Heart Failure & Hypertension Management

Heart Failure & Hypertension Management

Master cardiovascular pharmacotherapy with free flashcards and evidence-based treatment strategies. This lesson covers heart failure classification and drug therapy, hypertension management protocols, and guideline-directed medical therapy—essential concepts for NAPLEX success and clinical practice.

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Welcome to Cardiovascular Pharmacotherapy 💊

Cardiovascular diseases remain the leading cause of morbidity and mortality worldwide, making expertise in heart failure (HF) and hypertension (HTN) management critical for every pharmacist. The NAPLEX heavily tests these therapeutic areas because they require:

• Complex drug selection based on patient-specific factors
• Understanding of guideline updates from ACC/AHA and other organizations
• Recognition of contraindications and drug interactions
• Dosing optimization to achieve target goals
• Monitoring parameters for efficacy and toxicity

This lesson integrates the latest evidence-based guidelines with high-yield clinical pearls to prepare you for both exam success and real-world practice. 🎯

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Core Concepts: Heart Failure Management ❤️

Heart Failure Classification

Heart failure is classified by ejection fraction (EF), which fundamentally determines drug therapy:

Classification	Ejection Fraction	Primary Issue	Key Medications
HFrEF (Heart Failure with Reduced EF)	≤40%	Systolic dysfunction Heart can't pump effectively	ACE-I/ARB/ARNI, β-blockers, MRAs, SGLT2i
HFpEF (Heart Failure with Preserved EF)	≥50%	Diastolic dysfunction Heart can't relax/fill properly	Diuretics, treat HTN/comorbidities, SGLT2i
HFmrEF (Heart Failure with Mildly Reduced EF)	41-49%	Intermediate category	Similar to HFrEF therapy

💡 High-Yield Tip: The vast majority of NAPLEX questions focus on HFrEF because it has the most robust evidence for mortality reduction. Know the "Fantastic Four" drug classes cold!

The "Fantastic Four" for HFrEF 🌟

Guideline-directed medical therapy (GDMT) for HFrEF consists of four foundational drug classes—all with mortality benefit:

1. ACE Inhibitors / ARBs / ARNIs (RAAS Inhibitors)

Mechanism: Block the renin-angiotensin-aldosterone system (RAAS) to reduce afterload, preload, and ventricular remodeling.

Drug Class	Examples	Target Dose (HF)	Key Points
ACE Inhibitors	Enalapril Lisinopril Captopril	Enalapril 10-20 mg BID Lisinopril 20-40 mg daily	First-line unless contraindicated Monitor K⁺, SCr, BP
ARBs	Losartan Valsartan	Losartan 50-150 mg daily Valsartan 160 mg BID	Use if ACE-I intolerant (cough) NOT with ACE-I (ONTARGET trial)
ARNI	Sacubitril/valsartan (Entresto®)	97/103 mg BID	SUPERIOR to enalapril (PARADIGM-HF) 36-hour washout from ACE-I required Do NOT use with ACE-I (angioedema risk)

⚠️ Critical Contraindications:

• Pregnancy (all RAAS inhibitors are teratogenic—Category D/X)
• Bilateral renal artery stenosis
• History of angioedema (especially for ACE-I)
• Combined use of ACE-I + ARB (increased adverse events without benefit)

Monitoring Parameters:

• Potassium: Check at baseline, 1-2 weeks after initiation/dose increase. Target <5.5 mEq/L
• Serum creatinine: Acceptable if increases <35% from baseline or SCr <3.0 mg/dL
• Blood pressure: Titrate to avoid symptomatic hypotension

2. β-Blockers (Evidence-Based Only!) 🚫

Only three β-blockers have mortality benefit in HFrEF:

Drug	Starting Dose	Target Dose	Unique Features
Carvedilol	3.125 mg BID	25 mg BID (50 mg BID if >85 kg)	Non-selective β + α₁ blocker Take with food
Metoprolol succinate (Toprol-XL®)	12.5-25 mg daily	200 mg daily	β₁-selective Extended-release only! (NOT metoprolol tartrate)
Bisoprolol	1.25 mg daily	10 mg daily	β₁-selective Less commonly used in US

💡 NAPLEX Pearl: Metoprolol succinate (extended-release) is evidence-based for HFrEF. Metoprolol tartrate (immediate-release) is NOT—don't confuse them!

