Congestive heart failure angiotensin receptor blockers

Editor(s)-In-Chief: James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [mailto:jchang@caregroup.org] and C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School;

Synonyms and Keywords: Angiotensin II receptor antagonist, Angiotensin receptor blocker, ARB

Indications for an Angiotensin II receptor antagonist
1. The left ventricular ejection fraction (LVEF) is ≤ 40%

or

2. There is a prior history of myocardial infarction (MI)

Background

 * ACE-I or ARB therapy is recommended for ANY patient with reduced left ventricular ejection fraction (≤ 40%) regardless of the etiology of left ventricular systolic dysfunction (ischemic or nonischemic) or presence/absence of symptoms. Patients with or without heart failure (in other words, even those with asymptomatic left ventricular systolic dysfunction) are included in this recommendation.


 * In addition, ACE-I or ARB therapy is indicated for patients with history of myocardial infarction whether or not left ventricular systolic dysfunction or heart failure is present.


 * ACE-I or ARB therapy is also recommended for patients who are at high risk for the development of heart failure due to the presence of coronary, cerebrovascular, or peripheral vascular disease.


 * ARBs are reserved for patients who are intolerant of ACE-Is for reasons (such as persistent cough) OTHER than hyperkalemia, progression of chronic kidney disease/worsening azotemia, or hypotension caused by prior ACE-I therapy. If a patient experiences hyperkalemia, worsening azotemia, or hypotension as a result of ACE-I therapy, the same is likely to result from ARB therapy. In the CHARM study candesartan reduced both hospitalization and mortality.

Dosing

 * ACE-I or ARB therapy should be initiated at low dosage

==ACC/AHA Guidelines- Angiotensin II Receptor Blockers Recommendation == {{cquote|

Class I
1. Angiotensin II receptor blockers are recommended in patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF) who are ACE inhibitor-intolerant. (Level of Evidence: A)

Class IIa
1. Angiotensin II receptor blockers are reasonable to use as alternatives to ACE inhibitors as ﬁrst-line therapy for patients with mild to moderate heart failure and reduced left ventricular ejection fraction (LVEF), especially for patients already taking ARBs for other indications. (Level of Evidence: A)

Class IIb
1. The addition of an angiotensin II receptor blockers may be considered in persistently symptomatic patients with reduced left ventricular ejection fraction who are already being treated with conventional therapy. (Level of Evidence: B)

Class III
1. Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF). (Level of Evidence: C)}}

Vote on and Suggest Revisions to the Current Guidelines

 * The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult


 * 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation