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 consider her renal function, potassium levels, blood pressure, medication interactions, and history of angioedema. When considering the addition of an ACE inhibitor, several key factors must be evaluated to ensure safe and effective treatment.

• Renal function should be assessed through serum creatinine and estimated glomerular filtration rate (eGFR) as ACE inhibitors can cause acute kidney injury, especially in patients with renal artery stenosis which may coexist with her vascular disease 1.
• Baseline potassium levels should be checked since ACE inhibitors can cause hyperkalemia, particularly in patients with impaired renal function or those taking potassium supplements or potassium-sparing diuretics.
• Blood pressure should be monitored as ACE inhibitors may cause hypotension, especially with first doses.
• Her medication list should be reviewed for potential interactions, particularly NSAIDs which can reduce the effectiveness of ACE inhibitors and increase kidney injury risk.
• A history of angioedema would be a contraindication to ACE inhibitor therapy. The most recent and highest quality study 1 emphasizes the importance of careful patient selection and monitoring when initiating ACE inhibitor therapy, particularly in patients with coronary artery disease and carotid stenosis. Given the patient's history of coronary artery disease and carotid stenosis, an ACE inhibitor may be beneficial for cardiovascular protection, as suggested by the guidelines for the management of patients with chronic stable angina 1 and the guidelines for the prevention of stroke in patients with stroke or transient ischemic attack 1. However, the potential risks and benefits of ACE inhibitor therapy must be carefully weighed, and the patient should be closely monitored for any adverse effects. In terms of specific conditions to consider, the patient's carotid stenosis is a significant factor, and optimal medical therapy, including antiplatelet therapy, statin therapy, and risk factor modification, is recommended 1. Ultimately, the decision to add an ACE inhibitor should be based on a thorough evaluation of the patient's individual risk factors and medical history.

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 blood pressure levels, as ACE inhibitors are typically used to treat hypertension 3
• The presence of left ventricular dysfunction or congestive heart failure, as ACE inhibitors have been shown to improve survival and reduce morbidity in these patients 4
• The patient's symptoms, as ACE inhibitors may exacerbate angina in some patients with coronary artery disease 4
• The patient's renal function, as ACE inhibitors can affect kidney function
• The potential for interactions with other medications, such as beta blockers and calcium-channel blockers, which are commonly used to treat coronary artery disease and hypertension 3

Carotid Stenosis Considerations

In patients with carotid stenosis, the following considerations are important:

• The degree of stenosis and the presence of symptoms, such as transient ischemic attacks or strokes 5, 6
• The patient's overall cardiovascular risk profile, including the presence of coronary artery disease and other comorbidities 6
• The potential benefits and risks of carotid revascularization, including carotid endarterectomy (CEA) or percutaneous carotid angioplasty (CAS) 5, 6

Treatment of Hypertension in Patients with Coronary Artery Disease

The treatment of hypertension in patients with coronary artery disease should involve:

• The use of beta blockers and ACE inhibitors or angiotensin receptor blockers (ARBs) as first-line therapy 3
• The addition of long-acting nitrates and calcium-channel blockers as needed to control angina and blood pressure 3
• A target blood pressure of < 140/90 mm Hg in patients aged ≤ 80 years and < 150 mm Hg in patients aged ≥ 80 years 3