From the Guidelines
Enalapril should not be held in patients with heart block unless there is a high-degree atrioventricular block, as the benefits of continuing the medication often outweigh the risks. The 2022 AHA/ACC/HFSA guideline for the management of heart failure recommends that oral guideline-directed medical therapy (GDMT), including ACE inhibitors like enalapril, should not be withheld for mild or transient reductions in blood pressure or mild deteriorations in renal function 1. True contraindications for ACE inhibitors are rare and include advanced degree atrioventricular block in the absence of a pacemaker.
Key considerations for managing patients with heart block on enalapril include:
- Monitoring for signs of hemodynamic compromise such as hypotension, dizziness, or syncope, in which case the medication should be temporarily held and medical attention sought immediately.
- Regular ECG monitoring to assess the severity of the heart block and the potential impact of enalapril on cardiac conduction.
- Gradual dose adjustments of enalapril with appropriate follow-up to minimize the risk of adverse effects.
- Consultation with a cardiologist for patients with second-degree or third-degree heart block to determine the best course of management.
The benefits of continuing enalapril in patients with heart failure, as outlined in the guideline, include reduced mortality and morbidity, and these benefits should be weighed against the potential risks associated with heart block 1. The guideline also emphasizes that small to moderate worsening of renal function is not a contraindication for continuing GDMT, including ACE inhibitors like enalapril.
From the Research
Management of Heart Block
- The management of heart block, particularly third-degree atrioventricular block, involves prompt recognition and treatment to prevent complications such as hypotension, syncope, and bradycardia 2.
- The use of medications such as IV atropine and the placement of a transvenous pacemaker may be necessary to stabilize the patient 2.
Enalapril Use in Heart Block
- There is no direct evidence in the provided studies to suggest that enalapril should be held in patients with heart block.
- However, it is known that certain medications can exacerbate or contribute to the development of atrioventricular block, and careful consideration of the patient's medication regimen is necessary 3.
- Enalapril, an ACE inhibitor, is not specifically mentioned in the provided studies as a medication that should be held in patients with heart block.