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IBHRE CEPS study materials
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IBHRE CEPS: Pharmacologic Therapy and Clinical Management

IBHRE CEPS · Work through your exam, one topic at a time.

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Pharmacologic Therapy and Clinical Management

Pharmacologic Therapy and Clinical Management

This domain tests drug selection by mechanism and comorbidity, initiation and monitoring, and the clinical decisions surrounding anticoagulation and sudden death prevention.

Core rules

  • Vaughan-Williams: class I sodium-channel blockers (IA quinidine/procainamide, IB lidocaine/mexiletine, IC flecainide/propafenone); class II beta-blockers; class III potassium-channel blockers (amiodarone, sotalol, dofetilide, ibutilide, dronedarone); class IV calcium-channel blockers. Amiodarone also has class I, II, and IV effects.
  • Amiodarone: long half-life, load before maintenance, monitor TSH, liver enzymes, chest imaging, and eyes. It can worsen bradycardia and QT prolongation but is relatively safe in HFrEF.
  • Sotalol and dofetilide prolong QT and require inpatient initiation with ECG monitoring, QTc checks, and renal dose adjustment. Stop if QTc exceeds 500 ms.
  • Flecainide and propafenone are contraindicated in structural heart disease, prior MI, and reduced LVEF. In AF, pair them with an AV nodal blocker to avoid 1:1 conduction during flutter.
  • Adenosine is diagnostic for regular narrow-complex SVT; avoid in severe asthma and use caution in WPW because it can provoke AF. Ibutilide converts AF/flutter but causes torsades.
  • Anticoagulation: CHA2DS2-VASc guides use. DOACs are preferred except for mechanical valves and moderate-to-severe mitral stenosis, where warfarin is required.

Worked example

A 74-year-old with HFrEF (EF 30%), CKD stage 3, and CHA2DS2-VASc 5 has persistent AF. Flecainide and propafenone are contraindicated by structural disease; dronedarone is avoided in advanced HF; sotalol and dofetilide need renal dosing and inpatient QT monitoring. Amiodarone is the safest rhythm-control option. For anticoagulation, apixaban is reasonable with dose reduction only if two of: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL. The reasoning ties drug choice to EF, renal function, and stroke risk rather than to rhythm alone.

Traps

  • Prescribing flecainide in a patient with prior MI or low EF.
  • Forgetting renal dose adjustment for sotalol and dofetilide.
  • Using a DOAC in a mechanical valve.
  • Treating asymptomatic PVCs with antiarrhythmics in structural disease.
  • Missing amiodarone toxicity because the drug is assumed to be benign.