Tutorial CHF 2018

Anisa Hanifatin R

Farmasi B

155070501111018

E.C. is a 72-year-old white man who is hospitalized for edema, shortness of breath, and orthopnea. His
medical history includes hypertension (HTN), hyperlipidemia, type 2 diabetesmellitus (T2DM), and
coronary artery disease (CAD) with stent placement.

1. Which one of the following best summarizes the role of natriuretic peptides (NP) in diagnosis and
management of E.C.?

A. Serial measurements of NP should routinely be used to optimize medical treatment.

B. A baseline measurement of NP would yield diagnostic and prognostic information.

C. A baseline measurement of NP is not helpful due to co-morbid conditions.

D. A baseline measurement of NT-proBNP of 600 pg/mL indicates likely heart failure (HF).

2. E.C. is diagnosed with heart failure reduced ejection fraction (HFrEF) and treated with intravenous
diuretics. Guideline directed management and therapy (GDMT) is initiated before discharge. Ten days
later, when seen in the HF clinic, E.C. states that he feels “pretty good.” He has been “getting around
okay” but can’t walk his dog as far as he did before hospitalization without feeling tired. Which one of the
following best categorizes E.C.’s ACC Stage and NYHA class today?

A. ACC Stage C/ NYHA class IV

B. ACC Stage D/NYHA class II

C. ACC Stage C/NYHA class II

D. ACC Stage D/NYHA class IV

Jawaban C

Ada kelainan struktur jantung. NYHA tipe II dikarenakan pasien ada keterbatasan aktivitas yaitu
tidak dapat berjalan terlalu jauh. Stage C dikarenakan ada gejala yang dirasakan yaitu pasien
mudah lelah.

3. Which of the following patient profiles best fits a diagnosis of HFpEF?

A. 45-year-old woman, history includes HTN, peripheral edema; NT-proBNP 550 pg/mL; EF 55%
B. 45-year-old woman, history includes HTN, peripheral edema; NT-proBNP 250 pg/mL; EF 45%
C. 65-year-old man, history includes ST-elevation myocardial infarction; rales; NT-proBNP 675 pg/mL; EF 40-45%
D. 76-year-old woman, medical history noncontributory; rales; NT-proBNP 550 pg/mL; EF 60%
Jawab : A
Gangguan pada pengisian ventrikel kiri yang disebabkan oleh
ketidaksempurnaan relaksasi atau disfungsi distolik LV juga
mengakibatkan berkurangnya luaran jantung, dan biasanya LVEF
hanya sedikit berkurang atau tetap normal (lebih dari 40-50%).
Gagal jantung ini disebut gagal jantung dengan fraksi ejeksi terjaga
(HFpEF). NT-proBNP memiliki waktu paruh lebih panjang sekitar
2 jam dibandingkan BNP yang hanya 18 menit. Kadar dalam
plasma meningkat baik pada HFpEF maupun HFrEF walaupun
cenderung lebih tinggi pada HFrEF. Pasien disebut dengan gagal
jantung fraksi ejeksi terjaga (HFpEF) karena pasien memiliki nilai
EF sebesar 55 % dan pada usia 45 tahun, nilai NT-proBNP pasien
mengalami peningkatan dari nilai normal 450 pg/ml menjadi 550 pg/ml.
*HTN = hipertensi

Question 4 and 5 pertain to the following case.

K.S is a 67-year-old white man whose medical history includes HTN and CAD (stent placed 6 years ago). He
reports dysphea with less than normal activity and trace edema; he has been diagnosed with HFrEF (Stage C, NYHA
class II). Objective findings include: EF 25%, BP 132/77 mm Hg, heart rate (HR) 79 beats/minute, BUN 19 mg/dL,
SCr 0.9 mg/dL, and K is 3.8 mEq/L. His other lab values are within normal limints. K.S.’s home drugs include
aspirin 81 mg, atorvastatin 40 mg, amlodipine 5 mg daily, and chlorthalidone 12.5 mg daily.

