Congestive heart failure ACE inhibitors: Difference between revisions

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The Collaborative Group on ACE Inhibitor Trials demonstrated significant reduction in total mortality and hospitalization with the administration of [[ACEIs]] that was consistent among wide range of patients.<ref name="pmid7654275">{{cite journal |author=Garg R, Yusuf S |title=Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials |journal=[[JAMA : the Journal of the American Medical Association]] |volume=273 |issue=18 |pages=1450–6 |year=1995 |month=May |pmid=7654275 |doi= |url= |accessdate=2012-04-03}}</ref>
The Collaborative Group on ACE Inhibitor Trials demonstrated significant reduction in total mortality and hospitalization with the administration of [[ACEIs]] that was consistent among wide range of patients.<ref name="pmid7654275">{{cite journal |author=Garg R, Yusuf S |title=Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials |journal=[[JAMA : the Journal of the American Medical Association]] |volume=273 |issue=18 |pages=1450–6 |year=1995 |month=May |pmid=7654275 |doi= |url= |accessdate=2012-04-03}}</ref>


==ACE Inhibitors==
==Indications for an ACE Inhibitor or ARB==
===Indications for an ACE Inhibitor or ARB===


1. The [[left ventricular ejection fraction]] ([[LVEF]]) is ≤ 40%
1. The [[left ventricular ejection fraction]] ([[LVEF]]) is ≤ 40%
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2. There is a prior history of [[myocardial infarction]] ([[MI]])
2. There is a prior history of [[myocardial infarction]] ([[MI]])


====Background====
===Background===
*ACE-I or ARB therapy is recommended for '''ANY''' patient with reduced [[left ventricular ejection fraction]] (≤ 40%) regardless of the etiology of left ventricular systolic dysfunction (ischemic or nonischemic) or presence/absence of symptoms. Patients with or without heart failure (in other words, even those with asymptomatic left ventricular systolic dysfunction) are included in this recommendation.
*ACE-I or ARB therapy is recommended for '''ANY''' patient with reduced [[left ventricular ejection fraction]] (≤ 40%) regardless of the etiology of left ventricular systolic dysfunction (ischemic or nonischemic) or presence/absence of symptoms. Patients with or without heart failure (in other words, even those with asymptomatic left ventricular systolic dysfunction) are included in this recommendation.
*In addition, ACE-I/ARB therapy is indicated for patients with history of myocardial infarction whether or not left ventricular systolic dysfunction or heart failure is present.
*In addition, ACE-I/ARB therapy is indicated for patients with history of myocardial infarction whether or not left ventricular systolic dysfunction or heart failure is present.
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* Treatment should not be deferred in patients with few or no symptoms because of the significant mortality benefit derived from [[Angiotensin converting enzyme inhibitor|ACEI]] therapy.
* Treatment should not be deferred in patients with few or no symptoms because of the significant mortality benefit derived from [[Angiotensin converting enzyme inhibitor|ACEI]] therapy.


====Dosing====
===Dosing===
* ACE-I/ARB therapy should be initiated at low dosage such as 12.5 mg tid of [[captopril]], 2.5 mg bid of [[enalapril]]<ref name="pmid2057034">{{cite journal |author= |title=Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators |journal=[[The New England Journal of Medicine]] |volume=325 |issue=5 |pages=293–302 |year=1991 |month=August |pmid=2057034 |doi=10.1056/NEJM199108013250501 |url=http://dx.doi.org/10.1056/NEJM199108013250501 |accessdate=2012-04-03}}</ref><ref name="pmid2883575">{{cite journal |author= |title=Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group |journal=[[The New England Journal of Medicine]] |volume=316 |issue=23 |pages=1429–35 |year=1987 |month=June |pmid=2883575 |doi=10.1056/NEJM198706043162301 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198706043162301?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-03}}</ref>, or 2.5 mg daily lisinopril.
* ACE-I/ARB therapy should be initiated at low dosage such as 12.5 mg tid of [[captopril]], 2.5 mg bid of [[enalapril]]<ref name="pmid2057034">{{cite journal |author= |title=Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators |journal=[[The New England Journal of Medicine]] |volume=325 |issue=5 |pages=293–302 |year=1991 |month=August |pmid=2057034 |doi=10.1056/NEJM199108013250501 |url=http://dx.doi.org/10.1056/NEJM199108013250501 |accessdate=2012-04-03}}</ref><ref name="pmid2883575">{{cite journal |author= |title=Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group |journal=[[The New England Journal of Medicine]] |volume=316 |issue=23 |pages=1429–35 |year=1987 |month=June |pmid=2883575 |doi=10.1056/NEJM198706043162301 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198706043162301?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-03}}</ref>, or 2.5 mg daily lisinopril.
*  Every 4 to 6 weeks the dose is gradually uptitrated, as tolerated, toward target dosages of 20-40 mg daily for lisinopril, 10-20 mg twice daily for enalapril maleate, and 50-100 mg three times a day for captopril, or to the maximum tolerated dosage.
*  Every 4 to 6 weeks the dose is gradually uptitrated, as tolerated, toward target dosages of 20-40 mg daily for lisinopril, 10-20 mg twice daily for enalapril maleate, and 50-100 mg three times a day for captopril, or to the maximum tolerated dosage.
* ACE inhibitors are rarely adequate for the treatment of congestion without the use of [[diuretics]].
* ACE inhibitors are rarely adequate for the treatment of congestion without the use of [[diuretics]].


