ACE inhibitors include-

Benazepril, Captopril, Enalapril, Enalaprilat, Fosinopril, Lisonopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril

Refer Captopril

Interacting drugs- summary

 + ACE inhibitors

Potassium salts   

concurrent use result in elevated serum potsssium concentrations in certain patients

Hypersensitivity to benazepril or any other ACE inhibitor Pregnancy

History of angioedema

Benazipril -

Cardiovascular -

Hypotension,  parathesis , palpitations, Orthostatic hypotension, Peripheral edema < 1%

CNS -

Insomnia/sleep disturbances, vomiting < 1%, Headache 5%. Dizziness 3 % Fatigue 2%

Nervousness , Anxiety  <1%, 

GI/GU -

Abdominal pain, constipation , urinary tract infection, malena  < 1%, nausea 1%,

Respiratory -

Asthma , bronchitis, dyspnea,sinusitis,< 1%, cough 3%

Dermatologic-

Diaphoresis, increased sweating,flushing, < 1%

Miscellaneous-

Angioedema, inpotence, decreased libido, asthenia, syncope,myalgia , arthalgia

arthiritis  < 1%

Patients on diuretics may experience excessive BP reduction when benazapril is used.

Benazapril

May attentuate the potassium loss caused by thiazide diuretics which could be beneficial

Potassium sparing diuretics and Potassium supplements can increase the risk of hyperkalemia when used without benazapril.

No clinically important pharmacokinetic interactions of benazapril have been reported with concomittant use of thiazides, furosemide, digoxin, propranolol, atenolol, naproxen, or cimetidine. Are used concomitantly with beta blockers, calcium antagonists, diuretics, without any clinically important adverse reactions.

Approved by FDA in June 1991

Indications:

Hypertension

Dosage:

Initial - 10mg once daily

Maintenance- 20 to 40mg/day as a single dose or two divided doses.

Missed dose-

 1. If you miss a dose of this medicine, and remember within 6 hours of take it as soon as possible unless the dose is less than 4 hours.

2. However, if you do not remember until later, skip the missed dose and go back to your regular dosing schedule.

3. Do not double doses.

List of entries

1. Congestive Heart Failure (CHF)

2. Atrial Fibrillation

3. Atrial Flutter

1. Congestive Heart Failure (CHF)

Heart failure is charaterized by well known symptoms and physical signs. Heart failure is coinsidered to be pathophysiological state in which an abnormal cardiac function is responsible for the failure of the heart to pump blood at a rate communsurate with the requirement of the metabolizing tissues.

Heart failure is frequently but not always caused by a defect in myocardial contraction, and then the term myocardial failure is appropiate,. Increased cardiac output results in in diuresis and general amelioration of disturbances characteristic of fight heart failure (venous congestion, edema) and left heart failure ) dyspnea, orthopnea, cardiac asthma).

Digitalis is generaly most effective in "low output" failure and less effective in "high output " failure ) bronchopulmonary insufficiency, artriovenous fistula, anemia, hyperthyroidism.

2. Atrial fibrillation

This is a dysrhythmia in which the effective contraction of the atria is abolished and the AV node and the ventricles are bombarded with a very rapid and irregular series of stimuli. Many of these impulses are blocked at the AV node, but many are passed through, so that the ventricular contracrtions in the untreated patient are usually rapid and irregularly irregular.

Digitalis rapidly reduces ventricular rates and eliminates the pulse deficit. Palpitation,precordial distress or weakness are relieved and concomittant congestive failure ameliorated. Continue digitalis in doses necessary to maintain the desired ventricular rate, both ar rest and in response to excercise and other clinical effects.

3. Atrial flutter

The dysrhythmia is less common than artial fibrillation. There is a considerable controversy regarding its mechanism. A reciprocating rhythm or circus current movement is most likely. The atria contracts at a rate of 250 to 350 rates per minute. AV block is almost always present and its ratio is usually even numbered. Digitalis slows the heart; normal sinus rhythm appear.

Digitalis slows the ventricular rate, by decreasing the degree of AV block, and commonly converts flutter to fibrillation. When the drug is withdrawn , the atrial flutter will frequently revert spontaneosuly to normal sinus rhythm. If this not occur quinidine may be employed to restore sinus rhythm.

Heart Failure

Evidence Based Medicine (MIMS March 2003)

Beneficial

ACE inhibitors such as captopril, enalapril,lisonopril,and perindopril

Digoxin

Appropriate use of beta-blockers

Spironolactoone in severe cases

Likely to be beneficial

Multidisciplinary intereventions (nutrition, counselling)

Excercise

Angiotensin II receptor blockers

Amiiodarone

Implatable cardiac defibrillators

Unlikely to be beneficial

Calcium channel blockers

Likely to beineffective or harmful

Positive inotropes(non-digitalis)

Non-amiodarone antiarrhythmic drugs

Key Points

1. There is conflicting evidence of the efficacy of multidisciplinary approach

2. Pescribed excercise training improves functional capacity and quality of life and reduces the rate of adverses cardiac events

3. Ace inhibitors reduce mortality, admission to hospital for heart failue and ischaemic events in patients with heart failure but are still under-used.

4. One critical trial has found that angiotensin II receptor blockers are at least as effective as ACE inhibitors for reducing clinical events(death or admission to hospitals). They confer no advantage over ACE inhibitors but can be useful if ACE inhibitors are not tolerated

5. Positve inotropic drugs improve symptoms but do not reduce mortality

6. Adding beta-blocker to ACE inhibitors decreases the rate of death and admission to hospitals

7. One clinical trial has found that in severe heart failure, adding an aldosterone receptor antagonist to an ACE inhibitor reduces mortality compared with ACE inhibitors alone.

8. ACE inhibitors delay the onset of symptoms and reduce cardiovascular events in patients with asymtomatic left ventricular systolic dysfunction

ACE inhibitors include-

Benazepril, Captopril, Enalapril, Enalaprilat, Fosinopril, Lisonopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril

Refer Captopril

1. Take captopril 1 hour before meals. Take moexipril in the fasting state

2. Do not interupt or discontinue medication without consulting physician

3. Notify physician if any of the following occur- sore throat, fever, swelling of hands or feet, irregular heart beat , chest pains, signs of angioedema, excessive prespiration, dehydration, vomiting and diarrhea may lead to a fall in blood pressure.

4. May cause dizziness, fainting or lightheadedness, especially during the first days of therapy; avoid sudden changes in posture. If syncope occurs, discontinue drug until physician has been contacted. Heart failure patients should avoid rapid increases in physical activity.

5. May cause skin rash or impaired taste perception. Notify physician if these persist.

6. Do not use salt substitutes containing potassium without consulting a physician

7. A persistent dry cough may occur and usually does not subside unless the medication is stopped. If this effect become bothersome, consult a physician.

Refer- Ramipril- ACE inhibitors

Refer- Ramipril- ACE inhibitors

Refer - Ramipril- ACE inhibitors