Heart Failure

Question 1

What is the tx of chronic systolic heart failure?

Answer 1

Tx of chronic systolic heart failure:
> start an ACE inhibitor 
- low dose & increase slowly
- consider sartan if ACE inhibitor is not tolerated due to cough/angioedema(although cross-reactivity is possible)
> when stable, add a beta-blocker
- carvedilol
- controlled release metoprolol
- bisoprolol
- nebivolol
start with a low dose; increase slowly
> if still symptomatic, add an aldosterone antagonist treatment (eplerenone, spironolactone)
> if still symptomatic add digoxin

Question 2

Eplerenone.

Answer 2

Class: aldosterone antagonist
Indication: HF
Dose: 25-50mg d
AEs: Common
- hyperkalaemia
- hypotension
- dizziness
- altered renal function & increased creatinine concentration
Counseling: don’t take potassium supplements while you are taking this medicine unless your doctor tells you to
Monitoring:
- potassium concentration (at baseline, within 1 week, 1 month, then every 3 months and when clinically indicated
- stop tx/reduce dose if hyperkalaemia occurs

Question 3

Spironolactone.

Answer 3

Class: aldosterone antagonist

Indication:

• primary hyperaldosteronism
• refractory oedema associated with secondary hyperaldosteronism, eg cirrhosis of the liver
• hirsutism in females
• HF

Dose:

• range of 25-200mg d (1 or 2 doses)
• HF 25-50mg d

AEs:
Common
- hyperkaelamia, hyponatraemia, hypochloraemia
- weakness
- headache, nausea, vomiting
- mastalgia (breast pain)
Infrequent
- impotence
- gynaecomastia
- menstrual irregularities
- renal impairment
Rare
agranulocytosis, hepatotoxicity

Counseling: don’t take potassium supplements while you are taking this medicine unless your doctor tells you to

Monitoring:
- potassium (each week for the first month, then each month for 2 months, then every 3 months and when indicated)

Question 4

Frusemide.

Answer 4

Class: loop diuretic

Indication: 
oedema associated with:
- HF
- hepatic cirrhosis
- RI
- nephrotic syndrome

Dose: 20-400mg d. Max. 1g d

AEs:

• hyponatraemia, hypokalaemia, hypomagnesaemia
• dehydration
• gout, hyperuricaemia
• dizziness, orthostatic hypotension, syncope

Counseling:

• this medicine is usually taken once daily in the morning. If you are taking it twice a day, take the first dose in the morning and the second dose at lunchtime
• you may feel dizzy on standing when taking this medicine. Get up gradually from sitting/lying to minimise this effect; sit or lie down if you become dizzy

Question 5

Digoxin.

Answer 5

Class: cardiac glycoside

Indications:

• AF and atrial flutter
• heart failure

Dose:
Loading - 125–500 mcg q4–6h (max. 1.5 mg)
Maintenance - 62.5–500 mcg d

AEs: 
Common
- anorexia
- N&V&D
- blurred vision, visual disturbances
- confusion
- drowsiness, dizziness
- nightmares, agitation, depression

Counselling: tell your doctor/pharmacist that you are taking digoxin before using any other medicines including OTC and herbal products

Monitoring:

• renal function (b4 starting tx)
• electrolyte concentrations (b4 starting tx)
• digoxin toxicity (including resting heart rate)