====Complications of ACE Inhibitors====
===Complications of ACE Inhibitors===
* 5-10 % patients cannot tolerate [[ACE inhibitors]] because of [[cough]]. [[Cough]] can be a sign of elevated left-sided filling pressures or a side effect of ACE inhibitors due to excess [[bradykinin]].  
* 5-10 % patients cannot tolerate [[ACE inhibitors]] because of [[cough]]. [[Cough]] can be a sign of elevated left-sided filling pressures or a side effect of ACE inhibitors due to excess [[bradykinin]].  
*ARBs are reserved for patients who are intolerant of ACE-Is for reasons (such as persistent cough) '''''OTHER''''' than [[hyperkalemia]], progression of chronic kidney disease/worsening [[azotemia]], or [[hypotension]] caused by prior ACE-I therapy.  If a patient experiences [[hyperkalemia]], worsening [[azotemia]], or [[hypotension]] as a result of [[ACE]]-I therapy, the same is likely to result from [[ARB]] therapy. In the CHARM study [[candesartan]] reduced both hospitalization and mortality.<ref name="pmid13678868">{{cite journal |author=Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, Yusuf S, Pocock S |title=Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme |journal=[[Lancet]] |volume=362 |issue=9386 |pages=759–66 |year=2003 |month=September |pmid=13678868 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673603142821 |accessdate=2012-04-03}}</ref><ref name="pmid15492298">{{cite journal |author=Young JB, Dunlap ME, Pfeffer MA, Probstfield JL, Cohen-Solal A, Dietz R, Granger CB, Hradec J, Kuch J, McKelvie RS, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, Held P, Solomon SD, Yusuf S, Swedberg K |title=Mortality and morbidity reduction with Candesartan in patients with chronic heart failure and left ventricular systolic dysfunction: results of the CHARM low-left ventricular ejection fraction trials |journal=[[Circulation]] |volume=110 |issue=17 |pages=2618–26 |year=2004 |month=October |pmid=15492298 |doi=10.1161/01.CIR.0000146819.43235.A9 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15492298 |accessdate=2012-04-03}}</ref>
*ARBs are reserved for patients who are intolerant of ACE-Is for reasons (such as persistent cough) '''''OTHER''''' than [[hyperkalemia]], progression of chronic kidney disease/worsening [[azotemia]], or [[hypotension]] caused by prior ACE-I therapy.  If a patient experiences [[hyperkalemia]], worsening [[azotemia]], or [[hypotension]] as a result of [[ACE]]-I therapy, the same is likely to result from [[ARB]] therapy. In the CHARM study [[candesartan]] reduced both hospitalization and mortality.<ref name="pmid13678868">{{cite journal |author=Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, Yusuf S, Pocock S |title=Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme |journal=[[Lancet]] |volume=362 |issue=9386 |pages=759–66 |year=2003 |month=September |pmid=13678868 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673603142821 |accessdate=2012-04-03}}</ref><ref name="pmid15492298">{{cite journal |author=Young JB, Dunlap ME, Pfeffer MA, Probstfield JL, Cohen-Solal A, Dietz R, Granger CB, Hradec J, Kuch J, McKelvie RS, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, Held P, Solomon SD, Yusuf S, Swedberg K |title=Mortality and morbidity reduction with Candesartan in patients with chronic heart failure and left ventricular systolic dysfunction: results of the CHARM low-left ventricular ejection fraction trials |journal=[[Circulation]] |volume=110 |issue=17 |pages=2618–26 |year=2004 |month=October |pmid=15492298 |doi=10.1161/01.CIR.0000146819.43235.A9 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15492298 |accessdate=2012-04-03}}</ref>
* [[Renal artery stenosis]] should be considered if there's a decline in renal function with the initiation of [[ACE inhibitors]].
* [[Renal artery stenosis]] should be considered if there's a decline in renal function with the initiation of [[ACE inhibitors]].


