Cardiology II

Dr. Amr Medhat , BCPS.

Clinical Pharmacist , Egypt Air Hospital
Questions will be after each
Subject

Mobile ( Silent Mode )

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 Abbreviations
PCWP: pulmonary capillary wedge pressure
CO: Cardiac output
BP: blood pressure
PO: per oral
IV: Intravenous
LVEF: left ventricular ejection fraction
AF: atrial fibrillation
VT: ventricular tachycardia
AE: adverse effect
TDP: torsades de pointes
SVT: supraventricular tachycardia
VF: ventricular fibrillation
DCC: Direct current cardioversion
TEE:trans esophegial echo
AC:anti coagulation
RC:rate control
ICD: Intracardiac defbrillator Professional Training House
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 Cardiology II
Contents :
1- Acute Decompensated Heart Failure (ADHF)

2- Chronic Heart Failure

3-Pulmonary Arterial Hypertension

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 1- Acute Decompensated Heart Failure

Contents:-
1- Symptoms

2- Hemodynamic parameters

3- Treatment Guideline

4- Chronic Heart Failure in Acute Settings

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 1- Symptoms

1- Hypoperfusion
( Cold )

2- Pulmonary
Congestion
( Wet) Professional Training House
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1- Symptoms

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 1- Acute Decompensated Heart Failure

Contents:-
1- Symptoms

2- Hemodynamic parameters

3- Treatment Guideline

4- Chronic Heart Failure in Acute Settings

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 2)Hemodynamic parameters
MAP = diastole + (systole-diastole )/3
Parameter Normal Value ADHF Value

Mean arterial pressure (MAP) mm Hg 80-100 60-80

Heart rate (HR) beats/min. 60-80 70-90
Cardiac output ( CO) L/min. 4-7 2-4
Cardiac index (CI) L/min/m2 2.8-3.6 1.3-2
Pulmonary capillary wedge pressure (PCWP) 8-12 18-30
Central venous pressure (CVP) mm Hg 2-6 6-15
Systemic vascular resistance (SVR)
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PCWP CVP

SVR
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Cold : CI. < 2.2 Wet : PCWP >18
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 1- Acute Decompensated Heart Failure

Contents:-
1- Symptoms

2- Hemodynamic parameters

3- Treatment Guideline

4- Chronic Heart Failure in Acute Settings

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 1
PCWP <15
Symptoms & IV fluid
Hemodynamic
monitoring ADHF 2

Guidelines MAP <50

Dopamine

If Congestion If Cold &

PCWP Symptomatic
Warm & Wet Hypotension
BP

Diuretics Vasodilators
1st line
Inotropes 3
2nd line

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 1- Diuretics
Indicated in Fluid overload ( warm & wet ) 1st line

1- Fluid and sodium restriction

2- IV loops ( furosemide)

3- Increase dose or frequancy

4- Add second diuretic

5- Ultra filtration
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 1- Diuretics
Loop Diuretics Thiazides

Most widely used and most potent Less effective

effective at low CrCl (< 30 mL/minute) not effective at low CrCl level

furosemide 40 mg PO = furosemide 20 Reserved for add-on therapy if refractory

mg IV = bumetanide 1 mg IV/PO = to loops
torsemide 10 mg IV/PO

Increase dose before increasing frequency of loop diuretic

 Ceiling effect at about 160–200 mg IV furosemide

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 2-Vasodilators

Added to IV loop diuretics  rapidly improve

symptoms in acute pulmonary edema “ wet ” or
severe hypertension

Preferred over inotropes If adjunctive therapy is

required “ Wet “

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 Vasodilators

Na Nesiritide Nitroglycerine
Nitroprosside
1-Warm and wet & 1-Warm and wet
1-Warm and wet & alternative to 2- Excellent with
alternative to inotrope in cold and concomitant MI or
inotrope in cold and wet ADHF angina
wet ADHF
2- PCWP&SVR
2- A.E hypotension
3- A.E.hypotension 3- A.E hypotension
& cyanide toxicity
& tachycardia & tachycardia
3- Contraindication: 4- Naturetic effect
Renal, hepatic failure Professional Training House
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 3-Inotropes
Why to use???
Improve End-organ function in patients with reduced
LVEF and reduce end-organ damage

