ACE Inhibitors: Congestive Heart Failure: Difference between revisions

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(Update the introduction. Added a new section on contraindications. Provided other minor additional information.)
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== Introduction ==
== Introduction ==
Angiotensin Converting Enzyme (ACE) Inhibitors are one of the drugs used to treat  [[Heart Failure|Congestive Heart Failure]] (CHF). They work by increasing [[Vasodilators and Hypertension|vasodilation]] and decreasing workload of the heart in patients with CHF.    
Angiotensin Converting Enzyme (ACE) Inhibitors are a important class of drugs used in the management of [[Heart Failure|Congestive Heart Failure]] (CHF). They have been shown to decrease mortality in patients with left ventricular  systolic dysfunction or exhibit congestive heart failure after an infarction.<ref>Pitt B. ACE inhibitors in heart failure: prospects and limitations. Cardiovascular drugs and therapy. 1997 May;11(1):285-90.</ref>  In addition, there have been increasing evidences that support their effectiveness in reducing all-cause mortality and cardiovascular deaths.<ref>Tai C, Gan T, Zou L, Sun Y, Zhang Y, Chen W, Li J, Zhang J, Xu Y, Lu H, Xu D. Effect of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on cardiovascular events in patients with heart failure: a meta-analysis of randomized controlled trials. BMC cardiovascular disorders. 2017 Dec;17(1):1-2.</ref>     


== Mode of Action ==
== Mode of Action ==
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== Common Ace Inhibitors ==
== Common Ace Inhibitors ==
In general, these medications help decrease cardiac output by limiting vasoconstriction and inhibiting aldosterone secretion promoting vasodilation. Common ACE inhibitors for patients with CHF are:    
In general, these medications help decrease cardiac output by limiting vasoconstriction and inhibiting aldosterone secretion promoting vasodilation. Common ACE inhibitors for patients with CHF are:    
* Benazepril: given 10 mg once daily and gradually increased to 20-40 mg per day with a half-life of 10-11 hours and 12 hours respectively.  If given with a diuretic the initial dose should be 5mg<ref name=":1">U.S. Food and Drug Administration (FDA). Lotensin (benazepril hydrochloride). Available online at: <nowiki>https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/019851s042lbl.pdf</nowiki>. Last accessed 11/29/18.</ref><ref name=":2">U.S. Food and Drug Administration (FDA). MONOPRIL (fosinopril sodium tablets). Available online at: <nowiki>https://www.accessdata.fda.gov/drugsatfda_docs/label/2003/19915se5-037_monopril_lbl.pdf</nowiki>. Last accessed 11/29/18.</ref>.   
* Benazepril: given 10 mg once daily and gradually increased to 20-40 mg per day with a half-life of 10-11 hours and 12 hours respectively.  If given with a diuretic the initial dose should be 5mg<ref name=":1">U.S. Food and Drug Administration (FDA). Lotensin (benazepril hydrochloride). Available online at: <nowiki>https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/019851s042lbl.pdf</nowiki>. Last accessed 11/29/18.</ref><ref name=":2">U.S. Food and Drug Administration (FDA). MONOPRIL (fosinopril sodium tablets). Available online at: <nowiki>https://www.accessdata.fda.gov/drugsatfda_docs/label/2003/19915se5-037_monopril_lbl.pdf</nowiki>. Last accessed 11/29/18.</ref>. 


* Fosinopril: given 10 mg once daily and gradually increased to 20-40 mg per day with a half-life of 10-11 hours and 12 hours respectively.  If given with a diuretic the initial dose should be 5mg<ref name=":1" /><ref name=":2" />.   
* Fosinopril: given 10 mg once daily and gradually increased to 20-40 mg per day with a half-life of 10-11 hours and 12 hours respectively.  If given with a diuretic the initial dose should be 5mg<ref name=":1" /><ref name=":2" />.   