===2011 ACC/AHA Guidelines- Angiotensin-converting enzyme inhibitors <ref name="Hunt"> Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>===
==2011 ACC/AHA Guidelines- Angiotensin-converting enzyme inhibitors <ref name="Hunt"> Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>==
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====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]====
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
'''1.''' [[Angiotensin-converting enzyme inhibitors]] ([[ACEIs]]) are recommended for all patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]), unless contraindicated.<ref name="pmid6350401">{{cite journal |author= |title=A placebo-controlled trial of captopril in refractory chronic congestive heart failure. Captopril Multicenter Research Group |journal=[[Journal of the American College of Cardiology]] |volume=2 |issue=4 |pages=755–63 |year=1983 |month=October |pmid=6350401 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid7654275">{{cite journal |author=Garg R, Yusuf S |title=Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials |journal=[[JAMA : the Journal of the American Medical Association]] |volume=273 |issue=18 |pages=1450–6 |year=1995 |month=May |pmid=7654275 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid6329547">{{cite journal |author=Sharpe DN, Murphy J, Coxon R, Hannan SF |title=Enalapril in patients with chronic heart failure: a placebo-controlled, randomized, double-blind study |journal=[[Circulation]] |volume=70 |issue=2 |pages=271–8 |year=1984 |month=August |pmid=6329547 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=6329547 |accessdate=2012-04-05}}</ref><ref name="pmid2442560">{{cite journal |author=Chalmers JP, West MJ, Cyran J, De La Torre D, Englert M, Kramar M, Lewis GR, Maranhao MF, Myburgh DP, Schuster P |title=Placebo-controlled study of lisinopril in congestive heart failure: a multicentre study |journal=[[Journal of Cardiovascular Pharmacology]] |volume=9 Suppl 3 |issue= |pages=S89–97 |year=1987 |pmid=2442560 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid6388612">{{cite journal |author=Cleland JG, Dargie HJ, Hodsman GP, Ball SG, Robertson JI, Morton JJ, East BW, Robertson I, Murray GD, Gillen G |title=Captopril in heart failure. A double blind controlled trial |journal=[[British Heart Journal]] |volume=52 |issue=5 |pages=530–5 |year=1984 |month=November |pmid=6388612 |pmc=481676 |doi= |url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=6388612 |accessdate=2012-04-05}}</ref><ref name="pmid2994698">{{cite journal |author=Cleland JG, Dargie HJ, Ball SG, Gillen G, Hodsman GP, Morton JJ, East BW, Robertson I, Ford I, Robertson JI |title=Effects of enalapril in heart failure: a double blind study of effects on exercise performance, renal function, hormones, and metabolic state |journal=[[British Heart Journal]] |volume=54 |issue=3 |pages=305–12 |year=1985 |month=September |pmid=2994698 |pmc=481900 |doi= |url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=2994698 |accessdate=2012-04-05}}</ref><ref name="pmid6125809">{{cite journal |author=Cowley AJ, Rowley JM, Stainer KL, Hampton JR |title=Captopril therapy for heart failure. A placebo controlled study |journal=[[Lancet]] |volume=2 |issue=8301 |pages=730–2 |year=1982 |month=October |pmid=6125809 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(82)90920-5 |accessdate=2012-04-05}}</ref><ref name="pmid3924285">{{cite journal |author=Bayliss J, Norell MS, Canepa-Anson R, Reid C, Poole-Wilson P, Sutton G |title=Clinical importance of the renin-angiotensin system in chronic heart failure: double blind comparison of captopril and prazosin |journal=[[British Medical Journal (Clinical Research Ed.)]] |volume=290 |issue=6485 |pages=1861–5 |year=1985 |month=June |pmid=3924285 |pmc=1416765 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid2521816">{{cite journal |author=Drexler H, Banhardt U, Meinertz T, Wollschläger H, Lehmann M, Just H |title=Contrasting peripheral short-term and long-term effects of converting enzyme inhibition in patients with congestive heart failure. A double-blind, placebo-controlled trial |journal=[[Circulation]] |volume=79 |issue=3 |pages=491–502 |year=1989 |month=March |pmid=2521816 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=2521816 |accessdate=2012-04-05}}</ref><ref name="pmid8682023">{{cite journal |author=Erhardt L, MacLean A, Ilgenfritz J, Gelperin K, Blumenthal M |title=Fosinopril attenuates clinical deterioration and improves exercise tolerance in patients with heart failure. Fosinopril Efficacy/Safety Trial (FEST) Study Group |journal=[[European Heart Journal]] |volume=16 |issue=12 |pages=1892–9 |year=1995 |month=December |pmid=8682023 |doi= |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8682023 |accessdate=2012-04-05}}</ref><ref name="pmid2883575">{{cite journal |author= |title=Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group |journal=[[The New England Journal of Medicine]] |volume=316 |issue=23 |pages=1429–35 |year=1987 |month=June |pmid=2883575 |doi=10.1056/NEJM198706043162301 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198706043162301?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''}}