Titration Strategy: "Start low, go slow" (double dose every 2 weeks as tolerated)

Monitoring:

• Heart rate (target: 55-60 bpm at rest)
• Blood pressure
• Signs of worsening HF (may see temporary decline initially—this is expected!)

⚠️ Common Mistake: Stopping β-blockers during acute decompensation. Continue β-blockers during hospitalization unless cardiogenic shock or severe bradycardia.

3. Mineralocorticoid Receptor Antagonists (MRAs) 💧

Aldosterone antagonists reduce mortality and hospitalizations in HFrEF:

Drug	Indication	Dose	Key Considerations
Spironolactone	NYHA Class II-IV HFrEF	12.5-25 mg daily Max: 50 mg daily	Non-selective MRA Gynecomastia risk (10-15%) Cheaper option
Eplerenone	NYHA Class II-IV HFrEF Post-MI with HF	25 mg daily Target: 50 mg daily	Selective MRA No gynecomastia More expensive

Critical Monitoring:

• Potassium: MUST be <5.0 mEq/L before initiation
• Check K⁺ and SCr at 3 days, 1 week, then monthly for 3 months
• Hold if K⁺ >5.5 mEq/L
• Discontinue if K⁺ >6.0 mEq/L

Contraindications:

• K⁺ >5.0 mEq/L at baseline
• SCr >2.5 mg/dL (men) or >2.0 mg/dL (women)
• CrCl <30 mL/min
• Concomitant potassium-sparing diuretics

⚠️ Hyperkalemia Management: The biggest concern with triple RAAS blockade (ACE-I/ARB/ARNI + MRA). Consider:

• Dietary potassium restriction
• Loop diuretics (increase K⁺ excretion)
• Patiromer or sodium zirconium cyclosilicate (K⁺ binders) to allow continuation of GDMT

4. SGLT2 Inhibitors (The New Kid on the Block!) 🆕

Sodium-glucose cotransporter-2 inhibitors are the newest addition to HFrEF GDMT (2021 ACC/AHA guidelines):

Drug	Dose for HFrEF	Trial Evidence
Dapagliflozin (Farxiga®)	10 mg daily	DAPA-HF trial 26% ↓ CV death or HF hospitalization
Empagliflozin (Jardiance®)	10 mg daily	EMPEROR-Reduced trial 25% ↓ CV death or HF hospitalization

Benefits in HFrEF:

• Mortality reduction (even without diabetes!)
• Reduced HF hospitalizations
• Improved quality of life
• Mechanisms: Natriuresis, improved cardiac energetics, reduced inflammation

Monitoring:

• Volume status (mild diuretic effect)
• Genital mycotic infections (common, especially in women)
• eGFR (can continue until eGFR <20-25 mL/min/1.73m²)

💡 High-Yield Fact: Unlike their use in diabetes, SGLT2 inhibitors in HFrEF do NOT require eGFR ≥45 for initiation—they work in advanced CKD!

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Additional HFrEF Therapies

Hydralazine + Isosorbide Dinitrate (H-ISDN) 🔄

Component	Mechanism	Dose
Hydralazine	Direct arterial vasodilator (↓ afterload)	Target: 75-100 mg TID
Isosorbide dinitrate	Venodilator (↓ preload)	Target: 40 mg TID

Indications:

1. Self-identified Black patients with NYHA Class III-IV HFrEF (added to standard GDMT)—A-HeFT trial showed 43% mortality reduction
2. ACE-I/ARB/ARNI intolerant patients (alternative RAAS blockade)

Adverse Effects:

