Cardiovascular drugs

Cardiovascular drugs

اسم المريض هدى جبارالعمر:59سنةHypertension Rx Chlortalidone (Hygroton®) 50mg tab.1 tab daily.
Q1-To which type of diuretics, Hygroton belong? Is it has a shorter or longer duration than other thiazide?
[ Hygroton is a thiazide-related compound , has longer duration of action than the thiazides ]
Q2-What is the optimum time of the day (morning, night…) for administration? [Diuretics ideally should be dosed in the morning if given once daily and in the morning and afternoon if dosed twice daily to minimize the risk of nocturnal diuresis (1).(However, with chronic use thiazides, potassium-sparing diuretics, and aldosterone antagonists rarely cause a pronounced diuresis.) (1)
Q3-What are the side effects of thiazides and loop diuretics on serum (potassium, glucose, uric acid, and lipids)? [hypokalaemia ,hyperglycaemia ,hyperuricaemia ,altered plasma-lipid conc. ]. Can we use Thiazides and related diuretics in patients with severe renal impairment? [should be avoided ]
Q4- 6 months later the patient develops Type II diabetes mellitus and the physician decide to replace Hygroton by Indapamide (Natrilix®) 2.5 mg tab. Once daily).what is the idea behind this choice? [indapamide claimed to lower B.P with less metabolic disturbance ,particularly less aggravation of DM ]

اسم المريض: هند باسمالعمر:40سنةOliguriaRx Furosemide ( lasix®) injection250mg to be given slowly with i.v fluid
Q5 -To which type of diuretics, furosemide belong? Loop diuretics
Q6-With which of the following IV fluid you can mix furosemide injection (sodium chloride sol., ringer's sol., glucose sol.)
[continuous I.V infusion in Sodium chloride 0.9%]
Q7-Does the hpokalemia greater with thiazide or with loop diuretics and why?[hypokalaemia greater with loop diuretics because of its site of action (inhibit reabsorption from the ascending limb of loop of Henle in the renal tubule and are powerful diuretics)

Q8-If the nurse administered it rapidly? What side effects can occur due to this rapid administration? [Tinnitus and Deafness ]

اسم المريض: نايري جنان العمر:55سنةAscites due to liver cirrhosisRx spironolactone (Aldactone®)100mg tablet 1 tablet daily after foodLactulose solution 30ml 3 times daily
Q9-To which class of diuretics, spironolactone belong, is it indicated for the above condition?[ potassium sparing diuretics ],[yes it is indicated for these conditions] Why it is given after food?[ It is usually given with food to increase bioavailability and decrease the GIT disturbances]
Q10-Whart are the side effects of spironolactone on breast in men .[gynaecomastia]
Q11-The Dr. want to prescribed 10mg spironolactone once daily for the patient's newborn baby who has congenital heart disease. How you can give him an accurate dose if the available dosage form of spironolactone in Iraq are only tablets of (25 mg,50mg,and 100mg) .[A simple syrup suspension can be made by crushing 8 of 25 mg spironolactone tablet and suspending the powder in 50 ml of simple syrup (final conc. Is 4 mg/ml) suspension is stable for about 1 month refrigerated. (4) . This process is called: Extemporaneous preparation: (preparation of liquid dosage form from solid dosage form).


اسم المريض: عبير عصام العمر: 50سنة :AnginaRx Atenolol (Tenormin®)50 mg tab 1 x1
Q12-What is atenolol (selectivity and Solubility). What advisory label should be given to patient taking atenolol (and B-blockers in general)?
[ atenolol is cardioselective, water-soluble Beta-Blockers ] [advisory label is Do not stop taking this medicine unless your doctor tell you to stop]

Q13- After the use of Tenormin, the patient begin to have a new complaint of bradycardia, cold extremities and difficulties in walking (intermittent claudication). Rationalize?[ Because atenolol is cardio selective but not cardio specific]. Would switching to pindolol or oxprenolol (Trasicor®) may alleviate these troublesome side effects? Why? [yes using these drugs alleviate these side effects because they have intrinsic sympathomimetic activity ,they tend to cause less bradycardia than the other BB ,and may also cause less coldness of extremities]

Q14-However, the Dr. decides to stop Tenormin and use calcium channel blockers. How would the Tenormin be stopped? Why? [gradual reduction of dose is preferable, because sudden withdrawal may cause an exacerbation of angina ]

اسم المريض: عامر جاسم العمر: 30سنةthyrotoxicosisRx Propranolol (Inderal®) 40mg tab. 1 tab T.i.d
Q15-What is Propranolol (selectivity and Solubility)[ is non-selective lipid soluble Beta-Blockers ]
Q16-Knowing that the patient is intended for thyroidoctomy. What is the idea behind the use of Inderal? In this condition
[use in pre-operative preparation for thyroidectomy ,it can reverse clinical symptoms of thyrotoxicosis within 4 days ,thyroid gland is rendered less vascular making the surgery more easier ]
Q17- 2 days later, the patient has new compliant of awakening many times during the night, nightmares, and fatigue. Rationalize? Would switching to Nadolol (Corgard®) may alleviate these troublesome side effects? Why? [is because propranolol is lipid soluble which can enter blood brain barrier and cause these SE, Nadolol can alleviate these problems because it is water-soluble and less likely to enter BBB ]
Q18-Could we used BBs safely if the patient has history of asthma and bronchospasm? [we can't use BBs safely ]
Q19-What are the other uses of beta blockers?
[ use in alleviate some symptoms of anxiety, palpitation ,tremor , tachycardia, prophylaxis of migraine , glaucoma ]

