From the Guidelines
ACE inhibitors should not be held in patients with congestive heart failure (CHF) and are instead a crucial component of their treatment regimen. The use of ACE inhibitors is beneficial for patients with prior or current symptoms of chronic heart failure with reduced ejection fraction (HFrEF) to reduce morbidity and mortality, as established by large randomized controlled trials 1. These medications work by blocking the conversion of angiotensin I to angiotensin II, thereby decreasing afterload and preload while preventing cardiac remodeling.
Key Considerations for ACE Inhibitor Use in CHF
- The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors is recommended for patients with chronic HFrEF to reduce morbidity and mortality 1.
- ACE inhibitors should be started at low doses and titrated upward to doses shown to reduce the risk of cardiovascular events in clinical trials 1.
- Caution is advised when giving ACE inhibitors to patients with low systemic blood pressures, renal insufficiency, or elevated serum potassium (>5.0 mEq/L) 1.
- If maximal doses are not tolerated, intermediate doses should be tried; abrupt withdrawal of ACE inhibition can lead to clinical deterioration and should be avoided 1.
Alternatives to ACE Inhibitors
- For patients intolerant to ACE inhibitors due to cough or angioedema, angiotensin receptor blockers (ARBs) are recommended as an alternative to reduce morbidity and mortality 1.
- ARBs have been shown to reduce mortality and HF hospitalizations in patients with HFrEF in large RCTs and are a viable option for those who cannot tolerate ACE inhibitors 1.
- Angiotensin receptor-neprilysin inhibitors (ARNIs) may also be considered in certain cases, particularly when ACE inhibitors are not appropriate 1.
From the FDA Drug Label
In patients with severe heart failure whose renal function may depend on the activity of the renin-angiotensin-aldosterone system, treatment with angiotensin converting enzyme inhibitors, including enalapril maleate, may be associated with oliguria and/or progressive azotemia and rarely with acute renal failure and/or death About 93% of patients received concomitant ACE inhibitors
ACE inhibitors are not necessarily held in CHF, but caution is advised in patients with severe heart failure due to potential renal function changes. In some cases, ACE inhibitors may need to be discontinued or dosage reduced due to adverse reactions such as hyperkalemia or renal impairment. 2 3
From the Research
ACE Inhibitors in CHF
- ACE inhibitors are commonly used in the treatment of congestive heart failure (CHF) due to their ability to reduce mortality and hospitalization rates 4, 5, 6.
- Studies have shown that ACE inhibitors such as captopril, enalapril, and ramipril can improve hemodynamics, reduce symptoms of fatigue and dyspnea, and increase exercise capacity in patients with CHF 5, 7.
- The use of ACE inhibitors has been shown to be cost-effective, particularly in patients with chronic HF, with estimates suggesting that increasing the use of ACE inhibitors could save thousands of lives and reduce hospitalizations each year 6.
Comparison with Other Treatments
- ACE inhibitors have been compared to angiotensin II receptor antagonists, with some studies suggesting that ACE inhibitors may be more effective in reducing mortality and hospitalization rates 4.
- The combination of ACE inhibitors and beta-blockers has been shown to be beneficial in patients with CHF, with ACE inhibitors playing a pivotal role in the management of these patients 8.
Dosage and Titration
- Studies have suggested that starting with a low dose of ACE inhibitors and titrating up to higher doses may be beneficial in patients with CHF 8.
- The ATLAS trial compared high and low dose ACE inhibition, with equivocal findings, highlighting the need for further research on optimal dosing strategies 8.
Patient Populations
- ACE inhibitors have been shown to be beneficial in patients with impaired systolic function, as well as those with preserved systolic function 8.
- The HOPE trial demonstrated that ACE inhibitors can reduce the risk of myocardial infarction in patients with high cardiovascular risk, regardless of systolic function 8.