Lisinopril vs Telmisartan in Dilated Cardiomyopathy
Lisinopril (ACE inhibitor) is the preferred first-line choice over telmisartan (ARB) in dilated cardiomyopathy, as ACE inhibitors have substantially more robust evidence for mortality reduction and are explicitly recommended as foundational therapy in DCM guidelines. 1
Guideline-Directed Recommendations
Optimal medical therapy with ACE inhibitors is specifically recommended (Class I, Level A) in patients with DCM to reduce the risk of sudden death and progressive heart failure. 1 This recommendation is based on decades of clinical trial evidence demonstrating mortality benefit with ACE inhibitors in heart failure with reduced ejection fraction, which is the hallmark of DCM.
ARBs like telmisartan are positioned as alternatives when ACE inhibitors are not tolerated (typically due to cough or angioedema), but they are not the preferred first-line agent. 1
Evidence Supporting ACE Inhibitors in DCM
High-dose lisinopril (32.5-35mg daily) demonstrated superior outcomes compared to low-dose therapy in the ATLAS trial, with 12% lower risk of death or hospitalization (p=0.002) and 24% fewer heart failure hospitalizations (p=0.002) over 39-58 months of follow-up. 2
Japanese registry data spanning 20 years showed that increased use of ACE inhibitors/ARBs and beta-blockers significantly improved survival in DCM patients, with 5-year survival improving from 60.9% to 80.9% and 10-year survival from 34.8% to 65.3% (p=0.0079). 3
ACE inhibitors are considered essential foundational therapy in DCM, with vasodilators (particularly ACE inhibitors) appearing essential to prevent progression of ventricular dysfunction rather than waiting for treatable symptoms. 4
When to Consider Telmisartan
Telmisartan should be reserved for specific scenarios:
ACE inhibitor intolerance (persistent dry cough affecting quality of life, or angioedema). 1
Patients already on sacubitril/valsartan who cannot tolerate it and need ARB monotherapy (though this is a second-line scenario). 1
Dosing Strategy
Target high-dose ACE inhibitor therapy whenever possible:
Lisinopril should be titrated to 32.5-35mg daily as tolerated, based on ATLAS trial evidence showing dose-dependent benefits. 2
Monitor for hypotension and worsening renal function, which occur more frequently at higher doses but are generally manageable by adjusting lisinopril or concomitant medications without requiring discontinuation. 2
If switching to telmisartan is necessary, use 80mg daily to achieve maximal RAS blockade. 5
Critical Pitfalls to Avoid
Never combine lisinopril with telmisartan (dual RAS blockade), as this increases risk of hypotension, syncope, hyperkalemia, and acute kidney injury without additional cardiovascular benefit. 6, 5
Do not underdose ACE inhibitors - the mortality benefit is dose-dependent, and many patients in clinical practice receive suboptimal doses. 2, 7
Avoid premature discontinuation for mild adverse effects - hypotension and mild renal function changes at higher doses can usually be managed without stopping therapy. 2
Complementary Therapy
Regardless of whether lisinopril or telmisartan is used, patients with DCM require:
Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) as co-foundational therapy. 1, 3
Mineralocorticoid receptor antagonists (spironolactone or eplerenone) for additional mortality benefit. 1
ICD consideration for patients with LVEF ≤35% despite ≥3 months of optimal medical therapy who are NYHA class II-III and expected to survive >1 year with good functional status. 1
SGLT2 inhibitors (empagliflozin, dapagliflozin, or canagliflozin) should be strongly considered even in non-diabetic DCM patients, as they reduce heart failure hospitalizations. 1
Monitoring Requirements
Check serum creatinine/eGFR and potassium at baseline, 1-2 weeks after initiation or dose increase, then at least every 3-6 months. 5
Accept up to 30% increase in creatinine or decrease in eGFR as acceptable unless accompanied by hyperkalemia >5.5 mEq/L. 5
Titrate to target dose over 4-8 weeks rather than stopping at lower doses due to mild blood pressure reduction. 2