* Captropil<ref name=":0">Ciccone CD. Renin Angiotensin System Inhibitors. ''Pharmacology in rehabilitation.'' 5th ed. Philadelphia: F.A. Davis Company; 2016</ref>: given 25 mg 3 times daily and has a shorter half-life of 3.3 hours requiring the patient to take it more frequently<ref>U.S. Food and Drug Administration (FDA). CAPOTEN® (Captopril Tablets, USP). Available online at: <nowiki>https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/018343s084lbl.pdf</nowiki>.  Last accessed 11/29/18.</ref>.    
* Captropil<ref name=":0">Ciccone CD. Renin Angiotensin System Inhibitors. ''Pharmacology in rehabilitation.'' 5th ed. Philadelphia: F.A. Davis Company; 2016</ref>: given 25 mg 3 times daily and has a shorter half-life of 3.3 hours requiring the patient to take it more frequently<ref>U.S. Food and Drug Administration (FDA). CAPOTEN® (Captopril Tablets, USP). Available online at: <nowiki>https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/018343s084lbl.pdf</nowiki>.  Last accessed 11/29/18.</ref>.  


== Adverse Effects ==
== Adverse Effects ==
* Rare: Hypotension and Renal Failure because ACE inhibitors are primarily excreted through the kidneys.  
* Cough: Dry, non-productive paroxysmal cough is reported in about 1 to 10% of people who use ACE inhibitors.<ref>Pinargote P, Guillen D, Guarderas JC. ACE inhibitors: upper respiratory symptoms. BMJ Case Rep. 2014 Jul 17;2014</ref> <ref>Israili ZH, Hall WD. Cough and angioneurotic edema associated with angiotensin-converting enzyme inhibitor therapy. A review of the literature and pathophysiology. Ann Intern Med. 1992 Aug 01;117(3):234-42</ref>This adverse reaction is more commonly reported among women than men.<ref>Os I, Bratland B, Dahlöf B, Gisholt K, Syvertsen JO, Tretli S. Female sex as an important determinant of lisinopril-induced cough. Lancet. 1992 Feb 08;339(8789):372. </ref> Often, cessation of therapy leads to stoppage of cough.<ref>Herman LL, Padala SA, Ahmed I, et al. Angiotensin Converting Enzyme Inhibitors (ACEI) [Updated 2021 Aug 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK431051/</nowiki></ref> Experimental studies also suggest the use if non-steroidal anti-inflammatory agents and intermediate low-dose Aspirin to be helpful with ACE inhibitors-induced cough.<ref>Tenenbaum A, Grossman E, Shemesh J, Fisman EZ, Nosrati I, Motro M. Intermediate but not low doses of aspirin can suppress angiotensin-converting enzyme inhibitor-induced cough. Am J Hypertens. 2000 Jul;13(7):776-82</ref>   
* Rare: Hypotension and Renal Failure because ACE inhibitors are primarily excreted through the kidneys.
* Minor side effects, normally resolved with adjusting the dosage<ref name=":0" />, include:  
* Minor side effects, normally resolved with adjusting the dosage<ref name=":0" />, include:  
** Angioedema (an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes skin)<ref>Wikipedia [https://en.wikipedia.org/wiki/Angioedema Angioedema] Available from: https://en.wikipedia.org/wiki/Angioedema (last accessed 17.6.2019)</ref>  
** Angioedema (an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes skin)<ref>Wikipedia [https://en.wikipedia.org/wiki/Angioedema Angioedema] Available from: https://en.wikipedia.org/wiki/Angioedema (last accessed 17.6.2019)</ref>
** Rashes  
** Rashes
** GI discomfort
** GI discomfort
** Dizziness
** Dizziness
** Hypotension
== Contraindications ==
ACE inhibitors are generally contraindicated with patients who have a history of angioedema, either hereditary or idiopathic.<ref name=":3">Brown NJ, Ray WA, Snowden M, Griffin MR. Black Americans have an increased rate of angiotensin converting enzyme inhibitor-associated angioedema. Clin Pharmacol Ther. 1996 Jul;60(1):8-13. </ref> In addition, ACE inhibitors are also contraindicated in patients with hypersensitivity related to the drugs.<ref name=":3" /> Furthermore, ACE inhibitors should not be administered to patients already on a direct renin inhibitor such as Aliskiren. Also, ACE inhibitors have been known to be associated with cause complications in pregnancy, hence should not be administered during pregnancy.<ref>Quan A. Fetopathy associated with exposure to angiotensin converting enzyme inhibitors and angiotensin receptor antagonists. Early Hum Dev. 2006 Jan;82(1):23-8.</ref>