'''1.''' [[Angiotensin-converting enzyme inhibitors]] ([[ACEIs]]) are recommended for all patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]), unless contraindicated.<ref name="pmid6350401">{{cite journal |author= |title=A placebo-controlled trial of captopril in refractory chronic congestive heart failure. Captopril Multicenter Research Group |journal=[[Journal of the American College of Cardiology]] |volume=2 |issue=4 |pages=755–63 |year=1983 |month=October |pmid=6350401 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid7654275">{{cite journal |author=Garg R, Yusuf S |title=Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials |journal=[[JAMA : the Journal of the American Medical Association]] |volume=273 |issue=18 |pages=1450–6 |year=1995 |month=May |pmid=7654275 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid6329547">{{cite journal |author=Sharpe DN, Murphy J, Coxon R, Hannan SF |title=Enalapril in patients with chronic heart failure: a placebo-controlled, randomized, double-blind study |journal=[[Circulation]] |volume=70 |issue=2 |pages=271–8 |year=1984 |month=August |pmid=6329547 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=6329547 |accessdate=2012-04-05}}</ref><ref name="pmid2442560">{{cite journal |author=Chalmers JP, West MJ, Cyran J, De La Torre D, Englert M, Kramar M, Lewis GR, Maranhao MF, Myburgh DP, Schuster P |title=Placebo-controlled study of lisinopril in congestive heart failure: a multicentre study |journal=[[Journal of Cardiovascular Pharmacology]] |volume=9 Suppl 3 |issue= |pages=S89–97 |year=1987 |pmid=2442560 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid6388612">{{cite journal |author=Cleland JG, Dargie HJ, Hodsman GP, Ball SG, Robertson JI, Morton JJ, East BW, Robertson I, Murray GD, Gillen G |title=Captopril in heart failure. A double blind controlled trial |journal=[[British Heart Journal]] |volume=52 |issue=5 |pages=530–5 |year=1984 |month=November |pmid=6388612 |pmc=481676 |doi= |url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=6388612 |accessdate=2012-04-05}}</ref><ref name="pmid2994698">{{cite journal |author=Cleland JG, Dargie HJ, Ball SG, Gillen G, Hodsman GP, Morton JJ, East BW, Robertson I, Ford I, Robertson JI |title=Effects of enalapril in heart failure: a double blind study of effects on exercise performance, renal function, hormones, and metabolic state |journal=[[British Heart Journal]] |volume=54 |issue=3 |pages=305–12 |year=1985 |month=September |pmid=2994698 |pmc=481900 |doi= |url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=2994698 |accessdate=2012-04-05}}</ref><ref name="pmid6125809">{{cite journal |author=Cowley AJ, Rowley JM, Stainer KL, Hampton JR |title=Captopril therapy for heart failure. A placebo controlled study |journal=[[Lancet]] |volume=2 |issue=8301 |pages=730–2 |year=1982 |month=October |pmid=6125809 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(82)90920-5 |accessdate=2012-04-05}}</ref><ref name="pmid3924285">{{cite journal |author=Bayliss J, Norell MS, Canepa-Anson R, Reid C, Poole-Wilson P, Sutton G |title=Clinical importance of the renin-angiotensin system in chronic heart failure: double blind comparison of captopril and prazosin |journal=[[British Medical Journal (Clinical Research Ed.)]] |volume=290 |issue=6485 |pages=1861–5 |year=1985 |month=June |pmid=3924285 |pmc=1416765 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid2521816">{{cite journal |author=Drexler H, Banhardt U, Meinertz T, Wollschläger H, Lehmann M, Just H |title=Contrasting peripheral short-term and long-term effects of converting enzyme inhibition in patients with congestive heart failure. A double-blind, placebo-controlled trial |journal=[[Circulation]] |volume=79 |issue=3 |pages=491–502 |year=1989 |month=March |pmid=2521816 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=2521816 |accessdate=2012-04-05}}</ref><ref name="pmid8682023">{{cite journal |author=Erhardt L, MacLean A, Ilgenfritz J, Gelperin K, Blumenthal M |title=Fosinopril attenuates clinical deterioration and improves exercise tolerance in patients with heart failure. Fosinopril Efficacy/Safety Trial (FEST) Study Group |journal=[[European Heart Journal]] |volume=16 |issue=12 |pages=1892–9 |year=1995 |month=December |pmid=8682023 |doi= |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8682023 |accessdate=2012-04-05}}</ref><ref name="pmid2883575">{{cite journal |author= |title=Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group |journal=[[The New England Journal of Medicine]] |volume=316 |issue=23 |pages=1429–35 |year=1987 |month=June |pmid=2883575 |doi=10.1056/NEJM198706043162301 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198706043162301?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''}}
