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Benefits and Risks of Continuing Angiotensin-Converting Enzyme Inhibitors, Angiotensin II Receptor Antagonists, and
Estefania Oliveros1, Ebenezer T Oni2, Anum Shahzad3
1Mount Sinai Icahn School of Medicine, New York, New York, USA, estefaniaoliveros@gmail.com.
Insights
This review clarifies the use of renin-angiotensin-aldosterone system inhibitors (RAASi) in acute heart failure (HF). It provides a decision pathway for managing RAASi in hospitalized HF patients, especially with cardiorenal syndrome.
Area of Science:
- Cardiology
- Nephrology
- Pharmacology
Background:
- The renin-angiotensin-aldosterone axis is crucial in heart failure (HF) pathophysiology.
- Inhibitors of this axis are key therapies for chronic HF.
- Uncertainty exists regarding renin-angiotensin-aldosterone system inhibitors (RAASi) use in acute HF.
Purpose of the Study:
- To review RAASi physiology in acute HF and decongestion.
- To summarize evidence on RAASi risks and benefits in acute HF.
- To propose a decision pathway for RAASi management in acute HF.
Main Methods:
- Literature review of clinical trials and physiological data.
- Analysis of RAASi initiation, continuation, and cessation in acute HF.
- Development of a clinical decision-making framework.
Main Results:
- RAASi have established benefits in chronic HF.
- Evidence on RAASi in acute HF is less clear, with potential risks and benefits.
- A structured approach is needed for RAASi management during acute HF exacerbations.
Conclusions:
- RAASi management in acute HF requires careful consideration of individual patient factors.
- The proposed pathway aids clinicians in optimizing RAASi therapy for acute HF and cardiorenal syndrome.
- Further research may refine RAASi use in the acute HF setting.
Background:
The renin-angiotensin-aldosterone axis plays a pivotal role in the pathophysiology of acute and chronic heart failure (HF) and represents an important target for guideline-directed medical therapy.
Summary:
The use of appropriate directed medical therapies for inhibition of the renin-angiotensin-aldosterone axis in chronic HF has been the subject of several landmark clinical trials, with high levels of adherence exhibited in the outpatient setting. However, less clarity exists with respect to the initiation, continuation, and cessation of renin-angiotensin-aldosterone system inhibitors (RAASi) in the setting of acute HF and exacerbation of HF necessitating hospitalization. In this review, we summarize relevant aspects of the physiology of the renin-angiotensin-aldosterone axis in acute HF and during decongestion. We also summarize the available evidence for the risks and benefits of initiating and continuing RAASi in acute HF. Key Message: We offer a decision-making pathway for the use of RAASi in the setting of acute HF that would help guide the cardiologist and nephrologist caring for patients with acute HF and cardiorenal syndrome.
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