• Hydralazine: Lupus-like syndrome (especially doses >200 mg/day), reflex tachycardia, headache
• Isosorbide dinitrate: Headache (tolerance develops), hypotension, nitrate tolerance (require 12-14 hour nitrate-free interval)

Ivabradine ⚡

Mechanism: Selective I_f channel inhibitor in SA node—slows heart rate without negative inotropic effects

Indication: NYHA Class II-III HFrEF with:

• EF ≤35%
• Sinus rhythm with HR ≥70 bpm at rest
• On maximum tolerated β-blocker (or β-blocker contraindicated)

Dose: Start 5 mg BID; target 7.5 mg BID (goal: HR 50-60 bpm)

Monitoring: Heart rate, rhythm (avoid in atrial fibrillation—ineffective)

SHIFT Trial: 18% reduction in CV death or HF hospitalization

Digoxin 🏺 (The Old Guard)

Mechanism: Na⁺/K⁺-ATPase inhibitor—positive inotrope, negative chronotrope

Current Role: Symptom management only—does NOT reduce mortality

• Reduces HF hospitalizations (DIG trial)
• Used for rate control in atrial fibrillation with HF

Dosing:

• No loading dose in chronic HF
• Maintenance: 0.125 mg daily (lower doses in elderly, renal impairment, low body weight)
• Target level: 0.5-0.9 ng/mL (lower than historical targets—better outcomes)

Toxicity Red Flags 🚩:

• GI: Nausea, vomiting, anorexia (often earliest signs)
• Visual: Yellow-green halos, photophobia
• Cardiac: Bradycardia, AV block, PVCs, ventricular tachycardia
• CNS: Confusion, fatigue

Factors Increasing Toxicity Risk:

• Hypokalemia (most important!), hypomagnesemia, hypercalcemia
• Renal impairment
• Drug interactions: Amiodarone, dronedarone, verapamil, quinidine (↓ clearance, ↑ levels)

⚠️ Common Mistake: Not reducing digoxin dose when starting amiodarone—reduce digoxin by 50% and monitor levels!

Diuretics 💦

Purpose: Symptom relief (dyspnea, edema)—do NOT improve mortality

Class	Examples	Use in HF	Key Points
Loop Diuretics	Furosemide Bumetanide Torsemide	First-line for volume overload	Furosemide: Variable absorption (40-60%) Torsemide: Better bioavailability (80-90%) Monitor K⁺, Mg²⁺, renal function
Thiazides	HCTZ Metolazone	Combine with loop for refractory edema	Metolazone 30-60 min before loop diuretic Synergistic effect (blocks distal compensation)

Conversion Equivalents:

• Furosemide 40 mg PO ≈ Bumetanide 1 mg PO ≈ Torsemide 20 mg PO
• IV to PO: Furosemide has 2:1 ratio (40 mg IV ≈ 80 mg PO); bumetanide and torsemide are 1:1

Home Weight Monitoring: Patients should weigh daily and contact provider if gain >2-3 lbs in 1 day or >5 lbs in 1 week

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Core Concepts: Hypertension Management 📈

Blood Pressure Classification (2017 ACC/AHA Guidelines)

Category	Systolic (mmHg)	And/Or	Diastolic (mmHg)
Normal	<120	AND	<80
Elevated	120-129	AND	<80
Stage 1 HTN	130-139	OR	80-89
Stage 2 HTN	≥140	OR	≥90
Hypertensive Crisis	>180	AND/OR	>120

💡 NAPLEX Alert: The 2017 guidelines lowered the threshold for hypertension diagnosis (previously 140/90). This increased the number of patients diagnosed with HTN.

Treatment Goals 🎯

Population	Blood Pressure Goal
General population <65 years	<130/80 mmHg
Adults ≥65 years	<130/80 mmHg (if tolerated)
Diabetes	<130/80 mmHg
CKD	<130/80 mmHg
CAD	<130/80 mmHg

⚠️ Common Mistake: Overtreating elderly patients leading to hypotension, falls, and syncope. Use clinical judgment—patient tolerance matters!

