Management of the older patient after myocardial infarction
Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich in Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Patients with prior MI and hypertension should be treated with β-blockers and angiotensin-converting enzyme (ACE) inhibitors (16,27–35). If a third drug is needed, aldosterone antagonists may be used based on the EPHESUS trial (36). Patients treated with aldosterone antagonists should not have significant renal dysfunction or hyperkalemia. In an observational prospective study of 1212 older men and women, mean age 80 years, with prior MI and hypertension treated with β-blockers, ACE inhibitors, diuretics, calcium channel blockers, or alpha-blockers, at 40-month follow-up the incidence of new coronary events in persons treated with one antihypertensive drug was lowest among those treated with β-blockers or ACE inhibitors (35). In older persons treated with two antihypertensive drugs, the incidence of new coronary events was lowest in those treated with β-blockers plus ACE inhibitors (35).
The Nephroprotective Effect of Antihypertensive Treatment
Giuseppe Mancia, Guido Grassi, Konstantinos P. Tsioufis, Anna F. Dominiczak, Enrico Agabiti Rosei in Manual of Hypertension of the European Society of Hypertension, 2019
In recent years, aldosterone is regarded as a mediator of progressive renal damage (53). It is therefore relevant that aldosterone antagonists reduce proteinuria in patients with chronic kidney disease, even if they are already on a RAAS blocker (54,55). In a meta-analysis, the addition of an aldosterone antagonist to an ACEi or an ARB, decreased proteinuria by an estimate of 30–40% (55). A limiting factor for the wide use of aldosterone antagonists is linked with the risk of inducing hyperkalaemia, which becomes a prominent concern as renal function deteriorates (54,55). The recent appearance of new potassium binders could facilitate the maintenance of RAAS blockade including an ACEi or an ARB plus an aldosterone blocker in patients with stage 3–4 or more advanced CKD (56) because of their capacity to control increases in serum potassium that impede adequate RAAS blockade.
Cardiovascular Medications in Pregnancy
Afshan B. Hameed, Diana S. Wolfe in 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].
Treatment of sleep apnea with a combination of a carbonic anhydrase inhibitor and an aldosterone antagonist: a patent evaluation of CA2958110 and IN6616DEN2012
Published in Expert Opinion on Therapeutic Patents, 2018
Andrea Angeli, Claudiu T. Supuran
Aldosterone is a hormone belonging to the mineralocorticoid family, and downstream effector of angiotensin II in the renin–angiotensin–aldosterone system. It is primarily synthesized by the adrenal cortex, but is also present in other tissues leading to local autocrine or paracrine effects [19]. The main activity is sodium reabsorption with concomitant potassium and hydrogen ion excretion and the more widespread effects of hyperaldosteronism include sympathetic nervous system activation, increased oxidant stress with inflammation, remodeling, and apoptosis [20]. Aldosterone antagonists are used for the treatment of several clinical pathologies, such as primary and resistant aldosteronism, heart failure, and chronic kidney disease. In this application, five clinically aldosterone antagonists with different pharmacological characteristics, such as spironolactone, canrenone, eplerenone, mexrenone, and prorenone (Figure 3) have been employed.
Neopterin as a novel marker; well correlated with mortality and morbidity in patients with advanced systolic heart failure
Published in Acta Cardiologica, 2019
Şerafettin Demir, Hüseyin Ede, Mehmet Kaplan, Fethi Yavuz, Ceyhun Yücel, İbrahim Halil Kurt
Heart faılure is a common disabling complex condition with a poor dıagnosıs. Systolic HF is a leading cause of morbidity and mortality. Unless contraindicated, an ACE inhibitor and a beta blocker should be prescribed. Diuretics may be useful for control of oedema. For patients who remain symptomatic, an aldosterone antagonist may be considered. After this medications ivabradine, cardiac resynchronisation therapy or angiotensin neprilysin inhibitors may be considered. Overall the whole population, 0.2% were hospitalised due to HF per year, consisting of 5% of all medical admissions [1]. In ECHOES study, five-year mortality rate was found to be 47% [2]. In our study, one-year mortality rate was 36%. Higher mortality rate in our study can be explained by considering inclusion of subjects with advanced HF (NYHA class III or IV), lower LVEF, higher frequency of DM compared to subjects in ECHOES trial. It has been shown that every 5% decrement in EF under 45% leads a 14% increment in risk of death among patients with chronic HF [21]. Similarly, number of female patients was relatively less than male patients but this was not contradicting the literature. Since 69.4% of patients with systolic HF in ECHOES population and approximately 70% of the study population by Pocock et al. were males [2,21].
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].
Related Knowledge Centers
- Diuretic
- Hirsutism
- Receptor Antagonist
- Spironolactone
- Drug
- Aldosterone
- Mineralocorticoid Receptor
- Heart Failure
- Hyperaldosteronism
- Primary Aldosteronism