Angiotensin receptor blocker

HPI Six weeks after starting lisinopril for HTN, MM develops a dry nonproductive cough. After ruling out other causes of the cough, he was switched to losartan. 

PE Vitals T 36.8°C, BP 145/85 mm Hg, HR 80 beats/min, RR 16 breaths/min. Lungs clear to auscultation. Medications Hydrochlorothiazide and lisinopril. 

Angiotensin receptor blockers are selective and competitive angiotensin II receptor antagonists (Table 12-1). They block vasoconstriction and aldosterone-secreting effects similar to 

However, because ARBs do not block the metabolism or increase the levels of bradykinin, they are less likely to be associated with nonrenin-angiotensin effects such as cough and angioedema. 

Angiotensin II antagonists share the hemodynamic effects of ACE-I, and therefore have similar indications such as HTN, CHF, and diabetic nephropathy. However, ARBs have not been shown to be superior to ACE-I and are more expensive. In addition, there is an absence of data documenting comparable long-term cardiovascular benefits. Therefore, ARBs should be reserved principally for patients in whom ACE-I are indicated but who are unable to tolerate the medication. 

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Nickenig G, Ostergren J, Struijker-Boudier H (2006) Clinical evidence for the cardiovascular benefits of angiotensin receptor blockers. JRAAS 7 (Suppl 1) S1-S7... 

Other medications (e.g., angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics)... 

ACE, angiotensin-converting enzyme ARB, angiotensin receptor blocker ... 

ACE-I, angiotensin-converting enzyme inhibitor Aid Ant, aldosterone antagonist ARB, angiotensin receptor blocker BB, beta-blocker CCBA, calcium channel blocking agent DirVaso, direct vasodilator. 

Angiotensin receptor blockers show similar tolerability to ACE inhibitors with regard to hypotension and hyperkalemia, but they do not induce cough since ARBs do not cause an accumulation of bradykinin. Angiotensin receptor blockers can be considered in patients with ACE inhibitor-induced angioedema, but they should be initiated cautiously, as crossreactivity has been reported. Many of the other considerations for the use of ARBs are similar to those of ACE inhibitors,... 

FIGURE 3-1. Treatment algorithm for chronic heart failure. ACE, angiotensin-converting enzyme ARB, angiotensin receptor blocker EF, ejection fraction HF, heart failure LV, left ventricular Ml, myocardial infarction SOB shortness of breath. Table 3-5 describes staging of heart failure. 

To control risk factors and prevent major adverse cardiac events, statin therapy should be considered in all patients with ischemic heart disease, particularly in those with elevated low-density lipoprotein cholesterol. In the absence of contraindications, angiotensin-converting enzyme inhibitors should be considered in ischemic heart disease patients who also have diabetes melli-tus, left ventricular dysfunction, history of myocardial infarction, or any combination of these. Angiotensin receptor blockers... 

FIGURE 4-4. General treatment strategies for angina follow in clockwise fashion from the top center. ACE-I, angiotensinconverting enzyme inhibitor ARB, angiotensin receptor blocker. 

Many patients cannot tolerate chronic ACE inhibitor therapy secondary to adverse effects outlined below. Alternatively, the angiotensin receptor blockers (ARBs), can-desartan and valsartan, have been documented in trials to improve clinical outcomes in patients with heart failure.68,69 Therefore, either an ACE inhibitor or candesartan or valsartan are acceptable choices for chronic therapy for patients who have a low ejection fraction (EF) and heart failure following MI. Since more than five different ACE inhibitors have proven benefits in MI while only two ARBs have been studied, the benefits of ACE inhibitors are generally considered a... 

ACE, angiotensin-converting enzyme aPTT, activated partial thromboplastin time ARB, angiotensin receptor blocker BP, blood pressure CBC, complete blood count ECC, electrocardiogram HR, heart rate INR, International Normalized Ratio RR, respiratory rate SCr, serum creatinine, TTP, thrombotic thrombocytopenic purpura. 

ACE-I, angiotensin-converting enzyme inhibitors ARB, angiotensin-receptor blockers AZA, azathioprine CMV, cytomegalovirus CPK, creatinine phos-phokinase CSA, cyclosporine HMG-CoA, 3-hydroxy 3-methylglutaryl coenzyme A reductase K+, potassium LFTs, liver function tests Rl, renal insufficiency SCr, serum creatinine SRL, sirolimus TAC, tacrolimus TMP-SMX, trimethoprim-sulfamethoxazole. 

ACE inhibitors and angiotensin-receptor blockers (ARB) have definite benefits in patients with nephropathy and are believed to have renoprotective effects in most patients. Due to their ability to cause an initial bump in serum creatinine, these agents should be used cautiously when employed in combination with the calcineurin inhibitors. The dihydropyridine calcium channel blockers have demonstrated an ability to reverse the nephrotoxicity associated with cyclosporine and tacrolimus (Table 52-8). In general, antihypertensive therapy should focus on agents with proven benefit in reducing the progression of cardiovascular disease and should be chosen on a patient-specific basis.55 See Chapter 2 for further recommendations for treating HTN. 

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