080 3

2011 Updates in Therapeutics:
The Pharmacotherapy Preparatory Review &

Recertification Course
Cardiology III
Robert L Page, Pharm.D., MSPH, BCPS (AQ cards), FAHA, FCCP, FASHP, FASCP, CGP
University of Colorado School of Pharmacy and School of Medicine
Conflict of Interest Disclosures
I have no conflicts to disclose
Im Sorry
1
Learning Objectives
Page Pointers
Absolutely do not study this.
Page Pointers
Absolutely do study this.www.acc.org
2
Page Pointers
Absolutely do study this.
Page Pointers
And this.www.americanheart.org
Page Pointers
And
..www.nhlbi.nih.gov/guidelines/index.htm
3
Page POINTERS
Remember if it is.
Page POINTERS
Remember if it is.
CENSORED
Disclosures
4
Topics Covered
Chronic Heart Failure

Atrial Fibrillation
Hypertension
Chronic CAD and Stable Angina
Case #1
48 year old female
ETOH-induced HF, EF is 20%
NYHA class III (symptoms of dyspnea and fatigue)
BP = 112/70, HR = 68
Medications: Labs:
lisinopril 20 mg daily
140 105 12
furosemide 40 mg BID
98
carvedilol 12.5 mg BID 4.0 26 0.8
spironolactone 25mg daily
digoxin 0.125 mg daily

Ca 9.0 dig 0.7 ng/mL
Mg 2.0
Phos 2.8
Page Number 272-Case #1
Case #1-Question??
Which of the following is the best approach to

maximize the management of her heart failure?
aa. increase carvedilol to 25 mg BID

b. increase lisinopril to 40 mg daily
c. increase spironolactone to 50 mg daily
d. increase digoxin to 0.25 mg daily
5
Neurohormonal Blockade in HF
Page Number 275-280
ACEI Dosing in HF
Page Number 276-Table 4
Beta Blocker Dosing in HF
6
Aldosterone Blockade
and Digoxin Dosing in HF
Spironolactone
25 mg daily if SCr < 2.5, K < 5.0
Decrease to 12.5 mg daily or discontinue if K > 5.0
Eplerenone
25 mg daily if SCr < 2.5, K < 5.0
Increase to 50 mg daily if tolerated
Digoxin
Goal serum level 0.5-0.8 ng/mL
Minimizes adverse effects and ventricular arrhythmias
Remember drug interactions

Amiodarone, dronedarone, clarithromycin,erythromycin
CIs, Azole antifungals
Page Number 278-280
Case #1-Question??


Case #1-Question??


7
Other Considerations
Vitals
BP = 112/70
HR = 68
Titrated slowly
double dose Q2 weeks maximum
only 1% incidence of significant bradycardia
HR decreases an average of 12 bpm
No significant change in BP
Assess for edema/fluid retention, fatigue, dizziness
Case #2
62 year old male Medications
CAD (MI 3 years ago) aspirin 81mg daily
HF (EF = 25%) simvastatin 40 mg QHS
NYHA Class II enalapril 5 mg BID
HTN metoprolol CR/XL 50 mg daily
Depression furosemide 80 mg BID
CRI (SCr = 2.8 mg/dL) cilostazol 100 mg BID
PVD acetaminophen 650 mg QID
OA sertraline 100 mg daily7
Hypothyroidism levothyroxine 0.1 mg daily
Case #2
aspirin 81mg QD
CAD (MI 3 years ago) simvastatin 40 mg QHS
HF (EF = 25%) enalapril 5 mg BID
NYHA Class II metoprolol CR/XL 50 mg QD
HTN cilostazol 100 mg BID
D
Depression
i acetaminophen 650 mg QID
CRI (SCr = 2.8 mg/dL) sertraline 100 mg QD
levothyroxine 0.1 mg QD
PVD
OA
Hypothyroidism
8
Case #2
aspirin 81mg QD
Depression acetaminophen
t i h 650 mg QID
PVD
OA
Hypothyroidism
Case #2
aspirin 81mg QD
HTN cilostazol 100 mg
g BID
Depression acetaminophen 650 mg QID
PVD
OA
Hypothyroidism
Case #2
aspirin 81mg QD
g BID
PVD
OA
Hypothyroidism
9
Case #2
aspirin 81mg QD
D
Depression
i acetaminophen 650 mg QID
PVD
OA
Hypothyroidism
Case #2
aspirin 81mg QD
HTN cilostazol
il t l 100 mg BID
PVD
OA
Hypothyroidism
Case 2
aspirin 81mg QD
Depression acetaminophen
t i h 650 mg QID
PVD
OA
Hypothyroidism
10
Case #2
aspirin 81mg QD
g BID
PVD
OA
Hypothyroidism
Case # 2
BP = 120/70
HR = 72
Labs WNL except for Cr = 2.8
TSH = 2.6
2 6 mU/L
U/L
HF considered stable
Case #2-Question???
maximize the management of his heart failure?
a. Discontinue metoprolol and begin carvedilol 12.5 mg

