Angiotensin Converting Enzyme Inhibitors

ACEI  have multiple indications including:

Hypertension

In 2014, the Eighth Joint National Commission published evidence-based guidelines for the treatment of high blood pressure in adults, which recommended that ACE inhibitors are one of four drug classes recommended for initial therapy for adults with elevated blood pressure.  The other three classes of drugs are calcium channel blockers, thiazide diuretics, and angiotensin receptor blockers, which are useful as initial therapy for the general nonblack population. Only thiazide and calcium channel blockers are recommended as initial therapy for the general black population with elevated blood pressure.

Heart Failure

ACEi improves heart failure by decreasing afterload.  Apart from decreasing the afterload, it also reduces cardiac myocyte hypertrophy. The Heart Outcomes Prevention Evaluation (HOPE) Study demonstrated better outcomes for those prescribed ACE inhibitors.

Asymptomatic Left Ventricular Dysfunction

Has been shown to decrease the incidence of overt heart failure.

Post Myocardial Infarction

In 2000, The Heart Outcomes Prevention Evaluation (HOPE) Study Investigators published a landmark study demonstrating significantly reduced rates of death, myocardial infarction, and stroke in high-risk patients assigned to receive the ACE inhibitor, ramipril.

Since the HOPE Study, researchers have studied several angiotensin-converting enzyme inhibitors. Most of the patients in those studies had an ST-elevation MI. Most patients had not received a PCI but had received fibrinolytic therapy or no reperfusion, so data on the benefit with the addition of ACE inhibitors in patients receiving PCI is limited.  The research continued to demonstrate decreased mortality for patients with low left ventricular ejection fraction, heart failure, or anterior myocardial infarctions that begin on ACE inhibitors.  Other positive effects have been a drop in readmission for heart failure and a decrease in the incidence of re-infarction.

Diabetes

Current recommendations are the use of ACEi or ARB as first-line therapy for hypertension in patients with a history of diabetes. Also, the use of ACEi in diabetic hypertensive patients with no history of coronary heart disease has shown to decrease the incidence of myocardial infarction and improved heart function. 

Nephrotic Syndrome or Proteinuria

It has been shown that the use of ACEi reduces blood pressure and proteinuria in patients with kidney disease. The reduction in proteinuria is due to a reduction in the intraglomerular capillary pressure and blood pressure control.

Chronic Kidney Disease

ACEi or ARB are the first-line drugs in the management of chronic kidney disease (CKD) patients. The use of ACEI or ARB had a superior effect than no ACEI or ARB treatment on decreasing the proteinuria and slowing kidney disease progression. The efficacy of ACEI and ARB was comparable.

Glomerular Disease

The use of ACEi or ARB is the mainstay of treatment in patients with glomerular diseases. It slows down the decline in glomerular filtration rate (GFR) and proteinuria. 

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Regards         

Meria Den      

Managing Editor       

Stroke Research & Therapy