==Aldosterone Antagonists==
===Indications for Aldosterone Antagonists===
A patient should be on an aldosterone antagonist if:
1. The potassium (K) is ≤ 5.0 mmol/liter
'''''and'''''
2. The creatinine (Cr) is ≤ 2.5 mg/dl
'''''and'''''
3. The [[left ventricular ejection fraction]] ([[LVEF]]) is ≤ 35%
'''''OR'''''
1. The potassium (K) is ≤  5.0 mmol/liter
'''''and'''''
2. The creatinine (Cr) is ≤ 2.5 mg/dl
'''''and'''''
3. The [[left ventricular ejection fraction]] ([[LVEF]] is ≤ 40%<ref name="pmid21073363">{{cite journal |author=Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, Vincent J, Pocock SJ, Pitt B |title=Eplerenone in patients with systolic heart failure and mild symptoms |journal=[[The New England Journal of Medicine]] |volume=364 |issue=1 |pages=11–21 |year=2011 |month=January |pmid=21073363 |doi=10.1056/NEJMoa1009492 |url=http://dx.doi.org/10.1056/NEJMoa1009492 |accessdate=2012-04-03}}</ref>
'''''and'''''
4. There is a history of prior [[myocardial infarction]] ([[MI]])
====Background====
*Aldosterone antagonists are, as the name suggests, [[receptor antagonist]]s at the [[mineralocorticoid receptor]]. Antagonism of these receptors inhibits [[sodium]] resorption in the [[collecting duct]] of the [[nephron]] in the kidneys. This interferes with sodium/potassium exchange, reducing urinary potassium excretion and weakly increasing water excretion (diuresis). <ref>Rossi S, editor. [[Australian Medicines Handbook]] 2006. Adelaide: Australian Medicines Handbook; 2006.</ref>
*Members of this class in clinical use include: [[Spironolactone]]<ref name="pmid10471456">{{cite journal |author=Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J |title=The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators |journal=[[The New England Journal of Medicine]] |volume=341 |issue=10 |pages=709–17 |year=1999 |month=September |pmid=10471456 |doi=10.1056/NEJM199909023411001 |url=http://dx.doi.org/10.1056/NEJM199909023411001 |accessdate=2012-04-03}}</ref>; [[Eplerenone]]<ref name="pmid12668699">{{cite journal |author=Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M |title=Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction |journal=[[The New England Journal of Medicine]] |volume=348 |issue=14 |pages=1309–21 |year=2003 |month=April |pmid=12668699 |doi=10.1056/NEJMoa030207 |url=http://dx.doi.org/10.1056/NEJMoa030207 |accessdate=2012-04-03}}</ref><ref name="pmid21073363">{{cite journal |author=Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, Vincent J, Pocock SJ, Pitt B |title=Eplerenone in patients with systolic heart failure and mild symptoms |journal=[[The New England Journal of Medicine]] |volume=364 |issue=1 |pages=11–21 |year=2011 |month=January |pmid=21073363 |doi=10.1056/NEJMoa1009492 |url=http://dx.doi.org/10.1056/NEJMoa1009492 |accessdate=2012-04-03}}</ref> - more specific than spironolactone on target, but also more expensive; and [[Canrenone]] (canrenoate potassium)
* Aldosterone antagonist therapy is recommended for patients with advanced heart failure (NYHA class III or IV) and left ventricular systolic dysfunction (LVEF ≤ 35%), who are already receiving optimal medical therapy including loop diuretics, beta blockers and ACE-I/ARBs.
* In patients with diabetes mellitus or prior myocardial infarction, the LVEF below which this recommendation applies is 40%.
* In addition, the EMPHASIS-HF trial showed that [[eplerenone]] at a dose of 25-50mg daily reduced mortality and HF hospitalizations in patients with NYHA class I or II HF and should now be considered in these patients. This is not yet an AHA guideline but should be considered in this group of patients based on the available evidence.
====Contraindications====
* However, patients with baseline renal insufficiency (creatinine > 2.5 mg/dl or creatinine clearance < 30 ml/min), hyperkalemia (K > 5.0 mmol/liter), or who are unlikely to be available for frequent monitoring of renal function and electrolytes should '''''NOT''''' receive an aldosterone antagonist. Other potassium-sparing diuretics (such as triamterene) should not be administered concomitantly with an aldosterone antagonist.


