See below for the use of ACEIs in hypertension, heart failure and secondary prevention
Hypertension
Prescribing Notes
- Refer to NICE hypertension guidance.
- First dose hypotension may occur when ACE inhibitors are introduced to patients who are already receiving diuretics. Temporary withdrawal of the diuretic may reduce this risk (see BNF).
- Monitoring is required for all patients. Patient should have their electrolytes and renal function (creatinine and eGFR) checked:
-
- before initiating treatment
- within 2 weeks of commencing treatment
- within 2 weeks of last dose increase
- annually
- Treatment with ACE inhibitors can be initiated in the community but close medical supervision is required. ACE inhibitors should be initiated under specialist supervision and with careful monitoring in those with severe heart failure or in those with a number of co-morbidities (see BNF).
- ACE inhibitors tend to cause potassium retention. To avoid dangerous hyperkalaemia, potassium supplements or potassium-sparing diuretics should not be used with ACE inhibitors. If spironolactone is prescribed, serum potassium must be monitored.
- ACE inhibitors cause cough in some patients. In patients who are intolerant of ACE inhibitors, an ARB may be considered as an alternative (see section 2.5.5.2).
- ACE inhibitors and ARBs are contra-indicated in pregnancy and should be avoided in patients who become pregnant.
- In hypertension associated with diabetes, ACE inhibitors are the drugs of first choice. They reduce proteinuria and slow the deterioration in renal function.
- Prescribe perindopril as perindopril erbumine rather than perindopril arginine.
Cautions
- Patients taking ACE inhibitors or ARBs should be informed that they are at an increased risk of Acute Kidney Injury (AKI) if they develop an illness associated with hypovolaemia and hypotension. ACE inhibitors and ARBs should be stopped temporarily. Refer to ‘sick day guidance’ for further information.
- As elderly patients are at particular risk of renal impairment, renal function should be monitored pre-treatment in patients taking ACE inhibitors. Regular U&E checks may be needed after initiation.
- The use of ACE inhibitors in the setting of severe aortic stenosis or outflow tract obstruction is controversial with care needed to avoid precipitating hypotension. While recent small studies suggest potential benefits, such use is best guided by secondary care
- Caution is required in patients who may have renovascular disease. ACE inhibitors are contra-indicated in patients with renal artery stenosis.
Heart Failure
Prescribing Notes
- Refer to NICE heart failure guidance NG106.
- In heart failure, ACE inhibitors have been shown to improve symptoms and prolong life. They also improve outcome after myocardial infarction, particularly in patients with left ventricular dysfunction.
- First dose hypotension may occur when ACE inhibitors are introduced to patients who are already receiving diuretics. Temporary withdrawal of the diuretic may reduce this risk (see BNF).
- Monitoring is required for all patients. Patient should have their electrolytes and renal function (creatinine and eGFR) checked:
-
- before initiating treatment
- within 2 weeks of commencing treatment
- within 2 weeks of last dose increase
- annually
- Treatment with ACE inhibitors can be initiated in the community but close medical supervision is required. ACE inhibitors should be initiated under specialist supervision and with careful monitoring in those with severe heart failure or in those with a number of co-morbidities (see BNF).
- ACE inhibitors tend to cause potassium retention. To avoid dangerous hyperkalaemia, potassium supplements or potassium-sparing diuretics should not be used with ACE inhibitors. If spironolactone is prescribed, serum potassium must be monitored.
- Cough is common in heart failure. ACE inhibitors cause cough in some patients. Do not rule out an ACE inhibitor until you are certain it is causing the cough.
- In patients who are intolerant of ACE inhibitors, an ARB may be considered as an alternative (see section 2.5.5.2)
- ACE inhibitors and ARBs are contra-indicated in pregnancy and should be avoided in patients who become pregnant.
- Every patient with heart failure as a result of left ventricular systolic dysfunction and who has no contra-indications should be prescribed an ACE inhibitor.
- Prescribe perindopril as perindopril erbumine rather than perindopril arginine.
Cautions
- Patients taking ACE inhibitors or ARBs should be informed that they are at an increased risk of Acute Kidney Injury (AKI) if they develop an illness associated with hypovolaemia and hypotension. ACE inhibitors and ARBs should be stopped temporarily. Refer to ‘sick day guidance’ for further information.
- As elderly patients are at particular risk of renal impairment, renal function should be monitored pre-treatment in patients taking ACE inhibitors. Regular U&E checks may be needed after initiation.
- The use of ACE inhibitors or ARBs in the setting of severe aortic stenosis or outflow tract obstruction is controversial with care needed to avoid precipitating hypotension. While recent small studies suggest potential benefits, such use is best guided by secondary care.
- Caution is required in patients who may have renovascular disease. ACE inhibitors are contra-indicated in patients with renal artery stenosis.
Sacubitril /valsartan
- For the prescribing of sacubitril/valsartan (Entresto®) refer to NICE TA388. Treatment with sacubitril valsartan should be started by a heart failure specialist with access to a multidisciplinary heart failure team.
- Dose titration and monitoring should be performed by the most appropriate team member as defined in NICE NG106 Chronic heart failure in adults.
- Sacubitril/valsartan should not be co-administered with an ACE inhibitor or an ARB. Due to the potential risk of angioedema when used concomitantly with an ACE inhibitor, it must not be started for at least 36 hours after discontinuing ACE inhibitor therapy.
Secondary Prevention
Prescribing Notes
- First dose hypotension may occur when ACE inhibitors are introduced to patients who are already receiving diuretics. Temporary withdrawal of the diuretic may reduce this risk (see BNF)
- Monitoring is required for all patients. Patient should have their electrolytes and renal function (creatinine and eGFR) checked:
-
- before initiating treatment
- within 2 weeks of commencing treatment
- within 2 weeks of last dose increase
- annually
- Treatment with ACE inhibitors can be initiated in the community but close medical supervision is required. ACE inhibitors should be initiated under specialist supervision and with careful monitoring in those with severe heart failure or in those with a number of co-morbidities (see BNF)
- ACE inhibitors tend to cause potassium retention. To avoid dangerous hyperkalaemia, potassium supplements or potassium-sparing diuretics should not be used with ACE inhibitors. If spironolactone is prescribed, serum potassium must be monitored
- ACE inhibitors cause cough in some patients. In patients who are intolerant of ACE inhibitors, an ARB may be considered as an alternative (see section 2.5.5.2)
- ACE inhibitors and ARBs are contra-indicated in pregnancy and should be avoided in patients who become pregnant
- Prescribe perindopril as perindopril erbumine rather than perindopril arginine
Cautions
- Patients taking ACE inhibitors or ARBs should be informed that they are at an increased risk of Acute Kidney Injury (AKI) if they develop an illness associated with hypovolaemia and hypotension. ACE inhibitors and ARBs should be stopped temporarily. Refer to ‘sick day guidance’ for further information.
- As elderly patients are at particular risk of renal impairment, renal function should be monitored pre-treatment in patients taking ACE inhibitors. Regular U&E checks may be needed after initiation
- ACE inhibitors should be used with care or avoided in aortic stenosis or outflow tract obstruction
- Caution is required in patients who may have renovascular disease. ACE inhibitors are contra-indicated in patients with renal artery stenosis