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European Journal of Heart Failure 2005 7(5):710-721; doi:10.1016/j.ejheart.2005.07.002
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© 2005 European Society of Cardiology

Practical recommendations for the use of ACE inhibitors, beta-blockers, aldosterone antagonists and angiotensin receptor blockers in heart failure: Putting guidelines into practice

John McMurraya,*, Alain Cohen-Solalb, Rainer Dietzc, Eric Eichhornd, Leif Erhardte, F.D. Richard Hobbsf, Henry Krumg, Aldo Maggionih, Robert S. McKelviei, Ileana L. Piñaj, Jordi Soler-Solerk and Karl Swedbergl

a Department of Cardiology Western Infirmary, Glasgow, G12 8QQ, UK
b Hopital Beaujon Clichy, France
c Franz-Volhard-Klinik Berlin, Germany
d VA Hospital, Dallas, USA
e University Hospital, Malmo, Sweden
f Department of Primary Care and General Practice Birmingham, UK
g Departments of Epidemiology and Preventive Medicine and Medicine Monash University/Alfred Hospital Melbourne Victoria, Australia
h Research Centre, ANMCO, Florence, Italy
i Division of Cardiology McMaster University, Hamilton, Canada
j Case Western Reserve University Cleveland, Ohio, USA
k University General Hospital Barcelona, Spain
l Department of Medicine, Sahlgrenska University Hospital/Östra Sahlgrenska Academy at Göteborg University, Gothenburg, Sweden

* Corresponding author. Tel.: +44 141 211 1838; fax: +44 141 211 2252. E-mail address: j.mcmurray{at}bio.gla.ac.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Need for practical...
 3. Development of...
 4. Practical recommendations
 5. Conclusions
 References
 
Surveys of prescribing patterns in both hospitals and primary care have usually shown delays in translating the evidence from clinical trials of pharmacological agents into clinical practice, thereby denying patients with heart failure (HF) the benefits of drug treatments proven to improve well-being and prolong life. This may be due to unfamiliarity with the evidence-base for these therapies, the clinical guidelines recommending the use of these treatments or both, as well as concerns regarding adverse events. ACE inhibitors have long been the cornerstone of therapy for systolic HF irrespective of aetiology. Recent trials have now shown that treatment with beta-blockers, aldosterone antagonists and angiotensin receptor blockers also leads to substantial improvements in outcome. In order to accelerate the safe uptake of these treatments and to ensure that all eligible patients receive the most appropriate medications, a clear and concise set of clinical recommendations has been prepared by a group of clinicians with practical expertise in the management of HF. The objective of these recommendations is to provide practical guidance for non-specialists, in order to increase the use of evidenced based therapy for HF. These practical recommendations are meant to serve as a supplement to, rather than replacement of, existing HF guidelines.

Key Words: ACE inhibitors • Aldosterone antagonists • Angiotensin receptor blockers • Beta-blockers • Clinical recommendations • Digoxin • Eplerenone • Heart failure • Hydralazine • Isosorbide dinitrate • Pharmacology • Spironolactone • Treatment

Received April 18, 2005; Revised July 5, 2005; Accepted July 6, 2005


   1. Introduction
Top
 Abstract
 1. Introduction
2. Need for practical...
 3. Development of...
 4. Practical recommendations
 5. Conclusions
 References
 
Evidence-based medicine is an accepted goal to which doctors should aspire in their clinical practice.[1] Over the last three decades, a remarkable number of large, double-blind, controlled trials have been conducted in patients with chronic heart failure (HF) [2–20]. These trials have used clinically important outcome measures, including death or composites of death and relevant non-fatal events (e.g., hospital admissions). Often these trials also measured the effect of treatment on one or more of: symptoms, functional capacity and quality of life [2–20]. The aforementioned trials were also designed with adequate patient numbers and length of follow-up to provide the statistical power for unequivocal interpretation of the results. Consequently, there is now evidence for the efficacy and safety of a considerable number of pharmacological treatments for HF, irrespective of aetiology. With this recent increase in number of effective treatments available, the pharmacological management of HF, in generally elderly patients with often multiple co-morbidities, has become complex.

The uptake of these evidence-based treatments in clinical practice has been variable, despite publication of the trials in prominent journals and their summation in authoritative guidelines [21–31]. In some cases (e.g., ACE inhibitors and beta-blockers), uptake was slow and patients were thus denied the benefits of proven treatments shown to increase quality and quantity of life [32–35].

In contrast, very rapid uptake of the aldosterone antagonist, spironolactone, has been documented [36,37]. Unfortunately, that sudden change in practice was associated with inappropriate use of the drug and an unacceptably high rate of serious adverse effects related to hyperkalaemia.