==Vote on and Suggest Revisions to the Current Guidelines==
==Vote on and Suggest Revisions to the Current Guidelines==

Revision as of 16:23, 5 April 2012

Congestive Heart Failure Microchapters

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Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
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Diuretics
ACE Inhibitors
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Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
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Ultrafiltration
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ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

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Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure ACE inhibitors On the Web

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Ongoing Trials at Clinical Trials.gov

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Congestive heart failure ACE inhibitors in the news

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Risk calculators and risk factors for Congestive heart failure ACE inhibitors

Editor(s)-In-Chief: James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [1] and C. Michael Gibson, M.S., M.D. [2], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [3]

Overview

The Collaborative Group on ACE Inhibitor Trials demonstrated significant reduction in total mortality and hospitalization with the administration of ACEIs that was consistent among wide range of patients.[1]

Indications for an ACE Inhibitor or ARB

1. The left ventricular ejection fraction (LVEF) is ≤ 40%

or

2. There is a prior history of myocardial infarction (MI)

Background

  • ACE-I or ARB therapy is recommended for ANY patient with reduced left ventricular ejection fraction (≤ 40%) regardless of the etiology of left ventricular systolic dysfunction (ischemic or nonischemic) or presence/absence of symptoms. Patients with or without heart failure (in other words, even those with asymptomatic left ventricular systolic dysfunction) are included in this recommendation.
  • In addition, ACE-I/ARB therapy is indicated for patients with history of myocardial infarction whether or not left ventricular systolic dysfunction or heart failure is present.
  • ACE-I or ARB therapy is also recommended for patients who are at high risk for the development of heart failure due to the presence of coronary, cerebrovascular, or peripheral vascular disease.
  • Treatment should not be deferred in patients with few or no symptoms because of the significant mortality benefit derived from ACEI therapy.

Dosing

  • ACE-I/ARB therapy should be initiated at low dosage such as 12.5 mg tid of captopril, 2.5 mg bid of enalapril[2][3], or 2.5 mg daily lisinopril.
  • Every 4 to 6 weeks the dose is gradually uptitrated, as tolerated, toward target dosages of 20-40 mg daily for lisinopril, 10-20 mg twice daily for enalapril maleate, and 50-100 mg three times a day for captopril, or to the maximum tolerated dosage.
  • ACE inhibitors are rarely adequate for the treatment of congestion without the use of diuretics.

