Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers): Difference between revisions

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*In diabetics with [[MI|post-MI]], [[ACEI|ACE inhibition]] may slow the rate of progression of proteinuric chronic renal failure.
*In diabetics with [[MI|post-MI]], [[ACEI|ACE inhibition]] may slow the rate of progression of proteinuric chronic renal failure.
==Indications==
*[[ACEIs]] or [[ARB|ARBs]] are used as the first-line of agents in the management of [[hypertension]] in [[diabetics]] with [[microalbuminuria]] as they prevent the progression of [[renal dysfunction]].<ref name="pmid12777938">European Society of Hypertension-European Society of Cardiology Guidelines Committee (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12777938 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension.] ''J Hypertens'' 21 (6):1011-53. [http://dx.doi.org/10.1097/01.hjh.0000059051.65882.32 DOI:10.1097/01.hjh.0000059051.65882.32] PMID: [http://pubmed.gov/12777938 12777938]</ref> <ref name="pmid12502618">American Diabetes Association (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12502618 Standards of medical care for patients with diabetes mellitus.] ''Diabetes Care'' 26 Suppl 1 ():S33-50. PMID: [http://pubmed.gov/12502618 12502618]</ref>
*In patients with [[coronary artery disease]] and preserved left ventricular function, [[ACEIs]] may be indicated for secondary preventive therapy.<ref name="pmid15531767">Braunwald E, Domanski MJ, Fowler SE, Geller NL, Gersh BJ, Hsia J et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15531767 Angiotensin-converting-enzyme inhibition in stable coronary artery disease.] ''N Engl J Med'' 351 (20):2058-68. [http://dx.doi.org/10.1056/NEJMoa042739 DOI:10.1056/NEJMoa042739] PMID: [http://pubmed.gov/15531767 15531767]</ref> <ref name="pmid10639539">Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10639539 Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators.] ''N Engl J Med'' 342 (3):145-53. [http://dx.doi.org/10.1056/NEJM200001203420301 DOI:10.1056/NEJM200001203420301] PMID: [http://pubmed.gov/10639539 10639539]</ref> <ref name="pmid13678872">Fox KM, EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=13678872 Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study).] ''Lancet'' 362 (9386):782-8. PMID: [http://pubmed.gov/13678872 13678872]</ref>
==Adverse effects==
In comparison to other anti-hypertensive drugs, [[ACEIs]] although remain the standard drug of choice for [[hypertension]] and [[heart failure]], it has not been shown to confer overall protection against cardiovascular complications.<ref name="pmid14615107">Turnbull F, Blood Pressure Lowering Treatment Trialists' Collaboration (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14615107 Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials.] ''Lancet'' 362 (9395):1527-35. PMID: [http://pubmed.gov/14615107 14615107]</ref> <ref name="pmid12777939">Staessen JA, Wang JG, Thijs L (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12777939 Cardiovascular prevention and blood pressure reduction: a quantitative overview updated until 1 March 2003.] ''J Hypertens'' 21 (6):1055-76. [http://dx.doi.org/10.1097/01.hjh.0000059044.65882.db DOI:10.1097/01.hjh.0000059044.65882.db] PMID: [http://pubmed.gov/12777939 12777939]</ref> <ref name="pmid12759325">Psaty BM, Lumley T, Furberg CD, Schellenbaum G, Pahor M, Alderman MH et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12759325 Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis.] ''JAMA'' 289 (19):2534-44. [http://dx.doi.org/10.1001/jama.289.19.2534 DOI:10.1001/jama.289.19.2534] PMID: [http://pubmed.gov/12759325 12759325]</ref>


==ACC/AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT) <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref> <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref>==
==ACC/AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT) <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref> <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref>==

Revision as of 13:23, 3 September 2011

Chronic stable angina Microchapters

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Chronic Stable Angina
Atypical
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [5] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [6]; John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Patients diagnosed with syndrome X and hypertension may have microvascular angina where in there is a reduced coronary vasodilator reserve and increased sympathetic drive. ACE inhibition in such patients may attenuate sympathetic coronary vasoconstriction and normalize thallium perfusion defects and reduce exercise-induced ischemia with subsequent increase in myocardial oxygen supply.[1] [2]

Mechanisms of benefit

  • In diabetics with post-MI, ACE inhibition may slow the rate of progression of proteinuric chronic renal failure.

