Are there any types of myocardial infarctions (MIs) where Angiotensin-Converting Enzyme (ACE) inhibitors are contraindicated?

From the Guidelines

ACE inhibitors are not recommended in patients with certain types of myocardial infarctions (MIs), including right ventricular infarctions, inferior MIs with hypotension, and those with contraindications such as bilateral renal artery stenosis, pregnancy, history of angioedema, hyperkalemia, or severe renal dysfunction. According to the 2013 ACCF/AHA guideline for the management of heart failure 1, ACE inhibitors should be prescribed to all patients with heart failure with reduced ejection fraction (HFrEF) unless there is a contraindication. The 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1 also recommends ACE inhibitors for all patients with ST-elevation MI (STEMI) and no contraindications to their use. However, the guidelines emphasize the importance of individualizing the decision to use ACE inhibitors based on the patient's hemodynamic stability, renal function, and specific type of MI.

Some specific types of MIs where ACE inhibitors may not be recommended or should be used with caution include:

• Right ventricular infarctions, as these patients are preload-dependent and ACE inhibitors can reduce preload, potentially worsening hemodynamics
• Inferior MIs with hypotension, as these patients may experience excessive blood pressure drops with ACE inhibitors
• Patients with bilateral renal artery stenosis, as ACE inhibitors can worsen renal function in these patients 1
• Patients with pregnancy, history of angioedema with previous ACE inhibitor use, hyperkalemia, or severe renal dysfunction, as these conditions are contraindications to ACE inhibitor use 1.

In these cases, alternative medications like angiotensin receptor blockers (ARBs) might be considered instead, as they have been shown to be noninferior to ACE inhibitors in certain situations 1. Blood pressure and renal function should be monitored closely when initiating these medications after any type of MI.

From the FDA Drug Label

In the above pediatric studies, lisinopril was given either as tablets or in a suspension for those children and infants who were unable to swallow tablets or who required a lower dose than is available in tablet form The protocol excluded patients with hypotension (systolic blood pressure < 100 mmHg), severe heart failure, cardiogenic shock, and renal dysfunction (serum creatinine > 2 mg per dL and/or proteinuria > 500 mg per 24 h). Patients with acute myocardial infarction, treated with lisinopril, had a higher (9.0% versus 3.7%) incidence of persistent hypotension (systolic blood pressure < 90 mmHg for more than 1 hour) and renal dysfunction (2.4% versus 1. 1%) in-hospital and at six weeks (increasing creatinine concentration to over 3 mg per dL or a doubling or more of the baseline serum creatinine concentration)

Types of MI where ACE inhibitors are not given:

• Hypotension: ACE inhibitors like lisinopril are not given to patients with systolic blood pressure < 100 mmHg.
• Severe heart failure: Patients with severe heart failure are excluded from receiving ACE inhibitors like lisinopril.
• Cardiogenic shock: ACE inhibitors like lisinopril are not given to patients with cardiogenic shock.
• Renal dysfunction: Patients with renal dysfunction (serum creatinine > 2 mg per dL and/or proteinuria > 500 mg per 24 h) are excluded from receiving ACE inhibitors like lisinopril. 2

From the Research

Types of MI where ACE Inhibitors are not Given

• Myocardial infarction with nonobstructive coronary arteries (MINOCA) due to certain causes may not require ACE inhibitors as a treatment option 3
• Patients with acute myocardial infarction due to left main coronary artery occlusion may require emergency intervention and revascularization, but the use of ACE inhibitors is not specifically mentioned as a treatment option in this scenario 4
• Patients with Takotsubo cardiomyopathy, a type of MINOCA, may not require ACE inhibitors as part of their treatment plan 5
• Patients with myocardial infarction due to acute type A aortic dissection may require percutaneous coronary intervention (PCI) as a bridge treatment, but the use of ACE inhibitors is not mentioned as a necessary treatment option in this scenario 6

Considerations for ACE Inhibitor Use in MI

• The American Heart Association provides a framework for the diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease, but does not specifically address the use of ACE inhibitors in these patients 7
• The decision to use ACE inhibitors in patients with MI should be based on individual patient characteristics and the underlying cause of the MI, rather than a blanket approach to all patients with MI 3, 7