ACE Inhibitors and ARBs: Critical Safety Considerations
Pregnancy Contraindication
- The American College of Cardiology recommends avoiding ACE inhibitors and ARBs in pregnancy due to the risk of oligohydramnios, fetal renal dysfunction, skull hypoplasia, and neonatal death when used during the second and third trimesters 1
- Discontinue ACE inhibitors and ARBs as soon as pregnancy is detected, as recommended by the American College of Cardiology 1
Critical Safety Warnings
Angioedema Risk
- The American College of Cardiology advises against using ACE inhibitors in patients with a history of angioedema with ACE inhibitors 1
- For patients with ACE inhibitor-associated angioedema, the American College of Cardiology recommends waiting 6 weeks after ACE inhibitor discontinuation before initiating ARBs 1
Dual RAAS Blockade is Contraindicated
- The European Society of Cardiology and American College of Cardiology guidelines state that dual RAAS blockade is not recommended due to the increased risk of hyperkalemia and acute kidney injury 2, 3
- The American College of Cardiology recommends never combining ACE inhibitors, ARBs, and/or direct renin inhibitors due to the risk of adverse events 1, 2, 3
Bilateral Renal Artery Stenosis
- The American College of Cardiology recommends avoiding ACE inhibitors and ARBs in patients with bilateral renal artery stenosis due to the risk of acute kidney injury 1
- The American College of Cardiology also recommends avoiding ACE inhibitors and ARBs in patients with severe unilateral renal artery stenosis in a solitary kidney 1
Hyperkalemia Risk
- The American College of Cardiology recommends monitoring serum potassium within 1 month of initiation, after dose adjustments, and periodically during therapy due to the increased risk of hyperkalemia, especially in patients with CKD 1, 5
Monitoring Requirements
- The American College of Cardiology recommends checking serum creatinine within 1-2 weeks of initiation and after dose changes, and monitoring serum potassium within 1 month of starting therapy and periodically thereafter 5
- The American College of Cardiology advises against discontinuing ACE inhibitors or ARBs based solely on eGFR decline unless creatinine rises more than 30% 5