Contraindications and Precautions for ACEIs and ARBs

Absolute Contraindications

• The American Heart Association recommends that patients with a history of angioedema should not use ACEIs, and caution is advised when considering ARBs as alternatives 2
• The American Diabetes Association states that ACEIs and ARBs are contraindicated in pregnancy 3
• The American College of Cardiology advises that ACEIs and ARBs should be avoided in patients with bilateral renal artery stenosis or unilateral stenosis in patients with a solitary kidney, due to the risk of acute kidney injury 1

Relative Contraindications and Cautions

• The American College of Cardiology recommends that patients with systolic blood pressure <80 mmHg or those at immediate risk of cardiogenic shock should not initiate ACEIs or ARBs until stabilized 4, 5, 6
• The American Heart Association suggests that ACEIs and ARBs should be used with caution in patients with markedly increased serum creatinine (>3 mg/dL) or worsening renal function with previous exposure 4, 6, 1
• The American College of Cardiology advises caution in patients with serum potassium >5.5 mEq/L when using ACEIs or ARBs 4, 6

Monitoring Recommendations

• The American Heart Association recommends that before starting ACEI or ARB therapy, patients should undergo an initial assessment including baseline blood pressure, renal function, and serum potassium evaluation 7
• The American College of Cardiology suggests that patients on ACEIs or ARBs should be monitored closely after initiation, with reassessment of blood pressure, renal function, and potassium within 1-2 weeks 7
• The American Heart Association advises that for patients on aldosterone antagonists combined with ACEIs/ARBs, more vigilant monitoring of potassium and renal function is required 8, 9

Special Considerations

• The American College of Cardiology states that routine combined use of an ACEI, ARB, and aldosterone antagonist is potentially harmful due to increased risks of hyperkalemia and renal dysfunction 2, 8
• The American Heart Association recommends that ACEIs or ARBs should be discontinued immediately if significant adverse effects occur, such as persistent hyperkalemia or worsening renal function 1
• The American College of Cardiology advises against triple RAS blockade, as it significantly increases adverse event risk 2, 8