Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Metalloprotease inhibitor wikipedia , lookup
Prescription costs wikipedia , lookup
Discovery and development of direct thrombin inhibitors wikipedia , lookup
Psychopharmacology wikipedia , lookup
Neuropsychopharmacology wikipedia , lookup
Pharmacogenomics wikipedia , lookup
Adherence (medicine) wikipedia , lookup
Discovery and development of ACE inhibitors wikipedia , lookup
Dydrogesterone wikipedia , lookup
MONTEFIORE HEART FAILURE DISEASE MANAGEMENT PROGRAM Heart Failure Center General Outpatient Clinical Recommendations ACE Inhibitors Are FIRST LINE agents to use in chronic HF –they can have an extraordinary impact!! ACE Inhibitors (ACEI) can alleviate symptoms, improve clinical status, and enhance the overall sense of well-being of patients with heart failure. Because of their favorable effects on survival, ACE inhibitors should be prescribed to ALL patients with heart failure, especially those with LVEF ≤ 40%. Angiotensin receptor blockers (ARBs) are similar in efficacy to ACEI, but are considered when ACEIs are not tolerated due to cough or angioedema. In addition, ACE inhibitors can reduce the risk of death or hospitalization. Patients should not be given an ACEI or ARB if they have experienced life-threatening adverse reactions (anuric renal failure) during previous exposure to the drug or if they are pregnant. INITIATION AND MAINTENANCE: Treatment with an ACE inhibitor should be initiated at low doses, followed by gradual increments in dose. Renal function and serum potassium should be assessed within 1 week of initiation and with each dosing change, especially in patients with pre-existing renal insufficiency or hyperkalemia. Be careful with overdiuresis before administering ACEI. The best time to start the ACEI is when the patient is volume overloaded. Starting Dose: It is best to use an agent that has been shown to reduce morbidity and mortality in clinical trials, such as captopril 6.25 mg tid and titrate to 50 mg tid and then switch to enalapril 10 mg bid and keep uptitrating. Treatment can be initiated using LISINOPRIL 2.5- 5 mg daily. The dose is then increased slowly, over 2-4 weeks, to a target dose of 20-40mg daily. For potassium levels 5.0-5.5, the ACEI dose should be reduced. The drug should be discontinued for potassium >5.5 In patients with symptoms of lightheadedness or dizziness, offering QHS dosing often helps. . The overall goal is to increase the ACEI dose until the “target dose” is reached. The target dose of enalapril is usually 20 mg bid. Alternatively for the less sick patients, 10 mg bid may be reasonable. This should be done alongside beta blocker medication increases for nearly complete neurohormonal blockade. The addition of aldosterone blockade will complete the neurohormonal blockade. **Nonsteroidal anti-inflammatory drugs can block the favorable effects and enhance the adverse effects of ACEI in patients with heart failure and should be avoided** Adapted from: Ruggeneti, P; Remuzzi, G (2011) Worsening kidney function in decompensated heart failure: treat the heart; don’t mind the kidney. European Heart Journal, 32, 2476-2478 Revised: 04/2014