Cardiology

AHA BP goals

< 130/80 for EVERYBODY

Start treatment:

Clinical CVD or 10-year ASCVD ≥10%: ≥130/80 mmHg

No Clinical CVD and 10-year ASCVD risk <10%: ≥140/90

Post-MI

Goal is to reduce myocardial workload

Betablocker (metoprolol or carvedilol) + ACEI

• Aldosterone antagonist ONLY if HF present

Stroke Prevention

Thiazide diuretics + ACEI

• NO betablockers- want to increase perfusion

Heart failure

Betablocker + ACEI + Loop Diuretics + Aldosterone antagonists + Hydralazine/Isosorbide Dinitrate

Thiazide diuretics

Inhibit exchange of Na and Cl in distal convoluted tubule. Best for hypertension

• Hydrochlorothiazide- adults

• Chlorothiazide- pediatrics

• Chlorothalidone- longer acting

  • Metolazone- thiazide analogue, more for edema/extra diuresis in HF

Thiazide interactions

CANNOT be used in anuric renal failure/GFR<30

• Interactions with digoxin, lithium- electrolyte based, can lead to toxicity

• Potential sulfonamide allergy

• Okay w/ other ototoxic drugs

Thiazide side effects

-DEcreases Na, K, Cl, phos, Mg

-INcrease Ca, glucose, uric acid, lipids

-Photosensitivity

Loop diuretics

Inhibit exchange of Na/K/Cl in the loop of Henle- where urine is concentrated. Best for heart failure

• Lasix- 2-3 doses/day

• Bumex- very potent, refractory to Lasix

• Ethacrynic acid- safe for sulfonamide allergies

• Torsemide

Loop interactions

CAN be used in chronic renal failure with GFR < 30

• Digoxin toxicity

• Lithium toxicity

• Ototoxic- careful w/ aminoglycosides

  • Potassium sparing diuretics- if not monitored

Loop side effects

• HYPOKALEMIA

• DEcreases Na, Cl, Mg, Ca

• INcrease glycose, uric acid, lipids

• Rash, photosensitivity

• Ototoxicity- esp. in IV administration. No more than 10mg/min

Aldosterone Antagonists

BLOCK aldosterone in the distal convoluted tubule and collecting ducts. Usually used in combo w/ other diuretics

• Spironolactone- potassium sparing! Good for ascites, HF, d/t neurohormonal modulation

Triamterene/Amiloride

Acts on Na-K exchange is distal nephron

• Potassium sparing diuretics

• NO aldosterone effects

• Faster acting than spironolactone

• Need frequent K levels

• Usually used in combo w/ thiazides

ACE inhibitors

Block conversion of angiotensin 1 to angiotensin 2 in the lungs, therefor blocking aldosterone production and water retention

• Arterial AND venous vasodilation

• Reduces preload and aterload

• Increases cardiac output

• No HR effects

• Renoprotective in DM, CKD as it lowers both afferent/efferent pressures

  • CONTRAINDICATED in renal artery stenosis

ACEI interactions

• Potassium supplements- DEcreases excretion

• Aspirin

• Diuretics- lowers BP

ACEI side effects

• Dry cough (bradykinin build up)

• Rash

• Hyperkalemia

• Angioedema- esp. black women

• Neutropenia- ANC < 1000

• Teratogenic

• Renal insufficiency- increased Cr

Angiotensin II Receptor Blockers (ARBS)

Blocks angiotensin II receptors on cell membranes. Good for CHF, HTN who have failed ACEIs

• Losartan, Valsartan, Candesartan, Irbesartan

• CONTRAINDICATED in renal artery stenosis

ARB interactions

• HYPERKALEMIA w/ potassium sparing diuretics or supplements

• NSAIDS- renal damage. Stop in AKI

ARB side effects

• Hyperkalemia

• Angioedema

• Teratogenic

• Cough (rare)

Calcium Channel Blockers

Block INFLUX of calcium into smooth muscle by binding to calcium channels in the heart, coronaries, and peripheral vasculature

• Hypertension (Dihydropyridines like Amlodipine, Felodipine, Nifedipine, Isradipine)

• Prinzmetal’s angina (at rest)

• Heart failure

• Arrhythmias (non-dihydropyridines like verapamil, diltiazem)

Verapamil

CCB that DEcreases heart rate, contractility, and conduction. Dilates smooth muscle of vasculature.

• CONSTIPATION

• Dizziness, headache,

• Gingival hyperplasia

• Nausea

• Lower extremity edema

Verpamil interactions

• Digoxin- slows heart conduction too much, can lead to block

• Beta blockers- same as above

Caution in heart failure/block- decreases contractility

Diltiazem

CCB that DEcreases heart rate, contractility, and conduction

• LESS constipation

• Similar side effects, interactions to other CCBs

• Caution in acute decompensated heart failure or heart block

Amlodipine/Felodipine

Dihydropyridine CCBs that DILATE

• Used for hypertension and decompensated heart failure

• Can cause headache, peripheral edema, gingival hyperplasia

• May interact with beta blockers (slow heart rate, lower blood pressure

Beta-Adrenergic Blockers

Work by competitively inhibiting beta-adrenergic agonists → DEcrease sympathetic nervous system response, inhibits renin release

• Especially good in MI

Nonselective beta blockers

Propanolol, nadalol, timolol, penbutol, careolol, pindolol

• Block beta 1 and 2 receptors

  • Can cause bronchoconstriction, sluggishness, nightmares, or glucose issues

Selective beta blockers

Metoprolol (rate control- post MI!), Atenolol (pressure control), acebutolol, betaxolol, esmolol

• Affect only beta 1 receptors (at normal doses)

