From the Guidelines
ACE inhibitors or ARBs should be started as soon as possible in patients with new decompensated heart failure, typically within 24-48 hours of presentation once the patient is hemodynamically stable and renal function has been assessed. Begin with a low dose, such as enalapril 2.5 mg twice daily, lisinopril 2.5-5 mg once daily, or valsartan 40 mg twice daily, and titrate upward every 2-4 weeks as tolerated 1. Before initiating therapy, check baseline blood pressure, serum creatinine, and potassium levels. Do not start if systolic blood pressure is below 90 mmHg, if serum creatinine is significantly elevated (>3 mg/dL), or if potassium is >5.0 mEq/L.
Key Considerations
- Monitor renal function and electrolytes within 1-2 weeks after initiation and with each dose increase 1.
- These medications are beneficial because they block the renin-angiotensin-aldosterone system, reducing afterload, preventing cardiac remodeling, and improving long-term survival.
- If a patient cannot tolerate an ACE inhibitor due to cough, an ARB should be substituted 1.
- For patients with severe heart failure, consider starting at even lower doses and titrating more gradually 1.
Benefits of ACE Inhibitors and ARBs
- Reduce morbidity and mortality in patients with heart failure 1.
- Improve symptoms, functional capacity, and reduce hospitalization in patients with moderate and severe heart failure and left ventricular systolic dysfunction 1.
- Should be given as the initial therapy in the absence of fluid retention, and together with diuretics in patients with fluid retention 1.
From the FDA Drug Label
In patients with heart failure who have hyponatremia (serum sodium less than 130 mEq/L) or with serum creatinine greater than 1.6 mg/dL, therapy should be initiated at 2. 5 mg daily under close medical supervision The recommended initial dose is 2.5 mg. The recommended dosing range is 2. 5 to 20 mg given twice a day. Doses should be titrated upward, as tolerated, over a period of a few days or weeks. After the initial dose of enalapril maleate, the patient should be observed under medical supervision for at least two hours and until blood pressure has stabilized for at least an additional hour
The initial dose of enalapril for patients with new decompensated heart failure should be 2.5 mg, and the patient should be observed under medical supervision for at least two hours after the initial dose. The dose can then be titrated upward as tolerated. In patients with hyponatremia or renal impairment, the initial dose should also be 2.5 mg daily under close medical supervision 2.
From the Research
Initiating ACE Inhibitor Therapy in Decompensated Heart Failure
- The decision to start an ACE inhibitor in patients with new decompensated heart failure should be based on individual patient characteristics and clinical presentation 3, 4.
- According to the study by 3, lisinopril, an ACE inhibitor, has been shown to have beneficial hemodynamic effects and increased exercise tolerance in patients with congestive heart failure.
- The study by 4 also suggests that lisinopril may be comparable to captopril for the treatment of congestive heart failure.
Timing of ACE Inhibitor Initiation
- There is no specific guidance on the exact timing of ACE inhibitor initiation in decompensated heart failure, but it is generally recommended to start therapy as soon as possible after stabilization of the patient 5, 6.
- The study by 6 recommends in-hospital administration of oral evidence-based modifying chronic heart failure medications, including ACE inhibitors, to reduce morbidity and mortality.
Considerations for ACE Inhibitor Use
- When initiating ACE inhibitor therapy, it is essential to consider the patient's renal function, as ACE inhibitors can cause azotemia and hyperkalemia 3, 4.
- The study by 7 compares the efficacy and safety of valsartan, an angiotensin II antagonist, to lisinopril, an ACE inhibitor, and suggests that valsartan may be a suitable alternative for patients who cannot tolerate ACE inhibitors due to cough or other side effects.