Heart failure, chronic angiotensin receptor blockers

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. 

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... 

Erhardt LR. A review of the current evidence for the use of angiotensin-receptor blockers in chronic heart failure. IntJ Clin Pract. 2005 59 571-578. 

Cohn JN, Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med 2001 345 1667-1675. 

Cohn JN, Tognoni G, Glazer RD, Spormann D, Hester A. Rationale and design of the Valsartan Heart Failure Trial a large multinational trial to assess the effects of valsartan, an angiotensin-receptor blocker, on morbidity and mortality m chronic congestive heart failure. J Card Fail 1999 5(2) 155-60. 

Anand IS, Bishu K, Rector TS, Ishani A, Kuskowski A, Cohn JN. Proteinuria, chronic kidney disease, and the effect of an angiotensin receptor blocker in addition to an angiotensin-converting enzyme inhibitor in patients with moderate to severe heart failure. Circulation 2009 120 1577-84. 

Medications can increase the risk of hyperkalemia in patients with CKD, including angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, used for the treatment of proteinuria and hypertension. Potassium-sparing diuretics, used for the treatment of edema and chronic heart failure, can also exacerbate the development of hyperkalemia, and should be used with caution in patients with stage 3 CKD or higher. 

Paradoxically, these agents—not positive inotropic drugs—are the first-line therapies for chronic heart failure. The drugs most commonly used are diuretics, ACE inhibitors, angiotensin receptor antagonists, aldosterone antagonists, and blockers (Table 13-1). In acute failure,... 

The incidence of ACEI- or angiotensin II receptor blocker (ARB)-mediated renal failure has not been established. However, patients with severe atherosclerotic renal artery stenosis, those hospitalized with congestive heart failure, and those with chronic kidney disease, including diabetic nephropathy, are most likely to experience a significant decline in renal function with these agents. 

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