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AP > CVS: ACEi, ARB, BB, loop diuretics, aldosterone antagonists, digoxin > Flashcards

CVS: ACEi, ARB, BB, loop diuretics, aldosterone antagonists, digoxin Flashcards

ACEi/ARB/BB/Loop diuretics/Aldosterone antagonist/Digoxin

1
Q

Indications for ACEi?

E.g. ramipril, lisinopril, perindopril

A

HTN
Chronic heart failure
Ischaemic heart disease
Diabetic neuropathy with proteinuria
CKD with proteinuria

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2
Q

Mechanism of action for ACEi?

A

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.

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3
Q

Adverse effects of ACEi?

A

Dry cough
Hypotension
Hyperkalaemia
Renal failure
Angioedema
Anaphylactoid reaction

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4
Q

Warnings of ACEi?

A

Avoid ACEi in patients with:
- renal artery stenosis
- AKI
- pregnant women/planning to conceive
- breastfeeding women

Lower dose for CKD -monitor renal function closely.

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5
Q

Interactions of ACEi?

A

Avoiding prescribing ACEi and other potassium-elevating drugs

ACEi + diuretics -associated with first dose hypotension

ACEi + NSAID -increases risk of nephrotoxicity

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6
Q

How do you monitor ACEi?

A

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.

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7
Q

Patient education for ACEi?

A

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.

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8
Q

Indications of ARB?

E.g. losartan, candesartan, irbesartan

A

HTN
Chronic HF
Ischaemic heart disease
Diabetic neuropathy with proteinuria
CKD with proteinuria

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9
Q

Mechanism of action for ARB?

A

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.

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10
Q

Adverse effects of ARB?

A

Hypotension
Hyperkalaemia
Renal failure (esp pts with renal artery stenosis)
GI symptoms

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11
Q

Warnings of ARB?

A

Avoid in pts with:
- renal artery stenosis
- AKI
- pregnant women/planning to conceive
- breastfeeding

Lower dose in CKD -monitor renal function closely

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12
Q

Interactions of ARB?

A

Avoiding prescribing ACEi and other potassium-elevating drugs

ACEi + diuretics -associated with first dose hypotension

ACEi + NSAID -increases risk of nephrotoxicity

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13
Q

Monitoring of ARB?

A

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.

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14
Q

Pt education on ARB?

A

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.

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15
Q

Indication of BB?

E.g. bisoprolol, atenolol, propranolol, metoprolol, carvedilol

A

Ischaemic heart disease
Chronic HF
AF
SVT (Supraventricular tachycardia)
HTN

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16
Q

Mechanism of action of BB?

A

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.

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17
Q

Adverse effects of BB?

A

Fatigue
Cold extremities
Headache
GI disturbance
Impotence (unable to achieve or maintain erection or ejaculation)

18
Q

Warnings of BB?

A

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.

19
Q

Interactions of BB?

A

Do not prescribe BB with non-dihydropyridine CCB (e.g. verapamil, diltiazem).

This can lead to heart failure, bradycardia, and asystole.

20
Q

Monitoring of BB?

A

Adjust dose according to symptoms and heart rate.

In ischaemic heart disease, aim for resting HR of 55-60bpm.

21
Q

Pt education on BB?

A

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.

22
Q

Indications for loop diuretics?

E.g. furosemide, bumetanide

A

Acute pulmonary oedema
Chronic HF
Fluid overload in other conditions (e.g. renal disease, liver failure)

23
Q

Mechanism of action of loop diuretics?

A

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.

24
Q

Adverse effects of loop diuretics?

A

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

25
Q

Warnings of loop diuretics?

A

Contraindicated in severe hypovolaemia and dehydration.

Caution in:
- hepatic encephalopathy
- hypokalaemia
- hyponatraemia

Can worsen gout -loop diuretics taking chronically can inhibit uric acid excretion.

26
Q

Interactions of loop diuretics?

A

Can affect drugs excreted by kidneys.