اسم المريض: علي طالب العمر:66 سنةStable heart failureRx Lisinopril 5mg tab 1x1Carvedilol 3.125 mg tab 1 tab B.i.d after food.Spironolactone 25 mg tab 1x1
Q20-Is it recommended to use B-blockers for heart failure?
What B-Blockers are currently recommended for this indication?
The current guidelines recommend use of β-blockers in all stable patients with HF and a reduced left ventricular ejection fraction (LVEF) in the absence of contraindications (1).
Carvedilol, Bisoprolol, Nebivolol , and metoprolol controlled released/extended release (CR/XL) are currently recommended for use as an adjunctive therapy for patients with heart failure(1) [nebivolol is licensed for stable mild to moderate heart failure in the elderly patients over 70 years
Q21-What is the initial and maximum dose of Carvedilol in CHF and how we can reach it ? [initial dose is 3.125mg twice daily (with food),dose increased at interval of at least 2 weeks to 6.25mg ,twice daily; then to 25mg twice daily ;increased to highest dose tolerated, max.25mg twice daily in patient with sever heart failure or body wt less than 85kg and 50mg twice daily in patients with more than 85kg]
Q22- Why it is given with food (In heart failure, it should be taken with food to reduce the risk of hypotension


Q23-What are the benefits of using low doses of spironolactone in patient with moderate to severe heart failure ? [reduce symptoms &mortality in those patients]

اسم المريض: عزيزة ياسرالعمر: 35سنةCHF and pulmonary edema RxCaptopril (capoten®) tab
Q24-Does ACE inhibitors valuable in CHF, What is usual starting dose, and maximum dose of captopril in CHF. [ ACEIs are used in all grades of heart failure]
[initially 6.25-12.5mg 2-3 times daily under close medical supervision ,increased gradually at intervals of at least 2 weeks up to max.150mg daily in divided dose if tolerated.

Q25-At what time of the day (morning, or bedtime) the first dose of ACE inhibitors is usually given? Why? [first dose at bedtime, because may feel dizzy when you first start taking ACEIs

Q26-Can we use ACE inhibitors safely in pregnancy? [should be avoided ]

اسم المريض: مروة سلمان العمر: 53سنةRx Hypertension and type I diabetes Lisinopril(Zestril®) 5mg tab. One tablet daily
Q27-Why does ACE inhibitors and angiotensin-II receptor blockers (ARBs) considered the drug of choice for hypertension in diabetic patient ?[ All patients with diabetes and hypertension should be treated with either an ACE inhibitor or an ARB. Both classes provide nephroprotection (against diabetic nephropathy) and reduced CV risk ]

Q28- What is the target BP for patient with hypertension and DM? [Goal blood pressure values are less than 140/90 for uncomplicated hypertension and less than 130/80 for patients with diabetes mellitus, chronic kidney disease, coronary artery disease (myocardial infarction [MI] or angina), or stroke.

Q29- 2 months later the patient develops persistent dry cough that persist throughout the day and also made it difficult for him fall asleep at night? Do you suggest to use one of the (ARBs) as an alternative? (give an examples)
[ yes I suggest to use one of them ,Examples , Candesartan, Valsartan , Losartan ,eprosartan ,telmisartan ]

اسم المريض: علي علاء الدين العمر:37سنةGlaucomaRx Timlol 0.5% eye dropApply one drop twice dailyAcetazolamide 250mg tab.
Q30-What is the main indication of timolol eye drop and acetazolamide (carbonic anhydrase inhibitors diuretic) in such patient.[reduce IOP in glucoma ,and for the emergency management of raised IOP]


Q31-Knowing that the patient is an asthmatic patient on Salbutamol 100 mcg inhaler taken as required since 2 years. But recently he noticed a significant increase in his need to use the inhaler. ?what is the most likely cause? [BB ,even those with apparent cardio selectivity shouldn’t be used in patients with asthma or a history of obstructive airways disease ,unless no alternative treatment is available .in such case the risk of inducing bronchospasm should be appreciated and appropriate precaution taken.

Q32-Can we use acetazolamide safely if the patient is allergic to sulfonamide?

[ no we can't use it {contraindicated} ]

Further reading

A-Monitoring the hypokalemic effect of loop and thiazide diuretics:

The maximum hypokalemic effect is seen within the first month , therefore we should monitor serum potassium at; Baseline (i.e. Before starting diuretic), after 2 weeks , and at the end of 1 month.
After that repeat measurement only if a disease state or dosage change occurs.
K-supplement or K-sparing diuretics should be initiated if serum K below 3.5 mEq/L (2)

B-***Diuretic-induced hyperuricemia can precipitate gout. This side effect may be especially problematic in patients with a previous history of gout. However, attacks are unlikely in patients with no previous history of gout. If gout does occur in a patient who requires diuretic therapy, allopurinol can be given to prevent gout and will not compromise the antihypertensive effects of the diuretic (1).
*****High doses of thiazides and loop diuretics may increase fasting glucose and serum cholesterol values. These effects, however, usually are transient and often inconsequential.(1)

C-Rate of administration of I.V furoesmide

When administering IV dose, toxicity is rates related, and therefore, max. rate is:
20mg /min if the dose is less than 100mg or:
4mg / min if the dose is greater than 100mg (mix with 50-100ml IV fluid)( 3)