Starting ACE Inhibitors for Heart failure

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Starting ACE Inhibitors for Heart failure

Patient Presentation
GP
INITIATION NONE of these present- start
ACEI Ramipril 1.25mg or Lisinopril
2.5mg consider stopping NSAID or Potassium
sparing diuretic
TITRATION Titrate dose slowly by doubling dose
fortnightly depending on renal function, monitor
BP and check UE,.1-2 weeks after each titration

• Confirmed Left Ventricular Systolic Dysfunction

CAUTION Seek specialist advice from heart failure
nurse or cardiology if creatinine gt200, urea gt12,
potassium gt5.0, sodium lt130, systolic BP lt90,
aortic stenosis Contraindicated in renal artery
stenosis. See http//www.edren.org/pages/gpinfo/ac
e-inhibitors-how-to-start.php for detailed advice.

• MAINTAINENCE
• Aim for target doses (Lisinopril 20mg, Ramipril
  10mg, or 5mg bd or highest tolerated dose
• Remember some ACE is better than none
• Check for ADR- dizziness, cough, angiooedema,
  URT symptoms

Renal Impairment? Creatinine rise lt50 from
baseline acceptable if patient well If gt50 ,
consider stopping NSAIDs, reducing diuretics if
no fluid retention

• Problem Solving
• Potassium lt.5.5mmol/l acceptable on stable doses
  ACEI/Diuretic
• Between 5.5-6mmols, recheck within 24 hours
• gt6mmol/l stop ACEI., get cardiology advice
• gt7mmol/l urgent referral to hospital
• Symptomatic hypotension consider swapping to
  bedtime, consider reduing diuretic if no fluid
  overload or reconsider need for nitrates/calcium
  channel clocker.

• ACE Cough?
• Confrim dry and tickly if Ace cough swap to ARB
  such as Candesartan or Valsartan
• If not consider/treat LRTI, pulmonary oedema,

Useful information for patients with confirmed
LVSD

• Record daily weight
• Reduce salt intake to lt2gms daily
• Early symptom recognition and reporting
• Importance of medication compliance
• Flu Pneumococcal immunisations