Treatment with an ACE inhibitor decreases preload and afterload by blunting the exaggerated peripheral compensatory response. ACE inhibitors should be considered first-line therapy for HF owing to systolic dysfunction. Many clinical trials have provided consistent evidence that ACE inhibitors result in decreased symptoms, improved quality of life, 30% to 35% fewer hospitalizations, and 20% to 25% reductions in mortality for patients with NYHA class II-IV HF. In addition, ACE inhibitors slow the progression to HF among patients with asymptomatic LV systolic dysfunction. Although the positive effects of ACE inhibitors probably apply to all available drugs in this class, enalapril, captopril, lisinopril, and ramipril have the strongest evidence for mortality reductions. The physician should initiate treatment at low dosage and titrate to the doses shown to be effective in clinical trials. Improved patient outcomes appear to be dose related.
Contraindications to using an ACE inhibitor use include pregnancy, bilateral renal artery stenosis, angioedema or other allergic responses, or documented persistent intolerance to ACE inhibitor (symptomatic hypotension, severe renal dysfunction, hyperkalemia, or cough). To minimize the risk of symptomatic hypotension the lowest possible starting dose should be given to patients with hyponatremia (<135 meg/L), recent increase in diuretic dose, serum creatinine >1.7 mg/dL, and patients over 75 years of age. Physicians should consider giving a test dose of a short acting ACE inhibitor (captopril 6.25 mg) and observing the patient in the office for 2 hours before starting daily ACE inhibitor therapy in patients at risk for symptomatic hypotension.
Serum urea nitrogen, serum creatinine, and potassium concentrations, and blood pressure should be determined before starting ACE inhibitor therapy, within a few weeks after initiating therapy, and after changes in dose. If baseline serum creatinine
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