== Implications for Physiotherapy  ==
== Implications for Physiotherapy  ==

Revision as of 20:08, 19 November 2021

Original Editor - Lauren Pulliam Southern Top Contributors - Lucinda hampton, Lauren Pulliam Southern, Kim Jackson, Lauren Lopez, Beau Lawrence and Joseph Ayotunde Aderonmu

Introduction[edit | edit source]

Angiotensin Converting Enzyme (ACE) Inhibitors are a important class of drugs used in the management of Congestive Heart Failure (CHF). They have been shown to decrease mortality in patients with left ventricular systolic dysfunction or exhibit congestive heart failure after an infarction.[1] In addition, there have been increasing evidences that support their effectiveness in reducing all-cause mortality and cardiovascular deaths.[2]   

Mode of Action[edit | edit source]

ACE inhibitors prevent vasoconstriction by suppressing the angiotensin converting enzyme, preventing angiotensin I from converting into angiotensin II. Angiotensin converting enzyme is responsible for converting angiotensin I to angiotensin II which is responsible for vasoconstriction[3]. In addition to being a powerful vasoconstrictor, Angiotensin II is also responsible for hypertrophy of vascular tissues and aldosterone secretion.  Hypertrophy of vascular tissues causes vessels to become narrow resulting in increased workload on the heart.  Aldosterone secretion is primarily responsible for water retention which can increase vascular fluid volume also increasing the workload on the heart. Therefore, the inhibition of angiotensin II decreases the amount of pressure in the heart which decreases workload on the heart[4].  Another beneficial effect of ACE inhibitors is that they increase bradykinin levels in the blood by decreasing their breakdown.  Bradykinin is responsible for vasodilation[5].  

[6]

Common Ace Inhibitors[edit | edit source]

In general, these medications help decrease cardiac output by limiting vasoconstriction and inhibiting aldosterone secretion promoting vasodilation. Common ACE inhibitors for patients with CHF are:  

  • Benazepril: given 10 mg once daily and gradually increased to 20-40 mg per day with a half-life of 10-11 hours and 12 hours respectively.  If given with a diuretic the initial dose should be 5mg[7][8]. 
  • Fosinopril: given 10 mg once daily and gradually increased to 20-40 mg per day with a half-life of 10-11 hours and 12 hours respectively.  If given with a diuretic the initial dose should be 5mg[7][8]. 
  • Captropil[9]: given 25 mg 3 times daily and has a shorter half-life of 3.3 hours requiring the patient to take it more frequently[10].  

Adverse Effects[edit | edit source]

  • Cough: Dry, non-productive paroxysmal cough is reported in about 1 to 10% of people who use ACE inhibitors.[11] [12]This adverse reaction is more commonly reported among women than men.[13] Often, cessation of therapy leads to stoppage of cough.[14] Experimental studies also suggest the use if non-steroidal anti-inflammatory agents and intermediate low-dose Aspirin to be helpful with ACE inhibitors-induced cough.[15]
  • Rare: Hypotension and Renal Failure because ACE inhibitors are primarily excreted through the kidneys.
  • Minor side effects, normally resolved with adjusting the dosage[9], include:
    • Angioedema (an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes skin)[16]
    • Rashes
    • GI discomfort
    • Dizziness
    • Hypotension

Contraindications[edit | edit source]

ACE inhibitors are generally contraindicated with patients who have a history of angioedema, either hereditary or idiopathic.[17] In addition, ACE inhibitors are also contraindicated in patients with hypersensitivity related to the drugs.[17] Furthermore, ACE inhibitors should not be administered to patients already on a direct renin inhibitor such as Aliskiren. Also, ACE inhibitors have been known to be associated with cause complications in pregnancy, hence should not be administered during pregnancy.[18]

Implications for Physiotherapy[edit | edit source]

ACE inhibitors cause a reduction in BP this coupled with the naturally occurring post-exercise hypotension can result in excessive reductions in blood pressure. This can lead to dizziness and, in rare instances, syncope. Post-exercising clients on ACE inhibitors may need education in adhering to a gradual cool-down after each and every exercise session to prevent these symptoms and benefit the body by enhancing venous return and the prevention of blood pooling in the skeletal muscle. A gradual cool-down of five to 10 minutes of light aerobic activity allows the body to return to homeostasis and prevents excessive reductions in blood pressure.[19]