BID
b. Increase enalapril to 10 mg BID
c. Add spironolactone 25 mg daily
d. Add digoxin 0.125 mg daily
11
Case #2
discontinue metoprolol and begin carvedilol

12.5 mg BID
No reason to change beta blockers
No data clearly places one beta blocker as
better than another in HF so long as you
are recommending a beta blocker with
evidence
A reasonable option would be to increase
the metoprolol from 50 mg to 100 mg daily
Case # 2
add spironolactone 25 mg QD
Not appropriate therapy in this patient
Based on EMPHASIS trial, possibly
BUT Cr = 22.8
BUT..Cr 8 (K reportedly WNL)
Case #2
add digoxin 0.125 mg QD

Could be considered
Useful in patients with symptomatic LV dysfunction
despite optimal diuretic, ACEI, beta-blocker, and
spironolactone
p (if
( appropriate)
pp p ) therapy
py
Dose of 0.125 mg daily may be too high in 62 year old male

with creatinine = 2.8
No mortality benefit derived from digoxin therapy but the

composite of hospitalization and mortality!
12
Case #2
increase enalapril to 10 mg BID

Should be strongly considered
current enalapril 5 mg BID is not at ACEI target dose
associated with decreased morbidity and mortality.
BP = 120/70, should tolerate dosage increase without

problem
Monitor creatinine and K (currently WNL) after dosage

increase
Case #2

maximize the management of his heart failure?
a. Discontinue
Di ti metoprolol
t l l and
d begin
b i carvedilol
dil l
12.5 mg BID
b. Increase enalapril to 10 mg BID
c. Add spironolactone 25 mg QD
d. Add digoxin 0.125 mg QD
Hydralazine/Isosorbide dinitrate
MOA: Vasodilation and nitric oxide-dependent
endothelium function
Superior to placebo
Inferior to ACEI
Alternative to ACEI or ARB in truly intolerant or

contraindication situation
Added to standard therapy in class III-IV HF African-

Americans
Decreases mortality 39%
Decreases hospitalizations 33%
Hydralazine 40 mg + isosorbide dinitrate 75 mg TID
Page Number 279-280
13
Case #3
Which one of the medications from the patient

in case 2 may be adversely affecting his cardiac
prognosis?
a. acetaminophen
b. sertraline
c. cilostazol
d. levothyroxine
Page 280
Harmful medications
Promote fluid retention Negative inotropic activity

NSAIDs (cause neurohormonal
Corticosteroids
activation)
Class I and III
Minoxidil
antiarrhythmics
Thiazolidinediones
(except dofetilide and
amiodarone)
Exacerbate HF Diltiazem and Verapamil
Drondedarone Itraconazole
Page Number 281
14
Harmful medications
Positive inotropic Increase ventricular

activity/tachycardia arrhythmias
Anagrelide Class I and III
Amphetamines antiarrhythmics (except

dofetilide and
amiodarone)
Amphetamines
Cilostazol
Page Number 281
Case #3

prognosis?
a. acetaminophen
b. sertraline
c. cilostazol
d. levothyroxine
Page 280
Case #3Question

prognosis?
a. acetaminophen (drug of choice for pain in HF)

b. sertraline (SSRIs effective/safe in depression & HF)
c. cilostazol
d. Levothyroxine (hypothyroidism worsens HF)
Page 281
15
Case #4
52 year-old male
CC: Several weeks of a fluttering feeling in

his chest on occasion over the past several
weeks.
HTN-receiving verapamil 240 mg daily