Complications of ACE Inhibitors

2011 ACC/AHA Guidelines- Angiotensin-converting enzyme inhibitors [6][7]

“

Class I

1. Angiotensin-converting enzyme inhibitors (ACEIs) are recommended for all patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF), unless contraindicated.[8][1][9][10][11][12][13][14][15][16][3] (Level of Evidence: A)

”

Vote on and Suggest Revisions to the Current Guidelines

Guidelines Resources

References

  1. ↑ 1.0 1.1 Garg R, Yusuf S (1995). "Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials". JAMA : the Journal of the American Medical Association. 273 (18): 1450–6. PMID 7654275. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  2. ↑ "Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators". The New England Journal of Medicine. 325 (5): 293–302. 1991. doi:10.1056/NEJM199108013250501. PMID 2057034. Retrieved 2012-04-03. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 "Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group". The New England Journal of Medicine. 316 (23): 1429–35. 1987. doi:10.1056/NEJM198706043162301. PMID 2883575. Retrieved 2012-04-03. Unknown parameter |month= ignored (help)
  4. ↑ Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, Yusuf S, Pocock S (2003). "Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme". Lancet. 362 (9386): 759–66. PMID 13678868. Retrieved 2012-04-03. Unknown parameter |month= ignored (help)
  5. ↑ Young JB, Dunlap ME, Pfeffer MA, Probstfield JL, Cohen-Solal A, Dietz R, Granger CB, Hradec J, Kuch J, McKelvie RS, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, Held P, Solomon SD, Yusuf S, Swedberg K (2004). "Mortality and morbidity reduction with Candesartan in patients with chronic heart failure and left ventricular systolic dysfunction: results of the CHARM low-left ventricular ejection fraction trials". Circulation. 110 (17): 2618–26. doi:10.1161/01.CIR.0000146819.43235.A9. PMID 15492298. Retrieved 2012-04-03. Unknown parameter |month= ignored (help)
  6. ↑ 6.0 6.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
  7. ↑ 7.0 7.1 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
  8. ↑ "A placebo-controlled trial of captopril in refractory chronic congestive heart failure. Captopril Multicenter Research Group". Journal of the American College of Cardiology. 2 (4): 755–63. 1983. PMID 6350401. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  9. ↑ Sharpe DN, Murphy J, Coxon R, Hannan SF (1984). "Enalapril in patients with chronic heart failure: a placebo-controlled, randomized, double-blind study". Circulation. 70 (2): 271–8. PMID 6329547. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  10. ↑ Chalmers JP, West MJ, Cyran J, De La Torre D, Englert M, Kramar M, Lewis GR, Maranhao MF, Myburgh DP, Schuster P (1987). "Placebo-controlled study of lisinopril in congestive heart failure: a multicentre study". Journal of Cardiovascular Pharmacology. 9 Suppl 3: S89–97. PMID 2442560. |access-date= requires |url= (help)
  11. ↑ Cleland JG, Dargie HJ, Hodsman GP, Ball SG, Robertson JI, Morton JJ, East BW, Robertson I, Murray GD, Gillen G (1984). "Captopril in heart failure. A double blind controlled trial". British Heart Journal. 52 (5): 530–5. PMC 481676. PMID 6388612. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  12. ↑ Cleland JG, Dargie HJ, Ball SG, Gillen G, Hodsman GP, Morton JJ, East BW, Robertson I, Ford I, Robertson JI (1985). "Effects of enalapril in heart failure: a double blind study of effects on exercise performance, renal function, hormones, and metabolic state". British Heart Journal. 54 (3): 305–12. PMC 481900. PMID 2994698. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  13. ↑ Cowley AJ, Rowley JM, Stainer KL, Hampton JR (1982). "Captopril therapy for heart failure. A placebo controlled study". Lancet. 2 (8301): 730–2. PMID 6125809. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  14. ↑ Bayliss J, Norell MS, Canepa-Anson R, Reid C, Poole-Wilson P, Sutton G (1985). "Clinical importance of the renin-angiotensin system in chronic heart failure: double blind comparison of captopril and prazosin". British Medical Journal (Clinical Research Ed.). 290 (6485): 1861–5. PMC 1416765. PMID 3924285. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  15. ↑ Drexler H, Banhardt U, Meinertz T, Wollschläger H, Lehmann M, Just H (1989). "Contrasting peripheral short-term and long-term effects of converting enzyme inhibition in patients with congestive heart failure. A double-blind, placebo-controlled trial". Circulation. 79 (3): 491–502. PMID 2521816. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  16. ↑ Erhardt L, MacLean A, Ilgenfritz J, Gelperin K, Blumenthal M (1995). "Fosinopril attenuates clinical deterioration and improves exercise tolerance in patients with heart failure. Fosinopril Efficacy/Safety Trial (FEST) Study Group". European Heart Journal. 16 (12): 1892–9. PMID 8682023. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)


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