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Non-Communicable Diseases - Coggle Diagram
Non-Communicable Diseases
Heart Failure
Diuretics
Aldosterone and heart failure
Effects: Na & water retention, promotion of cardiac fibrosis, endothelial dysfunction
Spironolactone
Aldosterone antagonist - binds to mineralocorticoid receptor and decreases ENaC
Indication: NYHA III & IV despite treatment with ACE-I & Beta-blocker
Side effects: hyperkalaemia (especially when given with ACE-I) - do not give if K>5 OR Creat >120, affinity for other steroid receptors (gynaecomastia, hirsutism, sexual dysfunction)
Furosemide (loop diuretic)
MOA: Inhibits Na/K/Cl co-transporter
Side effects: electrolyte disturbances, hearing loss (ototoxicity), dehydration, metabolic alkalosis
Hydrochlorothiazide (thiazide diuretic)
MOA: Inhibits NaCl channel
Side effects: electrolyte disturbances, hyperuricaemia (& gout), hypercalcaemia, high doses = glucose intolerance & adverse lipid profile
Renin-angiotensin system blockers
ACE-I
Improvement in symptoms & prognosis: survival, rate of hospitalisation, symptoms, cardiac performance, neurohormonal levels, reverse remodeling
Side effects: increased plasma K, hypotension, decreased GFR, chronic dry cough
Contraindications: renal artery stenosis, pregnancy, previous angioedema, aortic stensois
If not tolerated - consider ARB
ANGIOEDEMA: withdraw ACE-I, supportive treatment, corticosterois + anti-histamine + adrenalin, once resolve discuss using ARB with specialist
ARB
Inotropes
Digoxin
MOA: positive inotropic (inhibts Na/K ATPase in myocardium, increased intracellular Ca) & increased parasympathetic activity (increased vagal activity)
Indications: AF, beta-blocker fail to control HR <70bpm, moderate/severe symptoms despite being on optimal treatment
Narrow margin - effective therapeutic & toxic doses. Check renal fx & potassium (hypokalaemia)
Features of toxicity
GI: anorexia, N&V, diarrhoea
Neuro: malaise, fatigue, confusion, facial pain, insomnia, depression, vertigo, coloured vision (halos around lights)
Cardiac: palpitations, arrythmias, syncope
Drugs contraindicated
NSAIDs - inhibits effect of diuretics & ACE-I, cause salt & water retention, can worsen both cardiac & renal fx
COX-2 inhibitors - same as NSAIDs
Tricyclic antidepressants (proarrhythmic potential)
Corticosteroids - adverse effects on salt & water retention
Non-dihydropyridine calcium antagonists - direct negative inotropic agents
Beta Blockers
Long-term benefits: survival, control of heart failure, reduced need for hospitalisation, improved quality of life, LV ejection fraction
Short-term risks: worsening HF, bradyarrhythmias, prolonged intraventricular conduction, hypotension, worsening renal fx
Principles: start low, titrate up (monitor for adverse effects, add to existing ACE-I & diuretics when stable, never stop abruptly (risk ischaemia & infarction)
Proven benefit only for carvedilol, metoprolol & bisoprolol
Contra-indications: HR<60, symptomatic hypotension, ?fluid retention?, signs of peripheral hypoperfusion, PR interval >0.24s, 2nd/3rd degree AV block, history of asthma/reactice airways, PAD with rest pain
MOA:
Atenolol - risk of type 2 diabetes, they impact on how well insulin works
Chronic management
Step 1: ACE-I & diuretic (mild = thiazide, significant fluid overload or poor renal fx = loop)
Step 2: Add Carvedilol
Step 3: Add Spironolactone
Step 4: Add Digoxin (discuss with specialist)
Statins
Familial hypercholesterolaemia
Diabetes