Labs-all WNL
Case #4
BP = 130/78
HR = 74
EKG findings:
irregularly irregular rhythm
no p-waves
Case #4..Question???
What is the most appropriate approach to manage
his atrial fibrillation?
a. Begin digoxin 0.25 mg daily

b B
b. Begin
i atenolol
l l 50 mg daily
d il
c. Begin amiodarone 400 mg BID, tapering to goal
dose of 200 mg daily over the next 6 weeks
d. Start warfarin 7.5 mg daily, adjust to a goal INR
= 2.5
16
UPDATEUPDATEMAKE A
NOTE
Atrial Fibrillation
Goals of therapy
Ventricular rate control
60-80 at rest, 90-115 during exercise
RACE-2: HR<110 beats per min (lenient) not inferior to
strict rate control of < 80 beats/min
Select agent(s) based on
concomitant disease states
individual response
Anticoagulation
Aspirin or warfarin based on risk factors
Page Number 284
Atrial Fibrillation.Hot Off the Press
17
Ventricular Rate Control
Beta blockade
Beta1 selective agents preferred
Labetalol or carvedilol may be used if additional BP

effects required
(concomitant alpha blockade)
Sotalol or propafenone useful if maintenance of NSR

is to be pursued for symptom control
(Class III antiarrhythmic properties)
Beta blockers particularly useful to control HR

increases with exercise
Page Number 284
Calcium Channel Blockers

Verapamil or diltiazem
Preferred over beta blocker if:

severe asthma/COPD
undesirable side effects
sexual dysfunction
fatigue
Page Number 284
Digoxin
Often ineffective as a single agent, especially during
exercise
Should be included in rate control regimen in

patients with systolic HF
Page Number 284
18
Anticoagulation
Anticoagulation
Anticoagulation in AF
Stroke Risk Reductions
Warfarin Better Control Better
AFASAK Reduction of
SPAF all--cause mortality
all
RRR 26%
BAATAF
CAFA
SPINAF
Reduction of
EAFT stroke
RRR 62%
All trials=6
100% 50% 0 -50% -100%

Page Number 285
Hart RG, et al. Ann Intern Med.
Med. 1999;131:492-
1999;131:492-501.
19
Aspirin vs Placebo
Reduction of Risk of Thromboembolism in AF
Relative Risk Reduction (95% CI)
AFASAK I
SPAF I
EAFT
ESPS II
LASAF
UK-
UK-TIA
All trials=6 22% (2%-

(2%-38%)
100 50 0 -50 -100

Aspirin
Page Number 258

Hart RG, et al. Ann Intern Med. 1999;131:492-501.
ACTIVE-W: Cumulative Risk of Stroke

0.10
RR=1.72 (1.24-2.37), P=.001
Cumulative Hazard Rates
0.08 Clopidogrel + aspirin
0.06
0.04
0.02
Oral anticoagulation
g therapy
y
0
0 0.5 1 1.5
Number at risk Years
Clopidogrel 3335 3168 2419 941.
+ aspirin
Oral anti- 3371 3232 2466 930
coagulation therapy
*ACTIVE=Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events.
Primary outcome: stroke, systemic embolus, MI, vascular death.
Clopidogrel + aspirin=5.6% risk/year vs warfarin=3.93% risk/year.
Connolly S, et al. Lancet. 2006;367:1903-1912.
Page Number 286
ACTIVE-A: Cumulative Risk of Stroke

0.15
HR=0.72 (0.62-0.84) P=.00002

0.10
Aspirin
05
0.0
Clopidogrel+Aspirin
0.0
0 1 2 3 4 Years
No. at Risk
C+A 3772 3488 3225 2567 1197
ASA 3782 3459 3155 2516 1184
Page Number 286

The ACTIVE Investigators. New England J Med. 2009;360:2066-2078.
20
ACTIVE-A: Cumulative Risk of Stroke
0.15
HR=0.72 (0.62-0.84) P=.00002

