Addition of Angiotensin II Receptor Blockade to Maximal Angiotensin-Converting Enzyme Inhibition Improves Exercise Capacity in Patients With Severe Congestive Heart Failure

Abstract

Losartan enhances peak exercise capacity and alleviates symptoms in patients with CHF who are severely symptomatic despite treatment with maximally recommended or tolerated doses of ACE inhibitors.

Combined Blockade of the Renin-Angiotensin System With Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Type 1 Receptor Antagonists

“…In patients with stable CHF, small studies have shown that combined RAS blockade provided greater benefit than singlesite blockade on surrogate end points such as improvement in cardiac load and function, 44 increase in exercise capacity, 45 prevention of LV remodeling, and reduction of neurohormonal activation. 35 All these clinical studies share the same limitations: short treatment periods, small group sizes, administration of a nonstandardized ACE inhibitor treatment that was not at a predetermined maximal dose, and the use of a single fixed dose of an AT1R antagonist.…”

Favourable effects on arterial wave reflection and pulse pressure amplification of adding angiotensin II receptor blockade in resistant hypertension

“…Finally, the ancillary properties of both ACE inhibitors, eg, interruption of kinin metabolism and interaction with nitric oxide (NO), and of AT 1 receptor antagonists, eg, interaction with NO and prostaglandins may be active when the two agents are used singly, but may be synergistic when the groups are combined. 28 Additive effects on blood pressure and renin release in sodium-depleted normotensive adults 29 and on exercise capacity in heart failure patients 30 has been described recently when an ACE inhibitor is combined with an ATII AT 1 receptor antagonist. It may be argued that 12 of the patients were already on calcium channel blockers, which also have favourable effects on arterial wave reflection.…”

Combined Angiotensin II Receptor Antagonism and Angiotensin-Converting Enzyme Inhibition Further Attenuates Postinfarction Left Ventricular Remodeling

“…17 The addition of AT 1 blockade to recommended or maximally tolerated ACEI was recently shown to improve exercise capacity and reduce symptoms in patients with heart failure. 18 Jorde et al 19 recently found, however, that maximally recommended doses of ACEI may be inadequate and that very-high-dose ACEI provided experimental hemodynamic effects similar to those with combined AT 1 blockade and standard-dose ACEI in patients with heart failure. The effects of combined ACEI and AT 1 antagonism on postinfarction LV remodeling are uncertain.…”