From the Guidelines
The first-line ACE inhibitor or ARB for cardiorenal syndrome is typically an ACE inhibitor, such as lisinopril, due to its strong evidence base for reducing morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF) 1. The choice between an ACE inhibitor and an ARB should be based on individual patient characteristics and tolerability.
- ACE inhibitors, such as lisinopril, have been shown to reduce morbidity and mortality in patients with HFrEF, with a Level of Evidence: A 1.
- ARBs, such as losartan, are a suitable alternative for patients who cannot tolerate ACE inhibitors, with a Level of Evidence: A 1. Key considerations when initiating ACE inhibitors or ARBs include:
- Starting at low doses and gradually titrating upward as tolerated
- Careful monitoring of blood pressure, renal function, and potassium levels
- Dose adjustments should be made every 2-4 weeks based on clinical response and laboratory values
- Monitoring serum creatinine and potassium within 1-2 weeks of initiation or dose changes to minimize the risk of acute kidney injury or hyperkalemia The use of ACE inhibitors or ARBs in patients with cardiorenal syndrome provides dual benefit by reducing both cardiac workload and proteinuria while protecting kidney function, ultimately improving morbidity, mortality, and quality of life 1.
From the FDA Drug Label
CLINICAL PHARMACOLOGY 12. 1 Mechanism of Action Lisinopril inhibits angiotensin-converting enzyme (ACE) in human subjects and animals. The FDA drug label does not answer the question.
From the Research
First Line ACE Inhibitor or ARB for Cardiorenal Syndrome
- The first line treatment for cardiorenal syndrome involves the use of ACE inhibitors or ARBs, with the goal of eliminating venous congestion and fluid retention 2.
- According to a 2018 study, there is little reason to use ACE inhibitors over ARBs for the treatment of hypertension or its compelling indications, due to equal outcome efficacy but fewer adverse events with ARBs 3.
- A 2002 study suggests that ACE inhibitors should still be considered first-line therapy in the treatment of left ventricular systolic dysfunction and heart failure, but ARBs are suitable substitutes for patients who have true ACE inhibitor intolerance 4.
- However, a 2010 study recommends that for patients at increased risk, telmisartan should be the ARB of choice, based on the results from the ONTARGET trial, which demonstrated equivalent protection to the reference angiotensin-converting enzyme inhibitor in a broad cross-section of at-risk patients but a better side-effect profile 5.
- It's worth noting that recent studies have investigated the use of SGLT2 inhibitors as a promising strategy in the management of cardiorenal syndrome, due to their efficacy in reducing both cardiac and renal outcomes 6, 2.