Pharmacotherapy of Cardiovascular and Metabolic Disorders
Core concepts
Candidates must master guideline-directed therapy for hypertension, heart failure, dyslipidaemia and diabetes. For hypertension, know first-line classes (thiazides, ACE inhibitors, ARBs, dihydropyridine calcium channel blockers) and that ACE inhibitors and ARBs are not combined. For heart failure with reduced ejection fraction, the four pillars are renin-angiotensin system inhibition (ACE inhibitor/ARB/ARNI), beta-blocker, mineralocorticoid receptor antagonist and SGLT2 inhibitor. For dyslipidaemia, statins are first-line, with ezetimibe and PCSK9 inhibitors as add-ons; know the LDL targets by risk category. For type 2 diabetes, metformin remains foundational, with SGLT2 inhibitors and GLP-1 receptor agonists preferred when atherosclerotic cardiovascular disease, heart failure or chronic kidney disease coexist.
Traps in questions
A classic trap is combining an ACE inhibitor with an ARB or with aliskiren in diabetic patients - contraindicated due to hyperkalaemia and renal risk. Another is using a beta-blocker as first-line monotherapy in uncomplicated hypertension in older adults (not preferred). Watch for questions that ignore renal dosing of metformin (avoid if eGFR very low) or that forget statins are contraindicated in pregnancy.
Worked rule of thumb
For HFrEF, remember "four pillars, titrate to target": start low, double every 1–2 weeks, check potassium and creatinine after each RAS or MRA change. For a patient with HFrEF, diabetes and CKD, an SGLT2 inhibitor addresses all three - one drug, three benefits.