacy with a new prescription for
spironolactone (Aldactone) 12.5mg daily.
S.S. Past Medical History indicates Hypertension x 15 years Congestive heart failure x 4
years.
Current medications: Metoprolol (Lopressor) 50mg twice daily x 10 years Digoxin
(Lanoxin) 0.125 mg daily x 5 years Ramipril (Altace) 10 mg daily x 4 years.

23- Which of the following is the suitable reference for review potential adverse effect
resulting from a drug interaction is S.S at risk of developing?
A-Therapeutic choice
B- Hansten & Horn's Drug Interactions
C-Physician drug reference
D-Compendium of Pharmaceutical Sciences
E-Patient self care
Ans-B

24 -An important counselling point to include when speaking with S.S about
spironolactone is:
A-Limit the intake of grapefruit juice.
B-Limit the intake of leafy green vegetables.
C-Limit the intake of bananas
D-Spironolactone decreases renal clearance
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E- Spironolactone decreases volume of distribution of fat-soluble drugs
Ans-C

25-If S.S has signs and symptoms of ankle edema, which of the following appropriate
changes in SS regimen:
I-Combination of digoxin and spironolactone may causing ankle edema therefore
discontinue spironolactone
II-Discontinue metoprolol with digoxin
III-Add loop diuretic furosemide for ankle edema treatment.
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Comments: ankle and lungs edema (pulmonary edema)loop diuretics DOC
Ans-B

26-SS mentions that she experiences occasional joint pain. The most appropriate
medication to recommend is:
A-Aspirin
B-acetaminophen
C-Ibuprofen
D-Naproxen
E-Indomethacin
Comments: digoxin have interactions with NSAIDs
Ans-B

Pharmacy Prep Tips
The following statements are correct;
A-chronic systolic heart failure -blocker
B-Less severe ventricular dysfunction---Sotalol
C-Severe ventricular dysfunction with b-blocker contraindication patient----Amiodarone
D-Systemic anticoagulation therapyfor patient atrial fibrillation, acute myocarditis
E-In Warfarin treatment recommended INR is 2.5 (range 2-3)
F-If Warfarin contraindicated use ASA 80 mg daily recommended (children aspirin)
(Note: baby aspirin 81 mg)
G-In systolic heart failure---choice of drug is ACE (if ACE contraindicated use CCB
amlodipine
H-For diastolic dysfunction- Verapamil (240 mg/day) or Diltiazem 180-240 mg day
I-Patient with hypertension and CHF with renal failure caution with ACE and ARB
J-When tolerated long-term use of ACE useful in preserving renal function.
K-Rosiglitazone--- antidiabetic caution in CHF patients
L-avoid NSAIDs. Ref: TC p 319-322



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12-8
27. A 60 years old patient having systolic CHF. His LVEF is 40%. He is intolerant to
-blocker. His doctor should Rx for him:
I CCB
II Only ACEI
III ACEI + ARBs
(A) I only
(B) III only
(C) I and II
(D) II and III
(E) All of the above
Answer: (B)
Reference: Therapeutic Choices 5th edition Page 488


28. In the above scenario if persistent symptoms i.e. if there is no improvement in LVEF,
then:
I Discontinue ACEI and ARBs and give Spironolactone
II Discontinue ACEI and ARBs and give Hydralazine/Isosorbide dinitrate
III Add Digoxin to the above regimen
(A) I only
(B) III only
(C) I and II
(D) II and III
(E) All of the above
Answer: (B)
TIPS: Since in case of persistent signs and symptoms, there is a possibility of cardiac
lesion, and the patient may develop SVA