Clinical outcome with enalapril in symptomatic chronic heart failure; a dose comparison

Poole‐Wilson, P.A.; Cleland, JG; Hubbard, W.N.; Sutton, George C.; Pittard, J; Osborne, Christina; Long, Chuyan; Ingham, Sheila Jean McNeill; Robinson, P.; Ball, Steven; Hampton, John R.; Poulter, NR; Murray, GD; Travill, Christopher; Bain, RJ; Baksi, A John; Baxter, R H; Been, A; Berkin, K E; Blackwood, Roger; Blandford, RL; Boyle, RM; Buchalter, M; Campbell, R. W. F.; Challenor, [No Value]; Cheadle, Barbara; Coats, A.J.S.; Collins, P.; Cowan, Campbell; Creamer, John; Dancy, CM; Davies, JE; Davies, RA; Ehsanulliah, M; Elder, Andrew; Fowler, J. M.; Ra, Fulcher; Ghosh, Manoj Kumer; Greenbaum, RA; Greenwood, TW; Grimmer, S.F.M.; Harvey, John N.; Heller, Allen H.; Henderson, A.; Hendra, T. J.; Hendrey, WG; Hogan, Jarred; Hollinrake, K.; Holt, P.; Hutton, J. Thomas

doi:10.1053/euhj.1997.0839

Cited by 162 publications

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“…Although small studies suggest that higher doses of ACE inhibitors may be associated with a significant incremental survival benefit [4, 18], larger trials do not seem to support this. In a recent trial comparing three doses of enalapril (twice daily doses of 2.5, 5 or 10 mg) in 1,532 patients, no significant differences in mortality were identified at 6 months [19]. Similarly, in a comparison of low-dose (2.5–5 mg) and high-dose (32.5–35 mg) lisinopril in 3,164 patients, the ATLAS trial demonstrated only a nonsignificant trend towards greater survival with higher doses of lisinopril after 3 years [20].…”

Section: Discussionmentioning

confidence: 99%

Angiotensin-Converting Enzyme Inhibitor Use in Elderly Patients Hospitalized with Heart Failure and Left Ventricular Systolic Dysfunction

Rangaswamy

Finn

Koelling³

2004

Cardiology

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Purpose: Although angiotensin-converting enzyme (ACE) inhibitors are recommended for all patients with systolic heart failure, prior studies suggest that elderly cohorts are less likely to receive such therapy. The purpose of this study was to determine the age dependence of adherence to guideline-based medical care in hospitalized heart failure patients. Methods: We performed a multicenter observational cohort study including 613 patients admitted to participating hospitals with a primary diagnosis of heart failure with ejection fraction ≤40%. This cohort was divided into four age groups (group 1: <60, group 2: 60–69, group 3: 70–79, and group 4: 80 years) and adherence to guideline-based medical care was measured. Results: ACE inhibitors were administered to 83% of ideal heart failure patients, and this rate was similar for all age groups. Elderly patients received significantly lower ACE inhibitor dosages compared to their younger counterparts (168, 148, 125 and 117 mg captopril in groups 1, 2, 3, and 4, respectively, p = 0.001). Lower creatinine clearance (p < 0.001), prior residence in a long-term care facility (p = 0.037), intolerance to ACE inhibitors (p = 0.006), lower blood pressure (p = 0.005), absence of a history of hypertension (p = 0.005), and no prior heart failure hospitalizations within the past year (p = 0.001) were found to be independent predictors of low ACE inhibitor dosing. Conclusions: In this heart failure benchmarking project, elderly patients received guideline-based ACE inhibitor therapy at similar rates, but at lower doses, compared to their younger counterparts.

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Section: Discussionmentioning

confidence: 99%

Angiotensin-Converting Enzyme Inhibitor Use in Elderly Patients Hospitalized with Heart Failure and Left Ventricular Systolic Dysfunction

Rangaswamy

Finn

Koelling³

2004

Cardiology

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“…After this, we suggest to start Betablockers. In the case Beta-blockers are not tolerated, the ACEI daily dose should be reduced, as low doses of ACEI are not related to increased mortality in patients with nonChagas disease heart failure, 51,52 and then Betablockers should be given to reach targeted dose or the maximal tolerated dose. 6 Digoxin has been used in patients with CHF not associated with Chagas cardiomyopathy to decrease morbidity, mainly hospitalization.…”

Section: Stage Cmentioning

confidence: 99%

The treatment of chronic heart failure secondary to Chagas cardiomyopathy in the contemporary era

