The first-time diuretic for managing CHF with volume overload

Provide strong natriuresis and diuresis, thus lower congestion-related symptoms in CHF

Improve quality of life, but not survival (mortality)

Serum K+ for patients on concomitant therapy of potassium-sparing diuretics and ACEIs/ARBs/NSAIDs/K+

Serum creatinine/eGFR for renal function monitoring

Add-on therapy in resistance hypertension, esp. in patients not responding to standard triple therapy

For HFrEF patients with LVEF <35% and NYHA Class II-IV symptoms - thus lower hospitalisations, lower mortality and improved symptoms and cardiac remodelling

Prevent hypokalemia

For primary hyperaldosteronism, and cirrhosis-related oedema ascites

First-line choice for patients with HFrEF (LVEF<40%): A vasodilator widens blood vessels to lower BP and decreased heart workload

Ex: Captopril, enalapril, fosinopril, lisinopril, quinapril

Inhibits ACE resulting in vasodilation ↦ lower BP, SVR, afterload, aldosterone release

Increase bradykinin level (potent vasodilator)

Pregnancy, renal artery stenosis

Hyperkalemia, hypotension, dry cough, dizziness, renal dysfunction

A vasodilator widens blood vessels to lower BP and decreased heart workload (alternative for ACEIs intolerant patients with symptomatic HF)

Ex: Losartan, valsartan, candesartan

Uses

Potent competitive antagonists of Ang II type 1 receptor: vasodilatation, lower afterload., SNS activity, aldosterone release

Hyperkalemia, renal failure, hypotension, dizziness, fatigue

Hyperkalemia (K+), pregnancy, bilateral renal artery stenosis

Mainly decreased preload (venodilation) and afterload (arteriolar dilation) ↦ relive congestion and improve haemodynamics and symptoms

Include: > Isosorbide dinitrate (Isordil) - Nitrate (venodilator for angina) > Nitroprusside (Nipride) - Direct vasodilator (IV use veno-) > Hydralazine (Apresoline) - Arteriodilator (used with nitrates in African-American HF patients) > Prazosin (Minipress) - a1-blocker (arteriodilator for HPT)

Uses

Venodilators ↦ increase venous capacitances, lower venous return and preload

Arteriodilators ↦ lower SVR and afterload

Lower preload and afterload ↦ lower myocardial O2 demand and improved CO

Can cause hypotension, reflex tachycardia, or headache

Nitroprusside: risk of cyanide toxicity

Nitrates: tolerance develops with long-term use

Cardioprotective hormones released by ventricular myocytes ↦ due to volume overload

The good side of HF response cause: vasodilation, natriuresis, decreased cardiac remodeling

Serves as a counter-regulator system to RAAS and SNS overactivation

Broken down by enzyme lysin

Play role both physiologically and pharmacologically

Suppress RAAS and SNS activation (act as natural antagonist)

Lower myocardial fibrosis and hypertrophy

Therapeutic use (limited use): Nesiritide

Related therapy: ARNI ↦ increase NP activity

Information

Used

S/Es

Contraindications

2 major pathways

A newer class of drugs used to treat HF, superior to ACEi

Sacubitril/valsartan = the 1st agent approved by FDA

Uses

Sacubitril = stops lysin breaking down NPs ↦ NPs stay active

Valsartan = blocks angiotensin II receptors, lower vasoconstriction, lower aldosterone (fluid retention) ↦ lower BP and workload

Lower BP, preload/afterload, improved heart function

Hypotension, hyperkalemia, renal impairment,

Not be used concomitantly with ACEIs

Patients with a history of ACEi/ARB-induced angioedema

Use caution in patients with hyperkalemia, hypotension, renal impairment

A new class of vasodilator and cardioprotective drugs

Ex: Riociguat, Vericiguat

Riociguat: Pulmonary arterial hypertension, and chronic thromboembolic pulmonary hypertension

Vericiguat: Chronic symptomatic HFrEF, especially after recent decompensation

Enhance the NO-sGC-cGMP pathway, promoting vasodilation and improving hemodynamics

Directly stimulate sGC enzyme in vascular smooth muscle ↦ improved endothelial and cardiac function

Cardiovascular: Hypotension, syncope

Hematologic: Anemia

CNS: Headache, dizziness

GI: Dyspepsia, nausea, diarrhea

Others: Peripheral edema

Pregnancy, concurrent use with PDE5 inhibitors, concurrent use with nitrates, symptomatic hypotension

Inhibitors were developed for DM = lower blood sugar by making the kidneys excrete glucose through urine

SGLT2i works independently of insulin ↦ so low risk of hypoglycemia

Treat T2DM, HF, CKD

Start SGLT2i early, as soon as T2DM, heart failure, or CKD is diagnosed

Include: Empagliflozin, Dapagliflozin, Canagliflozin, Ertugliflozin

Selectively inhibit SGLT2 transporter in proximal tube ↦ lower glucose reabsorption ↦ lower intraglomerular pressure

Increase NO bioavailability ↦ improves vasodilation & endothelial function

Overall result: Protects endothelial cells, and reduces vascular and renal damage

Genital mycotic and UT infections, volume depletion (hypotension, dizziness, dehydration), diabetic ketoacidosis

T1DM, severe kidney disease, or a hystory of ketoacidosis

Use caution in dehydrated/elderly/infection-prone patients

A selective sinus node inhibitor. AKA: If channel blocker/HR-reducing agent

Lower HR without affecting contractility, ventricular repolarization

For chronic, stable angina in sinus rhythm, patients, when BB are contraindicated, or as add-on therapy in symptomatic patients

As an adjunctive therapy for chronic HF patients who remain symptomatic and tachycardic

Selectively inhibits the "funny current", a mixed Na+/K+ inward current in the SA node that controls spontaneous HR

Overall, improve myocardial O2 balance and relief of angina

Cardiac (bradycardia, AF, conduction block, hypotension, syncope)

Visual (phosphenes: visual brightness, light flashes, blurred vision)

Neurological (dizziness, fatigue, headache)

Severe bradycardia

Pregnancy and lactation

Hypersensitivity

Caution: Concomitant HR-lowering drugs

Mild-moderate hepatic impairment

Elderly patients

Hypotension

Potent vasodilators, used to treat symptoms of HF

Include: Nitroglycerin, isosorbide dinitrate, isosorbide mononitrate

Uses

Vascular smooth muscle in veins, systemic arteries, coronary arteries: nitrates are converted into NO = vasodilation (mainly venodilation)

Nitrates + Hydralazine: Hydralazine is a direct vasodilator + nitrate ↦ balanced vasolidation

Headache (cerebral vasodilation)

Hypotension (excessive venodilation)

Reflex tachycardia (short-acting nitrates)

Vasodilatory effects (flushing, dizziness, syncope)

Severe hypotension, right ventricular infarction, severe anemia, hypersensitivity to nitrates