Lifespan considerations including pregnancy
• Statins
o avoid statin use in children younger than 10 years.
o Statins are contraindicated in
... [Show More] pregnancy. Ezetimibe and fibrates can be used in pregnancy, but benefit should outweigh risk.
o In patients 65 years and older, statins, compared with placebo, significantly reduced the risk for myocardial infarction as well as the risk for stroke by 23.8%. However, the cost-benefit evaluation of treatment in older-adult people should be considered.
• Warfarin
o Heparin is commonly used in infants needing anticoagulation. Argatroban has
been used successfully in infants with HIT. Warfarin is also administered to infants.
o Many anticoagulants can be used safely in children, just in smaller doses. Side- effect profiles are similar to those of adults.
o Warfarin is contraindicated in pregnancy. LMW heparins and unfractionated heparin are commonly used in pregnancy. In pregnant women with HIT, argatroban is a safe alternative.
• Blood pressure medications
o ACEIs, ARBs, and DRIs are contraindicated owing to their potential for harm
(fetal growth delay, congenital malformations, neonatal renal failure, neonatal death).
o Drugs of choice in treating pregnant women with mild preeclampsia include labetalol and methyldopa. Magnesium sulfate is used in the prevention of seizures in severe preeclampsia or for treatment of seizures in eclampsia.
o No data are available on the long-term effects of antihypertensive drugs on growth and development of children. Drugs recommended for treatment of hypertension in children 1–18 years old include ACEIs, diuretics, β blockers, and calcium channel blockers.
o Effects of RAAS-blocking drugs have not been studied in breastfeeding; β blockers, such as metoprolol, appear safe for the breastfeeding infant. Diuretics appear safe but may suppress lactation.
o Treatment with ACEIs, diuretics, and/or β blockers is reasonable. Caution must be taken to avoid overdiuresis when using diuretics in the older-adult population. Central acting alpha agonists and peripheral alpha-1 antagonists should also be avoided.
• Drug interactions to be mindful of, avoid, or adjust dosing with
- Warfarin
- Carbamazepine
- Digoxin
o hypokalemia secondary to the use of diuretics.
o Amiodarone, verapamil, sympathomimetics, can all increase serum levels of digoxin
- Quinidine
o Quinidine is an antidysrhythmic drug that can cause plasma levels of digoxin to rise. Quinidine increases digoxin levels by (1) displacing digoxin from tissue binding sites and (2) reducing renal excretion of digoxin. By elevating levels of free digoxin, quinidine can promote digoxin toxicity. Accordingly, concurrent use of quinidine and digoxin should be avoided.
▪ Black box warning: An analysis of older studies indicates that quinidine may actually increase mortality in patients with atrial flutter and atrial
fibrillation.
- Anticoagulants in general
• Treatment strategy for angina
- Goals of treatment
o Drug therapy of angina has two goals: (1) prevention of myocardial infarction (MI) and death and (2) prevention of myocardial ischemia and anginal pain.
- Drugs to accomplish goals
o Stable angina can be treated with three main types of drugs: organic nitrates, β blockers, and calcium channel blockers
• Monitoring
- Labs related to blood pressure medications
- Appropriate intervals for medication adjustments (4-6 WKs is ideal/appropriate)
• Heart Failure
- Role of aldosterone and how to manage those effects
o aldosterone antagonists—spironolactone (Aldactone) and eplerenone (Inspra)— can reduce symptoms, decrease hospitalizations, and prolong life.
o Aldosterone antagonists work primarily by blocking aldosterone receptors in the heart and blood vessels.
▪ Promotion of myocardial remodeling (which impairs pumping)
▪ • Promotion of myocardial fibrosis (which increases the risk for dysrhythmias)
▪ • Activation of the SNS and suppression of norepinephrine uptake in the heart (both of which can promote dysrhythmias and ischemia)
▪ • Promotion of vascular fibrosis (which decreases arterial compliance)
▪ • Promotion of baroreceptor dysfunction
- Spironolactone is associated with tumorigenesis in studies completed on rats.
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