✅How Do I Optimize Heart Failure Medications for
Patients with Hypotension or Chronic
Kidney Disease?
✅بالعربي كذا كيف بنضبط ادوية الفشل القلبي الاربعه( ACEi /ARB /(ARNIs)1 و BB و SGLT2I و mineralocorticoid receptor antagonists;) في وجود انحفاض في ضغط الدم SBP اقل من 90 او في حاله الفشل الكلوي المزمن CKD يعني GFR اقل من 60
✅طبعا الاربعه الادويه مع بعض يطلق عليها
guide-line-directed medical therapy (GDMT)

✅نبدا اولا في حاله hypotension

✅Determining the etiology of the
hypotension is essential when symptomatic hypotension
impairs the ability to initiate or uptitrate GDMT
✅يعني اولا نشوف سبب hypotension عشان نعرف اين من الادويه الاربعه هو السبب في انخفاض ضغط الدم

✅For example, if a patient with a blood pressure of 90/50 mm
Hg presents with acute kidney injury and evidence of hypoperfusion on examination, the cause is likely low car- diac output.
The solution may be to decrease BB therapy.
✅If the same patient is adequately perfused on examination,
but cardiac examination and electrocardiogram demon-
strates a new tachyarrhythmia, the solution may be to
increase BB therapy

✅يعني نشوف لو في انخفاض في ضغط الدم وبنفس الوقت في AKI وفي علامات ع hypoperfusion مثل بروده الاطراف هذا يدل على انه بسبب نقص CO والحل يكون بنقص جرعه ادويه BB ،ولكن اذا في adequately perfused وسويت تخطيط قلب وفي ارتفاع في النبض الحل هنا يكون بزياده جرعه البيتا بلوكر وليس انقاصها
✅حل اخر مثلا لو كان مريض الفشل القلبي ماشي ع Carvedilol وفي hypotension وكان السبب هو ادويه BB ممكن نغيره الى metoprolol succinate, افضل من خفض جرعه Carvedilol لانه benefits ل ادويه BB تكون ب Optimize dose

✅Renin-angiotensin system inhibitors: when patients are transitioned from an ACEi or ARB to ARNI, some become hypotensive as a result of increased
natriuresis. In this case, reduction of the diuretic is helpful. In patients with advanced HFrEF, ARNI
may not be tolerated because of symptomatic hypotension, in which case reinitiation of low-dose ACEi/ARB should be attempted.

✅بالعربي كذا لو كان المريض ماشي ع ادويه ACEI /ARB وتم تحويله الى أدوية ARNI ممكن يحصل له انفخاض في الضغط لو حصل وكان ماشي ع مدرات ايضا ممكن نخفض جرعه المدر ،اما اذا مازال الضغط منخفض يتم اعاده ادويه ACEI او ARB بجرعه اقل

🛑Mineralocorticoid receptor antagonists: in low doses,
these medications rarely cause hypotension in atients with HFrEF. In a study that included both spironolactone and eplerenone, 50 mg per day of eplerenone lowered blood pressure less than a 50-mg
per day dose spironolactone. Eplerenone may therefore be the preferred agent in patients with
hypotension.

✅ادويه spironolactone و Eplerenone نادرا ماتعمل انخفاض في ضغط الدم لكن في حاله كان مريض الفشل القلبي ع طول hypotension نفضل Eplerenone ع spironolactone

🛑SGLT2i: blood pressure reduction with an SGLT2i is
typically modest (1 to 2 mm Hg), and hypotension is uncommon, except in patients with poorly controlled diabetes in whom osmotic diuresis may
occur, necessitating a reduction in diuretic

✅ ادويه SGLT2I نادر ماتخفض ضغط الدم قد تخفض بنسبه قليله (1 to 2 mm Hg) لكن قد ننقص جرعه المدرات قبل اضافتها لتفادي الانخفاض

#NEJM
#salah

لما تعطي مدر لازكس عشان تعالج تورم القدم الناتج عن دواء amlodepin
رده فعل الكلى 😆 👇👇👇
#salah

