ACE inhibitors in heart failure

ACE inhibitors help cardiac failure:

• they improve symptoms and signs, such as exercise capacity
• they decrease systemic vascular resistance, venous pressure and levels of circulating catecholamines
• they prolong survival in patients with mild to moderate severe heart failure (CONSENSUS and SOLVD trials). In addition V-HeFT II showed improved survival with enalapril over a hydralazine and isosorbide dinitrate regimen (24 months follow up)

These drugs actually reduce mortality by up to 50%; this is the reason the consensus trial was prematurely halted. There is also reduced number of "events", which includes prevention of hospitalisation and premature deaths, with obvious economic benefits.

NICE recommends that all patients with left ventricular dysfunction should be taking an ACE inhibitor (1,2,3):

• ACE inhibitor therapy and beta blocker therapy are both first line
  • offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first
• measure serum sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor, and after each dose increment
• measure blood pressure before and after each dose increment of an ACE inhibitor
• once the target or maximum tolerated dose of an ACE inhibitor is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell (3)
  
  
• alternative treatments if ACE inhibitors are not tolerated
  • measure serum sodium and potassium, and assess renal function, before and after starting an ARB and after each dose increment
  • measure blood pressure after each dose increment of an ARB. Follow the recommendations on measuring blood pressure, including measurement in people with symptoms of postural hypotension, in the NICE guideline on hypertension in adults
  • once the target or maximum tolerated dose of an ARB is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell (3)

There is inadequate evidence to support the use of ACE inhibitors in HF patients with preserved left ventricular ejection fraction (HFPEF) (2).

Reference:

1. Geriatric Medicine (2005); 35 (1):37-42.
2. NICE (August 2010). Chronic heart failure
3. NICE (September 2018).Chronic heart failure in adults: diagnosis and management