Rapid Review·Cardiovascular
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HY Approach
T1Must knowApproach to Cardiac Drug Adverse Effects
Focus on
Step 2 tests cardiac drugs as decisions: which class first for this comorbidity, which one is contraindicated in this patient, which adverse effect this presentation is, and which toxicity this ECG shows. The seven drug families below each have a dedicated page; this one holds the traps that cross families.
Key takeaways
The exam's matching game
Four pairings
drug to indication, drug to contraindication, drug to adverse effect, and drug to the toxidrome on the electrocardiogram.Where the detail lives
the class pages (Antihypertensive Drugs, Antiarrhythmic Drugs, Lipid-Lowering Therapy, Anticoagulants & Antiplatelets, Vasopressors & Inotropes, Antianginal & Vasodilator Drugs); this page is the cross-cutting list.Which drug caused this
| Presentation | Drug |
|---|---|
| Dry cough; non-pruritic angioedema of the lips or tongue without hives | Angiotensin-converting-enzyme (ACE) inhibitor (bradykinin); also sacubitril-valsartan; never combine the two (36-hour washout) |
| Hyperkalemia with a creatinine bump | ACE inhibitor or receptor blocker, spironolactone, potassium supplements, especially combined or with kidney disease |
| Symmetric ankle edema without jugular distension or crackles | Dihydropyridine calcium-channel blocker (amlodipine); diuretics do not help, reduce or switch |
| Constipation, bradycardia, worsened heart failure | Verapamil (also hyperprolactinemia); diltiazem |
| Gynecomastia, painful breasts | Spironolactone (switch to eplerenone) |
| Hypokalemia, hyponatremia, hyperuricemia and gout, hyperglycemia, hypercalcemia | Thiazides |
| Ototoxicity, hypokalemia, hypocalcemia, alkalosis | Loop diuretics |
| Fatigue, erectile dysfunction, depression, bronchospasm, masked hypoglycemia, rebound hypertension on withdrawal | Beta blockers |
| Rebound hypertensive crisis after an abrupt stop | Clonidine (and beta blockers) |
| Drug-induced lupus (anti-histone antibodies) | Hydralazine, procainamide |
| Reflex tachycardia, headache, fluid retention, hirsutism | Hydralazine, minoxidil |
| Cyanide toxicity (lactic acidosis), methemoglobinemia | Nitroprusside (prolonged high dose, renal failure) |
| Headache, flushing, tolerance; profound hypotension with sildenafil | Nitrates |
| Pulmonary fibrosis, thyroid dysfunction, hepatitis, corneal deposits, blue-gray skin, bradycardia, long QT | Amiodarone |
| Cinchonism (tinnitus, headache), thrombocytopenia | Quinidine |
| Long QT and torsades | Class IA and class III antiarrhythmics (sotalol, dofetilide, ibutilide) |
| Nausea, anorexia, abdominal pain, yellow-green halos, confusion, arrhythmia with block | Digoxin |
| Myalgia, creatine kinase rise, transaminitis | Statins (worse with fibrates, macrolides, azoles, grapefruit) |
| Flushing, pruritus, hyperglycemia, gout | Niacin (aspirin before the dose reduces flushing) |
| Gallstones, myopathy with statins | Fibrates (gemfibrozil worst) |
| Bleeding; skin necrosis in the first days; teratogenic | Warfarin (protein C deficiency; bridge with heparin) |
| Thrombocytopenia with thrombosis on days 5 to 10 | Heparin (stop it, start argatroban) |
| Dyspnea, transient block, flushing, "impending doom" | Adenosine (blocked by caffeine and theophylline; potentiated by dipyridamole) |
| Luminous visual phenomena (phosphenes), bradycardia | Ivabradine |
| Genital mycotic infections, euglycemic ketoacidosis, volume depletion | Sodium-glucose cotransporter-2 inhibitors |
Contraindication pairings the exam loves
Beta blockers or non-dihydropyridine calcium-channel blockers
not in decompensated heart failure, high-grade block, or cocaine (unopposed alpha); not verapamil or diltiazem with a beta blocker in a bradycardic patient.Atrioventricular-nodal blockers
adenosine, beta blockers, calcium-channel blockers and digoxin are not used in pre-excited atrial fibrillation (Wolff-Parkinson-White Syndrome).Class IC (flecainide, propafenone)
not in structural heart disease or after infarction.ACE inhibitors and receptor blockers
not in pregnancy, bilateral renal artery stenosis, prior angioedema; never an ACE inhibitor plus a receptor blocker or plus sacubitril.Nitrates
not with phosphodiesterase-5 inhibitors, in right-ventricular infarction, or in obstructive cardiomyopathy and severe aortic stenosis.Direct oral anticoagulants
not with mechanical valves or rheumatic mitral stenosis.Others
thiazolidinediones and non-steroidal anti-inflammatory drugs in heart failure; dronedarone in permanent fibrillation or heart failure; sotalol in long QT or renal failure; cilostazol in heart failure.Interactions that change doses
Amiodarone
raises digoxin (halve the dose) and warfarin (cut by a third), and potentiates beta blockers and calcium-channel blockers.- Verapamil and quinidine also raise digoxin.
CYP3A4 inhibitors (azoles, macrolides, grapefruit, protease inhibitors)
raise simvastatin, atorvastatin and direct oral anticoagulant levels; rifampin and carbamazepine lower them.Potassium
potassium-sparing agents stack with ACE inhibitors.Cholestyramine
binds warfarin, digoxin and thyroxine (separate the doses).A hypertensive man started on a new drug develops swelling of the lips and tongue without hives or itching. Which drug is it, and which heart-failure drug must never be combined with it?
An ACE inhibitor (bradykinin-mediated angioedema). Never combine it with sacubitril-valsartan (a 36-hour washout is needed), nor with a receptor blocker.
How it's tested
A hypertensive woman develops painless swelling of her lips and tongue, no hives, three years into lisinopril: ACE-inhibitor angioedema — stop it forever, secure the airway, never sacubitril/valsartan without a washout; switch to an ARB only with caution.
Bilateral ankle swelling one month after starting amlodipine, with clear lungs and a normal JVP: dihydropyridine edema — not heart failure; reduce the dose or switch, do not add furosemide.
A man on amiodarone for a year develops dry cough and dyspnea with bilateral interstitial infiltrates: amiodarone pulmonary toxicity — stop the drug, steroids for severe cases.
Nausea, yellow vision and a slow irregular rhythm in a patient on digoxin whose spironolactone was recently increased: digoxin toxicity — level, potassium, Fab if severe (Digoxin Toxicity).
Which antihypertensive for a pregnant woman; which is forbidden: labetalol, nifedipine or methyldopa; ACE inhibitors, ARBs and aliskiren are teratogenic.
Go deeper
Related Step 2 pages: Antihypertensive Drugs, Antiarrhythmic Drugs, Lipid-Lowering Therapy, Anticoagulants & Antiplatelets, Vasopressors & Inotropes, Antianginal & Vasodilator Drugs, Digoxin Toxicity, Beta-Blocker Toxicity
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