Used when :
1- Systolic BP < 90 mm Hg ( Cold )
Symptomatic hypotension despite adequate filling pressure
2- No response to intravenous diuretics, vasodilators (Wet)
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 Inotropes

Dobutamine Milrinone
1- Inotrope – Lusitrope – 1- Inotrope – Lusitrope
chronotrope) Not chronotrope)
2-Consider if hypotension But
2-Consider if hypotension Slightly reduce B.P
If taken Bolus
3- Contraindicated with 3- consider if receiving
β - blockers β- blocker
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 1- Acute Decompensated Heart Failure

Contents:-
1- Symptoms

2- Hemodynamic parameters

3- Treatment Guideline

4- Chronic Heart Failure in Acute Settings

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 4- Chronic Heart Failure in Acute Setting
Initiate and/or continue standard HF therapies unless there is a reason to
avoid or discontinue such therapies

1- (ACE) a. Caution with initiation or up-titration during aggressive diuresis

Inhibitors b. Caution if SCr increases by greater than 0.5 mg/dL above baseline

Do not discontinue in patients who are stable on dose prior to admission

2- β-Blockers a. Do not initiate or up-titrate until Euvolemic.

b. Hold if hemodynamically unstable. ( hypotension, bradycardia)

a. Keep serum digoxin concentration of 0.5–0.8 ng/mL.

3- Digoxin b. Avoid discontinuation unless there is a reason because digoxin

withdrawal  worsening of HF symptoms.

c. Caution if renal functionTraining

Professional begins to deteriorate .
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 1
Symptoms &
Hemodynamic ADHF PCWP <15
IV fluid
monitoring
Guidelines 2
If Congestion If Cold & MAP <50
PCWP Symptomatic Dopamine
Warm & Wet Hypotension
BP
Diuretics Vasodilators
1st line
Inotropes 3
2nd line
1- Fluid and sodium restriction Nitrogly • Excellent with
cerine MI or angina
• Contraindicated
Dobutamine with B-blocker
1- IV loops ( furosemide)
• Diuretic effect
Nesiritide
3- Increase dose or frequancy • PCWP&SVR

4- Add second diuretic Na • consider if

Nitropro • 3 line
rd
Milrinone receiving
5- Ultra filtration sside • cyanide toxicity β- blocker
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Questions ??

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 Case 1
D.D. is a 72-year-old man admitted to the hospital for HF
decompensation. D.D. notes progressively increased dyspnea when
walking and orthopnea increased lower extremity swelling , 13-kg
weight gain in the past 3 weeks.

He has a history of idiopathic dilated cardiomyopathy (LVEF 25%,

NYHA class III), (AF), and hyperlipidemia.
laboratory values are as follows: B-type natriuretic peptide (BNP)
2300 pg/mL (0–50 pg/mL), K+ 4.9 mEq/L, blood urea nitrogen (BUN)
32 mg/dL, SCr 2.0 mg/dL, (AST) 40 IU/L, (ALT) 42 IU/L,

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international normalized ratio (INR) 1.3, activated partial
thromboplastin time (aPTT) 42 seconds, BP 118/72 mm Hg,
and HR 82 beats/minute.
Home drugs include carvedilol 12.5 mg 2 times/day,
lisinopril 40 mg/day, furosemide 80 mg 2 times/day,
spironolactone 25 mg/day, and digoxin 0.125 mg/day.
Which one of the following is best for treating his ADHF?

A. Carvedilol 25 mg 2 times/day.
B. Nesiritide 2-mcg/kg bolus; then 0.01 mcg/kg/minute.
C. Furosemide 120 mg intravenously 2 times/day.
D. Milrinone 0.5 mcg/kg/minute.