Lifestyle Modifications (First-Line for ALL Patients!) 🏃

Modification	Recommendation	Expected BP Reduction
Weight loss	Achieve ideal body weight	5-20 mmHg per 10 kg lost
DASH diet	↑ fruits, vegetables, low-fat dairy ↓ saturated fat	8-14 mmHg
Sodium restriction	<1500 mg/day (ideal) <2300 mg/day (minimum)	2-8 mmHg
Exercise	150 min/week moderate aerobic activity	4-9 mmHg
Limit alcohol	≤2 drinks/day (men) ≤1 drink/day (women)	2-4 mmHg

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Antihypertensive Drug Classes 💊

First-Line Agents ("ABCD Approach")

A = ACE inhibitors / ARBs
B = β-Blockers (NOT first-line unless compelling indication)
C = Calcium Channel Blockers
D = Diuretics (thiazides)

Thiazide Diuretics 💧

Drug	Dose	Key Points
Chlorthalidone	12.5-25 mg daily	Preferred thiazide (longer half-life, better outcomes) More potent than HCTZ
Hydrochlorothiazide	25-50 mg daily	Most commonly prescribed (but less effective than chlorthalidone) Loses efficacy when CrCl <30 mL/min
Indapamide	1.25-2.5 mg daily	Thiazide-like May have fewer metabolic effects

Adverse Effects:

• Hypokalemia (most common—monitor K⁺!)
• Hyponatremia, hypomagnesemia
• Hyperuricemia (↑ gout risk)
• Hyperglycemia (↑ blood glucose)
• Hyperlipidemia (↑ LDL, triglycerides)
• Hypercalcemia
• Photosensitivity

💡 Tip: Combine with ACE-I/ARB (↓ K⁺ loss) or give K⁺ supplementation

ACE Inhibitors & ARBs (Covered in HF section above)

Compelling Indications:

• Diabetes with proteinuria
• CKD (slow progression)
• Post-MI
• Heart failure

Ethnic Considerations: Less effective as monotherapy in Black patients (low-renin hypertension)—combine with CCB or thiazide

Calcium Channel Blockers (CCBs) 🧱

Subclass	Examples	Characteristics	Adverse Effects
Dihydropyridines (DHP)	Amlodipine Nifedipine XL Felodipine	• Peripheral vasodilators • NO negative chronotropy/inotropy • Safe in asthma/COPD • Preferred for HTN	• Peripheral edema (dose-dependent) • Headache • Flushing • Gingival hyperplasia • Reflex tachycardia
Non-dihydropyridines (Non-DHP)	Diltiazem Verapamil	• Negative chronotropy (↓ HR) • Negative inotropy (↓ contractility) • Used for rate control (A-fib) • ⚠️ Avoid in HFrEF	• Bradycardia, AV block • Constipation (verapamil>diltiazem) • Worsening HF • Gingival hyperplasia

Drug Interactions:

• Non-DHPs + β-blockers: Additive bradycardia/AV block risk—use cautiously
• Verapamil/diltiazem inhibit CYP3A4—many drug interactions (statins, immunosuppressants, etc.)

💡 Pearl: Amlodipine is the most commonly used CCB for HTN—long half-life (24-48 hours), once-daily dosing, minimal drug interactions

⚠️ Avoid Non-DHPs in: HFrEF, 2nd/3rd-degree AV block, sick sinus syndrome (without pacemaker)

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Compelling Indications: Matching Drug to Condition 🎯