  • Better in PVD, DM, reactive airway disease

Beta blocker indications

• Post-MI (esp. metoprolol)

• Angina

• Heart failure

CONTRAINDICATED in decompensated heart failure/fluid overload, diabetes, PVD, asthma, heart block

Beta blocker side effects

• Hypotension

• Bradycardia

• Nightmares

• Hyperlipidemia

• Impotence

• Drug withdrawal

Beta blocker interactions

• Other antihypertensives

• Oral hypoglycemics- may masking hypoglycemia symptoms of sweating, shaking (epinephrine-driven)

Carvedilol/Labetalol

Alpha/Beta Adrenergic Blocker: block beta 1, beta 2, and alpha 1 receptors

• May cause dizziness, orthostatic hypotension

• NO effects on lipid or carbohydrate metabolism

Alpha-1 Adrenergic blockers

Block alpha-1 receptors → arterial AND venous smooth muscle relaxation

• Used for hypertension, BPH

• Centrally acting!

• Decrease PVR/afterload

• Minimal changes in CO, renal blood flow, GFR

Prazosin

Alpha-1 blocker used for hypertension

• May cause palpitations

• Postural hypotension- especially with first dose!

• Syncope

Clonidine

Centrally acting ALPHA 2 agonist

• Used for hypertension, adjunct pain management

• Can cause REBOUND hypertension if stopped abruptly

• Also drowsiness, dizziness, dry mouth, constipation

  • Anticholinergic effects- harder on elderly

Methyldopa

Centrally acting ALPHA 2 agonist

• Can be useful for hypertension in pregnancy

• Can cause HEMOLYTIC ANEMIA, LUPUS-LIKE SYNDROME, sedation, orthostatic hypertension, increased LFTs

  • Frequent lab monitoring

Hydralazine

ARTERIAL vasodilator: decreases PVD/ afterload

• Used in hypertension/hypertensive crisis

• Can cause reflex tachycardia, headache, nausea, angina, lupus-like syndrome

NYHA heart failure classification

Class 1- No symptoms w/ normal activity

Class 2- Symptoms with ordinary activity

Class 3- Symptoms with less than ordinary activity

Class 4- Symptoms at rest

ACC/AHA Heart Failure Stages

Stage A- High risk for failure

Stage B- Asymptomatic structural heart failure

Stage C- Symptomatic structural heart failure

Stage D- Continuous symptomatic heart failure despite usual therapy

Compensation in heart failure

• Ventricular hypertrophy

• Activation of the adrenergic and RAA systems

  • Secretion of ADH and ANP/BNP → remodeling → fluid retention → increased demand

Left sided heart failure

Think lungs!

• Pulmonary congestion

• Cough, DOE, paroxysmal nocturnal dyspnea

• Cardiomegaly, rales, pulmonary edema

Right sided heart failure

Think REST of body!

• Systemic venous congestion

• Pitting edema

• Abdominal pain

• Hepatomegaly

• JVD

• Splenomegaly

• Ascites

High vs low output HF

Increased demand (like in thyroid disease) vs diminished pump function

Systolic vs Diastolic heart failure

Also Reduced EF (<30%) vs Preserved (>50%)

• Decreased pump function vs impaired ventricular filling

• Most patients have some of both!

Digoxin

Cardiac Glycoside: positive inotrope, DEcreases neurohormonal systems

• Inhibits Na/K ATPase → INcrease Ca influx to cardiac cells + Sensitizes cardiac baro receptors → DEcreased sympathetic outflow

• No effect on mortality, BUT improves quality of life

• Need frequent levels: goal 0.05-1

  • Monitor potassium levels

Spironolactone

Aldosterone antagonist: Decreases RAAS effect

• Good in heart failure

• May effect other adrenal hormones like cortisol or sex hormones

  • Can cause gynecomasty in men

    • Alternative is Eplerenone- very expensive!

CCB in HF

ONLY used if more afterload reduction is needed and other therapies have been maxed out

• Use dihydropyridines: Amlodipine, Nifedipine, Nicardipine

BiDil

Combination drug of hydralazine and isosorbide dinitrate for arterial/afterload and venous/preload dilation/reduction. May also mitigate nitrate tolerance, so nitric oxide stays around longer

• Used in HF where ACEIs and ARBs haven’t been effective

• Especially helpful in African American patients

• May cause headache, reflex tachycardia, GI effects, syncope, flushing

Isosorbide Dinitrate

Venous dilator that works by releasing nitric oxide in the blood vessel wall

• Lasts ~12 hours

• May be especially useful in AA patients with heart failure

Digoxin side effects

Digitalis intoxication- bradycardia, cognitive deficits

Nausea, vomiting

Dizziness

Visual disturbances

Hyper/hypokalemia, conduction abnormalities

VERY narrow therapeutic window!

INCREASE digoxin levels

• Amiodarone

• Calcium channel blockers

• Diuretics

• Macrolides

• Think CYP enzymes

DECREASE digoxin levels

• Antacids- needs an acidic environment to work

• Metoclopramide

• St. John’s Wort

Digoxin monitoring

Caution with electrolyte disorders, renal disease, thyroid disorders/hypermetabolic states

• Goal levels for CHF: 0.5-0.8

• Goal levels for Afib: 0.8-1.2

• Need to keep K at 4, Phos at 3, Mag at 2!

Entresto

Combination of ARB and Neprilysin inhibitor (Valsartan/Sacubitril). Also called an ARNI

• Neprilysin inhibition → raise BNP → additional diuresis → increase angiotensin II

• Valsartan blocks effects from angiotensin II

• Works over long term, not short term: for patients with worsening status despite other therapies maxed