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 Case 2
After initiation of intravenous loop diuretics with only minimal
urine output, D.D. is transferred to the coronary care unit for
further management of diuretic-refractory decompensated HF.
His BP is 110/75 mm Hg, and his HR is 75 beats/minute.
D.D.’s SCr is now 2.7 mg/dL .In addition to a one-time dose
of intravenous chlorothiazide, which one of the following best
represents ways in which D.D.’s decompensated HF should be
treated?

A. Nitroglycerin 20 mcg/minute.
B. Sodium nitroprusside 0.3 mg/kg/minute.
C. Dobutamine 5 mcg/kg/minute.
D. Milrinone 0.5 mcg/kg/minute.
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 Case 3
D.D. initially responds with 2 L of urine output overnight, and his weight
decreases by 1 kg the next day. However, by day 5, his urine output has
diminished again, and his SCr has risen to 4.3 mg/dL. He was drowsy and
confused this morning during rounds. His extremities are cool and cyanotic, BP is
89/58 mm Hg, and HR is 98 beats/minute. It is believed that he is no longer
responding to his current regimen. A Swan-Ganz catheter is placed to determine
further management. Hemodynamic values are cardiac index (CI) 1.5 L/minute/
m2, SVR 2650 dynes/cm-5, and PCWP 30 mm Hg.Which one of the following is
the best drug given his current symptoms?

A. Milrinone 0.2 mcg/kg/minute.

B. Dobutamine 5 mcg/kg/minute.
C. Nesiritide 2-mcg/kg bolus; then 0.01 mcg/kg/minute.
D. Phenylephrine 20 mcg/minute.
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1- Chronic Heart
Failure

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 1- Heart failure
Outlines :

1- Systolic and diastolic heart failure Overview

2- Heart failure principle of therapy
3- Pharmacologic Therapy for Systolic HF
4-Drugs to Avoid or Use with Caution
5- Diastolic dysfunction

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 1- Systolic and Diastolic heart failure Overview

1- Systolic dysfunction (decreased EF less than 40%)

1- (Ischemic Cardiomyopathy ) : Post-MI
2- ( Non-ischemic Cardiomyopathy) :
 Hypertension ,Thyroid disease ,Valvular disease , Myocarditis
Idiopathic , Cardiotoxins

2. Diastolic dysfunction (normal EF > 40%)

a. Right side failure .
b. Impaired ventricular relaxation and filling
(decreases in the elastic properties)
c. Most are caused by hypertension and age-related .
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 1- Systolic and diastolic heart failure Overview

3. Primary symptoms ( Systolic HF)

a. Dyspnea b. Fatigue
c. Edema d. Exercise intolerance

New York Heart Association classification of HF

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 1- Heart failure
Outlines :

1- Systolic and diastolic heart failure Overview

2- Heart failure principle of therapy
3- Pharmacologic Therapy for Systolic HF
4-Drugs to Avoid or Use with Caution
5- Diastolic dysfunction

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 Pathophysiology of Heart Failure
Reduces the efficiency of the myocardium, or heart muscle

Reduced stroke volume Hypotension Baroreceptors Catecholamines

Binding to alpha-1 receptors results in systemic Arterial Vasoconstriction

Binding to beta-1 receptors in the myocardium Increases the Heart rate

Reduced perfusion to kidneys stimulates the release of renin which catalyses the
production of angiotensin Angiotensin ǁ make further vasoconstriction

Ang2. stimulate secretion of Aldosterone Salt and fluid retention

Cold extremities, cyanosis, generalized edema , cardiac remodelling and mortality

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 2- Heart failure principle of therapy

Block the Compensatory neurohormonal activation (Catecholamines)

Minimize Na and water retention.

Eliminate symptoms / Hospitalization

Slow the progression of cardiac dysfunction / Decrease mortality.