Condition	Preferred Agent(s)	Rationale
Diabetes + CKD	ACE-I or ARB	Renal protection (↓ proteinuria, slow GFR decline)
Post-MI	β-blocker + ACE-I/ARB	↓ Mortality, prevent remodeling
Heart Failure (HFrEF)	ACE-I/ARB/ARNI + β-blocker + MRA + SGLT2i	Guideline-directed medical therapy
CKD (non-diabetic)	ACE-I or ARB	Slow progression
Stable angina	β-blocker or CCB	↓ Myocardial oxygen demand
Atrial fibrillation	Non-DHP CCB (diltiazem/verapamil) or β-blocker	Rate control
Migraine prophylaxis	β-blocker (propranolol, metoprolol)	↓ Frequency of attacks
Benign prostatic hyperplasia	α₁-blocker (doxazosin, terazosin)	↓ Urinary symptoms + BP
Osteoporosis	Thiazide diuretic	↓ Urinary calcium excretion, ↓ fracture risk

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Special Populations & Considerations 👥

Black Patients

• Initial therapy: Thiazide diuretic OR calcium channel blocker (more effective than ACE-I/ARB alone)
• Lower renin levels → less responsive to RAAS inhibitors
• Exception: If CKD present, use ACE-I/ARB

Pregnancy 🤰

Safe Agents:

• Methyldopa (first-line—long track record)
• Labetalol (α+β blocker)
• Nifedipine (immediate-release for acute; extended-release for maintenance)
• Hydralazine (usually for acute management)

CONTRAINDICATED (teratogenic):

• ❌ ACE inhibitors (Category D)
• ❌ ARBs (Category D)
• ❌ Direct renin inhibitors (Category D)
• ❌ Atenolol (fetal growth restriction)

Elderly Patients (≥65 years)

• Start low, go slow (more sensitive to hypotension)
• Thiazide or CCB often preferred (evidence from ALLHAT, HYVET trials)
• Monitor orthostatic hypotension, falls risk
• Goal: <130/80 mmHg if tolerated

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Treatment Algorithm 📊

┌────────────────────────────────────────────────────────────┐
│              HYPERTENSION TREATMENT PATHWAY                │
└────────────────────────────────────────────────────────────┘

         LIFESTYLE MODIFICATIONS (ALL PATIENTS)
                        │
                        ↓
         ┌──────────────┴──────────────┐
         │ Stage 1 HTN + Low CV Risk   │  Stage 1 HTN + High CV Risk
         │        (ASCVD <10%)         │  OR Stage 2 HTN
         └──────────────┬──────────────┘
                        │                         │
                        ↓                         ↓
              Lifestyle + Reassess         Start 2 medications
              in 3-6 months                (usually combination)
                        │                         │
                        ↓                         ↓
              Still elevated? ──────────→  Thiazide/CCB + ACE-I/ARB
                                                   │
                                                   ↓
                                           NOT at goal in 1 month?
                                                   │
                        ┌──────────────────────────┴────────┐
                        ↓                                    ↓
              Optimize doses of              Add 3rd agent
              current medications            (from different class)
                        │                                    │
                        └──────────────┬─────────────────────┘
                                       ↓
                           Still NOT at goal?
                                       │
                        ┌──────────────┴──────────────┐
                        ↓                             ↓
              Add 4th agent              Consider secondary HTN
              (spironolactone often      (evaluate for resistant HTN:
              effective as 4th line)      renal artery stenosis,
                                          primary aldosteronism, etc.)

💡 NAPLEX Tip: Most patients need ≥2 medications to reach goal BP. Starting with combination therapy improves adherence and outcomes.

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Resistant Hypertension 🔴

Definition: BP remains above goal despite:

• Lifestyle modifications
• 3 antihypertensive agents of different classes (including a diuretic) at optimal doses
• OR controlled on ≥4 medications

Workup: Rule out secondary causes

• Medication non-adherence (most common!)
• White coat hypertension
• Suboptimal diuretic therapy
• Drug interactions (NSAIDs, decongestants, steroids, OCPs, stimulants)
• Secondary causes: Primary aldosteronism, renal artery stenosis, OSA, pheochromocytoma, Cushing's, thyroid disease

Treatment:

1. Optimize diuretic: Switch to chlorthalidone or add loop diuretic if CKD
2. Add spironolactone (very effective as 4th agent—PATHWAY-2 trial)
3. Consider other agents: Clonidine, hydralazine, minoxidil