4. K.S.’s physician plans to discontinue amlodipine and chlorthalidone and add furosemide 40 mg daily, and asks for
a recommendation on starting GDMT. Which one of the following is the best initial treatment plan to recommend
for K.S.?
A. Begin lisinopril 5 mg daily.
B. Begin lisinopril 20 mg daily.
C. Begin carvedilol 3.125 mg twice daily.
D. Begin lisinopril 5 mg daily and carvedilol 3.125 mg twice daily.
*Guideline-directed medical therapy (GDMT)
*CAD = coronary artery desease
Jawab : C

5. K.S. is seen in clinic and his HF regimen is adjusted over the

following months. At his 4-month visit, he is taking lisinopril 20 mg
daily and carvedilol 25 mg twice daily, and furosemide 20 mg three
times weekly as needed based on daily weight. Relevant objective
findings: BP is 119/70 mm Hg, HR 70 beats/minute, BUN 14 mg/dL,
SCr 1 mg/dL, and K 4 mEq/L. K.S. is clinically stable although he
states that “he gets winded (sesak) a little easier than he used to.”
Which of the following is best to recommend adding to K.S.’s HF
regimen?
A. Spironolactone 12.5 mg daily (antagonis reseptor aldosteron) -->
dosis seharusnya 25 mg daily, dan dapat menurunkan K karena nilai K
pasien rendah (K normal= 3.7-5.1)
B. n-3 PUFA 1 g daily (asam lemak dari minyak ikan, minyak alga dll)
C. Valsartan 40 mg twice daily
D. Digoxin 0.125 mg daily
Jawab : D

6. A 73-year-old African American man who has recently relocated is being seen in your HF clinic for the first time.
He was diagnosed with HFrEF 4 years ago (Stage C HFrEF; EF 30%) His medical history includes HTN, T2DM,
peripheral artery disease, chronic kidney disease 4, and benign prostatic hyperplasia. Objective data: BP 112/66 mm
Hg, HR 86 beats/minute, BUN 15 mg/dL, SCr 3.1 mg/dL, eGFR 26 mL/min/1.73m2 (stable over past 12 months), K
3.7 mEq/L. His home drugs include aspirin 81 mg daily, atorvastatin 80 mg daily, carvedilol 12.5 mg
twice daily, clopidogrel 75 mg daily, finasteride 5 mg daily, lisinopril 40 mg daily, and sitagliptin 25 mg daily.
Which one of the following is best to recommend for this patient?
A. Discontinue lisinopril based on renal function.
B. Discontinue lisinopril and titrate carvedilol to 25 mg twice daily.
C. Continue current regimen and titrate carvedilol to 25 mg twice daily.
D. Continue current regimen
Jawab : B
Karena pasien memiliki gagal ginjal stadium 4 sebaiknya obat lisinopril dihentikan karena kontraindikasi dengan
penderita gagal ginjal. Obat lisinopril juga dieliminasi melalui ginjal sebesar 106 ml/min

7. A physician contacts you for help regarding changing a patient from losartan 100 mg daily to sacubitril/valsartan.
The patient is a 55-year-old white woman with HFrEF, stage C, NYHA class III. She has a history of angioedema
with lisinopril. She is also taking carvedilol 25 mg twice daily, furosemide 40 mg twice daily, spironolactone 12.5
mg daily. Her BP is 120/70 mm Hg and HR 75 beats/minute. Her K is 5.0 mEq/L and SrCr is 1.2 mg/dL. Which one
of the following is best to recommend for this patient?
A. Start sacubitril/valsartan 49/51 mg twice daily 36 hours after the last dose of losartan.
B. Start sacubitril/valsartan 97/103 mg at the next dosing interval.
C. Do not start sacubitril/valsartan because of K 5.0 mEq/L.
D. Do not start sacubitril/valsartan because of history of angioedema with angiotensin-converting enzyme
inhibitor (ACEI).
Jawab : D
Efek samping paling umum dalam penelitian adalah hipotensi, hiperkalemia, dan gangguan ginjal. Angioedema juga
menjadi salah satu efek samping yang dilaporkan. Pasien kulit hitam memiliki risiko efek samping lebih besar.
Pasien yang mengonsumsi obat ini direkomendasikan untuk mencari pertolongan medis segera bila mengalami efek
samping angioedema atau kesulitan bernapas pada saat sedang mengonsumsi sacubitril/valsartan. Para ahli
kesehatan perlu mengingatkan pasien untuk tidak mengonsumsi sacubitril/valsartan bersama obat golongan
penghambat ACE (angiotensin converting enzyme), karena peningkatan risiko angioedema. Jika ingin mengganti
terapi sacubitril/valsartandengan penghambat ACE, penggunaan kedua obat harus dipisahkan dalam 36 jam.

