Considering that the patient’s history of stable ischemic heart disease puts him at risk for future recurrent cardiac events and after considering current evidence and guidelines, is it reasonable to consider adding an ACEI to this patient's standard medical therapy?
Pharmacologic Effects of Antagonists on the Renin-Angiotensin-Aldosterone System Angiotensinogen Angiotensin I Angiotensin II Kininogen Bradykinin Inactive Ceconi C, et al. Cardiovasc Res 2007;73:237-46; Faxon DP, et al. Circulation 2004;109:2617-2625; Schmidt-Ott KM, et al. Regul Pept 2000; 93:65-77; Song JC, White CM. Pharmacotherapy 2000;20:130-9; Song JC, White CM. Clin Pharmacokinet 2002;41:207-24; Coleman CI, et al. AHRQ Comparative Effectiveness Review No. 18. October 2009. Angiotensin-converting enzyme Renin Kallikrein Kininase II Angiotensin-converting enzyme inhibitor Angiotensin II-receptor blocker Angiotensin II Type I Receptors Stimulatory signal Reaction Inhibitory pharmacologic effect LEGEND
You suggest to this patient that they discuss the possibility of adding an ACEI to his current medications.
In order to do this, you review with him a patient guide titled, “ ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease , from the Effective Health Care Program website at: http://effectivehealthcare.ahrq.gov.
You explain to him that the guide is based on a review of multiple studies about specific medications for patients with stable ischemic heart disease.
In explaining the evidence of benefits, the patient asks, “If I take this, I won’t have another heart attack?” You:
Agree with him and write the prescription.
Caution him that the studies are generalized and that the evidence may not apply to his specific case.
Show him the pictograph in the consumer guide titled, “ ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease , of the evidence concerning the modest likelihood of benefit so that he can see the probability of facing a fatal heart attack with or without the medicine. Review the likelihood of the other benefits using the same pictograph as a model.
Explain to him that the likelihood of benefit is minimal, and that taking an ACEI may not make that much of a difference.
You then discuss the possible risks of adverse effects from taking an ACEI, so that the patient can weigh the benefits and harms with you to determine an appropriate decision. You explain that research has found that he may experience:
At this point in the discussion you explain to him that this medication is being given in order to reduce the risk of future cardiac events even further than if he was only taking his usual medication.
You counsel the patient to call you immediately if he experiences any of the adverse effects such as swelling of the lips or mouth area, which could indicate the patient has developed angioedema.
You give him his own copy of the consumer guide titled, “ ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease , to take home with him to review and keep these important adverse effects in mind.
The patient asks about the source of the information that you have given him, and you explain it is a summary of a large analysis done at a university that included many studies on the benefits and harms of adding an ACEI and/or ARB to standard therapies for patients with stable ischemic heart disease and preserved LVSF.
This information was summarized in a way that would allow patients to make decisions with their doctors regarding their course of treatment.
You counsel him to take this guide (“ ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease ) home to share with his family, refer to it from time to time to remind him why he's taking the drugs, and refer to it for descriptions of the adverse effects.
After this discussion, you and your patient determine that the decreased risk of nonfatal heart attack, stroke, and death are worth the risk of possibly getting a cough, high levels of potassium, or suddenly fainting.
This patient is sent home with his medications and the consumer summary guide “ ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease ), which he can continue to refer to in the event of questions.
In six weeks, he returns to your office with a dry persistent cough that keeps him up at night.
He has been referring to the consumer summary guide and wonders if there are any other drugs he can take to help him.
After reviewing the evidence presented in the Clinician's Guide titled, Adding ACEIs and/or ARBs to Standard Therapy for Stable Ischemic Heart Disease: Benefits and Harms , which medication is an acceptable alternative for a patient with stable ischemic heart disease with preserved left ventricular systolic function who is intolerant to an ACEI?
The patient asks you about the adverse effects of taking an ARB. After reviewing the clinician guide, you inform him that there is only low level evidence available about patients such as himself who are taking an ARB due to intolerable adverse effects from ACEIs. Taking an ARB may increase his risk of what?