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Hypertensive Emergencies vs. Urgencies 🚨

Feature	Hypertensive Urgency	Hypertensive Emergency
BP	>180/120 mmHg	>180/120 mmHg
End-organ damage	NO	YES (encephalopathy, MI, stroke, acute HF, aortic dissection, eclampsia, acute kidney injury)
Treatment setting	Outpatient	ICU
BP reduction goal	Gradual over 24-48 hours (oral agents)	Immediate IV therapy Reduce MAP by 10-20% in 1st hour Then 5-15% over next 23 hours
Agents used	Oral: Captopril, labetalol, clonidine	IV: Nicardipine, laberolol, clevidipine, nitroprusside, fenoldopam

⚠️ Critical Warning: Do NOT rapidly lower BP in urgency—risk of stroke, MI, or renal hypoperfusion!

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Clinical Examples 📋

Example 1: Initiating GDMT in New HFrEF Patient

Case: JT is a 62-year-old male recently diagnosed with HFrEF (EF 30%) after presenting with dyspnea and lower extremity edema. He is euvolemic after diuresis in the hospital. Labs: K⁺ 4.2 mEq/L, SCr 1.1 mg/dL, BP 128/78 mmHg, HR 88 bpm.

Question: Which medications should be initiated before discharge?

Answer: Start the "Fantastic Four" simultaneously (recent guidelines support this):

1. Sacubitril/valsartan 24/26 mg BID (or enalapril 2.5 mg BID if cost-prohibitive)

   • No prior ACE-I, so no washout needed
   • Start at lowest dose, titrate every 2 weeks

2. Carvedilol 3.125 mg BID

   • Start low despite stable BP
   • Titrate every 2 weeks to target (25 mg BID)
   • Educate: May feel worse initially before improvement

3. Spironolactone 12.5 mg daily

   • K⁺ within range
   • Recheck labs in 3 days, 1 week, then monthly

4. Dapagliflozin 10 mg daily

   • No diabetes required for HF indication
   • Start immediately—don't wait!

5. Furosemide 20 mg daily (for symptoms)

   • Educate on daily weights
   • PRN dose if weight increases

Monitoring Plan:

• Labs (K⁺, SCr, BUN) in 1-2 weeks
• BP and HR at each titration
• Follow-up in 2 weeks for medication titration

💡 Teaching Point: Don't delay starting all four classes—studies show early comprehensive GDMT improves outcomes!

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Example 2: Managing Hyperkalemia with GDMT

Case: SM is on enalapril 10 mg BID, carvedilol 25 mg BID, and spironolactone 25 mg daily for HFrEF. Recent labs show K⁺ 5.8 mEq/L. Patient is asymptomatic. SCr stable at 1.4 mg/dL.

Question: How should hyperkalemia be managed?

Answer: Goal is to continue GDMT (mortality benefit outweighs hyperkalemia risk in most cases):

1. Hold spironolactone temporarily (most potassium-sparing)
2. Continue ACE-I and β-blocker (greater mortality benefit)
3. Dietary counseling: Restrict high-potassium foods
4. Ensure adequate diuresis: Increase furosemide (promotes K⁺ excretion)
5. Consider patiromer or sodium zirconium cyclosilicate (K⁺ binders)
6. Recheck K⁺ in 3-5 days
7. Resume spironolactone at lower dose (12.5 mg daily) once K⁺ <5.5 mEq/L with continued K⁺ binder if needed

⚠️ Common Mistake: Permanently discontinuing MRA without attempting rechallenge with K⁺ binder—this deprives patient of mortality benefit!

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Example 3: Selecting Antihypertensives with Comorbidities

Case: DB is a 58-year-old Black male with:

• BP 156/94 mmHg (average of multiple readings)
• Type 2 diabetes (A1C 7.8%)
• Microalbuminuria (urine albumin:creatinine ratio 45 mg/g)
• eGFR 68 mL/min/1.73m²
• No known CAD or HF

Question: What is the optimal initial antihypertensive regimen?

