Congestive heart failure ACE inhibitors

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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

Indications for an ACE Inhibitor or ARB

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

or

2. There is a prior history of myocardiial 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

• Initial therapy usually consist of 12.5 mg tid of captopril, 2.5 mg bid of enalapril, or 2.5 mg daily lisinopril. The optimal dose is usually established by optimizing the dose every 4 to 6 weeks.
• ACE-I/ARB therapy should be initiated at low dosage and 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

• 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.
• Renal artery stenosis should be considered if there's a decline in renal function with the initiation of ACE inhibitors.

Aldosterone Antagonists

• Spironolactone is third line therapy for CHF
• An important side effect of spironolactone is hyperkalemia

References

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