#remember

✅Patients who do not respond to usual doses of loop diuretic therapy may be resistant
المريض الذي لم يستجيب للجرعات المعتاده من
المدرات قد يحصل لديه diuretic resistant

✅والسبب قله افراز المدرات في منقطه عملها tubular lumen يعني مافيش kidney perfusion بشكل كافي لعده اسباب

✅اما heart failure بتالي قله cardiac output

✅او cirrhosis الذي ممكن يعمل renla vasoconstriction

✅او مشكله في الكلى نفسها ⬅️قله glomerular filtration ⬅️ بتالي تركيز عالي من organic acid الذي ينافس المدرات على مكان عملها

🛑للذي يحبها بالانجليزي

🛑Patients who do not respond to usual doses of loop diuretic therapy may be resistant because of decreased diuretic secretion into the tubular lumen. This may result from decreased kidney perfusion in patients with heart failure (due to the reduced cardiac output), cirrhosis (due to renal vasoconstriction), and kidney dysfunction (due to competitive inhibition of tubular diuretic secretion by high concentrations of organic anions that accumulate when the glomerular filtration rate is low)

#UpTodate2023
#salah

🛑Update on Managing Community-Acquired Pneumonia

✅For patients with CAP and a positive respiratory viral panel, the writers make the following antibiotic recommendations:

🅰️Outpatients without comorbidities: No antibiotics

🅱️Outpatients with comorbidities: Antibiotics are suggested

🅾️Inpatients: Antibiotics are suggested for all patients regardless of CAP severity*

✅The following antibiotic durations are recommended for patients who achieve clinical stability (defined as normal vital signs, normal mental status, and no need for supplemental oxygen or only baseline oxygen requirements):

🅰️Outpatients: 3-to-4–day course with a plan for close follow-up

🅱️Inpatients with nonsevere CAP: 3-to-4–day course

🅾️Inpatients with severe CAP: ≥5-day course

✅The writers make the following recommendations for systemic steroids:

🅰️Outpatients: Not indicated

🅱️Inpatients with nonsevere CAP: Not recommended

🅾️Inpatients with severe CAP: Steroids are suggested, except when patients have concurrent influenza

#NEJM watch 2025

#remember
✅Don't prescribe different routes of administration of paracetamol at the same time.

#NHS guideline

🛑clozapin and surgery
✅If possible avoid clozapine for 12 h
✅. Clozapine should be restarted within 48 hours at normal dose. If it is more than 48 hours since last dose, treatment should be re-titrated on advice from Mental Health*, starting from 12.5mg.

#NHS
#Clinical_Notes @Clinical_Notes

🛑 Acid reducers in patients with cirrhosis

✅ we use famotidine for patients with cirrhosis, and dose adjustments are not needed due to cirrhosis. However, dose modification is typically needed for patients with coexisting kidney impairment
✅✅ For patients with cirrhosis and an indication for PPIs, we typically use esomeprazole, when available, based on pharmacokinetic data

✅. For patients with
decompensated cirrhosis, omeprazole, lansoprazole, and rabeprazole are generally avoided

#UpTodaet 2025

🛑 systemic corticosteroids and adverse effects (related dose)

✅Hypertension
Rare with <10 mg/day of prednisolone

✅Weight gain
Typically with >5 mg/day of prednisolone
✅Fluid retention
Reported with ≥5 mg/day of prednisolone

✅Osteoporosis
Reported with as low as 2.5 mg/day of prednisolone (Screen for osteoporosis in patients with >3 months of treatment )

✅Gastritis, peptic ulcer
Reported with <20 mg/day of prednisolone

✅Mood disorders, including anxiety and depression
Typically with >7.5 mg/day of prednisolone

✅Psychosis
Almost always with >20 mg/day of prednisolone
✅Memory impairment Reported with as low as 5 mg/day of prednisolone for 1 year

#UPTODATE 2025

✅Cataracts
Reported with <5 mg
Typically with >10 mg/day of prednisolone

✅Elevated intraocular
pressure/glaucoma

Typically with >7.5 mg/day of prednisolone