HEART TALK ( II )

In
Pandemic of COVID-19
CARDIOVASCULAR
MEDICINES
IN COVID-19 PANDEMIC
AND RAMADHAN
PROF DR FRANCISCUS D SUYATNA PHD. SPFK
DEPARTMENT OF PHARMAKOLOGY AND THERAPEUTICS
MEDICAL FACULTY UNIVERSITY OF INDONESIA
A) Proportion of patients and B) Proportion of patients and
their comorbid conditions that their comorbid conditions that
were diagnosed with COVID-19. died from COVID-19.

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COMORBIDITIES
In a cohort of 138 hospitalized patients with COVID-19 :
 Comorbidities were similary prevalent :
 46% overall, 72% in patients requiring an ICU
 Cardiovascular comorbidities:
 HTN in 31% (58% in patients requiring an ICU),
 CVD in 15% (25% in patients requiring an ICU),
 DM in 10% (22% in patients requiring an ICU).

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 HYPERTENSION
As the most common comorbidity in COVID - 19

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 ACE-INHIBITORS AND ARB
INHIBIT PRODUCTION OF ANGIOTENSIN II (VASOCONSTRICTOR) BY BLOCKING ACE CONVERTING ENZYME
INHIBIT BINDING OF ANGIOTENSIN II TO ANGIOTENSIN RECEPTOR (AT1)

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 ACEI AND ARB INTERACTION

NSAIDs reduce antihypertensive effect,

K-sparing diuretics increase hyperkalemia,
Increase plasma digoxin,
Increase hypersensitivity to allopurinol,
Antacids reduce bioavailability,
Capsaicin worsens side effect cough
 DOSAGES ARB

Losartan : 25-100 mg (once or twice daily)

Valsartan : 80-320 mg once daily
Irbesartan : 150-300 mg once daily
(higher bioavailability)
Candesartan : 4-32 mg (once or twice daily)
Olmesartan : 20-40 mg once daily
Telmisartan : 40-80 mg once daily
Other uses for Heart failure

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 DOSAGES ACEI
Captopril 6,25 mg 3x daily or 25 mg 2x daily
given 1 hour before meal
Lisinopril 5-10 mg once daily
Ramipril 1.25-20 mg single or divided dosage
Benazepril 5-80 mg single or divided dosage
Fosinopril 10-80 mg single or divided dosage
Trandolapril 1-8 mg single or divided dosage
Quinapril 5-80 mg single or divided dosage

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The Council on Hypertension of the European Society of Cardiology wish to highlight the lack of any evidence
Supporting harnful effect of ACE-I and ARB in the context of the pandemic COVID-19 outbreak.

The Council on Hypertension strongly recommend that physician and patients should continue treatment with
Their usual anti-hypertensive therapy because there is no clinical or scientific evidence to suggest that treatment
With ACEi or ARBs should be discontinued because of the Covid-19 infection. ESC council of HTN

We therefore advise people taking these medication to continue to take them. If they become unwell such that need to seek
Medical help, the doctor may advise stopping the drugs depending on their clinical condition Renal Association UK
position Statement

Abrupt withdrawal of RAAS inhibitors

in high-risk patients (HF or MI), may result in
clinical instability and adverse health outcomes
NEJM, doi - NEJMsr2005760-
Calcium Channel Blocker (CCB)

Inhibit Ca entry via slow channel

CCB: VERAPAMIL, DILTIAZEM and NIFEDIPINE

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Nifedipine
 Short acting.
Increased reflex tachycardia and rebound hypertension Dosages : 5, 10 mg, 3x daily
 Long acting
Dosages : 20 mg, 1-2 times daily

Amlodipin
Less tachycardia, long acting Dosages 5-10 mg once daily

Diltiazem
Dosages : 30-60 mg tablet, 3x daily
SR form. : 90 – 180 mg, 2x daily
CD form. : 100 – 200 mg, once daily

Verapamil
Dosages : 240 mg tablet, 1-2 tablets daily
Other uses : Antiangina
Antiarrhythmia

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 CCB INTERACTION

combination of verapamil and beta blockers is

contraindicated because increase risk of AV block and
severe ventricular depression,

increase plasma digoxin level (use of verapamil to treat

digoxin toxicity is contraindicated)

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 BETA BLOCKERS

Beta-blockers that are used clinically can be divided into

two classes:

1. non-selective blockers (block both β1and β2

receptors)
2. relatively selective β1 blockers ("cardioselective“)
beta- blockers

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15
 BETA BLOCKERS

Decrease cardiac output and heart rate.

