ACE Inhibitor in CHF

Aka: ACE Inhibitor in CHF, Angiotensin Converting Enzyme Inhibitor in CHF

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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: ACE Inhibitors

  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

V. 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)

VI. 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

VII. 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

VIII. 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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