I. See Also
II. Indication
- Most patients with Systolic Dysfunction
- ACE Inhibitors are the most important CHF agents
III. Contraindications
- Caution in Class IV Congestive Heart Failure
IV. Agents
-
Captopril (Capoten)
- Start: 6.25 to 12.5 mg PO tid
- Target: 50 mg PO tid
- Maximum: 100 mg PO tid
-
Enalapril (Vasotec)
- Start: 2.5 to 5.0 mg PO bid
- Target: 10 mg PO bid
- Maximum: 20 mg PO bid
-
Fosinopril (Monopril)
- Start: 5 to 10 mg PO qd
- Target: 20 mg PO qd
- Maximum: 40 mg PO qd
-
Lisinopril (Zestril)
- Start: 2.5 to 5 mg PO qd
- Target: 20 mg PO qd
- Maximum: 40 mg PO qd
-
Quinapril (Accupril)
- Start: 5 to 10 mg PO qd
- Target: 20 mg PO qd
- Maximum: 40 mg PO qd
-
Ramipril (Altace)
- Start: 1.25 to 2.5 mg PO qd
- Target: 5 mg PO qd
- Maximum: 10 mg PO qd
V. General pointers
- Maximize dose (e.g. Lisinopril 40 mg per day)
- Highest survival benefit at high dose
- Rochon (2004) J Gen Intern Med 19:676-83 [PubMed]
- Split to twice daily dosing while increasing
- Prevents precipitous Blood Pressure drops
- Example: 2.5 mg bid
- Avoid manipulating dosage based on Blood Pressure
- Only symptomatic Hypotension should decrease dose
VI. Adverse Effects
- If ACE Inhibitor increases BUN or Creatinine
- Try decreasing Loop Diuretic
-
Cough often related to Congestive Heart Failure
- ACE Inhibitor associated with 35% Incidence cough
- Placebo associated with 25% Incidence of cough
VII. Alternatives for CHF patient (ACE Inhibitor intollerant)
- Regimen 1
- Hydralazine (max: 75 mg qd)
- Isosorbide Dinitrate (max: 30-40 mg tid)
- Other potential alternative agents
- Angiotensin II Receptor Antagonists