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 1- Heart failure
Outlines :

1- Systolic and diastolic heart failure Overview

2- Heart failure principle of therapy
3- Pharmacologic Therapy for Systolic HF
4-Drugs to Avoid or Use with Caution
5- Diastolic dysfunction

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 3- Pharmacologic Therapy for Systolic HF
1- Diuretics
Place in Management of fluid overload
therapy No benefit on mortality : Never use as the only therapy
Monitor Na , K and Mg especially with loop diuretics
Loop diuretics have greater diuretic capabilities;
Loop diuretics retain efficacy with decreased renal function

May combine loop diuretic with another class (e.g., thiazide diuretic) for synergy if needed

Start with a low initial dose then double the dose and titrate on the basis of the patient’s
weight.

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 3- Pharmacologic Therapy for Systolic HF
2. Angiotensin-converting enzyme inhibitors
Benefits of Decreased mortality , hospitalizations
ACE inhibitor Improved clinical status , Symptoms

Place in therapy Should be used in all patients with LV dysfunction (even if asymptomatic)

SrCr may rise (up to a 0.5-mg/dL increase is acceptable) .

 Use cautiously in patients with a baseline SCr more than 3.0 mg/dL (NOT a
contraindication; they should still be used, just with smaller dosage changes .

Monitoring BP / symptoms of hypotension (e.g., dizziness, light-headedness).

 Symptoms of hypotension are often Not present with small dose increase

Potassium may rise because of decreased glomerular filtration rate .

 Use cautiously in those with aTraining
Professional baseline K greater than 5.0 mEq/L
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 3- Pharmacologic Therapy for Systolic HF
2. Angiotensin-converting enzyme inhibitors
(a) Start low and increase (double) dose every 1–4 weeks to Target dose
Dosing
Considerations (b) patients who received higher-dose showed the same risk of
death and decrease hospitalizations for HF
Angioedema: (less than 1%) : could switch to angiotensin II receptor blockers
or hydralazine–isosorbide dinitrate
Adverse effect

Cough (20%) : could switch to ARBs (less than 1%)

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 3- Pharmacologic Therapy for Systolic HF
3. Angiotensin II receptor blockers (ARBs)
Place in
Have never been proved superior to ACE inhibitors at target HF dosages
therapy
ACE inhibitor substitutes for patients unable to take ACE inhibitors because
Role of cough , angioedema

A 150-mg/day dosage of losartan significantly reduced the risk of death or HF

hospitalization for almost 5 years compared with a dosage of 50 mg/day in patients
with systolic HF who could not tolerate ACE inhibitors

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 3- Pharmacologic Therapy for Systolic HF
4. β-Blockers
Decreased mortality , hospitalizations
Benefits Improve clinical status , Symptoms

Should be used in all stable patients (Added to existing ACE inhibitor )

Place in  Not receiving IV inotropic or diuretic therapy,
therapy  Without significant peripheral and pulmonary congestion (Euvolemic)
 With LV dysfunction (even if asymptomatic)

Start low and increase (double) the dose every 2–4 weeks to Target dose

Dosing Avoid abrupt discontinuation; can precipitate clinical deterioration

Considerations (even during HF exacerbation)

Benefits of high versus low doses (Reduce mortality)

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 3- Pharmacologic Therapy for Systolic
4. β-Blockers
 provides β, α1-blockade.
Carvedilol Will have a greater reduction in BP compared with metoprolol
Monitoring - If Significant hypotension, bradycardia, or dizziness
 Lower the dose by 50%.
Blood Discontinue the drug only if patient has heart block or is in cardiogenic shock.
pressure, HR
If hypotension alone is the problem, reduce the dose of the ACE inhibitor first

Adverse effect Increased edema ( fluid retention) / Fatigue

The net decrease in HR at goal doses of β-blocker is only 10–15 beats/minute from baseline

Used safely in those with depression, diabetes, and heart block with a pacer

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 3- Pharmacologic Therapy for Systolic HF
5. Aldosterone blockade ( Spironolactone )
Decreased mortality , hospitalizations
Benefits Improve clinical status , Symptoms

Place in All patients with class III and IV HF who are receiving
therapy ACE inhibitor, diuretic, and β-blocker .

