See also left ventricular systolic dysfunction

Northumberland Heart Health Programme


ACEI in the primary care management of adults with symptomatic heart failure (partially updated)

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Recommendations

  1. Heart failure is a common chronic condition in general practice and has a very poor prognosis. ACE inhibitors are clinically effective in the treatment of heart failure ( Ia ) . The beneficial effects of ACE inhibitors are demonstrated for symptomatic patients with a reported left ventricular ejection fraction of 35% or less ( Ib ).
  2. All patients with symptomatic heart failure and evidence of impaired left ventricular function should be treated with an ACE inhibitor ( A ).
  3. Patients with recent myocardial infarction and evidence of left ventricular dysfunction (current or transient) should also be treated with an ACE inhibitor ( A ).
  4. Symptoms and exercise tolerance improve when patients with symptomatic heart failure are given an ACEI inhibitor ( Ia ). However, the value of the improvements in terms of general patient well-being is uncertain ( Ia ).
  5. ACE inhibitors appear to be a cost-effective use of resources whenc compared with other common health service interventions ( III ). Since there is no good evidence of clinically important differences in the effectiveness of available CE inhibitors, patients should be treated with the cheapest drug that they can use effectively ( B ).
  6. Electrocardiogram, chest X-ray and a trial of diuretics can be used in diagnosis ( IV ). Left ventricular function should be evaluated in patients using echocardiography or radionuclide measurements where these are available ( A ).
  7. All patients being considered for treatment with ACE inhibitors should have their creatinine, electrolytes and blood pressure measured ( D ). Hospital referral for assessment and supervised initiation of treatment may be considered if these are outside normal bounds, or heart failure is severe ( D ). ACE inhibitors should be used with increasing caution with increasing patient age ( D ), and in patients with severe periperal vascular disease ( D ). Doses of ACE inhibitors should be titrated upward over 2-3 weeks with a goal of reaching the doses used in trials ( A ). Subsequent treatment should be monitored .
  8. Side effects should be enquired about on a regular basis ( D ). Compliance with treatment is important and should be checked regularly, especially if symptom centrol is poor or treatment is about to be increased ( D ). Patients should be offered education about their treatment ( D ).
  9. Referral to a cardiologist is appropriate for those patients who have abnormal initial test values , are difficult to manage, who express a preference for hospital supervision or in whom there is diagnostic doubt ( D )

Commencing ACEI treatment

Patients at increased risk of hypotension or renal dysfunction

Changes occuring as a result of ACEI Rx

BP changes:
Rarely below 90 systolic and usually within 30-60mins, passing by 90mins.
Renal function changes:
Can rise by up to 25%. If more than this or creatinine > 200, halve captopril or reduce diuretic. Avoid NSAID which can also impair renal function. If dehydration occurs as a result of intercurrent infection, reduce/stop diuretic.
Potassium changes:
Stop ACEI if K+ exceeds 5.5mmol/l. Avoid potassium-sparing diuretics. Avoid NSAID as they can indirectly cause hyperkalaemia and fluid retention.