Answer:

First-line: Lisinopril 10 mg daily + Amlodipine 5 mg daily

Rationale:

• ACE-I (lisinopril): Compelling indication for diabetes + CKD (proteinuria)—slows progression despite Black race
• CCB (amlodipine): Enhances BP-lowering in Black patients (ACE-I less effective as monotherapy)
• Combination therapy: Stage 2 HTN (≥140 systolic)—start 2 agents per guidelines

Alternative: Could use ARB (losartan) instead of ACE-I if patient develops cough

Monitoring:

• BP goal: <130/80 mmHg
• Recheck BP in 1 month
• Labs (K⁺, SCr) in 2-4 weeks after starting ACE-I
• Urine albumin:creatinine ratio annually (should improve with ACE-I therapy)

Avoid: Thiazide as sole initial therapy (would miss renal protection from ACE-I)

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Example 4: β-Blocker Selection Pitfall

Case: Pharmacy receives prescription for metoprolol tartrate 50 mg BID for patient with HFrEF (EF 28%).

Question: What is the issue, and what should the pharmacist do?

Answer:

Problem: Metoprolol tartrate (immediate-release) is NOT evidence-based for HFrEF. Only metoprolol succinate (extended-release) has mortality benefit (MERIT-HF trial).

Pharmacist Action:

1. Contact prescriber to clarify—likely intended metoprolol succinate
2. If HFrEF confirmed: Recommend switching to metoprolol succinate 25 mg daily (appropriate starting dose)
3. If patient already on tartrate: Don't abruptly switch—use conversion:
   • Metoprolol tartrate total daily dose ≈ metoprolol succinate daily dose
   • Example: Tartrate 50 mg BID (100 mg total) → Succinate 100 mg daily

Documentation: Document intervention in patient profile and communicate with prescriber

💡 High-Yield Pearl: This is a frequently tested NAPLEX scenario—know the difference between tartrate and succinate!

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Common Mistakes to Avoid ⚠️

Heart Failure Mistakes

1. Using the wrong metoprolol formulation

   • ❌ Metoprolol tartrate for HFrEF
   • ✅ Metoprolol succinate (extended-release)

2. Stopping β-blockers during HF decompensation

   • ❌ Discontinuing during hospitalization
   • ✅ Continue unless cardiogenic shock or severe symptomatic bradycardia

3. Not reducing digoxin dose with amiodarone

   • ❌ Continuing same digoxin dose → toxicity
   • ✅ Reduce digoxin by 50% when starting amiodarone

4. Combining ACE-I + ARB

   • ❌ Dual RAAS blockade (increased harm—ONTARGET trial)
   • ✅ Use ACE-I OR ARB OR ARNI (never combine)

5. Starting ARNI without ACE-I washout

   • ❌ Immediate switch → angioedema risk
   • ✅ 36-hour washout from ACE-I required

6. Permanently stopping MRA for hyperkalemia

   • ❌ Discontinuing without rechallenge
   • ✅ Manage with K⁺ binders, dietary restriction, diuretics—then resume at lower dose

7. Using non-evidence-based β-blockers

   • ❌ Atenolol, propranolol for HFrEF
   • ✅ Only carvedilol, metoprolol succinate, bisoprolol have mortality data

8. Targeting high digoxin levels

   • ❌ Targeting 1.0-2.0 ng/mL (outdated)
   • ✅ Target 0.5-0.9 ng/mL (better outcomes, less toxicity)

Hypertension Mistakes

9. Rapid BP reduction in hypertensive urgency

   • ❌ Aggressive lowering over hours
   • ✅ Gradual reduction over 24-48 hours (avoid ischemia)

10. Using ACE-I/ARB in pregnancy

    • ❌ Continuing RAAS inhibitors (teratogenic)
    • ✅ Switch to methyldopa, labetalol, or nifedipine