Adverse effect Gynecomastia / hyperkalemia

Eplerenone : Lower incidence of gynecomastia
Dosing
Spironolactone 12.5–25 mg/day / Eplerenone 25–50 mg/day
considerations
Contraindication SCr>2.5 mg/dL, CrCl <30 mL/min. , or serum K > 5. 5mEq/L

Avoid use in combination with both ACE inhibitor and ARB; three agents effects K
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 3- Pharmacologic Therapy for Systolic HF
6. Digoxin
Benefits of Improved symptoms & Decreased hospitalizations
digoxin No effect on mortality
Place in In patients with LVEF 40% or less , symptoms of HF while receiving
therapy standard therapies including ACE inhibitors or ARBs and β-blockers

 Serum conc. 0.7–0.9 ng/dL are effective in HF.

Dosing  Risk of toxicity increased with age and renal dysfunction

considerations  Risk of toxicity increased with hypokalemia or hypomagnesemia
and • 0.125 mg/day is adequate to achieve the desired serum conc.
monitoring • Loading doses are not recommended in those with HF.
• Useful initial agent for patient with Concomitant AF

Drug Digoxin conc. increased if concomitant use with :-

(a) Clarithromycin, erythromycin (b) Amiodarone, dronedarone, verapamil
Interactions (c) Itraconazole, posaconazole, voriconazole
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 3- Pharmacologic Therapy for Systolic HF
7. Hydralazine–isosorbide dinitrate
Benefits Decreases mortality, hospitalizations

African Americans already receiving an ACE inhibitor (or ARB),

Place in β-blocker, and diuretic therapy
therapy
A reasonable alternative in patients unable to take an ACE inhibitor or
ARB because of severe renal insufficiency, hyperkalemia, or angioedema

Headache
Monitoring Hypotension
Drug-induced lupus with hydralazine

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 1- Heart failure
Outlines :

1- Systolic and diastolic heart failure Overview

2- Heart failure principle of therapy
3- Pharmacologic Therapy for Systolic HF
4- Drugs to Avoid or Use with Caution
5- Diastolic dysfunction

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 4- Drugs to Avoid or Use with Caution
1 NSAIDs& selective COX-2 inhibitors)
2 Corticosteroids
3 Minoxidil Fluid retention
4 Thiazolidinediones
5 Pregabalin
Class I and III antiarrhythmic agents
6
(except for amiodarone and dofetilide)

7
Calcium channel blockers (except for Negative inotropic activity
amlodipine and felodipine)
8 Itraconazole
9 Anagrelide
10 Amphetamines Arrhythmias
11 Cilostazol
12 Metformin Increased risk of lactic acidosis
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 1- Heart failure
Outlines :

1- Systolic and diastolic heart failure Overview

2- Heart failure principle of therapy
3- Pharmacologic Therapy for Systolic HF
4- Drugs to Avoid or Use with Caution
5- Diastolic dysfunction

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 5- Diastolic dysfunction

There is a lack of objective data to guide

therapy for patients with diastolic
dysfunction.
The following recommendations are based
primarily on the opinion of cardiovascular
experts.
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 5- Diastolic dysfunction

1. Angiotensin-converting enzyme inhibitors

Reduction in hospitalizations, symptoms, exercise tolerance

2. Angiotensin II receptor blockers:

3. Digoxin
No effect on all-cause mortality .

4. β-Blockers, verapamil, and diltiazem:

Benefits are targeted symptom relief.
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 Heart failure
Diuretics : Fluid overload (edema) Not affect mortality

ACE-Inhibitor-ARBs : Decreased mortality-hospitalizations-Symptoms (1st line)

B-blockers: Decreased mortality-hospitalizations- Symptoms (1st line)

Spironolactone : Class III and IV HF / Decreased mortality-hospitalizations- Symptoms ( 2nd line)

