Why is my patient on Vasotec (Enalapril)?

Why Your Patient is on Vasotec (Enalapril)

Your patient is most likely on Vasotec (enalapril) for one of three primary indications: hypertension, heart failure with reduced ejection fraction, or asymptomatic left ventricular dysfunction. 1

Primary Indications for Enalapril

Hypertension

• Enalapril is FDA-approved for treating hypertension, either as monotherapy or combined with thiazide diuretics. 1
• The target blood pressure for patients with chronic kidney disease or diabetes is <130/80 mm Hg, with ACE inhibitors like enalapril being preferred first-line agents. 2
• Typical dosing starts at 5 mg daily and titrates to a goal of 10-40 mg daily in 1-2 divided doses. 2
• Enalapril lowers blood pressure by reducing peripheral vascular resistance without increasing heart rate or causing reflex tachycardia. 3, 4

Heart Failure with Reduced Ejection Fraction (HFrEF)

• Enalapril is indicated for symptomatic congestive heart failure, typically combined with diuretics and digitalis, as it improves symptoms, increases survival, and decreases hospitalization frequency. 1
• The SOLVD trial demonstrated that enalapril (2.5-5 mg twice daily titrated to 10 mg twice daily) reduced all-cause mortality by 13% (relative risk 0.87) in patients with CHF and LVEF ≤35%. 2
• ACE inhibitors remain strongly recommended for all classes of HFrEF unless the patient is on an ARNI (angiotensin receptor-neprilysin inhibitor). 2
• Starting dose is 2.5 mg twice daily, with gradual titration to the target dose of 10 mg twice daily. 2

Asymptomatic Left Ventricular Dysfunction

• In clinically stable asymptomatic patients with left ventricular dysfunction (ejection fraction ≤35%), enalapril decreases the rate of development of overt heart failure and reduces hospitalization for heart failure. 1
• This indication is based on mortality trials showing benefit even before symptoms develop. 1

Diabetic Kidney Disease

• ACE inhibitors like enalapril are preferred agents for patients with diabetes and chronic kidney disease, as they slow progression of kidney disease characterized by microalbuminuria. 2
• The recommended starting dose is 5 mg daily, with a goal of 10-40 mg daily in 1-2 divided doses. 2
• ACE inhibitors decrease urine albumin excretion and delay progression from microalbuminuria to macroalbuminuria in both type 1 and type 2 diabetes. 2

Post-Myocardial Infarction

• Enalapril may be used in patients presenting within 24 hours of acute MI, though this indication requires careful hemodynamic monitoring. 2
• The CONSENSUS II trial used enalapril 20 mg/day starting within 24 hours of MI onset. 2

Common Pitfalls and Monitoring Requirements

Critical Monitoring Parameters

• Monitor renal function and potassium levels within 1-2 weeks after initiating or changing enalapril therapy. 5
• Assess blood pressure regularly during dose titration. 5
• Watch for first-dose hypotension, especially in volume-depleted patients or those on diuretics. 2

Key Contraindications and Cautions

• Use with extreme caution in patients with bilateral renal artery stenosis, elevated serum creatinine, hyperkalemia (>5.0 mEq/L), or hypotension. 2, 5
• Angioedema occurs in <1% of patients but is more frequent in Black patients and women. 2
• Pregnancy is an absolute contraindication. 2
• Dry cough affects 5-20% of patients and is the most common reason for discontinuation. 6, 4

Drug Interactions to Avoid

• Never combine two ACE inhibitors or combine an ACE inhibitor with an ARB, as this significantly increases risk of hypotension, hyperkalemia, and renal dysfunction without additional benefit. 5, 7
• Avoid routine triple combination of ACE inhibitor + ARB + aldosterone antagonist due to severe hyperkalemia risk. 5

Dosing Strategy

• Start low (2.5-5 mg daily or twice daily) and titrate gradually every 2-4 weeks based on blood pressure response and tolerability. 5, 6
• Target the higher end of the dose range (10-20 mg twice daily) when possible for maximum cardiovascular benefit. 2
• The average effective dose in clinical trials was 16.6 mg/day. 5, 6