[Management of the treatment with converting enzyme inhibitors in chronic heart failure]
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1Cardiologie et pharmacologie clinique, hôpital Central, Nancy.
Insights
Angiotensin-converting enzyme (ACE) inhibitors are beneficial for all patients with left ventricular dysfunction or chronic heart failure. Starting with low doses and gradually increasing them ensures optimal treatment outcomes for heart failure management.
Area of Science:
- Cardiology
- Pharmacology
Context:
- Left ventricular dysfunction and chronic heart failure necessitate timely intervention.
- Angiotensin-converting enzyme (ACE) inhibitors represent a key therapeutic class for cardiovascular conditions.
Purpose:
- To review the established benefits and administration guidelines for ACE inhibitors in managing heart failure.
- To discuss the role of various ACE inhibitors, including captopril, enalapril, and lisinopril, in cardiac failure treatment.
Summary:
- ACE inhibitors can be initiated at any stage of left ventricular dysfunction or chronic heart failure, regardless of etiology.
- Captopril and enalapril demonstrate well-established benefits, while lisinopril offers once-daily dosing advantages.
- Treatment requires careful dose titration, starting low and gradually increasing to the highest tolerated level.
Impact:
- ACE inhibitors can be safely integrated with existing heart failure therapies, with precautions for diuretic use.
- Potential interactions with spironolactone warrant careful consideration, though combination therapy may offer benefits in specific cases.
- Evidence supports the broad utility of ACE inhibitors in improving outcomes for patients with cardiac dysfunction.
Abstract:
Treatment with angiotensin-converting enzyme (ACE) inhibitors can begin at any time when a left ventricular dysfunction has been diagnosed. In the absence of rare contra-indications (renal artery stenosis, connective tissue disease, severe renal failure), all patients with asymptomatic or, a fortiori, symptomatic chronic heart failure can benefit from ACE inhibitors, whatever the origin of the heart failure. Among the ACE inhibitors now available, the benefits of captopril (3 daily doses) and of enalapril (2 daily doses) on all the targets of cardiac failure treatment are now well established. The effects of lisinopril on mortality are not yet known, but the haemodynamic and symptomatic benefits of this drug are also well established (with the advantage of once daily administration). Other ACE inhibitors with less numerous and less convincing trial reports can be used or rejected depending on the physician's faith in the effects of this pharmaceutical class. With all ACE inhibitors the initial dose must be very low, to be gradually increased over several days or even weeks until the highest dose tolerated is reached. ACE inhibitors can be associated with the classical treatment of cardiac failure. A previous diuretic treatment with sodium depletion may increase the risks of first dose effect and renal intolerance due to the introduction of the ACE inhibitors. Theoretically, the combination of ACE inhibitors and spironolactone is to be avoided for fear of hyperkalaemia and renal deterioration. Yet, provided some precautions are taken this combination may improve the benefits of ACE inhibition when the renin-angiotensin-aldosterone system inhibition is not optimal. However, this has yet to be demonstrated by prospective clinical trials.