Digoxin : Improve symptoms of HF while receiving standard therapies including

ACE inhibitors or ARBs and β-blockers ( specially AF ) { No effect on mortality )
Hydralazine–isosorbide dinitrate : alternative to ACEI, ARBs when
contraindicated / African American
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 Case 4
• L.S. is a 48-year-old woman with alcohol-induced cardiomyopathy. Her most
recent LVEF is 20%; her daily activities are limited by dyspnea and fatigue
(NYHA class III). Her medications include lisinopril 20 mg/day, furosemide
40 mg 2 times/day, carvedilol 12.5 mg 2 times/day, spironolactone 25
mg/day, and digoxin 0.125 mg/day. She has been on these doses of
medications for the past month. Her most recent laboratory results include
the following: sodium (Na) 140 mEq/L, potassium (K) 4.0 mEq/L, , serum
creatinine (SCr) 0.8 mg/dL, and digoxin 0.7 ng/mL. Her vital signs today
include BP 112/70 mm Hg and HR 68 beats/minute.Which one of the
following is the best approach for maximizing the management of her HF?

A. Increase carvedilol to 25 mg 2 times/day.

B. Increase lisinopril to 40 mg/day.
C. Increase spironolactone to 50 mg/day.
D. Increase digoxin to 0.25 mg/day.
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 Case 5
J.T. is a 62-year-old man with a history of CAD (MI 3 years ago), hypertension,
depression, chronic renal insufficiency (baseline SCr is 2.8 mg/dL), peripheral
arterial disease, osteoarthritis, hypothyroidism, and HF (LVEF of 25%). His
medications include aspirin 81 mg/day, simvastatin 40 mg every night, enalapril
5 mg 2 times/day, metoprolol succinate 50 mg/day, furosemide 80 mg 2
times/day, cilostazol 100 mg 2 times/day, acetaminophen 650 mg 4 times/day,
sertraline 100 mg/day, and levothyroxine 0.1 mg/day. His vital signs include BP
120/70 mm Hg and HR 72 beats/minute. Laboratory results are within normal
limits, except for an SCr of 2.8 mg/dL. Thyroid-stimulating hormone is 2.6
milliunits/L. His HF is stable and considered NYHA class II. Which one of the
following is the best approach for maximizing the management of his HF?

A. Discontinue metoprolol and begin carvedilol 12.5 mg 2 times/day.

B. Increase enalapril to 10 mg 2 times/day.
C. Add spironolactone 25 mg/day.
D. Add digoxin 0.125 mg/day.
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3-Pulmonary Arterial Hypertension
(PAH)

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 3-Pulmonary Arterial Hypertension
(PAH)

Contents
1- Etiology & Symptoms

2- PAH Classification , Diagnosis

3- Treatment protocol

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 1- Etiology & symptoms
Pulmonary arterial Hypertension Etiology
Idiopathic , Scleroderma , connective tissue diseases, chronic
thromboembolic disease Or medications, toxins, others

Symptoms
a. Dyspnea with exertion , fatigue, chest pain, syncope, weakness
Caused by impaired oxygen delivery to tissues .

b. Orthopnea, peripheral edema, liver congestion, abdominal bloating

c. Right ventricular hypertrophy and failure occur .

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 2- PAH Classification , Diagnosis
World Health Organization Classification for PAH

Diagnostic Findings of PAH

Hemodynamic alterations: mPAP > 25 mm Hg (Normal 12-16 mmHg)
ECG : ST abnormalities - Echo : Enlarged RV
Physical Examination : Dyspnea , cool & cyanotic Extremities & peripheral edema , ascites
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3-Pulmonary Arterial Hypertension (PAH)

Contents

1- Etiology & Symptoms

2- PAH Classification , Diagnosis

3- Treatment protocol

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 3- Treatment protocol

1- Vasoactive test

Use intravenous epoprostenol, inhaled nitric oxide, or intravenous

adenosine

• Positive response: Reduction in mean pulmonary arterial

pressure (mPAP) of at least 10 mm Hg .

