Congestive heart failure ACE inhibitors

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Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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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 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 Inhibitors (ACEI) should be considered as first-line therapy for the treatment of patients with clinical heart failure due to reduced left ventricular systolic dysfunction (LVSD), patients with asymptomatic LV dysfunction, and 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.
• 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 inhibitors are rarely adequate for the treatment of congestion without the use of diuretics.
• 5-10 % patients cannot tolerate ACE inhibitors because of cough. Cough can be a sign of elevated left-sided filling pressures. Sometimes cough will diminish with the treatment of heart failure. A
• Renal artery stenosis should be considered if there's a decline in renal function with the initiation of ACE inhibitors.

Angiotensin receptor blockers (ARB)

• In the CHARM study candesartan reduced both hospitalization and mortality.

Aldosterone Antagonists

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

References

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