Indications

Adverse effects

In comparison to other anti-hypertensive drugs, ACEIs although remain the standard drug of choice for hypertension and heart failure, it has not been shown to confer overall protection against cardiovascular complications.[4] [5] [11]

ACC/AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT) [12] [13]

“

Class I

1. ACE inhibitors in all patients with significant coronary artery disease by angiography or previous myocardial infarction who also have diabetes and/or left ventricular systolic dysfunction. (Level of Evidence: A)

2. ACE inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction less than or equal to 40% and in those with hypertension, diabetes, or chronic kidney disease unless contraindicated. (Level of Evidence: A)

3. ACE inhibitors should be started and continued indefinitely in patients who are not lower risk (lower risk defined as those with normal left ventricular ejection fraction in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. (Level of Evidence: B)

4. Angiotensin receptor blockers are recommended for patients who have hypertension, have indications for but are intolerant of ACE inhibitors, have heart failure, or have had a myocardial infarction with left ventricular ejection fraction less than or equal to 40%. (Level of Evidence: A)

5. Aldosterone blockade is recommended for use in post-MI patients without significant renal dysfunction (creatinine should be less than 2.5 mg per dL in men and less than 2.0 mg per dL in women) or hyperkalemia (potassium should be less than 5.0 mEq per L) who are already receiving therapeutic doses of an ACE inhibitor and a beta blocker, have a left ventricular ejection fraction less than or equal to 40%, and have either diabetes or heart failure. (Level of Evidence: A)

Class IIa

1. ACE inhibitor in patients with coronary artery disease by angiography or previous myocardial infarction or other vascular disease. (Level of Evidence: B)

2. It is reasonable to use ACE inhibitors among lower-risk patients with mildly reduced or normal left ventricular ejection fraction in whom cardiovascular risk factors are well controlled and revascularization has been performed. (Level of Evidence: B)

Class IIb

1. Angiotensin receptor blockers may be considered in combination with ACE inhibitors for heart failure due to left ventricular systolic dysfunction. (Level of Evidence: B)

”

ESC Guidelines- Pharmacological therapy to improve prognosis in patients with stable angina (DO NOT EDIT) [14]

“

Class I

1. ACE-inhibitor therapy in patients with coincident indications for ACE-inhibition, such as hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes. (Level of Evidence: A)

Class IIa

1. ACE-inhibitor therapy in all patients with angina and proven coronary disease. (Level of Evidence: B)

”

Vote on and Suggest Revisions to the Current Guidelines

Sources

  • TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [12]
  • The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [13]
  • Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [14]
  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [15]

References

  1. ↑ 1.0 1.1 Kaski JC, Rosano G, Gavrielides S, Chen L (1994) Effects of angiotensin-converting enzyme inhibition on exercise-induced angina and ST segment depression in patients with microvascular angina. J Am Coll Cardiol 23 (3):652-7. PMID: 8113548
  2. ↑ 2.0 2.1 van den Heuvel AF, Dunselman PH, Kingma T, Verhorst P, Boomsma F, van Gilst WH et al. (2001) Reduction of exercise-induced myocardial ischemia during add-on treatment with the angiotensin-converting enzyme inhibitor enalapril in patients with normal left ventricular function and optimal beta blockade. J Am Coll Cardiol 37 (2):470-4. PMID: 11216965
  3. ↑ Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration (2002) Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 360 (9349):1903-13. PMID: 12493255
  4. ↑ 4.0 4.1 Turnbull F, Blood Pressure Lowering Treatment Trialists' Collaboration (2003) Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet 362 (9395):1527-35. PMID: 14615107
  5. ↑ 5.0 5.1 Staessen JA, Wang JG, Thijs L (2003) Cardiovascular prevention and blood pressure reduction: a quantitative overview updated until 1 March 2003. J Hypertens 21 (6):1055-76. DOI:10.1097/01.hjh.0000059044.65882.db PMID: 12777939
  6. ↑ European Society of Hypertension-European Society of Cardiology Guidelines Committee (2003) 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 21 (6):1011-53. DOI:10.1097/01.hjh.0000059051.65882.32 PMID: 12777938
  7. ↑ American Diabetes Association (2003) Standards of medical care for patients with diabetes mellitus. Diabetes Care 26 Suppl 1 ():S33-50. PMID: 12502618
  8. ↑ Braunwald E, Domanski MJ, Fowler SE, Geller NL, Gersh BJ, Hsia J et al. (2004) Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med 351 (20):2058-68. DOI:10.1056/NEJMoa042739 PMID: 15531767
  9. ↑ Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (2000) Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 342 (3):145-53. DOI:10.1056/NEJM200001203420301 PMID: 10639539
  10. ↑ Fox KM, EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators (2003) Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 362 (9386):782-8. PMID: 13678872
  11. ↑ Psaty BM, Lumley T, Furberg CD, Schellenbaum G, Pahor M, Alderman MH et al. (2003) Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA 289 (19):2534-44. DOI:10.1001/jama.289.19.2534 PMID: 12759325
  12. ↑ 12.0 12.1 Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58.[1] PMID: 12515758
  13. ↑ 13.0 13.1 Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[2] PMID: 17998462
  14. ↑ 14.0 14.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). [url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [3] "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology"] Check |url= value (help). Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.
  15. ↑ Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. [4] PMID: 10351980


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