What conditions should be considered before adding an Angiotensin-Converting Enzyme (ACE) inhibitor to a 69-year-old woman with a history of coronary artery disease and carotid stenosis?

From the Guidelines

Before adding an Angiotensin-Converting Enzyme (ACE) inhibitor to a 69-year-old woman with a history of coronary artery disease and carotid stenosis, it is crucial to evaluate her renal function, potassium levels, blood pressure, and medication list to minimize potential adverse effects. The patient's renal function should be assessed by checking serum creatinine and estimated glomerular filtration rate, as ACE inhibitors can cause acute kidney injury, particularly in patients with renal artery stenosis 1.

Key Considerations

• Baseline potassium levels should be measured since ACE inhibitors can cause hyperkalemia, especially in patients with elevated levels of serum potassium (>5.0 mEq/L) 1.
• Blood pressure should be evaluated, as these medications may cause significant hypotension, especially with the first dose, and caution should be exercised in patients with very low systemic blood pressure (systolic blood pressure <80 mm Hg) 1.
• The patient's medication list should be reviewed for potential drug interactions, particularly diuretics, NSAIDs, and potassium supplements.
• A history of angioedema would be an absolute contraindication, and the clinician should inquire about a history of chronic cough, as this is a common side effect that may necessitate discontinuation.

Additional Recommendations

• Starting with a low dose and gradually titrating upward while monitoring renal function and potassium levels is recommended to minimize adverse effects while achieving cardioprotective benefits.
• The benefits of ACE inhibition were seen in patients with mild, moderate, or severe symptoms of heart failure and in patients with or without coronary artery disease, and ACE inhibitors should be prescribed to all patients with heart failure with reduced ejection fraction (HFrEF) unless there is a contraindication 1.
• The results of the Heart Outcomes Prevention Evaluation (HOPE) trial confirm that use of the ACE inhibitor ramipril reduced the incidence of cardiovascular death, myocardial infarction, and stroke in patients who were at high risk for, or had, vascular disease in the absence of heart failure 1.

From the FDA Drug Label

In patients at risk for excessive hypotension, sometimes associated with oliguria and/or progressive azotemia, and rarely with acute renal failure and/or death, include those with the following conditions or characteristics: heart failure, hyponatremia, high dose diuretic therapy, recent intensive diuresis or increase in diuretic dose, renal dialysis, or severe volume and/or salt depletion of any etiology. Similar considerations may apply to patients with ischemic heart or cerebrovascular disease, in whom an excessive fall in blood pressure could result in a myocardial infarction or cerebrovascular accident.

The conditions to be considered before adding an Angiotensin-Converting Enzyme (ACE) inhibitor to a 69-year-old woman with a history of coronary artery disease and carotid stenosis include:

• Heart failure
• Hyponatremia
• High dose diuretic therapy
• Recent intensive diuresis or increase in diuretic dose
• Renal dialysis
• Severe volume and/or salt depletion of any etiology
• Ischemic heart disease
• Cerebrovascular disease 2

From the Research

Conditions to Consider Before Adding an ACE Inhibitor

Before adding an Angiotensin-Converting Enzyme (ACE) inhibitor to a 69-year-old woman with a history of coronary artery disease and carotid stenosis, several conditions should be considered:

• The patient's cardiac symptoms and left ventricular function, as ACE inhibitors have been shown to prevent progressive deterioration in left ventricular function and reduce mortality in patients with congestive heart failure or left ventricular dysfunction 3
• The presence of hypertension, as ACE inhibitors can attenuate myocardial ischemia in hypertensive patients with coronary artery disease 3
• The severity of carotid stenosis, as patients with severe carotid stenosis may require carotid revascularization prior to or in conjunction with medical management 4, 5
• The patient's neurological symptoms, as carotid revascularization may be justified in symptomatic or high-risk patients 4, 5
• The potential risks and benefits of ACE inhibitors in patients with coronary artery disease, as they may not be beneficial in all patients and may even worsen angina in some cases 3

Medical Management

The medical management of patients with carotid stenosis and coronary artery disease should include:

• Antiplatelet drugs, antihypertensive drugs, and lipid-lowering drugs, as recommended by the American and European Societies for Vascular Surgery 5
• A tri-therapy strategy with antiplatelet, statins, and ACE inhibitors, as part of best medical therapy 6
• Lifestyle intervention and pharmacological treatment to correct cardiovascular risk factors 6

Carotid Revascularization

The decision to perform carotid revascularization should be based on:

• The severity of carotid stenosis, with a threshold of 70% for formal indication for revascularization in symptomatic patients 6
• The presence of neurological symptoms, as carotid revascularization may be justified in symptomatic or high-risk patients 4, 5
• The patient's anatomy, prior illness or treatment, and patient risk, as these factors may influence the choice of procedure 6