CVS: ACEi, ARB, BB, loop diuretics, aldosterone antagonists, digoxin Flashcards
ACEi/ARB/BB/Loop diuretics/Aldosterone antagonist/Digoxin (42 cards)
Indications for ACEi?
E.g. ramipril, lisinopril, perindopril
HTN
Chronic heart failure
Ischaemic heart disease
Diabetic neuropathy with proteinuria
CKD with proteinuria
Mechanism of action for ACEi?
Blocks the action of angiotensin-converting enzyme, which prevents the conversion of angiotensin I to angiotensin II.
This reduces peripheral vascular resistance, which reduces BP.
ACEi can dilate the efferent glomerular arteriole, which reduces intraglomerular pressure and slows the progression of CKD.
ACEi reduces aldosterone level, which promotes sodium and water excretion. This reduces venous return, which is beneficial in HF.
Adverse effects of ACEi?
Dry cough
Hypotension
Hyperkalaemia
Renal failure
Angioedema
Anaphylactoid reaction
Warnings of ACEi?
Avoid ACEi in patients with:
- renal artery stenosis
- AKI
- pregnant women/planning to conceive
- breastfeeding women
Lower dose for CKD -monitor renal function closely.
Interactions of ACEi?
Avoiding prescribing ACEi and other potassium-elevating drugs
ACEi + diuretics -associated with first dose hypotension
ACEi + NSAID -increases risk of nephrotoxicity
How do you monitor ACEi?
Efficacy (reduced symptoms)
- reduced SOB
- BP controlled
Safety
- U&Es (before starting tx, repeat 1-2wks into tx and after increasing dose).
- STOP ACEi if serum creatinine concentration increases more than 30% OR the eGFR falls more than 25%.
- if serum potassium is above 5.0mmol/L, stop other potassium-elevating drugs and nephrotoxic drugs. If it is still high, lower ACEi dose.
- STOP ACEi if potassium is >6.0mmol/L.
Patient education for ACEi?
ACEi aims to improve BP/reduce strain on the heart.
May cause dizziness after first dose due to low BP.
May experience dry cough.
Seek urgent medical advice if they experience an allergic reaction like facial swelling or stomach pain.
Requires blood test monitoring to assess kidney function and potassium levels.
Avoid OTC anti-inflammatories due to risk of kidney damage.
Indications of ARB?
E.g. losartan, candesartan, irbesartan
HTN
Chronic HF
Ischaemic heart disease
Diabetic neuropathy with proteinuria
CKD with proteinuria
Mechanism of action for ARB?
Blocks the action of angiotensin II on the angiotensin types 1 receptor.
This reduces peripheral vascular resistance, which lowers BP.
ARB can dilate glomerular arteriole, which reduces intraglomerular pressure and slows the progression of CKD.
Reducing aldosterone level leads to sodium and water excretion. This reduces venous return, which is beneficial in HF.
Adverse effects of ARB?
Hypotension
Hyperkalaemia
Renal failure (esp pts with renal artery stenosis)
GI symptoms
Warnings of ARB?
Avoid in pts with:
- renal artery stenosis
- AKI
- pregnant women/planning to conceive
- breastfeeding
Lower dose in CKD -monitor renal function closely
Interactions of ARB?
Avoiding prescribing ACEi and other potassium-elevating drugs
ACEi + diuretics -associated with first dose hypotension
ACEi + NSAID -increases risk of nephrotoxicity
Monitoring of ARB?
Efficacy (reduced symptoms)
- reduced SOB
- BP controlled
Safety
- U&Es (before starting tx, repeat 1-2wks into tx and after increasing dose).
- STOP ACEi if serum creatinine concentration increases more than 30% OR the eGFR falls more than 25%.
- if serum potassium is above 5.0mmol/L, stop other potassium-elevating drugs and nephrotoxic drugs. If it is still high, lower ACEi dose.
- STOP ACEi if potassium is >6.0mmol/L.
Pt education on ARB?
ARB aims to improve BP/reduce strain on the heart.
May cause dizziness after first dose due to low BP.
Won’t experience dry cough like in ACEi.
Requires blood test monitoring to assess kidney function and potassium levels.
Avoid OTC anti-inflammatories due to risk of kidney damage.
Indication of BB?
E.g. bisoprolol, atenolol, propranolol, metoprolol, carvedilol
Ischaemic heart disease
Chronic HF
AF
SVT (Supraventricular tachycardia)
HTN
Mechanism of action of BB?
Two subtypes of beta receptors:
- Beta 1 adrenoreceptors (found in the heart)
- Beta 2 adrenoreceptors (found in smooth muscle of blood vessels and airways)
Via B1 receptor, BB reduce force of contraction and speed of conduction in the heart. This relieves myocardial ischaemia by reducing cardiac work
BB improves prognosis in HF by protecting the heart from chronic sympathetic stimulation
BB slows the ventricular rate in AF by prolonging the refractory period of AV node.
BB may terminate SVT.
BB lowers BP, for e.g by reducing renin secretion from the kidney.
Adverse effects of BB?
Fatigue
Cold extremities
Headache
GI disturbance
Impotence (unable to achieve or maintain erection or ejaculation)
Warnings of BB?
Contraindicated in asthma (bronchospasm) and heart block.
Avoid in haemodynamically instable pts.
Offer B1 selective BB for COPD pts (e.g. bisoprolol, metoprolol).
In HF, start very low dose and increase slowly.
Reduce dose in hepatic failure.
Interactions of BB?
Do not prescribe BB with non-dihydropyridine CCB (e.g. verapamil, diltiazem).
This can lead to heart failure, bradycardia, and asystole.
Monitoring of BB?
Adjust dose according to symptoms and heart rate.
In ischaemic heart disease, aim for resting HR of 55-60bpm.
Pt education on BB?
Discuss common SEs, including impotence in men.
Seek medical attention if symptoms deteriorate in HF pts.
If pts with obstructive airway disease develop breathing difficulty, STOP BB and seek medical advice.
Indications for loop diuretics?
E.g. furosemide, bumetanide
Acute pulmonary oedema
Chronic HF
Fluid overload in other conditions (e.g. renal disease, liver failure)
Mechanism of action of loop diuretics?
Loop diuretics act on the ascending limb of the loop of Henle, where they inhibit the Na+/K+/2Cl- co-transporter.
- This stops ions entering the epithelial cell from the tubular lumen. So water is unable to follow via osmosis, hence there is a strong diuretic effect (more urine outflow).
Loop diuretics cause dilation of capacitance veins, which reduces preload and improves contractile function of the heart muscle in acute heart failure.
Adverse effects of loop diuretics?
Dehydration
Hypotension
Increases urinary losses of Na+, K+, Cl-, which indirectly increases excretion of Mg2+, Ca2+, H+.
- hyponatraemia
- hypokalaemia
- hypochloraemia
- hypocalcaemia
- hypomagnesaemia
- metabolic alkalosis
Hearing loss
Tinnitus
