Cardiovascular Medicine Book

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ACE Inhibitor in CHF

Aka: ACE Inhibitor in CHF, Angiotensin Converting Enzyme Inhibitor in CHF
  1. See Also
    1. ACE Inhibitor
    2. Renin-Angiotensin System
  2. Indication
    1. Most patients with Systolic Dysfunction
      1. ACE Inhibitors are the most important CHF agents
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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)
  8. 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]

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