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Interaction between aspirin and ACE inhibitors in patients with heart failure
1Unité de Recherches Therapeutiques, Service de Medicine Interne A, H pital Lariboisière, Paris, France. jf.bergmann@lrb.ap-hop-paris.fr
Insights
The concurrent use of aspirin and ACE inhibitors in heart failure patients raises safety concerns due to their interaction with prostaglandins. Evidence remains conflicting, necessitating careful consideration of patient characteristics and drug dosages.
Area of Science:
- Cardiology
- Pharmacology
- Internal Medicine
Background:
- Heart failure patients often have concomitant ischaemic heart disease, leading to combined aspirin and ACE inhibitor use.
- Both aspirin and ACE inhibitors interact with the prostaglandin-mediated pathway, crucial for managing vasodilation in heart failure.
- The safety and impact of this drug combination on patient survival remain unclear.
Purpose of the Study:
- To review existing data on the interaction between aspirin and ACE inhibitors in heart failure patients.
- To explore potential mechanisms and clinical implications of this drug association.
- To provide insights for optimizing treatment strategies.
Main Methods:
- Literature search of MEDLINE (1960-2000) using keywords: heart failure, aspirin, ACE inhibitors.
- Review of experimental studies on hemodynamic parameters.
- Summary of retrospective clinical studies and subgroup analyses on hemodynamic parameters and survival.
Main Results:
- Conflicting conclusions exist in the literature regarding the safety and efficacy of aspirin and ACE inhibitor co-administration.
- Potential interaction mechanisms involve prostaglandin synthesis inhibition by aspirin and ACE inhibitors' effects on bradykinin.
- Retrospective studies and subgroup analyses yielded inconsistent results on hemodynamic parameters and survival outcomes.
Conclusions:
- The clinical relevance of hemodynamic parameter changes requires further investigation.
- Differences in study design, patient characteristics, and drug dosages contribute to conflicting findings.
- Further prospective studies are needed to definitively assess the long-term impact of aspirin and ACE inhibitor combination therapy on survival in post-infarction heart failure patients.
Abstract:
Both aspirin (acetylsalicylic acid) and ACE inhibitors are often used concomitantly, especially in patients with both heart failure and ischaemic heart disease, which is the most common underlying cause of heart failure. The safety of the association has been questioned because both drugs affect a related prostaglandin-mediated pathway. Thanks to their vasodilating properties, prostaglandins play an important role in heart failure where peripheral vasoconstriction occurs. Some of the beneficial effects of ACE inhibitors might be related to reduced degradation of bradykinin that enhances the synthesis of prostaglandins, while aspirin, through inhibiting the enzyme cyclo-oxygenase, inhibits the production of prostaglandins. To date no prospective study has been conducted to investigate the effect of long term aspirin treatment in the postinfarction period allowing the possible impact of the interaction between aspirin and ACE inhibitors upon survival to be confirmed or negated. However, the practitioner needs to know how to optimise the treatment of his or her patients. In order to stimulate arguments for and against the use of aspirin in patients with heart failure receiving ACE inhibitors, we searched MEDLINE from 1960 to 2000 using the key words heart failure, aspirin, and ACE inhibitors for English language articles and conducted a review of the available data. We report on the potential mechanisms of the interaction and the results of experimental studies on haemodynamic parameters. Results of retrospective clinical studies, subgroup analysis that were undertaken to evaluate the overall action upon haemodynamic parameters and survival of the association are summarised. Conflicting conclusions have been reported in the literature. Many explanations can be advanced to try to understand these conflicting conclusions: differences in study design (results of retrospective trials have to be interpreted with caution); differences in the choice of the evaluation parameter (problem of the clinical relevance of haemodynamic parameters); differences in the characteristics of the patient (different underlying cardiopathy, e.g. heart failure, hypertension or ischaemic cardiopathy); and differences in the type and the dosage of each treatment (especially ACE inhibitors and aspirin since an interaction might occur more often with dosage of aspirin greater than 250mg).