II. Indication

  1. Most patients with Systolic Dysfunction
    1. ACE Inhibitors are the most important CHF agents

III. 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

IV. Preparations

  1. Captopril (Capoten)
    1. Start: 6.25 to 12.5 mg PO tid
    2. Target: 50 mg PO tid
    3. Maximum: 100 mg PO tid
  2. Enalapril (Vasotec)
    1. Start: 2.5 to 5.0 mg PO bid
    2. Target: 10 mg PO bid
    3. Maximum: 20 mg PO bid
  3. Fosinopril (Monopril)
    1. Start: 5 to 10 mg PO qd
    2. Target: 20 mg PO qd
    3. Maximum: 40 mg PO qd
  4. Lisinopril (Zestril)
    1. Start: 2.5 to 5 mg PO qd
    2. Target: 20 mg PO qd
    3. Maximum: 40 mg PO qd
  5. Quinapril (Accupril)
    1. Start: 5 to 10 mg PO qd
    2. Target: 20 mg PO qd
    3. Maximum: 40 mg PO qd
  6. Ramipril (Altace)
    1. Start: 1.25 to 2.5 mg PO qd
    2. Target: 5 mg PO qd
    3. Maximum: 10 mg PO qd

V. 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

VI. 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

VII. Preparations: Alternatives for CHF patient (ACE Inhibitor intollerant)

  1. Regimen 1
    1. Angiotensin II Receptor Antagonists
  2. Regimen 2
    1. Hydralazine (max: 75 mg qd)
    2. Isosorbide Dinitrate (max: 30-40 mg tid)

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