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Cardiac diseases in pregnancy
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Saravanan Kuppuswamy, Sudarshan Balla
Angiotensin-converting enzyme inhibitors (ACEI), and angiotensin receptor blockers (ARB), and aldosterone antagonists like spironolactone are contraindicated throughout pregnancy. Due to the risks of embryopathy associated with ACE inhibitor use in the first trimester, ACEI should be discontinued when the woman with chronic stable HF is attempting conception. Beta blockers are generally safe and effective during pregnancy, although some adverse effects have been reported (106).
Respiratory, endocrine, cardiac, and renal topics
Published in Evelyne Jacqz-Aigrain, Imti Choonara, Paediatric Clinical Pharmacology, 2021
Evelyne Jacqz-Aigrain, Imti Choonara
Spironolactone is an aldosterone antagonist. It has weak diuretic action and increases potassium reabsorption. Because of this potassium-sparing effect, it is often associated with other diuretics, such as thiazides or furosemide (see above).
Cardiovascular Medications in Pregnancy
Published in Afshan B. Hameed, Diana S. Wolfe, Cardio-Obstetrics, 2020
Heart failure with pulmonary congestion is treated with loop diuretics and thiazides if required; however, diuretics should be avoided in the absence of pulmonary congestion, due to the potential reduction in placental blood flow [28]. Hydralazine and nitrates can be used instead of ACEIs/ARBs for afterload reduction. Dopamine and levosimendan can be used if inotropic drugs are needed. Beta blockers can also be used in pregnancy but should be prescribed with careful titration to the tolerated dose [1]. Beta-blocker treatment is indicated for all patients with congestive heart failure if it is tolerated, with the preference of using B1-selective drugs (i.e., metoprolol). Atenolol should not be used. Diuretics should only be used if pulmonary congestion is present since they may decrease blood flow over the placenta [29]. Furosemide and hydrochlorothiazide are the two most frequently used. Aldosterone antagonists such as spironolactone should also be avoided since it can be associated with antiandrogenic effects in the first trimester. Data for eplerenone are lacking [30].
Optimal cardiovascular medical therapy: current guidelines and new developments
Published in Baylor University Medical Center Proceedings, 2022
Shirley Cotty Reed, Nikita Dhir, R. Jay Widmer
When implementing use of aldosterone antagonists, caution is advised for patients with renal dysfunction or hyperkalemia. The RALES, EMPHASIS-HF, and EPHESUS trials excluded patients with serum creatinine >2.5 mg/dL (or estimated glomerular filtration rate <30 mL/min/1.73 m2 in EMPHASIS-HF) and serum potassium >5.0 mEq/L. In the RALES trial, incidence of serious hyperkalemia was not significantly different in patients treated with spironolactone compared to placebo. In the EPHESUS and EMPHASIS-HF trials, a higher incidence of potassium >5.5 mEq/L was reported in the eplerenone treatment groups compared to placebo; however, doses were titrated to 50 mg in the trials.26,27 With both trials, one notable finding was that the earlier these agents were implemented in the therapeutic regimen, the greater the improvement. Thus, aldosterone antagonists should be used early and often in patients with reduced ejection fraction—especially after large anterior MI—assuming there are no perturbations in renal function or potassium levels. Compared to spironolactone, eplerenone also appears to have a reduced proclivity toward causing gynecomastia, which can be a troubling side effect in men.
Pharmacological management of portal hypertension and its complications in children: lessons from adults and opportunities for the future
Published in Expert Opinion on Pharmacotherapy, 2021
Sarah Henkel, Carol Vetterly, Robert Squires, Patrick McKiernan, James Squires
The first line diuretic therapy for patients with liver disease are aldosterone antagonists, most commonly spironolactone [50]. Aldosterone antagonists combat the hyperaldosteronism inherent in ascites accumulation secondary to portal hypertension and selectively antagonize sodium retention due to aldosterone, aiding in a gentle diuresis [47]. In addition, studies have shown that adult patients with cirrhosis have delayed metabolism of spironolactone, so lower doses and daily dosing can achieve a sustained effect [51]. Following initiation of aldosterone antagonists, 3–5 days of therapy are needed before the full clinical response is realized and a decision to increase the dose can be made. Known side effects of spironolactone are hyperkalemia, acidosis, and gynecomastia; other aldosterone antagonists such as eplerenone, may provide similar diuretic effects without reported side effects [51,52].
Antihypertensive treatment for hypertensive patients with heart failure using real-world Japanese data: subanalysis of the Retrospective study of antihypertensives for lowering blood pressure (REAL) study
Published in Clinical and Experimental Hypertension, 2020
Mitsuru Ohishi, Takuo Yoshida, Nobuhiro Nishigaki, Akinori Oh, Yukio Shimasaki
Regarding the category of diuretics, a difference between patients in the general group and the HF subgroup was also observed in the JMDC database. Thiazide diuretics were more often prescribed in patients in the general group, while loop diuretics were more common in patients in the HF subgroup. Comparing hospitals and clinics in the HF subgroup, thiazide diuretics were most frequently prescribed in clinics while loop diuretics were most frequently prescribed in hospitals. Loop diuretics and aldosterone antagonists were frequently prescribed for patients in both the general group and the HF subgroup in the MDV database. Loop diuretics provide a more pronounced diuretic effect but have a lesser blood pressure-lowering effect than thiazide diuretics (28); therefore, thiazide diuretics are more commonly used as an antihypertensive drug (29). Loop diuretics are generally used as HF treatment to reduce symptoms caused by congestion (10). Aldosterone antagonists reduce the risk of both morbidity and death among patients with severe HF when added to standard therapy (30). Aldosterone antagonists, in particular, are recommended for patients with severe or refractory HF (10). Therefore, the results suggest that treatment of hypertension might be prioritized in clinics, while treatment of HF might be a priority over that of hypertension for patients in the HF subgroup in hospitals, including DPC hospitals.