References[edit | edit source]

  1. ↑ Pitt B. ACE inhibitors in heart failure: prospects and limitations. Cardiovascular drugs and therapy. 1997 May;11(1):285-90.
  2. ↑ Tai C, Gan T, Zou L, Sun Y, Zhang Y, Chen W, Li J, Zhang J, Xu Y, Lu H, Xu D. Effect of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on cardiovascular events in patients with heart failure: a meta-analysis of randomized controlled trials. BMC cardiovascular disorders. 2017 Dec;17(1):1-2.
  3. ↑ Montezano AC, Nguyen Dinh Cat A, Rios FJ, Touyz RM. Angiotensin II and vascular injury. Current Hypertension Reports. 2014;16(6):431
  4. ↑ Katragadda S, Arora RR. Role of angiotensin-converting enzyme inhibitors in vascular modulation: beyond the hypertensive effects. American Journal of Therapeutics. 2010;17(1):e11-23
  5. ↑ Regoli D, Plante GE, Gobeil F Jr. Impact of kinins in the treatment of cardiovascular diseases. Pharmacology & Therapeutics. 2012;135(1):94-111.
  6. ↑ British Heart Foundation How do ACE inhibitors work? Available from: https://www.youtube.com/watch?v=xIlaQuRaZmk (last accessed 17.6.2019)
  7. ↑ 7.0 7.1 U.S. Food and Drug Administration (FDA). Lotensin (benazepril hydrochloride). Available online at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/019851s042lbl.pdf. Last accessed 11/29/18.
  8. ↑ 8.0 8.1 U.S. Food and Drug Administration (FDA). MONOPRIL (fosinopril sodium tablets). Available online at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2003/19915se5-037_monopril_lbl.pdf. Last accessed 11/29/18.
  9. ↑ 9.0 9.1 Ciccone CD. Renin Angiotensin System Inhibitors. Pharmacology in rehabilitation. 5th ed. Philadelphia: F.A. Davis Company; 2016
  10. ↑ U.S. Food and Drug Administration (FDA). CAPOTEN® (Captopril Tablets, USP). Available online at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/018343s084lbl.pdf.  Last accessed 11/29/18.
  11. ↑ Pinargote P, Guillen D, Guarderas JC. ACE inhibitors: upper respiratory symptoms. BMJ Case Rep. 2014 Jul 17;2014
  12. ↑ Israili ZH, Hall WD. Cough and angioneurotic edema associated with angiotensin-converting enzyme inhibitor therapy. A review of the literature and pathophysiology. Ann Intern Med. 1992 Aug 01;117(3):234-42
  13. ↑ Os I, Bratland B, Dahlöf B, Gisholt K, Syvertsen JO, Tretli S. Female sex as an important determinant of lisinopril-induced cough. Lancet. 1992 Feb 08;339(8789):372.
  14. ↑ Herman LL, Padala SA, Ahmed I, et al. Angiotensin Converting Enzyme Inhibitors (ACEI) [Updated 2021 Aug 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431051/
  15. ↑ Tenenbaum A, Grossman E, Shemesh J, Fisman EZ, Nosrati I, Motro M. Intermediate but not low doses of aspirin can suppress angiotensin-converting enzyme inhibitor-induced cough. Am J Hypertens. 2000 Jul;13(7):776-82
  16. ↑ Wikipedia Angioedema Available from: https://en.wikipedia.org/wiki/Angioedema (last accessed 17.6.2019)
  17. ↑ 17.0 17.1 Brown NJ, Ray WA, Snowden M, Griffin MR. Black Americans have an increased rate of angiotensin converting enzyme inhibitor-associated angioedema. Clin Pharmacol Ther. 1996 Jul;60(1):8-13.
  18. ↑ Quan A. Fetopathy associated with exposure to angiotensin converting enzyme inhibitors and angiotensin receptor antagonists. Early Hum Dev. 2006 Jan;82(1):23-8.
  19. ↑ American Council of Exercise How Common Medications May Affect Your Clients’ Exercise Programs Available from: https://www.acefitness.org/certifiednewsarticle/3296/how-common-medications-may-affect-your-clients/ (last accessed 17.6.2019)
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