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ACE Inhibitor in CHF

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ACE Inhibitor in CHF, Angiotensin Converting Enzyme Inhibitor in CHF

  • See Also
  1. ACE Inhibitor
  2. Renin-Angiotensin System
  • Indication
  1. Most patients with Systolic Dysfunction
    1. ACE Inhibitors are the most important CHF agents
  • Contraindications
  1. See ACE Inhibitor
  2. Caution in Class IV Congestive Heart Failure
  3. Avoid if Serum Creatinine >2.5 mg/dl or GFR <30 ml/min
  4. Avoid if Serum Potassium >5 mEq/L
  1. Captopril (Capoten)
    1. Start: 6.25 to 12.5 mg orally three times daily
    2. Target: 50 mg orally three times daily
    3. Maximum: 100 mg orally three times daily
  2. Enalapril (Vasotec)
    1. Start: 2.5 to 5.0 mg orally twice daily
    2. Target: 10 mg orally twice daily
    3. Maximum: 20 mg orally twice daily
  3. Fosinopril (Monopril)
    1. Start: 5 to 10 mg orally daily
    2. Target: 20 mg orally daily
    3. Maximum: 40 mg orally daily
  4. Lisinopril (Zestril)
    1. Start: 2.5 to 5 mg orally daily
    2. Target: 20 mg orally daily
    3. Maximum: 40 mg orally daily
  5. Quinapril (Accupril)
    1. Start: 5 to 10 mg orally daily
    2. Target: 10-20 mg orally twice daily
    3. Maximum: 40 mg orally daily
  6. Ramipril (Altace)
    1. Start: 1.25 to 2.5 mg orally twice daily
    2. Target: 5 mg orally twice daily
    3. Maximum: 10 mg daily
  7. Perindopril (Aceon)
    1. Start: 2 mg once daily
    2. Target: 8 to 16 mg orally daily
  8. Trandalopril (Mavik)
    1. Start: 1 mg once daily
    2. Target: 4 mg once daily
  • Preparations
  • Alternatives for CHF patient (ACE Inhibitor intollerant)
  1. Regimen 1: Angiotensin Receptor Antagonists (ARBs)
    1. Candesartan (Atacand) 4 mg orally daily (may titrate to 32 mg orally daily)
    2. Valsartan (Diovan) 40 mg orally twice daily (may titrate to 160 mg orally twice daily)
  2. Regimen 2
    1. Hydralazine 37.5 mg three times daily (max: 75 mg three times daily)
    2. Isosorbide Dinitrate (Isordil) 20 mg orally three times daily (max: 40 mg three times daily)
  • Management
  • General pointers
  1. Maximize dose (e.g. Lisinopril 20-40 mg per day)
    1. Highest survival benefit at high dose
    2. Rochon (2004) J Gen Intern Med 19:676-83 [PubMed]
  2. Split to twice daily dosing while increasing
    1. Prevents precipitous Blood Pressure drops
    2. Example: 2.5 mg bid
  3. Avoid manipulating dosage based on Blood Pressure
    1. Only symptomatic Hypotension should decrease dose
  • Adverse Effects
  1. If ACE Inhibitor increases BUN or Creatinine
    1. Try decreasing Loop Diuretic
  2. Cough often related to Congestive Heart Failure
    1. ACE Inhibitor associated with 35% Incidence cough
    2. Placebo associated with 25% Incidence of cough
  • References
  1. Hoyt (2001) Am Fam Physician 63(8):1593-8 [PubMed]
  2. Pfeffer (1992) N Engl J Med 327(10):669-677 [PubMed]
  3. (1992) N Engl J Med 327(10):685-691 [PubMed]