These contrasting experiences emphasise the need for practical guidance on the appropriate and safe use of treatments of proven benefit in the setting of HF.


   2. Need for practical guidance
Top
 Abstract
 1. Introduction
 2. Need for practical...
3. Development of...
 4. Practical recommendations
 5. Conclusions
 References
 
ACE inhibitors were the first "new" treatment introduced for HF.[2,3] In spite of a number of trials showing significant improvements in survival and reductions in hospital admissions for patients with HF, irrespective of aetiology, who received ACE inhibitors (Table 1), many clinical surveys conducted in different countries revealed that a substantial proportion of patients who should have been treated with an ACE inhibitor were not receiving that treatment, both in primary care [38,39] and in hospital practice (although, in hospital practice, the rate of use of ACE inhibitors in patients with systolic dysfunction seems to have improved recently) [40–43]. Furthermore, the doses of ACE inhibitors used in clinical practice were (and remain) lower than the doses shown to have survival and other benefits in the clinical trials [34,35,44–49]. Both under-treatment and under-dosing may be more common in women and the elderly [34,35,44–53]. Recent studies have showed that this situation is improving but treatment remains suboptimal [34,35,44–53]. Why doctors were reluctant to prescribe ACE inhibitors is still not entirely clear. Initially there seems to have been undue concern about possible adverse effects, such as hypotension and renal insufficiency [38,54,55]. The experience with ACE inhibitors illustrates why, detailed guidance spelling out the benefits of treatment, appropriate selection of patients for treatment (and identification of those not suitable), dosing strategies and what adverse effects to anticipate (as well as how to deal with these) are important.


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  		Table 1 Benefits of evidence-based pharmacological treatment in patients with heart failure and a low left ventricular ejection fraction

 
The second treatment shown to be convincingly beneficial in HF was a low dose of the aldosterone antagonist, spironolactone (Table 1) [8]. In patients with severe HF, already receiving a diuretic and ACE inhibitor, spironolactone improved survival and reduced hospital admissions, compared to placebo, irrespective of aetiology. A recent report suggested that publication of this trial (RALES) led to a rapid increase in use of spironolactone in the Canadian province of Ontario [36]. Unfortunately, however, this increase in use also seemed to be associated with an increase in hospital admissions and deaths related to hyperkalaemia. The Canadian and Danish experience (and that of other investigators) suggests that many of the problems encountered were due to misuse of spironolactone i.e., prescription in inappropriate patients, use of unnecessarily high doses of the drug and failure to closely monitor blood chemistry [37,56–58]. Paradoxically, physicians seem not to have been concerned about the possible adverse effects of an "old" drug and perhaps one thought easier to initiate without the blood pressure (and heart rate) lowering effects of an ACE inhibitor (or beta-blocker). As a generic drug, the usual educational programmes related to the launch of a new indication for a patented drug did not accompany the use of spironolactone in severe HF. Whatever their explanation, the findings from Ontario emphasise that encouragement of evidence-based treatment also carries with it the responsibility of ensuring the safe use of these drugs. We believe that the experience with spironolactone is another illustration of why detailed and practical guidance of the type presented here is important.

Beta blockers were the next class of agent shown to be of benefit in HF. Four large clinical trials, published between 1999 and 2001, showed that the addition of a beta blocker to standard treatment with a diuretic and ACE-inhibitor, led to a significant increase in survival, reduction in hospital admissions and improvement in symptoms and well-being, irrespective of aetiology (Table 1) [4,6,7,9,10,13]. Though both the efficacy and safety of beta blockers in HF was convincingly demonstrated in these trials, there was considerable concern about whether these drugs could be used safely in ordinary clinical practice. Regulatory labelling in many countries even restricted the use of beta blockers in HF to hospital-based specialists. Nowhere has the need for detailed practical guidance been more critical than with beta-blockers.

Angiotensin receptor blockers (ARBs) are the most recent class of drug to be shown to be of benefit in HF. Two large trials have shown morbidity and mortality benefits in patients with mild-moderately severe HF already treated with an ACE inhibitor, beta blocker and, in a minority of cases, spironolactone, irrespective of aetiology (Table 1) [11,12,15–18]. The prospect of using at least three neurohumoral antagonists (an ACE inhibitor, a beta blocker and an ARB or an aldosterone antagonist) and two or even three inhibitors of the renin–angiotensin–aldosterone system (an ACE inhibitor and an ARB or an aldosterone antagonist or both) has led us to update the earlier version of this guidance (see below) [59]. We also see the present guidance as a companion document to the European Society of Cardiology guidelines on the diagnosis and treatment of HF which have also recently been updated [31].


