Does Angiotensin-Converting Enzyme Inhibitor (ACEI) improve quality of life in patients with Chronic Heart Failure?

From the Guidelines

Angiotensin-converting enzyme inhibitors (ACEIs) significantly improve quality of life in patients with chronic heart failure and should be considered a cornerstone of heart failure management. Common ACEIs used include enalapril (2.5-20 mg twice daily), lisinopril (2.5-40 mg once daily), ramipril (1.25-10 mg once daily), and perindopril (2-8 mg once daily) 1. Treatment should be initiated at low doses and gradually titrated upward over 2-4 weeks to target doses as tolerated. ACEIs improve quality of life by reducing symptoms such as dyspnea and fatigue, increasing exercise tolerance, and decreasing hospitalizations. These benefits occur through multiple mechanisms: ACEIs block the conversion of angiotensin I to angiotensin II, reducing vasoconstriction and sodium retention, decreasing cardiac afterload and preload, and preventing adverse cardiac remodeling. They also decrease aldosterone secretion, further reducing fluid retention.

Key benefits of ACEIs in chronic heart failure management include:

• Reducing mortality: ACEIs have been shown to reduce mortality in patients with chronic heart failure, with a relative risk reduction (RRR) of 27% in the CONSENSUS trial and 16% in the SOLVD-Treatment trial 1.
• Improving symptoms: ACEIs improve symptoms such as dyspnea and fatigue, increasing exercise tolerance, and decreasing hospitalizations 1.
• Enhancing exercise tolerance: ACEIs have been shown to improve exercise tolerance in patients with chronic heart failure, allowing for increased physical activity and improved quality of life 1.

Patients should be monitored for potential side effects including hypotension, hyperkalemia, cough, and rarely angioedema. Renal function and potassium levels should be checked before initiation, 1-2 weeks after starting therapy, and with each dose increase. ACEIs are particularly beneficial in patients with reduced ejection fraction heart failure (HFrEF) but may provide symptomatic benefit across the spectrum of heart failure 1.

From the FDA Drug Label

There was a beneficial effect on severity of heart failure as measured by the New York Heart Association (NYHA) classification and on symptoms of dyspnea and fatigue. Effects on exercise tolerance, heart size, and severity and symptoms of heart failure were observed in placebo-controlled studies lasting from eight weeks to over one year Use of enalapril was associated with an 11 percent reduction in all-cause mortality and a 30 percent reduction in hospitalization for heart failure. Enalapril-treated subjects had 32% fewer first hospitalizations for heart failure, and 32% fewer total heart failure hospitalizations Compared to placebo, 32 percent fewer patients receiving enalapril developed symptoms of overt heart failure.

The use of enalapril in patients with chronic heart failure is associated with an improvement in quality of life, as evidenced by a reduction in symptoms of dyspnea and fatigue, and an improvement in exercise tolerance. Key benefits include:

• Reduction in hospitalization for heart failure by 30%
• Reduction in all-cause mortality by 11%
• Reduction in first hospitalizations for heart failure by 32%
• Reduction in total heart failure hospitalizations by 32%
• Reduction in development of symptoms of overt heart failure by 32% 2

From the Research

ACE Inhibitors and Quality of Life in Chronic Heart Failure

• ACE inhibitors have been shown to improve symptoms and survival in patients with chronic heart failure (CHF) by inhibiting the renin-angiotensin-aldosterone system (RAAS) and increasing plasma bradykinin levels 3.
• The administration of ACE inhibitors is associated with improved hemodynamics, reduced symptoms of fatigue and dyspnea, increased exercise capacity, and correction of hyponatremia 4.
• ACE inhibitors have been found to improve certain domains of health-related quality of life (HRQL) in patients with CHF, although the data is confounded by a placebo effect and high noncompletion rates for sicker patients 5.
• Multicenter trials have indicated that ACE inhibitors do not compromise and may actually improve certain components of quality of life in patients with CHF, while having favorable effects on survival, exercise capacity, hemodynamics, or symptoms 5.

Comparison with Angiotensin Receptor Antagonists

• Angiotensin receptor antagonists (ARBs) have been found to have similar hemodynamic effects to ACE inhibitors, but with a different mechanism of action and certain adverse effects 3, 6.
• Clinical trials have shown that ARBs can provide symptomatic relief in patients with CHF, but have not been shown to improve survival 3, 6.
• The addition of an ARB to an ACE inhibitor has been found to reduce the risk of hospitalization, but increases the risk of renal failure and hyperkalemia 6.

Clinical Implications

• ACE inhibitors remain the first-line option for the treatment of CHF, with ARBs considered as an alternative for patients who do not tolerate ACE inhibitors 6.
• The use of ACE inhibitors has been found to prevent myocardial infarction and control blood pressure, making them a pivotal part of the management of patients with CHF, particularly those with underlying ischemic heart disease 7.