Carvedilol & nebivolol reduce peripheral resistance

SE : cold hands and feet, weight gain, depression,

shortness of breath, asthmatic attack, masking
hyperglycemia, sotalol induces QT prolongation

Contraindication : hypotension, bradycardia, Raynaud

syndrome

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 BETA BLOCKERS INTERACTION
 antiarrhythmic drugs (quinidine, lidocaine) :
depressive effects, hypotension, bradycardia

 amiodarone :
hypotension, bradycardia

 clonidine:
Sinus bradycardia, rebound hypertension

 insulin & OAD :

 Hypo / hyperglycemia,
 hypoglycemi recovery time increase,
 SU effect decrease

 antidepressant :
beta blocking effect increase

 NSAID :
antihypertensive beta blockers decrease
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 METHYLDOPA

Centrally-acting antihypertensive
agent and prodrug
SE :
Sedation, depression, dry mouth, gynecomastia,
hepatotoxicity, blood dyscrasias

Indication :
Hypertension in pregnancy

Dosages :
250 mg, 2x daily
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 DIURETICS

Decreased extracellular fluid volume,

Na------BP decreases Vasodilation

a. Furosemide----for HF
b. Hydrochlorothiazide

SE : hypokalemia, hyperuricemia,
hyponatremia, hypomagnesemia,
hypercalcemia, hypotension, hyperglycemia
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 DIURETICS
c. K-sparring diuretics
(spironolacton, amiloride, triamterene) Natriuresis,
K-retention
Use In combination with K-depletion diuretics

SE : hyperkalemia
Interaction : increase hyperkalemia (renal failure,
ACE-I, supplement, NSAIDs)

Dosages : Spironolactone 25-200 mg, once daily

Other uses : Heart failure
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ANTIDIABETICS

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ANTIDIABETICS

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 ANTIDIABETICS

1. Sulfonylurea (SU)
 Hypoglycemia risk is high
 Use short acting (glimepiride, glipizide)
If once a day : take during evening, not in the Sahour time
If 2x daily : reduce half a dose for morning dose
It can be replaced by DPP4-inhibitors
Not recommended in patients with COVID19

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 ANTIDIABETICS
2. Thiazolidindione
 No dose adjustment for pioglitazone
 Not recommended for severe condition COVID19 infection(volume
overload)
 Pioglitazone induces ACE2 expression

3. Incretin-based OAD
 Less risk for hypoglycemia
 No adjustment, except when combined with other drug eg. metformin
 Not recommended during COVID19 (nausea, vomiting)
 Induce ACE2 expression

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 ANTIDIABETICS
4. SGLT-2i (glifozins)
 Safe during fasting, needs added hydration
 Not recommended during COVID19 (volume contraction, acidosis)
 Induce ACE2 expression

5. Insulin
 T1DM on basal bolus should omit midday-rapid-acting dose and
reduce background dose by 20% if blood glucose below 7 mmol/l (127
mg/dl), if level is >7mmol/l, consult physician
 Patients using single basal insulin (incl. glargine & determir) should
reduce their dose by 20% & give in the evening.
 Patients using pre-mixed insulin should use their morning dose in the
evening and halve their evening dose and use this in the Sahour.

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 ANTIDIABETICS

 Short acting insulin may be used instead of normal

insulin.
 Check blood glucose before Sohour, Iftar &
during the day
 Break fast if BG < 3.9 mmol/l (71 mg/dl) in the
morning, especially when on insulin or SU
 Do not fast if BG > 16.7 mmol/l (304 mg/dl)
(hyperglycemia)
 Induce ACE2 expression

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Terima Kasih
MOGA MANFAAT,
Aamiin