0.10
Aspirin
05
0.0
Clopidogrel+Aspirin
0.0
0 1 2 3 4 Years
No. at Risk
C+A 3772 3488 3225 2567 1197
ASA 3782 3459 3155 2516 1184
Page Number 286

The ACTIVE Investigators. New England J Med. 2009;360:2066-2078.
Role of Clopidogrel..Hot Off the Press
Dabigatran-Hot off the Press
Page Number 287
21
What is the most appropriate approach to manage
his atrial fibrillation?
a. Begin digoxin 0.25 mg daily

b B
b. Begin
i atenolol
l l 50 mg daily
d il
d. Start warfarin 7.5 mg daily, adjust to a goal INR
= 2.5
HR = 76, well controlled on verapamil 240 mg
daily
No need for antiarrhythmic (rhythm control)
therapy
a. Begin digoxin 0.25mg daily
b. Begin atenolol 50 mg daily
c. Begin amiodarone 400 mg BID, tapering to
goal dose of 200 mg daily over the next 6
weeks
k
d. Start warfarin 7.5 mg daily, adjust to a goal
INR = 2.5
At high-risk of stroke due to HTN, begin
warfarin
22
Case #5
67 year-old male
HTN
Moderate mitral valve insufficiency
Atrial fibrillation x 4 years
M di i
Medications:
Ramipril 5 mg BID
Sotalol 120 mg BID
Digoxin 0.125 mg daily
Warfarin 5 mg daily
Case# 5
CC: shortness of breath, palpitations,
and some bilateral lower extremity edema
Vitals: BP 115/70, HR = 88
Labs: All WNL, except INR = 2.8
ECG: Atrial fibrillation
Echocardiogram: EF of 35-40 %, moderate
mitral valve insufficiency
Case# 5Question???
What is the most appropriate approach to
manage his atrial fibrillation?
a. Discontinue sotalol, and begin metoprolol tartrate
12.5 mg BID
b. Add aspirin 325 mg QD
c. Begin amiodarone 400 mg BID, tapering to goal dose
of 200 mg daily over the next 6 weeks
d. Add metoprolol tartrate 25 mg BID
23
Heart Failure
and Atrial Fibrillation
Biggest issue: Rate vs Rhythm Control in a
patient with symptoms?
Symptoms may be attributed to both:
HF (SOB,
(SOB edema)
d )
Atrial fibrillation (SOB, palpitations)
Page Number 288
Heart Failure and

Atrial Fibrillation
Biggest issue: Rate vs Rhythm Control in a
patient with symptoms?
Symptoms may be attributed to both:
HF (SOB, edema)
Atrial fibrillation (SOB, palpitations)
Fact: Rate Control preferred

Increased hospitalizations and GI side effects
when Rhythm Control is pursued with
antiarrhythmic therapy
Page Number 288
Heart Failure and

Atrial Fibrillation
General rules
Optimize HF and Rate Control therapies
Consider antiarrhythmic therapy if unacceptable
y p
symptoms p
persist
Page Number 288
24
Anticoagulants and Antiarrhythmics
Prior to attempting cardioversion, the risk of

stroke must be minimized
Stroke rate with thrombus present + cardioversion
= 91%
Without anticoagulation, AFib for
< 48 hours = < 1 % rate of thrombus
> 48 hours = 15% rate of thrombus
> 72 hours = 30% rate of thrombus
Page Number 288
Atrial Fibrillation in HF
Patients usually poorly tolerant to Afib
loss of atrial kick (15 - 20% of CO)
Only dofetilide and amiodarone have been proven
SAFE in this population
so e oother
some e agents
ge s (not
( o all)) have
ve been
bee shown
s ow too increase
c e se
mortality in patients with HF
Rate control options
beta-blocker (metoprolol or carvedilol) preferred
digoxin useful adjunct
avoid CCBs (negative inotropes, contraindicated in HF)
Page Number 289-290
Atrial Fibrillation Rhythm Control
Page Number 291-Figure 4
25
Dronedarone.HOT off Press
Page Number 290
Case # 5
Medications:
Ramipril 5 mg BID
Sotalol 120 mg BID
Digoxin 0.125 mg daily
Warfarin 5 mg daily (INR = 2.8)
Important Points:
Pt with hx Afib, new diagnosis of HF and symptoms
of SOB, edema, and palpitations.
HF regimen needs improvement
INR = 2.8 (therapeutic)
Case #5.Question

a. Discontinue sotalol, and begin metoprolol tartrate
12 5 mg BID
12.5
b. Add aspirin 325 mg daily
26
Case# 5.Question???