8. An 87-year-old white woman comes to the HF clinic. Her medical history includes HFrEF (Stage C, NYHA class
II, EF 15%–20%), atrial fibrillation, HTN, and hypothyroidism. Objective findings: BP 120/83 mm Hg, HR 108
beats/minute, BUN 10 mg/dL, SCr 0.6 mg/dL, K 4.3 mEq/L, TSH 0.82 mIU/L and Free T4 0.97 ng/dL. Her home
drugs include ramipril 5 mg daily, carvedilol 12.5 mg twice daily, levothyroxine 25 mcg daily, apixaban 5 mg twice
daily. The medical resident is considering adding ivabradine to improve HR control. Which of the following is best
to recommend for this patient?
A. Initiate ivabradine 5 mg twice daily and stop carvedilol.
B. Initiate ivabradine 5 mg twice daily and continue carvedilol.
C. Do not start ivabradine; increase carvedilol to 25 mg twice daily.
D. Do not start ivabradine; continue carvedilol 12.5 mg twice daily and add digoxin 0.125 mg daily.
Jawab : C
Ivabradine memiliki mekanisme penghambatan CYP 450 pada liver shingga dapat menyebabkan peningkatan kadar
obat lain yang dapat menyebabkan toksisitas meningkat. Pasien juga mengalami hipotiroid yang menyebabkan
metabolisme terganggu yaitu penurunan metabolisme. Obat ini menyebabkan pemanjangan depolarisasi diastolic
sehingga dapat meningkatkan tekanan darah yang merupakan salah satu faktor resiko HF.

9. A patient with diabetic kidney disease, HFrEF, and K 5.8 mEq/L is undergoing dietary changes. The primary care
physician wants to know if patiromer is likely to improve outcomes. The patient is taking valsartan 80 mg twice
daily, metoprolol succinate 200 mg daily, and bumetanide 2 mg twice daily. Which one of the following is the best
response to this question?
A. Patiromer will take 2–3 days to reduce the K levels and will decrease hospitalizations because the valsartan will
not need to be discontinued.
B. Patiromer will improve HF outcomes because after K levels are normalized valsartan can be increased to
target dose.
C. Patiromer is effective at achieving normal K levels while maintaining stable doses of RAAS inhibitors, but there
are no data regarding hospitalizations or other HF outcomes.
D. Patiromer’s effectiveness at achieving normal K levels in HF patients while using RAAS inhibitors is unknown.
Jawab : B
Patiromer merupakan obat untuk hyperkalemia, dimana pasien mengalami diabetes mellitus dengan data lab kalium
tinggi sedangkan untuk HF tidak diperbolehkan memiliki kadar kalium tinggi karena dapat meningkatkan
vasokontriksi jantung.

10. A 70-year-old white woman is being seen in the clinic for routine follow-up. Her medical history includes HTN,
hyperlidemia, and HFpEF (Stage C, NYHA class III, EF 55%). Objective data include BP 135/72 mm/Hg, HR 70
beats/minute, BUN 14 mg/dL, SCr 1.1 mg/dL, K 3.8 mEq/L, eGFR > 60, and NT-proBNP 600 pg/mL. Her home
drugs include amlodipine 5 mg daily, aspirin 81 mg, daily, atorvastatin 20 mg daily, candesartan 16 mg daily, and
furosemide 20 mg daily. Using information from the TOPCAT study, which one of the following best assesses the
use of spironolactone in this patient?
A. It has proven mortality benefit.
B. It may improve quality of life.
C. It does not affect HF hospitalizations but can be added for hypertension.
D. It should not be used.
Jawab : A
Pemberian spironolakton bagi pasien class C III dapat menurunkan mortalitas, menurunkan MRS dan penurunan
kematian dari cardiovascular disease karena MRS, sehingga pemberian spironolakton dapat menurunkan mortalitas.

11. You are preparing an in-service for mid-level providers in your clinic. You plan to focus on management of
HFpEF because you have received several questions recently on this topic. Which of the following statements is
most important to include in the presentation?
A. For patients with HFpEF, the prognosis is notably worse than HFrEF due to less clarity regarding medication
interventions with mortality benefit.
B. For patients with HFpEF, a focus of care should be carefully managing BP to achieve an appropriate
target.
C. For patients with HFpEF, initiating spironolactone should be done as early as possible in as many patients as
possible.
D. For patients with HFpEF and T2DM, initiating empagliflozin should be considered as first line management of
T2DM.
Jawab : B
Pasien yang memiliki penyakit HFpEF merupakan suatu penyakit dengan keadaan sistolik yang tidak sesuai
sehingga perawatan harus berhati-hati sampai mencapai BP target karena sistolik merupakan salah satu bagian dari
tekanan darah yang sangat mudah untuk meningkat.

Questions 12 and 13 pertain to the following case.

K.J. is a 60-year-old woman with newly diagnosed HFrEF who is referred to the HF clinic for evaluation. Her EF is
30%, and prior work-up was negative for coronary disease. K.J. is taking lisinopril 10 mg daily and furosemide 20
mg daily. Her BP is 110/65 with a HR of 90 beats/minute. She has NYHA class III symptoms (stage B) . Today’s
examination is benign except for tachycardia and mild LE edema. K.J.’s other lab values include CrCl 80 mL/min
and K 4.5 mEq/L.