Bestetti¹,

Daniel²

2016

ICFJ

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<p>Chronic Heart Failure (CHF) affects about half patients with Chagas cardiomyopathy. Outcome of CHF secondary to Chagas cardiomyopathy is relentless with an annual mortality approaching 20%, which is higher than that observed in non-Chagas disease heart failure. The pathophysiology of Chagas disease is similar to that found in non-Chagas disease heart failure with a marked activation of the neurohormonal system. No randomized trial has been conducted in patients with Chagas cardiomyopathy with CHF to assess the effect of a drug on mortality of such patients. Therefore, the treatment of CHF secondary to Chagas cardiomyopathy relies on drugs prescribed to patients with non-Chagas disease heart failure<strong>. </strong>Patients with Chagas disease heart failure have been classified into stages A to D according to the American College of Cardiology/American Heart Association. Little can be done to patients in the stage A of CHF, except for treatment of comorbidities. In patients in the stage B of CHF, aldosterone receptor antagonist, angiotensin converting enzyme inhibitors (ACEI), and Betablockers (BB) can be indicated. In patients in the stage C of CHF, the same drugs are of value. In addition, diuretics, digoxin, angiotensin receptor blockers to patients intolerant to ACEI have also been used. Cardiac Resynchronization Therapy and Implantable Cardioverter Defibrillator may have indications similar to that of non-Chagas disease patients. In stage D of CHF, heart transplantation is a valid option for patients with this condition. </p>

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“…From 1923 articles identified, we included 14 RCTs with sample size ranging from 83 to 3846 participants (Fig 1). We identified evidence for the following interventions: ACEIs (7 studies, n = 5,817),[10],[11],[12],[13],[14],[15],[16] ARBs (3 studies, n = 4,908),[17],[18],[19] and BBs (4 studies, n = 1,018). [20],[21],[22],[23]…”

Section: Resultsmentioning

confidence: 99%

Higher versus lower doses of ACE inhibitors, angiotensin-2 receptor blockers and beta-blockers in heart failure with reduced ejection fraction: Systematic review and meta-analysis

et al. 2019

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Background Current heart failure (HF) guidelines recommend titrating angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) and beta-blockers (BBs) to target doses used in pivotal placebo-controlled randomized controlled trials (RCTs). Despite a number of RCTs comparing different doses (i.e. higher versus lower doses) of ACEIs, ARBs and BBs, the effects of higher versus lower doses on efficacy and safety remains unclear. For this reason, we performed a systematic review and meta-analysis to evaluate the efficacy and safety of higher versus lower doses of ACEIs, ARBs and BBs in patients with HFrEF. Methods We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) via Ovid from inception to April 25 th , 2018 and opentrials.net and clinicaltrials.gov for relevant trials that compared different doses of medications in heart failure. We analyzed trials by drug class (ACEIs, ARBs, and BBs) for efficacy outcomes (all-cause mortality, cardiovascular mortality, all-cause hospitalizations, HF hospitalizations, HF worsening). For safety outcomes, we pooled trials within and across drug classes. Results Our meta-analysis consisted of 14 RCTs. Using GRADE criteria, the quality of evidence for ACEIs and ARBs was assessed as generally moderate for efficacy and high for adverse effects, whereas overall quality for BBs was very low to low. Over ~2–4 years higher versus lower doses of ACEIs, ARBs or BBs did not significantly reduce all-cause mortality [ACEIs relative risk (RR) 0.94 (95% confidence interval 0.87–1.02)], ARBs RR 0.96 (0.87–1.04), BBs RR 0.25 (0.06–1.01)] or all cause hospitalizations [ACEIs relative risk (RR) 0.94 (95% confidence interval 0.86–1.02)], ARBs RR 0.98 (0.93–1.04), BBs RR 0.93 (0.39–2.24)]. However, all point estimates favoured higher doses. Higher doses of ARBs significantly reduced hospitalization for HF [RR 0.89 (0.80–0.99)– 2.8% ARR], and higher doses of ACEIs and ARBs significantly reduced HF worsening [RR 0.85 (0.79–0.92)– 5.1% ARR and 0.91 (0.84–0.99)– 3.2% ARR, respectively] compared to lower doses. None of the differences between higher versus lower doses of BBs were significant; however, precision was low. Higher doses of these medications compared to lower doses increased the risk of discontinuation due to adverse events, hypotension, dizziness, and for ACEIs and ARBs, increased hyperkalemia and elevations in serum creatinine. Absolute increase in harms for adverse effects ranged from ~ 3 to 14%. Conclusions Higher doses of ACEIs and ARBs reduce the risk of HF worsening compared to lower doses, and higher doses of ARBs also reduce the risk of HF hospitalization but the evidence is sparse and imprecise. Higher doses increase the chance of adverse effects compared to lower doses. Evidence for BBs is inconclusive. These results support initially always starting at low doses of ACEIs/ARBs and only titr...

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Clinical outcome with enalapril in symptomatic chronic heart failure; a dose comparison

Cited by 162 publications

References 0 publications

Angiotensin-Converting Enzyme Inhibitor Use in Elderly Patients Hospitalized with Heart Failure and Left Ventricular Systolic Dysfunction

Angiotensin-Converting Enzyme Inhibitor Use in Elderly Patients Hospitalized with Heart Failure and Left Ventricular Systolic Dysfunction

The treatment of chronic heart failure secondary to Chagas cardiomyopathy in the contemporary era

Higher versus lower doses of ACE inhibitors, angiotensin-2 receptor blockers and beta-blockers in heart failure with reduced ejection fraction: Systematic review and meta-analysis

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