a. Discontinue sotalol, and begin metoprolol
tartrate 12
12.55 mg BID
b. Add aspirin 325 mg QD
dose of 200 mg QD over the next 6 weeks
Case #6
50-year old African-American male

Hospital discharge s/p AMI
PMH = HTN (was on HCTZ 25 mg daily)
EF = > 60%
Vitals: BP = 150/94, HR = 80
Case# 6Question

manage his hypertension?
a. Discontinue hydrochlorothiazide, add diltiazem

b. Continue hydrochlorothiazide, add metoprolol
c. Discontinue hydrochlorothiazide, add losartan
d. Continue hydrochlorothiazide, add losartan
27
Step 1: Define HTN
BP 140/90
Taking antihypertensive drug therapy
Page Number 293. Table 12
Step 2: Address
Lifestyle Modifications
Encouraged in ALL individuals
Recommended in:
Prehypertensive
Stage 1 HTN
Stage 2 HTN
Modification SBP reduction
Weight Reduction 5-20 mm Hg/10 kg lost
DASH Diet 8-14 mm Hg
Sodium restriction 2-8 mm Hg
Physical Activity 4-9 mm Hg
Limit alcohol consumption 2-4 mm Hg
Page Number 292-293
Step 3: Define Treatment Goal
Page Number 294.Table 13
28
Step 3: Define Treatment Goal
Page Number 294.Table 14
Step 4: Assess for

Compelling Indication
Page Number 294. Figure 5.
Step 4: Assess for

Compelling Indication
Page Number 295. Figure 5.
29
Case #6
50-year old African-American male

Hospital discharge s/p AMI
PMH = HTN (was on HCTZ 25 mg QD)
EF = > 60%
Vitals: BP = 150/94, HR = 80
Case #6
Is he hypertensive?
Case # 6
Is he hypertensive? Yes
BP > 140/90 (150/94, Stage 1)
Takes antihypertensive medication
30
Case # 6
BP > 140/90 (150/94, Stage 1)
Recommend Lifestyle Modifications?
Case # 6
BP > 140/90, (150/94, Stage 1)
Recommend Lifestyle Modifications? Yes
Has HTN
Case 6
BP > 140/90, (150/94, Stage 1)
Has HTN
BP Goal
31
Case# 6
BP > 140/90, (150/94, Stage 1)
Has HTN
BP Goal
No DM or renal disease
Goal is < 130/80
Case #6
BP > 140/90 (150/94, Stage 1)
Recommend Lifestyle
y Modifications? Yes
Has HTN
BP Goal
Goal is < 130/80
Any compelling indications?
Case #6
BP > 140/90, (150/94, Stage 1)

Has HTN
BP Goal
Goal is < 140/90
Any compelling indications? Yes

Post-MI
1st line = BB
Then add ACEI or ARB also recommended
32
Case# 6Question


Case# 6Question


33
Case #7
45-year old Caucasian female

PMH: Type II diabetes (on glyburide 5mg daily)
BP today = 138/88 mm Hg, HR = 70 bpm
BP att last
l t visit
i it was 136/85
Labs: 140 102 14 NR
4.0 28 1.8
Case # 7..Question??
What is the best management of her HTN at
this time?
a. Begin lifestyle modifications