   3. Development of recommendations
Top
 Abstract
 1. Introduction
 2. Need for practical...
 3. Development of...
4. Practical recommendations
 5. Conclusions
 References
 
On the assumption that the previously demonstrated reluctance of doctors to prescribe ACE inhibitors [34,35,38–50,60] and beta-blockers [34,35,44,46–48,61–67] reflected, in part, a lack of practical, easy-to-follow advice on dosing, (both initiation and maintenance) and identification of potential problems, with clear recommendations on how to handle these if they should arise, a group of clinicians with expertise in the diagnosis and management of HF met on one occasion (meeting sponsored by AstraZeneca) [50,68,69]. The output of that original meeting was a step-wise, concise set of clinical recommendations for each of beta-blockers, ACE inhibitors and spironolactone, based on the questions which a physician is likely to ask when considering treatment options; why should the treatment be given, in whom and when, where (in which setting), which agent and what dose, how to use, advice to patient, and problem solving [59]. The group did recognise, however, that even easy to follow practical recommendations are only valuable if widely disseminated to their target audience, and read and acted upon by that audience.

We were therefore pleased to discover that the original version of this guidance was also reproduced in the NICE guidelines for the treatment of HF which were distributed to all doctors in the UK [29].

However our practical recommendations were not (and are not) meant to replace existing guidelines but rather to complement them and offer a simple tool to facilitate their implementation [21–31].

Following the presentation and publication of the ARB trials in HF, the same committee met again in order to update the original guidance [11,12,15–18]. The opportunity was also taken to revise and update the prior guidance on spironolactone in light of the aforementioned findings from Ontario and elsewhere [36,56–58], as well as the publication of an important trial in patients with HF after myocardial infarction which used another aldosterone antagonist [70] Similarly, the section on beta-blockers was updated to take account of a trial comparing two beta blockers [14]. and a new trial with a further beta-blocker in very elderly patients with HF [20].


   4. Practical recommendations
Top
 Abstract
 1. Introduction
 2. Need for practical...
 3. Development of...
 4. Practical recommendations
5. Conclusions
 References
 
The recommendations start from on the assumption that the physician has made a clinical diagnosis of HF and may have initiated a diuretic to treat the symptoms and signs of sodium and water retention. Unfortunately, there is no good evidence-base for the use of diuretics, but the reader may wish to consult some examples of recommended practice [71,72].

Step 1 requires that the presence of left ventricular systolic dysfunction (typically defined as an ejection fraction <0.40) is confirmed using echocardiography, radionuclide ventriculography, radiological left ventricular angiography or cardiac magnetic resonance imaging. The use of one of these investigations is regarded as representing the minimum standard of care [21–31].

Step 2 requires the initiation of first-line therapy which, for all patients with HF due to LVSD, consists of both an ACE inhibitor and a beta-blocker, unless these are contra-indicated. It is important that contra-indications and cautions are observed. It is recommended that the ACE inhibitor is initiated first, quickly followed by the beta-blocker. The ACE inhibitor should initially be introduced at a low dose, up-titrated slowly and titrated to the target dose used in the clinical trials, checking tolerability and blood chemistry. Precisely the same approach should be adopted with the beta-blocker. These steps are detailed in Tables 2 and 3 In patients with severe HF (NYHA Class IV), beta-blockers should be initiated under expert supervision and only in those patients who are not currently decompensated.


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  		Table 2 Practical guidance on the use of ACE inhibitors in patients with HF due to left ventricular systolic dysfunction

 


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  		Table 3 Practical guidance on the use of beta-blockers in patients with HF due to left ventricular systolic dysfunction

 
The objective is to treat all patients with both an ACE inhibitor and a beta-blocker, both, ideally at the target doses used in the large randomised trials. There is now good evidence that this goal can be achieved in the majority of patients if a determined and concerted effort is made in hospital, at outpatient clinics and in the community [61,66,73–77]. It was, however, the panel's view that lower doses of both treatments were still likely to be of value and should be used if larger doses are not tolerated. These recommendations are set out in more detail in Table 2 for ACE inhibitors and Table 3 for beta-blockers.

ACE inhibitors are also of benefit in patients with asymptomatic left ventricular systolic dysfunction (i.e., in NYHA class I).

There is also new evidence since the publication of the first version of this guidance that an ARB should be used in place of an ACE inhibitor if the latter drug is not tolerated [12,16]. This is especially true if intolerance is due to cough (as ARBs do not cause cough). ARBs are as likely as an ACE inhibitor to cause hypotension and renal dysfunction but are probably less likely to cause angioedema.

