Table 2

Guidance on when, where and how to use ACE inhibitors and ARBs in heart failure and guidance on ‘troubleshooting’ common issues

When to useACE inhibitors are the first-line treatment in all patients with systolic heart failure alongside β-blockers. ARBs can be used instead of ACE inhibitors in those that have a definite proven intolerance of an ACE inhibitor.
ContraindicationsRenal artery stenosis, history of angiooedema.
CautionAortic stenosis, potassium >5.0 mmol/L, creatinine >221 μmol/L, symptomatic or severe hypotension (be aware of first dose hypotension), other drugs (NSAIDs, other nephrotoxic drugs).
How to use‘Start low and go slow’. Double the dose every 2 weeks at the fastest. Monitor blood pressure and blood biochemistry 1–2 weeks after initiation and final dose titration.
CounsellingExplain expected benefits and possible side effects, advise on monitoring and drugs to avoid. Liaise with community heart failure nurse-led services.
TroubleshootingHypotension
If asymptomatic, no action is usually required. If symptomatic, consider reducing the dose of other medications, for example, diuretics or other antihypertensive drugs that do not offer prognostic benefit in heart failure such as calcium channel blockers.
Cough
Initially seek alternative cause. Many patients with heart failure will smoke and many will have a degree of pulmonary oedema either of which can cause a cough. A severe cough might warrant the withdrawal of an ACE inhibitor. This should be proven where possible by withdrawal and re-initiation. Replace with an ARB only if intolerant, they are not interchangeable in terms of prognostic benefit.
Worsening renal function
A 50% increase in creatinine above baseline or up to 266 μmol/L or a K+ <5.5 mmol/L does not usually require a change in dose.
If changes exceed these parameters, consider stopping other nephrotoxic medication including if possible diuretics. If this does not help or is not possible, the ACE inhibitor or ARBs dose can be halved and bloods can be rechecked in 1–2 weeks.
If creatinine more than doubles, the creatinine peaks above 310 μmol/L or the potassium rises to >5.5 mmol, the ACE inhibitor or ARB should be stopped immediately and specialist advice sought.
Renal function should be monitored serially until parameters reach a plateau.
  • Adapted from McMurray et al and the British National Formulary.17 ,18

  • ACE, angiotensin-converting enzyme; ARBs, angiotensin receptor blockers; NSAIDs, non-steroidal anti-inflammatory drugs.