b Begin lifestyle modifications + losartan 50 mg/day
b.
c. Begin lifestyle modifications + lisinopril 2.5 mg/day
d. Begin lifestyle modifications + atenolol 25 mg/day
Case #7
Is she hypertensive?
34
Case # 7
Is she hypertensive? No
BP < 140/90 (138/88, prehypertension)
Case #7
Recommend Lifestyle Modifications?
Case #7
H prehypertension
Has h t i
35
Case 7
H prehypertension
Has h t i
BP Goal
Case 7
H prehypertension
Has h t i
BP Goal
DM and renal disease (Creatinine = 1.8)
Goal is < 130/80
Case 7
H prehypertension
Has h t i
BP Goal
DM and renal disease (Creatinine = 1.8)
Goal is < 130/80
Any compelling indications?
36
Case 7
Has prehypertension
BP Goal
DM and d renall di
disease (C
(Creatinine
ti i = 1.8)
1 8)
Goal is < 130/80
Any compelling indications? Yes
DM and kidney disease
1st line = ACEI or ARB
diuretic, CCB or combo also recommended
Case #7Question???
What is the best management of her HTN at
this time?
a. Begin lifestyle modifications

b. Begin
eg lifestyle
es y e modifications
od c o s + losartan
os 50 mg g ddaily
y
c. Begin lifestyle modifications + lisinopril 2.5 mg
daily
d. Begin lifestyle modifications + atenolol 25 mg daily
Case #8
58-year old white male

PMH = HTN (was on HCTZ 12.5 mg/day)
Hospital discharge for AMI
EF > 60%
Vitals: BP = 130/65, HR = 64
Current medications (for discharge)
- ASA 81 mg daily - Atorvastatin 80 mg daily
- Atenolol 50 mg QD - SL NTG prn chest pain
- HCTZ 25 mg daily
37
What is the most appropriate action for you to

take in response to this discharge regimen?
a. Discontinue HCTZ, add diltiazem 240 mg/day

b. Continue HCTZ, add amlodipine 5 mg/day
c. Discontinue HCTZ, add rampiril 5 mg/day
d. Continue HCTZ, add Vitamin E 400 IU/day
NEW Guidelines Expected
Assess in all Patients with CAD

A = Aspirin and Antianginal therapy, ACEI
B = Beta-blocker and Blood pressure
C = Cigarette smoking and Cholesterol
D = Diet and Diabetes
E = Education
ducat o a and
d Exercise
e c se
Unhelpful/potentially harmful therapies in

CAD
Vitamin E
Hormone replacement therapy
Antibiotic Therapy
Page Number 297
38
Case #8 - Patient Assessment
A Aspirin (alt. Clopidogrel)
Antianginal therapy NA
ACEI -
B Beta-blocker (HR = 64)
Blood pressure (goal 140/90) (BP = 130/65)
C Cigarette Smoking NA
Cholesterol (follow-up)
D Diet counsel
Diabetes NA
E Exercise counsel
Education counsel
Page Number 297




39
Case #9
64-year old white female
PMH: MI x 2, stent x3, EF > 60%
CC: SOB and chest heaviness with activity x 3 months
Vitals: BP 132/80,
132/80 HR 72
Medications:
- aspirin 325 mg/day - simvastatin 40 mg QPM
- enalapril 10 mg BID - metoprolol 50 mg BID
- prn sl NTG (uses ~ 3/day)
Case# 9
64-year old white female

PMH: MI x 2, stent x3, EF > 60%
CC: SOB and chest heaviness with activity x 3 months
Medications:
- aspirin 325 mg/day - simvastatin 40 mg QPM
- enalapril 10 mg BID - metoprolol 50 mg BID
- prn sl NTG ~ 3/day
Dx: stable angina
Case #9Question???
What do you recommend in order to improve her

stable angina symptoms and increase her level of
activity?
a Discontinue metoprolol,
a. metoprolol begin diltiazem 240 mg
daily
b. Have patient take sl NTG before activity
c. Add isosorbide mononitrate 60 mg QAM
d. Increase metoprolol to 100 mg BID, and add
isosorbide mononitrate 60 mg QAM
40
Stable Angina Management
Revascularization
Stent placement , balloon angioplasty, CABG,
brachytherapy
Goals of medication management

Decrease myocardial O2 demand
Increase myocardial O2 supply
Page Number 298
Stable Angina Management

Increase Decrease
Medication supply demand Comments
Beta-blocker - goal rest HR = 55-60
- exercise HR < 75%
pain threshold
Calcium - add on to BB if needed