Step 3 requires the prescription of additional therapy for those patients in whom there are persisting signs and symptoms of HF. The prior guidance recommended spironolactone in patients with severe symptoms (NYHA Class III/IV) and this has not changed. However, the experience from Ontario emphasises the importance of appropriate patient selection, the need to check baseline renal function and blood chemistry, to monitor these measures after the introduction of treatment and to use only low doses of this treatment. The newer, more selective aldosterone antagonist, eplerenone, may be substituted if spironolactone causes unpleasant anti-androgenic side effects such as painful gynaecomastia in men.

There is new evidence since the publication of the first version of this guidance that an ARB should be added in patients with persisting symptoms (NYHA Class II–IV). This treatment should be added after optimisation of ACE inhibitor and beta-blocker therapy.

It is important to note, however, that there is insufficient evidence as to whether both an ARB and spironolactone should be used in addition to an ACE inhibitor and little experience with this triple treatment. There is no definite evidence of benefit but renal dysfunction and hyperkalaemia are definitely more likely to occur. Use of these three agents together is, therefore, not recommended and if all three are used, very careful monitoring of blood chemistry, especially potassium and creatinine, is essential.

One or other of an ARB or an aldosterone antagonist should be used in a patient who remains symptomatic despite treatment with an ACE inhibitor, beta-blocker or, ideally, both. It is important that contra-indications and cautions are observed. Whichever is used, it should be initiated at a low dose and then up-titrated checking tolerability and blood chemistry. The recommendations for an ARB are set out in Table 4 and aldosterone antagonists in Table 5.


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  		Table 4 Practical guidance on the use of ARBS in patients with HF due to left ventricular systolic dysfunction

 


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  		Table 5 Practical guidance on the use of aldosterone antagonists in patients with HF due to left ventricular systolic dysfunction

 
In many hospital centres and in primary care, specially trained HF nurses successfully assist in the initiation, up titration and monitoring (including adjustment of dose as necessary) of all of the aforementioned evidence-based treatments [73,77–79].

Digoxin has not been included in this revised summary, though one large trial showed that it reduced the need for hospital admission, particularly for worsening HF, though this treatment had no effect on survival, either positive or negative.5 It is also important to note that the trial was conducted at a time when the role of beta-blockers, aldosterone antagonists and ARBs in the treatment of heart failure had not been established. Digoxin may still have a special role in the patient with atrial fibrillation when rapid control of the ventricular rate is needed (which cannot be achieved with cautious introduction and up-titration of a beta-blocker). This initial treatment with digoxin should not preclude subsequent introduction of a beta-blocker. Digoxin can be withdrawn if an excessive bradycardia develops during combined digoxin beta-blocker treatment.

In another recent study (A-HeFT), the combination of hydralazine (initiated at a dose of 37.5 mg and titrated to a target of 75 mg tid) and isosorbide dinitrate (initiated at a dose of 20 mg and titrated to a dose of 40 mg tid), given in a combined medication formulation, improved survival and additional outcomes when added to other evidence-based treatments in African-Americans with NYHA class III or IV HF [19]. This combination had been shown previously to reduce mortality in patients with heart failure in the "pre-ACE inhibitor era". Subsequently, in a head to head comparison, the combination proved inferior to enalapril. The A-HeFT trial now suggests that hydralazine and isosorbide dinitrate is of benefit when added to and ACE inhibitor (and beta-blocker and spironolactone), at least in black Americans. At present the place of hydralazine and isosorbide dinitrate in other patients with HF is as an alternative when neither an ACE inhibitor nor ARB is tolerated [80,81].


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Need for practical...
 3. Development of...
 4. Practical recommendations
 5. Conclusions
References
 
Under-prescribing and under-dosing of some treatments which reduce both mortality and morbidity in patients with HF in controlled clinical trials is a persisting problem. This under-treatment has denied patients the benefits of these treatments; it may also have had an adverse effect on health services (in terms of avoidable hospital admissions). Conversely, inappropriate use of spironolactone appears to have led to an unacceptably high risk of serious hyperkalaemia-related hospitalisations and death. The preparation of these concise and practical clinical recommendations for the prescribing of proven pharmacological treatments should provide doctors with the confidence to practise evidence-based medicine in their patients with HF whilst avoiding unnecessary toxicity. This should improve not only the outcomes for the individual patient but also reduce the burden of HF on health care systems [82].


   Acknowledgement
 
Although the costs associated with the two meetings were met by an educational grant from AstraZeneca, the remit of the faculty was to review all the relevant published clinical trials and produce a set of clinical recommendations independent of any other interests.


   References
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 Abstract
 1. Introduction
 2. Need for practical...
 3. Development of...
 4. Practical recommendations
 5. Conclusions
 References
 

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