A 40-year-old woman with dilated cardiomyopathy is seen in the heart failure clinic complaining of a persistent dry cough. Her exercise capacity is 1 mile while walking on the flat. She can climb two flights of stairs without difficulty. Her medication consists of ramipril 10 mg daily, aspirin 75 mg daily, carvedilol 6.25 mg twice daily and frusemide 40 mg daily. On examination her heart rate is 70 beats/min and her blood pressure is 100/60 mmHg. Both heart sounds are normal and the chest is clear.
How would you alter her treatment?
a. Add spironolactone.
b. Substitute ramipril with losartan.
c. Reduce carvedilol to 3.125 mg twice daily.
d. Double the dose of furosemide.
e. Add digoxin.
Answer:
b. Substitute ramipril with losartan.
The patient is in NYHA functional class II with respect to her symptoms. She is on the correct dose of ramipril and is appropriately being treated with a beta-blocker. The dry cough that the patient is experiencing is almost certainly the side-effect of ramipril. Angiotensinconverting enzyme inhibitors are associated with a dry cough in 15–20% of patients owing to increases in circulating bradykinin levels. In such patients the ACE inhibitor should be stopped and substituted with an angiotensin receptor blocker such as losartan. The efficacy of losartan compared with an ACE inhibitor (captopril) was fully evaluated in the ELITE II study.
The study revealed similar mortality rates and similar rates of progression of heart failure when comparing patients on losartan 50 mg daily with those prescribed captopril 50 mg three times daily. The study suggests that losartan is as effective as ACE inhibitors in the management of heart failure. However, the use of losartan in heart failure is still currently reserved for patients who develop side-effects to ACE inhibitors. A recent study evaluating the role of angiotensin receptor blockers (CHARM study; evaluated candesartan) in patients with heart failure showed reduced hospitalization rates and mortality in heart failure patients who were on candesartan instead of an ACE inhibitor, or candesartan as additional therapy to an ACE inhibitor.
Clinical