12. Which one of the following is best to recommend for K.J.?

A. Change lisinopril to sacubitril/valsartan 49/51 mg twice daily.
B. Add carvedilol 12.5 mg twice daily.
C. Add bisoprolol 1.25 mg daily.
D. Add spironolactone 12.5 mg daily.
Jawab : C
Karena jawaban D dapat menyebabkan pasien hipokalemi, padahal nilai K pasien dibawah normal.
 Beta blocker ditambahkan jika terdapat penggunaan terapi ACE inhibitor yaitu lisinopril, jadi perlu ditambahkan
bisoprolol atau carvedilol. Namun, carvedilol tidak dipilih karena dosisnya kurang sesuai. Sedangkan pasien adalah
newly diagnosis sehingga dosis carvediol yang seharusnya adalah 3,125 mg bid.

13. Six months later, after multiple medication adjustments and titrations, K.J. is now on a regimen of
sacubitril/valsartan 49/51 mg twice daily, metoprolol succinate 100 mg daily (increased 2 weeks ago from 50 mg
daily), spironolactone 12.5 mg daily, and furosemide 40 mg daily. K.J. currently complains of worsening fatigue,
dyspnea, and weight gain (5 lb). Her BP is 100/60 mm Hg and HR 95 beats/minute. She has 1+ pitting edema to her
shin, + JVD, and her lungs are clear. Her renal function is stable and K is 5.1 mEq/L. Which one of the following, in
addition to increasing furosemide to 40 mg twice daily, is best to recommend for K.J.?
A. Decrease metoprolol to 50 mg daily.
B. Continue other drugs as prescribed.
C. Increase sacubitril/valsartan to 97/103 mg twice daily.
D. Increase metoprolol to 150 mg daily.
Jawab : A
Menurunkan dosis metoprolol karena dikhawatirkan pasien mengalami hipotensi (tekanan darah pasien saat ini
100/60 mmHg).
14. A 40-year-old man with HFrEF comes to the clinic for a routine follow-up visit. Two weeks ago he was
hospitalized for HF at another institution; this was attributed to not following his low-sodium diet. The patient’s
eplerenone was increased to 50 mg daily (from 25 mg) on discharge, and he was continued on his home regimen of
sacubitril/valsartan 97/103 mg twice daily, carvedilol 25 mg twice daily, and furosemide 40 mg twice daily. He
reports he is back to his baseline NYHA class II symptoms, is back to following a low-sodium diet, and is trying to
eat healthier overall to lose weight. His BP is 140/80 mm Hg and HR is 70 beats/minute. Lab results have been
stable over the last few years; 1 month ago they were BUN 15 mg /dL, SCr 1.2 mg/dL, and K 4.5 mEq/L. Which
one of the following is the best plan to monitor this patient’s renal function and potassium?
A. Check in 2 months, then every 3-4 months
B. Check in a week, 3 months, then every 6 months
C. Check today, then monthly for 90 days, then every 3-4 months
D. Check today, in 1 month, then every 3-4 months

15. The VAL-HeFT study randomized HF patients to treatment with valsartan 160 mg twice daily or placebo. The
mean EF of patients in the study was 27%; 93% of patients were also receiving an ACEI, and 35% were receiving a
β-blocker. In a post-hoc subset analysis, the effects of valsartan on the outcome of mortality was examined by
background therapy. The table below provides relative risks and confidence intervals for the effect of valsartan on
mortality when used with or without ACEI and/or β-blocker.

Effect of ACEI β-Blocker Number of Relative Riska 95% CIa

Valsartan on Patients
Mortality
Subgroup
Analysis by
Background
Therapy
Yes No 3034 0.98 0.85-1.15
Yes Yes 1610 1.40 1.11-1.85
No No 226 0.58 0.35-1.05
No Yes 140 0.80 0.35-1.8
Relative risk and confidence intervals estimated from forest plot in original publication.

Which one of the following most accurately describes these results?

A. It is fairly certain than the addition of valsartan to a β-blocker without an ACEI reduces mortality.
B. The greatest relative risk reduction was seen when valsartan was combined with an ACEI only (no β-
blocker).
C. Addition of valsartan to both an ACEI and β-blocker suggested an increased risk of harm.
D. In the subset of patients receiving neither an ACEI nor β-blocker, the 95% CI includes 1, suggesting an increased
risk of harm in this subgroup.

Jawab : C

Karena nilai RR paling tinggi sehingga beresiko meningkatkan mortalitas