Antagonists - in place of BB 2 SE
- avoid short-acting
dihydropyridines
Nitroglycerin - most useful with BB
- ALWAYS PRN
- can be used pre-activity
Page Number 299
Case #9Question???

activity?
a Discontinue metoprolol,
a. metoprolol begin diltiazem 240 mg
daily
41
Case #9
What do you recommend in order to improve her stable angina

symptoms and increase her level of activity?
a. Discontinue metoprolol, begin diltiazem 240 mg daily

- Goal resting HR is < 60 (HR = 72)
- BB is first-line therapy
d. Increase metoprolol to 100 mg BID, and add isosorbide
mononitrate 60 mg QAM
Case # 9
activity?
a. Discontinue metoprolol, begin diltiazem 240 mg

dailyy
- can be done, but after other therapies maximized
Case # 9
activity?
a. Discontinue metoprolol, begin diltiazem 240 mg
daily
b. Have ppatient take sl NTG before activityy
- will both increase supply and decrease demand
- good add-on after HR at goal
42
Case # 9
What do you recommend in order to improve her stable
angina symptoms and increase her level of activity?
a. Discontinue metoprolol, begin diltiazem 240 mg daily

b. Have ppatient take sl NTG before activity
y
d. Increase metoprolol to 100 mg BID, and add isosorbide
mononitrate 60 mg QAM
- will work towards goal of rest HR < 60
- will also increase O2 supply
Case #9..Question??

activity?
a. Discontinue
Di ti metoprolol,
t l l begin
b i diltiazem
dilti 240 mg
daily
Summary
Heart failure
Atrial Fibrillation
Hypertension
Ch
Chronici Stable
St bl Angina
A i
Chronic Coronary Artery Disease
All very common disease states

encountered in the outpatient setting
43
Questions: robert.page@ucdenver.edu
44

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2011 Updates in Therapeutics:

The Pharmacotherapy Preparatory Review &

Conflict of Interest Disclosures

I have no conflicts to disclose

Absolutely do not study this.

Chronic Heart Failure

Chronic CAD and Stable Angina

digoxin 0.125 mg daily

Page Number 272-Case #1

Which of the following is the best approach to

aa. increase carvedilol to 25 mg BID

Page Number 272-Case #1

Page Number 275-280

Page Number 276-Table 4

Beta Blocker Dosing in HF

Page Number 277-Table 5

Decrease to 12.5 mg daily or discontinue if K > 5.0

Increase to 50 mg daily if tolerated

Minimizes adverse effects and ventricular arrhythmias

Remember drug interactions

Page Number 278-280

Which of the following is the best approach to

aa. increase carvedilol to 25 mg BID

Page Number 272-Case #1

Which of the following is the best approach to

aa. increase carvedilol to 25 mg BID

Page Number 272-Case #1

only 1% incidence of significant bradycardia

HR decreases an average of 12 bpm

Assess for edema/fluid retention, fatigue, dizziness

Page Number 272-Case #2

Page Number 272-Case #2

Page Number 272-Case #2

Page Number 272-Case #2

Page Number 272-Case #2

Page Number 272-Case #2

Page Number 272-Case #2

Page Number 272-Case #2

Page Number 272-Case #2

Page Number 272-Case #2

a. Discontinue metoprolol and begin carvedilol 12.5 mg

Page Number 272-Case #2

discontinue metoprolol and begin carvedilol

Page Number 272-Case #2

add digoxin 0.125 mg QD

Dose of 0.125 mg daily may be too high in 62 year old male

No mortality benefit derived from digoxin therapy but the

increase enalapril to 10 mg BID

BP = 120/70, should tolerate dosage increase without

Monitor creatinine and K (currently WNL) after dosage

Which of the following is the best approach to

Page Number 272-Case #2

Alternative to ACEI or ARB in truly intolerant or

Added to standard therapy in class III-IV HF African-

Decreases hospitalizations 33%

Hydralazine 40 mg + isosorbide dinitrate 75 mg TID

Page Number 279-280

Which one of the medications from the patient

Promote fluid retention Negative inotropic activity

Page Number 281

Positive inotropic Increase ventricular

Amphetamines antiarrhythmics (except

Page Number 281