• Positive response predicts mortality reduction with long-term

calcium channel blocker of vasodilator use
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3- Treatment protocol

Vasoactive test

Positive Negative
response response

If bradycardia IF High risk

If tachycardia IF Low risk
use: use:
use: diltiazem use: Bosentan
amlodipine Epoprostenol

Epoprostenol may used in low risk PAH if Training

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 1-Calcium channel blockers Class II

Adverse Hypotension, headache, dizziness, peripheral edema,

effect cardiac conduction delay (diltiazem)

Without positive response to acute vasodilatory

Contraindication
response testing

Select agent on the basis of HR at baseline

 Diltiazem, amlodipine, nifedipine most commonly used

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 2-Prostacyclin analogues

Epoprostenol Treprostinil Inhaled iloprost

Jaw pain, nausea, vomiting, Severe erythema

flushing, headache, muscle pain (83%) and injection
site pain (85%)
Mild, transient
Adverse Catheter related thrombosis limits use cough, flushing,
effect headache, syncope
IV line infections; rebound headache,
worsening of symptoms if nausea, diarrhea,
Abruptly discontinued rash

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 3-Endothelin antagonists
Bosentan Ambrisentan
Hypotension, Increased LFs hypotension 0%, Increased LFs 0%
Adverse
effect
• Potential teratogen; if childbearing age, use two contraceptive methods
(reduced efficacy of hormonal contraceptives); monthly pregnancy test required
• Peripheral edema , flushing , palpitations , fluid retention

Monitor LFTs monthly LFTs monthly

hemoglobin/hematocrit periodically
•Severe drug interactions with glyburide Caution with cyclosporine
and cyclosporine (decreased efficacy of
both cyclosporine and bosentan)
Drug No CYP drug interactions
interaction Efficacy decreased with inducers documented
and toxicity increased with
inhibitors of CYP2C8/9 and 3A4
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 4-Phosphodiesterase Inhibitors
Sildenafil Tadalafil
Headache, flushing, indigestion, nausea,
Headache, epistaxis, facial flushing, blurry
backache, myalgia, nasopharyngitis,
vision, light sensitivity, dyspepsia, insomnia
respiratory tract infection

Half-life 4–5 hours Half-life 17.5 hours

May augment effects of other vasodilators when used in combination (especially prostacyclin)

• Contraindicated in patients receiving nitrates

• Avoid combined use with strong CYP3A4 inhibitors (e.g., ritonavir, cimetidine,erythromycin)
and inducers (rifampin)
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 3- Treatment protocol
Additional management :

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 Case 6
R.W. is a 38-year-old obese woman who presents with increasing symptoms
of fatigue and shortness of breath. Her arterial blood gas is pH 7.31/Pco2
65/Po2 53/85% O2 saturation.

She has orthopnea and 3+ pitting edema in her lower extremities. Medical
history is significant only for AF.

Computerized tomographic angiography shows that her pulmonary artery

trunk is substantially enlarged, with a mean pressure of 56 mm Hg.
Echocardiography shows right atrial and ventricular hypertrophy.

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laboratory test values are BUN 21 mg/dL, SCr 1.2 mg/dL, AST 145 IU/L,
ALT 90 IU/L, INR 2.1, and PTT 52 seconds; vital signs include BP 108/62
mm Hg and HR 62 beats/minute. Home medications are warfarin 2.5
mg/day, ipratropium 2 puffs every 6 hours, salmeterol 2 puffs 2
times/day, and diltiazem 480 mg/day.

Her diagnosis is IPAH. From the options below, which one of the following is
the best evidencebased management strategy?

A. Increase diltiazem to 600 mg/day.

B. Start sildenafil 20 mg 3 times/day.
C. Start epoprostenol 2 ng/kg/minute.
D. Start bosentan 62.5 mg 2 times/day.
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• 10. Which one of the following medications is best to
recommend for treating M.M.’s lipids (from patient
case 8)?

A. Ezetimibe 10 mg/day.
B. Fenofibrate 145 mg/day.
C. Colesevelam 625 mg 6 tablets/day.
D. Atorvastatin 20 mg/day

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