Indications for Angiotensin Receptor Blockers (ARBs)
ARBs are primarily indicated for patients with heart failure or myocardial infarction with left ventricular ejection fraction <40% who are ACE inhibitor intolerant, and for patients with hypertension who have diabetes, chronic kidney disease, or albuminuria. 1
Primary Indications for ARBs
First-line Indications:
- Heart Failure: ARBs are recommended for patients with heart failure with reduced ejection fraction (HFrEF) who are ACE inhibitor intolerant 1
- Post-Myocardial Infarction: For patients with left ventricular dysfunction following MI who cannot tolerate ACE inhibitors 1, 2
- Diabetic Nephropathy: For treatment of diabetic nephropathy with elevated serum creatinine and proteinuria in patients with type 2 diabetes and hypertension 3, 4
- Chronic Kidney Disease: Particularly in patients with albuminuria (≥300 mg/g) 1, 5
Second-line Indications:
- ACE Inhibitor Intolerance: Reasonable to use ARBs in any patient who is ACE inhibitor intolerant 1, 6
- Hypertension: Can be used as first-line therapy or added later in treatment titration, especially effective in combination with thiazide diuretics or calcium channel blockers 7
Specific Patient Populations
Patients with Left Ventricular Dysfunction:
- ARBs reduce the risk of hospitalization for heart failure in patients with NYHA class II-IV heart failure 2
- ARBs reduce cardiovascular mortality in patients with left ventricular failure or dysfunction following myocardial infarction 2
Patients with Chronic Kidney Disease:
- ARBs are indicated for CKD stage 3 or higher or stage 1-2 with albuminuria ≥300 mg/g 1
- They reduce the rate of progression of nephropathy in patients with type 2 diabetes 3, 8
- ARBs significantly reduce proteinuria in patients with CKD and hypertension 5
Patients with Diabetes:
- First-line choice for patients with diabetes and hypertension 1
- Particularly beneficial in patients with diabetes and albuminuria 4
- Can prevent/delay development of diabetic nephropathy in patients with type 2 diabetes and microalbuminuria 4
Contraindications and Cautions
- Pregnancy: ARBs are contraindicated in pregnancy due to risk of fetal damage 1
- Hyperkalemia Risk: Monitor potassium levels, especially in patients with CKD 1
- Renal Function: Monitor serum creatinine and potassium 7-14 days after initiation or dose change 1
- Combination Therapy: Combining ARBs with ACE inhibitors is not recommended due to increased risk of hyperkalemia and acute kidney injury without added benefit 1, 6
Dosing and Administration
- Can be used as monotherapy or in combination with other antihypertensive agents 3, 2
- Particularly effective when combined with thiazide diuretics or calcium channel blockers 7
- For hypertension with BP between 130/80 mmHg and 150/90 mmHg, may begin with a single agent 1
- For BP ≥150/90 mmHg, initial combination therapy with two agents from different classes is recommended 1
Clinical Benefits Beyond Blood Pressure Control
- Renoprotective effects independent of blood pressure reduction in diabetic nephropathy 4, 8
- Reduction in cardiovascular events, particularly hospitalization for heart failure 4
- Favorable impact on proteinuria with both monotherapy and combination therapy 5
Monitoring
- Monitor serum creatinine, eGFR, and potassium levels at baseline and periodically during treatment 1
- For patients with CKD, more frequent monitoring may be necessary 1
- Evaluate for orthostatic hypotension before starting or intensifying therapy 1
ARBs represent a valuable class of medications with proven benefits for reducing morbidity and mortality in various cardiovascular and renal conditions, particularly when ACE inhibitors cannot be tolerated.