Friday, April 20, 2018

Time to Ditch ACE Inhibitors for CVD?

There is “little, if any, clinical reason” to use angiotensin-converting enzyme (ACE) inhibitors for the treatment of hypertension or other cardiovascular indications because angiotensin receptor blockers (ARBs) are just as effective with fewer side effects, a new review concludes.

The review, published in the Journal of the American College of Cardiology on April 3, was led by Franz Messerli, MD, University Hospital, Bern Switzerland.

Messerli and colleagues reviewed data from 119 randomized clinical trials of ACE inhibitors and ARBs in more than half a million patients and found no difference in efficacy between the two drug classes with regard to the surrogate endpoint of blood pressure and the outcomes of all-cause mortality, cardiovascular mortality, myocardial infarction, heart failure, stroke, and end-stage renal disease. But ACE inhibitors have a higher incidence of adverse reaction – namely cough and very low risks of angioedema and fatalities – that are more prevalent in dark-skinned people, they write.

Despite this, most guidelines for the management of patients with cardiovascular disease recommend ACE inhibitors as first-choice therapy, whereas ARBs are merely considered an alternative for ACE inhibitor-intolerant patients, Messerli and colleagues point out.

My Take:
The rest of the article is rebuttal from various cardiologists on the pros and cons of using ARBs in lieu of ACE. The best quote – “And the side effect of angioedema, although rare, can be fatal, and if ACE inhibitors are proposed as part of the polypill then millions will be exposed and fatalities will occur.”

Polypill is a reference to polypharmacy – taking five or more medications daily. More drugs, more drug interactions, more side effects and more fatalities. I believe he is specifically referring to the use of an ACE inhibitor to reduce hypertension (high blood pressure). This causes edema, most notably swollen ankles. So a diuretic is prescribed. However, that causes a potassium deficiency, so a potassium supplement is added. The potassium supplement irritates the digestive tract and now a PPI (proton pump inhibitor) joins the mix. Congratulations, you have reach polypill, the lifestyle of the average American, just one script short of polypharmacy.

Side effects from ACE inhibitors are quite common. These drugs work by reducing renin production in the kidneys. Renin is produced in response to increased fluid in the kidneys (due to edema). As renin is released it increases blood pressure to force more fluid through the kidneys. This is a small part of the control mechanisms utilized by the body to manage circulation. Interfering with renin chemistry creates aspects of congestive heart failure. The early symptoms are a chronic cough (fluid in the lungs) and swollen ankles. While this can also be true with ARBs, calcium channel blockers and beta blockers, it is more prevalent with ACE inhibitors.

The herb licorice can have the opposite effect on the kidneys, increasing renin production, when used for extended time periods. Licorice is a tonic for the adrenals, giving immediate support but has no long term benefit in terms of rebuilding the adrenals like an adaptogen.
Typically, I use licorice in very small quantities in most of my liquid herbal blends. It has a synergistic effect, helping the herbs work together.

The Bottom Line:
Please avoid the use of ACE inhibitors. If you current take one, ask your prescribing physician to try alternate medication.

Source: April 5, 2018 Medscape

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