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eg. Isosorbide mononitrate (ISMN), isosorbide dinitrate (ISDN)

Dosing for ISMN: 120mg daily in divided doses
Dosing for ISDN: 40- 240mg daily in divided doses

- causes venous dilation hence reducing preload
- improves coronary blood flow
- must be used with vasodilator

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eg. hydralazine

Dosing: 25mg to 75mg three times per day to four times per day

- causes arteriolar dilation, hence reducing afterload
- must be prescribed with nitrates
- useful in African American patients as ACEI and ARB do not function in their metabolism pathway

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- Spironolactone has also been associated with an increased risk of adverse events (AEs), such as hyperkalemia and decreasing renal function.
- Spironolactone consistently increased the risk of hyperkalemia, worsening renal function, and permanent drug discontinuation due to AEs in all eGFR categories, in a manner associated with the severity of renal dysfunction.

- This suggests a heightened risk for spironolactone intolerance with declining renal function.

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- The cellular Na+/K+-ATPase is inhibited by digitalis chemicals. Cardiac glycosides improve contractility by blocking the Na+/K+-ATPase, causing intracellular sodium concentration to rise (inotropy).
- Digitalis compounds have a small direct diuretic effect on the kidneys, which is beneficial in heart failure patients.
- If patients have renal failure, dose should be adjust according to their condition

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- Inhibit type 1 angiotensin II receptors on blood vessels and other tissues such as the heart
- patients who experience hyperkalemia or worsened renal function while taking ACE inhibitors are likely to have the same complications with an ARB

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excess glucose stick to proteins--> efferent arteriole become stiff and narrow--> obstruct blood from leaving glomerulus-->increase pressure in glomerulus--> hyperfiltration-->mesangial cell secrete more structural matrix expands the size of glomerulus-->diminish nephron ability

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e.g. Furosemide

Dosing : 20 - 80 mg once a day as a single dose or divided and given twice per day.

-  Prescribed if there is any oedema present
- reduce pulmonary and/or systemic congestion and oedema.
- added on to either an ACEI/ARB to improve mortality and morbidity.

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Hypertension leading to chorionic kidney disease

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Hypertension leading to chorionic kidney disease

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increased pressure-->artery wall that supply the kidney thicken-->narrowed lumen--> less blood an O2 delivered to the kidney--->ischemic injury to the nephron glomerulus-->immune cell slip into damaged glomerulus-->secrete growth factor-->mesangial cell regress-->glomerulosclerosis-->decrease nephron ability to filter blood

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- Beta blockers
- Diuretics
- Cardiac glycosides
- Vasodilator & Nitrates

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- hyperkalemia can be caused by acute renal failure

- prescribed for patients who cannot tolerate ACEI/ARB due to hyperkalemia or persistent cough.

- can be used to reduce preload and afterload

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Type of drugs for heart failure that does not affect renal impairment

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Type of drugs for heart failure that does not affect renal impairment

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e.g. Bisoprolol & carvedilol

Dosing : Initial: 1.25 mg once daily; gradually increase the dose to 10 mg once daily while monitoring for signs and symptoms of heart failure

- it improves survival rates & reduce risk of heart failure related hospitalization
- reduces heart rate and arterial pressure

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Angiotensin Converting Enzyme (ACE) inhibitor

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Angiotensin Converting Enzyme (ACE) inhibitor

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Because ACE inhibitors are processed by the kidneys, they can harm them, especially if you're dehydrated, which is common in individuals who already have renal issues such as chronic kidney disease has higher risk of getting renal impairment

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- avoid excessive fluid intake
- fluid restriction may be required in patients with severe heart failure
- eat healthily, avoid excessive salt intake
- stop smoking and drinking
- undertake regular exercise to provoke mild or moderate breathlessness
- monitor body weight daily increments of 1kg overnight or 2-3kg over 2-3 days like due to fluid accumulation --> seek medical attention

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eg. Furosemide
1. Heart failure leads to activation of the renin-angiotensin-aldosterone system --> causes increased sodium and water retention by the kidneys.
2. Only patients with heart failure can effectively in unloading sodium and water than thiazide diuretics be prescribed with loop diuretics.

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- Dyspnoea when patient exerts himself or lies down
- Fatigue and weakness
- Oedema in the legs, ankles and feet
- Rapid or irregular heartbeat
- Reduced ability to exercise
- Persistent cough or wheezing with white or pink blood-tinged phlegm
- Increased need to urinate at night
- Swelling of the abdomen (ascites)
- Very rapid weight gain from fluid retention
- Lack of appetite and nausea
- Difficulty concentrating or decreased alertness
- Sudden, severe shortness of breath and coughing up pink, foamy mucus
- Chest pain if heart failure is caused by a heart attack

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Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen. Basically, the heart can’t keep up with its workload.

There are 2 types of heart failure:

1. Diastolic heart failure
- Heart muscles become stiff and loses ability to relax --> heart chambers cannot properly fill with blood
- Fluid accumulation in the feet, ankles and legs. Some patients may have lung congestion.

2. Systolic heart failure
- Heart’s ability to contract decreases --> cannot pump with enough force to push a sufficient amount of blood into the circulation
- Blood coming into the heart from the lungs may back up and cause fluid to leak into the lungs --> pulmonary congestion

The heart compensates for the loss of function through ventricular remodeling in diastolic and systolic heart failure. In the long run, it will worsen heart failure.

Types of ventricular remodelling:

1.  Dilatation
- Enlargement of the heart which allows more blood into the heart
- Due to systolic heart failure

2. Hypertrophy
- Thickening of muscle fibres to strengthen the heart muscle, which allows the heart to contract more forcefully and pump more blood
- Due to diastolic heart failure

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Type of drugs for heart failure that may affect renal impairment 

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Type of drugs for heart failure that may affect renal impairment 

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- High blood pressure (hypertension)
- Coronary artery disease
- Heart attack
- Diabetes
- Usage of alcohol and tobacco
- Obesity
- Irregular heartbeats

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1st line :
- ACEI/ARB + BB or ISMN/ISDN (nitrates) + hydralazine [if ACEI & ARB don't work]

2nd line :
- Spironolactone

3rd line :
- Digoxin (only given if still have symptoms after all the above medication doesn't work)

if got edema, use FUROSEMIDE at any stage.

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4. Complication of heart failure with kidney failure

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4. Complication of heart failure with kidney failure

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Heart failure can reduce the blood flow to the kidneys, which will cause kidney failure if left untreated. Kidney damage from heart failure can require dialysis for treatment

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1. Electrocardiogram (ECG)
2. Blood tests
3. Echocardiogram
4. Breathing tests
5. Chest X-ray

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8.Treatment adjustment to renal impairment

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8.Treatment adjustment to renal impairment