Cardiovascular Disease Management

Introduction to Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers

• Angiotensin-Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs) are crucial in managing cardiovascular diseases, including heart failure and hypertension, as recommended by the American Heart Association and the European Society of Cardiology 1, 2

Adverse Effects of ACE Inhibitors and ARBs

• ACE inhibitors can cause cough in up to 20% of patients due to bradykinin accumulation, and angioedema occurs in <1% of patients, more frequently in Black patients and women, according to the American Heart Association and the American College of Cardiology 1, 3
• ACE inhibitors can also cause hypotension, hyperkalemia, and renal dysfunction, as reported by the American Heart Association 1
• ARBs have a lower incidence of cough and angioedema compared to ACE inhibitors, but can cause hypotension, deterioration of renal function, and hyperkalemia, as stated by the European Society of Cardiology and the American College of Cardiology 4, 5

Treatment Recommendations for Heart Failure and Hypertension

• The American College of Cardiology recommends ACE inhibitors as first-line therapy for heart failure with reduced ejection fraction (HFrEF) 1
• The European Society of Cardiology suggests ARBs as alternatives for patients who cannot tolerate ACE inhibitors due to cough or angioedema 1, 6
• Both ACE inhibitors and ARBs are effective first-line treatments for hypertension, according to the American Diabetes Association and the American Heart Association 7, 8

Combination Therapy and Patient Management

• The European Heart Society advises against dual RAS blockade with both ACE inhibitor and ARB due to increased risk of hyperkalemia, hypotension, and renal dysfunction without significant additional benefits 9
• The American College of Cardiology recommends switching to an ARB if a patient develops intolerable cough or angioedema on ACE inhibitor 1
• Monitoring requirements for ARBs and ACE inhibitors include renal function, serum potassium, and blood pressure, including postural changes, as recommended by the American Heart Association and the European Society of Cardiology 10, 11

Dosage and Administration of ARBs

• The initial and maximum doses of ARBs are as follows:

• Target doses for heart failure management: candesartan 32 mg once daily, valsartan 160 mg twice daily, and telmisartan 40-80 mg once daily 10, 11, 12

Special Considerations and Contraindications

• ARBs are contraindicated in pregnancy (category D) 13
• The combination of an ACE inhibitor and an ARB should be avoided due to increased risk of adverse effects (hyperkalemia and acute kidney injury) without significant additional benefits 12, 7
• ARBs can be combined with diuretics to potentiate their effect, but combination therapy with ARBs, ACE inhibitors, or aldosterone antagonists increases the risk of hyperkalemia and renal dysfunction significantly 11, 5