Treatment of Hypertension and Heart Failure

Introduction to ACE Inhibitors

ACE inhibitors, such as perindopril, are effective in reducing cardiovascular morbidity and mortality in patients with hypertension and chronic heart failure, particularly in those with stable coronary artery disease, as demonstrated in the EUROPA trial 1

The combination of perindopril (ACE inhibitor) and indapamide (thiazide-like diuretic) is effective for managing hypertension, reducing cardiovascular morbidity and mortality, with a 14% reduction in death from any cause and a 9% reduction in major macrovascular and microvascular events, as recommended by the European Society of Cardiology 2, 3, 4
This combination is particularly beneficial in patients with type 2 diabetes, as demonstrated in the ADVANCE trial, and can reduce recurrent stroke risk in patients with a history of stroke or transient ischemic attack (TIA), as demonstrated in the PROGRESS trial 4, 5, 6

The American Diabetes Association recommends perindopril, as demonstrated by the ADVANCE trial, which showed a significant reduction in mortality and major cardiovascular events in patients with diabetes when combined with indapamide 7, 2, 6
The European Society of Cardiology recommends perindopril for the treatment of hypertension and reduction of cardiovascular events in patients with stable coronary artery disease, as shown in the EUROPA trial, with a typical dosing range of 4-8 mg once daily for hypertension 1, 8, 9
The 2024 ESC guidelines recommend a RAS blocker (such as ACE inhibitor) with a diuretic as one of the preferred combinations, and fixed-dose combinations of perindopril and indapamide are available, which improve adherence 3, 10, 11

Monitoring is necessary to watch for potential hypokalaemia, renal function should be monitored, particularly when initiating therapy in patients with pre-existing renal impairment, and dry cough may occur with perindopril, as with other ACE inhibitors 5
Perindopril is contraindicated in patients with a history of angioedema related to previous ACE inhibitor therapy, and requires monitoring of renal function and potassium levels, with use cautioned in patients with renal artery stenosis 5
The combination has shown efficacy in elderly patients aged 65-85 years, and can be used in patients with mild to moderate chronic renal failure, though dose adjustment may be required 4

The typical dosing range for perindopril is 4-8 mg once daily for hypertension, with treatment initiated at low doses and gradually increased, and dosage adjustment required in elderly patients and those with renal impairment 8
The EUROPA trial demonstrated a significant reduction in cardiovascular events in patients with stable coronary artery disease using 8 mg of perindopril daily, with a 24-hour antihypertensive effect allowing once-daily dosing 1, 9

The ALLHAT trial showed that lisinopril had no special advantage over chlorthalidone for most cardiovascular outcomes in diabetic patients, and was less effective than chlorthalidone in reducing cardiovascular endpoints in Black patients, as referenced by the American College of Physicians 12