Learning Cardiology

Q. Which of the following is not an absolute contraindication of Sacubitril/valsartan combination? A. History of hypersensitivity to valsartan B. History of hyperkalemia with valsartan C. 1st trimester of pregnancy D. History of angioedema with ACE inhibitors Answer:  B. History of hyperkalemia with valsartan Absolute contraindications of sacubitril include 1. History of hypersensitivity to any of component of sacubitril 2. H/o angioedema due to ACE inhibitors or ARBs 3. Pregnancy Past history of hyperkalemia with valsartan is not a contraindication for the use of sacubitril as such potassium should be normal while starting it. However, potassium level should be monitored more carefully in these patients. Hence, sacubitril can be given to patients who have past history of hyperkalemia due to any cause.

Q. All of the following have shown mortality benefit in heart failure except? A. Eplerenone B. Enalapril C. Digoxin D. Metoprolol Answer: C. Digoxin Explanation: Drugs which have shown mortality benefit in patients with heart failure with reduced ejection fraction (HFrEF) are- 1. Beta blockers 2. ACE inhibitors 3. Angiotensin receptor blockers 4. Aldosterone antagonist Digoxin did not show any survival advantage in these patients. None of drugs till date have shown mortality benefit in patients with heart failure with preserved ejection fraction (HFpEF).

Q. Which of the following is not a major criteria for congestive heart failure? A. Hepatojugular reflex B. PND attacks C. S3 gallop D. Tachycardia (Heart rate more than 120/minute) Answer: D. Tachycardia (Heart rate more than 120/minute) Explanation:  Framingham proposed the diagnostic criteria for congestive heart failure. Either 2 major or one major and 2 minor criterias should be fulfilled for the diagnosis of CHF Major criterias are: Paroxysmal nocturnal dyspnea Weight loss of 4.5 kg in 5 days in response to treatment Neck vein distention Rales Acute pulmonary edema Hepatojugular reflux S  3  gallop Central venous pressure >16 cm water Circulation time of ≥25 seconds Radiographic cardiomegaly Pulmonary edema, visceral congestion, or cardiomegaly at autopsy And minor criterias are: Nocturnal cough Dyspnea on ordinary exertion A decrease in vital capacity by one third the maximal value recorded Pleural effusion T

Q. Which of the following drug may be stopped in asymptomatic patients with low left ventricular ejection fraction? A. Beta blocker B. ACE inhibitor C. Diuretic D. All of them should be stopped unless patient is symptomatic Answer: C. Diuretic Explanation: Beta blockers and ACE inhibitors are used in CHF because they have suvival benefit. Both of these are class I recommendation in patients with heart failure with reduced ejection fraction (HFrEF). Whereas, Diuretics are used only for symptomatic benefit. So, if the patient is asymptomatic but having low ejection fraction, beta blockers and ACE inhibitors should be continued and diuretics are given according to symtoms of the patient.