Pharmacotherapy of Cardiovascular and Renal Disease
What the exam tests
Cardiovascular and renal pharmacotherapy questions integrate guideline-directed therapy, comorbidity, renal function and electrolytes. You must sequence drugs, choose alternatives when renal function falls, and recognize life-threatening adverse effects.
Core rules
- HFrEF: start the four pillars early - ARNI (or ACEi/ARB), evidence-based beta-blocker, MRA and SGLT2 inhibitor - unless contraindicated. Do not wait for full titration of one before adding the next.
- ACEi and ARNI must not overlap: allow a 36-hour washout when switching.
- Hypertension with CKD and albuminuria: ACEi or ARB at the maximum tolerated dose, plus an SGLT2 inhibitor; monitor potassium and creatinine 1–2 weeks after initiation.
- ACS: aspirin, P2Y12 inhibitor, statin and beta-blocker; add anticoagulation. Fibrinolysis is used when primary PCI cannot be delivered within the recommended time.
- Warfarin: target INR 2–3 for most indications; 2.5–3.5 for mechanical mitral valves. DOACs need renal and weight checks.
- CKD: avoid NSAIDs, adjust renally cleared drugs, and hold metformin during acute illness or contrast exposure.
Worked example
A 68-year-old with HFrEF, eGFR 28 mL/min/1.73 m² and potassium 4.8 mmol/L is on furosemide. Add an SGLT2 inhibitor (dapagliflozin 10 mg daily) and an ARNI; avoid spironolactone initially because eGFR is below 30 and potassium is borderline. Recheck potassium and creatinine in one week. Furosemide dose is titrated to congestion, not to a fixed number.
Traps
Starting a beta-blocker during acute decompensation; combining ACEi with ARNI; using spironolactone when eGFR <30 or K+ >5.0; ignoring hyperkalemia risk with trimethoprim; assuming all DOACs are interchangeable in renal impairment.