  • Increased lithium levels (due to reduced excretion)
  • Increased digoxin toxicity risk (due to diuretic-associated hypokalaemia).
  • Increase ototoxicity and nephrotoxicity of aminoglycosides.
27
Q

Monitoring of loop diuretics?

A

Efficacy
- improvements in symptoms

Monitor:
- weight (aim for losses <1kg/day)

Safety:
- U&Es (particularly in first few wks of tx)

28
Q

Pt education on loop diuretics?

A

Explain to pt that their body is overloaded with water.

Loop diuretic increase urine flow to improve this.

Taking doses earlier in the day will prevent from getting up at night to use the toilet.

29
Q

Indications of aldosterone antagonists?

E.g. spironolactone, eplerenone

A

Ascites and oedema in liver cirrhosis
Chronic HF
Primary hyperaldosteronism

30
Q

Mechanism of action of aldosterone antagonists?

A

Inhibits the effects of aldosterone by competitively binding to the aldosterone receptor.

This increases sodium and water excretion AND potassium retention.

31
Q

Adverse effects of aldosterone antagonists?

A

Hyperkalaemia
Muscle weakness
Arrhythmias
Gynaecomastia
Liver impairment
Jaundice
Stevens-Johnson syndrome (causes bullous skin eruption)

32
Q

Warnings of aldosterone antagonists?

A

Contraindicated in pts with:
- severe renal impairment
- hyperkalaemia
- Addison’s disease

Avoid in pregnant or breastfeeding women.

33
Q

Interactions of aldosterone antagonists?

A

Increase risk of hyperkalaemia if combined with potassium-elevating drugs.

Should not be combined with potassium supllements.

34
Q

Monitoring of aldosterone antagonists?

A

Efficacy
- improvement in symptoms like reduction in ascites, oedema, BP.

Safety
- U&Es
- serum potassium

35
Q

Pt education on aldosterone antagonists?

A

Warn men about growth and tenderness of tissue under the nipples and impotence, but it is benign and reversible.

Return to GP to reduce dose if you’re having troublesome SEs.

Can cause potassium levels to increase, hence monitoring blood tests are important.

36
Q

Indications of digoxin?

A

AF
Atrial flutter
Severe HF

37
Q

Mechanism of action of digoxin?

A

Negatively chronotropic (reduces HR)
Positively inotropic (increases force of contraction)

In AF and atrial flutter:
- Increased vagal (parasympathetic) tone reduces conduction of the AV node, hence reducing the ventricular rate.

In heart failure:
- digoxin inhibits Na+/K+-ATPase pumps, which causes accumulation of Na+ in the cell. This causes Ca2+ to accumulate in the cell, increasing contractile force.

38
Q

Adverse effects of digoxin?

A

Bradycardia
GI disturbance
Rash
Dizziness
Visual disturbance (blurred or yellow vision)
Arrhythmias
Digoxin toxicity (narrow therapeutic index)

39
Q

Warnings of digoxin?

A

Contraindicated in:
- 2nd degree heart block
- intermittent complete heart block
- ventricular arrhythmia

Reduce dose in renal failure.

Certain electrolyte abnormality increase the risk of digoxin toxicity:
- hypokalaemia
- hypomagnesaemia
- hypercalcaemia

40
Q

Interactions of digoxin?

A

Loop and thiazide diuretics increase the risk of digoxin toxicity due to hypokalaemia.

Drugs that increase concentration of digoxin, thus digoxin toxicity:
- CCB
- amiodarone
- spironolactone
- quinine

41
Q

Monitoring of digoxin?

A

Efficacy:
- improvements in symptoms
- heart rate

Monitor:
- ECG
- U&Es

May cause ST-segment depression (reverse tick sign) -does not signify toxicity.

Digoxin levels are not routinely monitored, but helpful when suspecting toxicity.

42
Q

Pt education on digoxin?

A

Aims to slow down HR and make their heart beat more strongly.

Common SEs e.g. GI disturbances and headache.

Seek medical advice if SEs are getting worse as the dose might be too high.

AP (27 decks)

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