11. Inadequate diuretic dosing in resistant HTN

    • ❌ Low-dose HCTZ (12.5 mg)
    • ✅ Chlorthalidone 25 mg or adequate loop diuretic if CKD

12. Ignoring white coat hypertension

    • ❌ Treating elevated office BP without confirmation
    • ✅ Confirm with home BP monitoring or ABPM

13. Combining non-DHP CCB + β-blocker without caution

    • ❌ Verapamil/diltiazem + β-blocker → severe bradycardia
    • ✅ Use DHP CCB (amlodipine) with β-blocker, OR monitor closely

14. Starting spironolactone with K⁺ >5.0 mEq/L

    • ❌ Initiating MRA with elevated potassium
    • ✅ Correct K⁺ first, then start at low dose with close monitoring

15. Forgetting compelling indications

    • ❌ Using β-blocker as first-line in uncomplicated HTN
    • ✅ Reserve for post-MI, HF, CAD; use thiazide/CCB for uncomplicated HTN

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Key Takeaways 🎯

Heart Failure (HFrEF)

✅ The "Fantastic Four" all reduce mortality: ACE-I/ARB/ARNI, β-blockers (carvedilol, metoprolol succinate, bisoprolol), MRAs, SGLT2 inhibitors

✅ ARNI (sacubitril/valsartan) is superior to ACE-I—preferred when affordable; requires 36-hour ACE-I washout

✅ Metoprolol SUCCINATE only for HFrEF (not tartrate)—this is high-yield!

✅ Triple RAAS blockade (ACE-I/ARB/ARNI + MRA) requires close potassium monitoring; use K⁺ binders to maintain GDMT

✅ Digoxin doesn't reduce mortality—used only for symptoms; target level 0.5-0.9 ng/mL; reduce dose 50% when starting amiodarone

✅ SGLT2 inhibitors work even without diabetes—initiate in all HFrEF patients (eGFR >20-25)

✅ Hydralazine-ISDN added to GDMT in self-identified Black patients with NYHA III-IV HFrEF

✅ Diuretics are for symptoms only—no mortality benefit; furosemide has poor bioavailability (torsemide preferred by some)

Hypertension

✅ 2017 ACC/AHA guidelines lowered threshold: HTN now defined as ≥130/80 mmHg

✅ Most patients need ≥2 agents to reach goal—consider starting combination therapy for Stage 2 HTN

✅ First-line agents: Thiazides (chlorthalidone preferred), ACE-I/ARBs, CCBs

✅ β-blockers are NOT first-line for uncomplicated HTN—reserve for compelling indications (post-MI, HF, CAD)

✅ Match drug to comorbidity: ACE-I/ARB for diabetes/CKD, β-blocker for CAD/post-MI, CCB/thiazide for Black patients

✅ Avoid in pregnancy: ACE-I, ARBs, direct renin inhibitors (teratogenic)—use methyldopa, labetalol, nifedipine

✅ Non-DHP CCBs (diltiazem, verapamil) cause bradycardia—avoid with β-blockers and in HFrEF

✅ Resistant HTN: Optimize diuretic, add spironolactone as 4th agent, rule out secondary causes

✅ Hypertensive urgency vs. emergency: Emergency has end-organ damage requiring ICU and IV therapy; urgency treated gradually outpatient

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📚 Further Study

Deepen your understanding with these authoritative resources:

1. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
   https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063
   The definitive guideline for HF management—includes latest SGLT2i recommendations

2. 2017 ACC/AHA Guideline for High Blood Pressure in Adults
   https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065
   Updated BP thresholds and treatment algorithms

3. NAPLEX Competency Statements (Cardiovascular)
   https://nabp.pharmacy/programs/naplex/
   Official exam blueprint—review testable outcomes

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Congratulations! 🎉 You've completed this comprehensive lesson on heart failure and hypertension management. Master these concepts, practice with the flashcards throughout, and you'll be well-prepared for NAPLEX success and confident clinical practice. Remember: Guidelines evolve, so always verify current recommendations in practice. Keep learning! 💪