Paper I
Question
A 65-year-old woman presents with swelling over ankle and feet and over the face in morning. Weakness, fatigue, cough at night. A diagnosis of moderate heart failure is made by physician (
- (a) Enumerate four drug groups with two examples each to treat heart failure. ( 6 mark(s)
- (b) Describe the rationale for using each drug group. ( 4 mark(s)
- (c) Mention the other uses and adverse effects of ACE Inhibitors. 5 mark(s)
Answer
a) Four drug groups for heart failure, two examples each
| Group | Examples |
|---|---|
| Diuretics | Furosemide, Spironolactone |
| ACE inhibitors / ARBs | Enalapril, Losartan |
| Beta-blockers | Carvedilol, Bisoprolol |
| Digoxin (cardiac glycoside) | Digoxin |
b) Rationale for each group
- Diuretics — furosemide relieves congestive symptoms (pulmonary/peripheral edema, as seen in this patient’s ankle/facial swelling) by reducing preload through natriuresis; no independent mortality benefit, addresses symptoms only. Spironolactone additionally blocks aldosterone’s pro-fibrotic, pro-remodelling myocardial action, providing a genuine mortality benefit independent of its diuretic effect.
- ACE inhibitors/ARBs — cornerstone, disease-modifying therapy: block angiotensin II formation/action, reducing both afterload and preload while independently slowing the maladaptive ventricular remodelling (hypertrophy, fibrosis) angiotensin II otherwise drives.
- Beta-blockers — despite being negative inotropes, specific agents (carvedilol, bisoprolol, metoprolol succinate) show a clear mortality benefit in stable, compensated heart failure, by blunting the chronic sympathetic overactivity that itself drives remodelling and arrhythmia; started at very low dose in stable patients only, never during acute decompensation.
- Digoxin — positive inotrope (partial Na⁺/K⁺-ATPase inhibition, raising intracellular Ca²⁺), improves symptoms and reduces hospitalization, particularly valuable with concurrent atrial fibrillation, but no mortality benefit.
c) Other uses and adverse effects of ACE inhibitors Other uses: hypertension, diabetic nephropathy (reduces intraglomerular pressure, renoprotective), post-myocardial infarction (limits remodeling).
Adverse effects: dry cough (bradykinin accumulation), hyperkalemia, first-dose hypotension, angioedema, teratogenicity (contraindicated in pregnancy), acute renal failure in bilateral renal artery stenosis.