Diltiazem or Sildenafil

[Wanderer HitchHiker]

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In NBME 16 there's a question asking about which is contraindicated in a patient with low EF systolic HF 30% who is perscribed hydralazine and nitrates? diltiazem or sildenafil
I think both are contraindicated why would i choose one over the other?
If anybody had this NBME online kindly provide me with the right answer.

 

[USMLEHeadache]

As far as I know. Nitrates and Sildanafil always CI can result in life-threatening hypotension

 

[Wanderer HitchHiker]

Ok but also non-dihydropyridine CCBs (diltiazem and verapamil) are contraindicated in systolic HF

 

[orangetea]

You have to remember that non-dihydropyridines have minimal vasodilatory activity- although Diltiazem has some vs the dihydropyridines that do vasodilate.

Verapamil and Diltiazem mainly work at the AV and SA node to decrease nodal activity hence why they are good drugs for AFIB. You are right that it would be CI but in this case there is a better answer because of the drugs he is already on.

Sildenafil is the better answer because it is a potent vasodilator in addition to the nitrate and hydralazine which can cause severe hypotension.

 

[Wanderer HitchHiker]

I considered diltiazem contraindicated due to its -ve inotropic not because its action on conduction

 

[USMLEHeadache]

That was well written orangetea

 

[mk2015]

I had a similar thought when I first saw this question. Ultimately, I thought that sildenafil made more sense because diltiazem + systolic heart failure would be more of a relative contraindication whereas sildenafil + nitrates are an absolute contradiction due to the obvious risk of profound hypotension.

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[Wanderer HitchHiker]

i thought the opposite that sildenafil can be given with 4 hours gap after nitrates that's why it should be relative ... but maybe i was confused and this percaution apply to prazosin and other alpha blockers not sildenafil, it was during CK preparation.
but for sure diltiazem and verapamil are contraindicated.

 

[Money Moniker]

Come on Bah Benz Brah, there is a whole sentence in the Sketchy pharm video on nitrates devoted to pointing out that PDE5 inhibitors are absolutely contraindicated with nitrates. A whole sentence! This should be a gimme.

 

[Wanderer HitchHiker]

and there's a whole guideline that say nondihydropyridine ccbs are contraindicated in systolic hf.
all i say is that both are contraindicated

 

[Instatewaiter]

You are right, both are contraindicated and the heart failure guidelines from 2013 make this abundantly clear. And because of this, you'd never get this question on a real exam for that reason. They may however give you someone with an EF of 40-45% as it is a gray area with heart failure with intermediate/mid-range EF and diltiazem.

However, in this circumstance, I think they are looking for you to recognize the interaction of PDE inhibitors and nitrates. But again, you'd never get this question on a real exam.

 

[Wanderer HitchHiker]

Instatewaiter, Thanks for your mature response.
No thanks to the childish person who thought this was funny