0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
324 Chronic Heart Failure➣Side effects: cardiac arrhythmias (ectopic and reentrant tachy-
cardias), bradycardia and heart block, anorexia, nausea, vomit-
ing, visual disturbances (“yellow halo”), disorientation, con-
fusion, hypotension, fluid retention and worsening of heart
failure, worsens bronchospasm, CNS symptoms (depression, ni-
ghtmares, excitement, confusion), fatigue, lethargy, impotence,
increase triglycerides (depression of HDL).
➣Absolute Contraindications: Ventricular fibrillation, ventricular
tachycardia, significant AV block, anuria.
➣Relative Contraindications: Renal failure
■Angiotensin II receptor blockers: Candesartan and valsartan FDA
approved for heart failure treatment. Use in addition to optimal
standard therapy (ACE inhibitor, beta blocker) or substitute for
ACE inhibitor in patients who are ACE inhibitor intolerant due to
cough or angioedema (ARB may also cause angioedema). Improves
morbidity; in patients unable to take ACE inhibitor, improves mor-
tality.
➣Indications: Heart failure due to systolic dysfunction (NYHA class
II–IV) for symptom improvement, as add-on to standard care or
replace ACE inhibitor (IF ACE intolerant)
➣Side Effects and Complications: Hyperkalemia (especially with
Type IV RTA), hypotension, angioedema (less frequent than ACE
inhibitor), dizziness, skin rash (less frequent than ACE inhibitor),
hepatotoxicity
➣Absolute Contraindications: Any prior angioedema, pregnancy,
hyperkalemia, renovascular disease
➣Relative Contraindications: Renal failure, volume depletion
■Aldosterone antagonists: spironolactone, eplerenone (FDA ap-
proved for post-myocardial heart failure), neurohormonal antag-
onist, weak potassium-sparing diuretic. Improves morbidity and
mortality in advanced heart failure patients (spironolactone) and in
post-myocardial infarction heart failure patients (eplerenone). Care-
fully monitor potassium.
➣Indications: Heart failure due to systolic dysfunction (NYHA class
IIIB–IV) or post-myocardial infarction; consider in patients with
less severe heart failure symptoms who require potassium sup-
plementation
➣Side Effects and Complications: Hyperkalemia (especially with
Type IV RTA), agranulocytosis, anaphylaxis, gynecomastia, hypo-
tension, headache, dizziness, confusion, skin rash, impotence,
irregular menstrual bleeding