What is the Optimal Angiotensin‐Converting Enzyme Inhibitor Dose in Heart Failure?

Abstract

Doses of angiotensin‐converting enzyme (ACE) inhibitors used in the landmark heart failure trials that demonstrated survival benefit are rarely reached in routine practice. The authors review the current literature regarding optimal dosing of ACE inhibitors in heart failure with specific focus on neurohormonal, functional capacity, and clinical outcomes. Neurohormonal studies have shown that lower ACE inhibitor dosing may provide inadequate suppression of the renin‐angiotensin‐aldosterone system. Higher doses of ACE inhibitors have resulted in greater increments in exercise and functional capacity. Clinically, patients on high‐dose ACE inhibitor therapy had significant reductions in all‐cause mortality or hospitalization, cardiovascular hospitalizations, and heart failure‐specific hospitalizations. There is, however, conflicting evidence, and so continued uncertainty exists regarding optimal dosing. Despite underutilization of ACE inhibitors, there is insufficient evidence to support lower doses. Likewise, limited data exist for doses higher than those used in the landmark trials. Clinicians should therefore attempt to reach target doses in heart failure whenever possible.

An update on treatment and prognostic indicators in canine myxomatous mitral valve disease

“…Thus, ACE inhibitors may decrease the tendency for fluid retention and counteract peripheral vasoconstriction and other negative effects on the heart. In man, the administered dose of ACE inhibitor is frequently lower than those used in the landmark trials, and it has been suggested that this lower dose leads to a worse outcome when compared with a higher dose (Schwartz and others 2003, Thomas and Geltman 2006). The doses of ACE inhibitors administered to dogs enrolled in all the clinical trials of ACE inhibitors (including the QUEST trial) have been within the recommended dose range for dogs.…”

Terapia com inibidor da ECA com dosagens relativamente altas e risco de agravamento renal na insuficiência cardíaca crônica

“…Furthermore, another issue worthy of debate is that among the studies [35][36][37] which have faced the problem of dosage of the ACE-inhibitor therapy in CHF patients, the enrolled cohorts were consistently characterized by preliminary selection of the study population, aimed to exclude any CHF patient with overt renal failure at baseline, according to an overly strict enrollment criterion. Therefore, there was the selection of a kind of patient more likely to not feel the effects of ACE-inhibitor high doses, that instead are usually believed to be capable of provoking harmful renal changes just in CHF patients already suffering from renal failure.…”