What is the value of Angiotensin-Converting Enzyme (ACE) inhibitors and dexamethasone?

Value of ACE Inhibitors and Dexamethasone in Clinical Practice

ACE inhibitors are highly recommended for patients with heart failure with reduced ejection fraction (HFrEF) and should be prescribed to all patients with current or prior symptoms unless contraindicated, as they significantly reduce mortality, improve symptoms, and decrease hospitalization rates. 1

ACE Inhibitors in Cardiovascular Disease

Benefits in Heart Failure

• ACE inhibitors alleviate symptoms, improve clinical status, enhance overall well-being, reduce mortality risk, and decrease hospitalization in patients with HFrEF 1
• These benefits are observed in patients with mild, moderate, or severe symptoms, with or without coronary artery disease 1
• ACE inhibitors should be initiated at low doses and gradually titrated upward if well tolerated 1
• Treatment should aim to reach doses proven effective in clinical trials rather than being titrated based on symptomatic improvement alone 1

Indications for ACE Inhibitors

• First-line therapy for patients with reduced left ventricular systolic function (EF <40-45%) with or without symptoms 1
• Essential for asymptomatic patients with documented left ventricular systolic dysfunction to delay or prevent heart failure development 1
• Recommended for patients after myocardial infarction, even if symptoms are transient, to improve survival and reduce reinfarctions 1
• First-line therapy for hypertension in patients with diabetes and albuminuria to reduce risk of progressive kidney disease 1

Dosing and Administration

• Start with low doses and gradually increase if tolerated 1
• Monitor renal function and serum potassium within 1-2 weeks of initiation and periodically thereafter 1
• Specific monitoring is needed when:
  • Increasing ACE inhibitor dose
  • Adding treatments that may affect renal function
  • In patients with renal dysfunction or electrolyte disturbances 1

Adverse Effects

• Most common: cough (8.9% higher rate than placebo), dizziness, hypotension 1
• More serious but less common: angioedema, hyperkalemia, renal insufficiency 1
• Medication-attributable adverse events are generally manageable, with only a 5% higher discontinuation rate compared to placebo 1

Contraindications and Cautions

• Absolute contraindications: previous angioedema with ACE inhibitor, bilateral renal artery stenosis, pregnancy 1
• Use with caution in patients with:
  • Very low blood pressure (systolic <80 mmHg)
  • Markedly elevated serum creatinine (>3 mg/dL)
  • Elevated serum potassium (>5.5 mEq/L) 1

Practical Considerations for ACE Inhibitor Use

Drug Selection

• No significant differences among ACE inhibitors in their effects on symptoms or survival 1
• Preference should be given to ACE inhibitors proven to reduce morbidity and mortality in clinical trials: captopril, enalapril, lisinopril, perindopril, ramipril, and trandolapril 1
• ACE inhibitors are generally preferred over ARBs due to greater evidence supporting their effectiveness, though ARBs are an effective alternative for patients who develop cough or angioedema 1, 2

Combination Therapy

• ACE inhibitors are typically used together with beta-blockers in heart failure 1
• Should be combined with diuretics in patients with fluid retention 1
• Combination of ACE inhibitors with ARBs is not recommended due to increased risk of adverse events without additional cardiovascular benefit 1

Special Populations

• In patients with diabetes and kidney disease, ACE inhibitors slow progression of kidney disease characterized by microalbuminuria 1
• For patients with diabetes and established coronary artery disease, ACE inhibitors are recommended as first-line therapy for hypertension 1
• In renal insufficiency, dose adjustment is required only below a creatinine clearance level of 30 ml/min 3

Dexamethasone

Unfortunately, the provided evidence does not contain specific information about dexamethasone's value in clinical practice. The evidence focuses primarily on ACE inhibitors and their use in cardiovascular and renal conditions.

Clinical Pitfalls to Avoid

• Initiating ACE inhibitors without assessing baseline renal function and serum potassium 1
• Starting with high doses rather than gradually titrating from low doses 1
• Failing to monitor renal function after initiation or dose increases 1
• Using ACE inhibitors without diuretics in patients with fluid retention 1
• Combining ACE inhibitors with ARBs or direct renin inhibitors 1
• Abrupt withdrawal of ACE inhibitor treatment, which can lead to clinical deterioration 1
• Using ACE inhibitors in patients with bilateral renal artery stenosis, which can cause acute renal failure 4