Angiotensin converting enzyme inhibitors for long-term management of acute coronary syndromes

Angiotensin converting enzyme inhibitors (ACEIs) reduce cardiovascular mortality after myocardial infarction. Unless contraindicated, start an ACEI within 24 to 48 hours of acute myocardial infarction.

Contraindications to early ACEI use include haemodynamic instability and hypotension (systolic pressure less than 90 mmHg).

Suitable ACEI regimens for long-term management of acute coronary syndromes are1:

1captopril 6.25 mg orally, twice daily, increasing to maximum 150 mg daily in divided doses captopril captopril captopril

OR

1enalapril 2.5 mg orally, daily, increasing to maximum 40 mg daily enalapril enalapril enalapril

OR

1fosinopril 5 mg orally, daily, increasing to maximum 40 mg daily fosinopril fosinopril fosinopril

OR

1lisinopril 2.5 mg orally, daily, increasing to maximum 40 mg daily lisinopril lisinopril lisinopril

OR

1perindopril arginine 2.5 mg orally, daily, increasing to maximum 10 mg daily perindopril perindopril perindopril

OR

1perindopril erbumine 2 mg orally, daily, increasing to maximum 8 mg daily perindopril perindopril perindopril

OR

1quinapril 2.5 mg orally, daily, increasing to maximum 40 mg daily quinapril quinapril quinapril

OR

1ramipril 2.5 mg orally, daily, increasing to maximum 10 mg daily ramipril ramipril ramipril

OR

1trandolapril 0.5 mg orally, daily, increasing to maximum 4 mg daily2. trandolapril trandolapril trandolapril

Titrate to the maximum tolerated dose and continue the ACEI long term. Gradually increase the dose within 4 to 6 weeks after discharge. Monitor for hypotension, kidney impairment and hyperkalaemia.

In patients with clinical heart failure and a left ventricular ejection fraction (LVEF) of 40% or less, an alternative renin-angiotensin system inhibitor (eg sacubitril+valsartan) may be indicated instead of an ACEI; for more information, see Renin-angiotensin system inhibitors for HFrEF.

The combination of an ACEI with an angiotensin II receptor blocker (ARB) is not recommended except with specialist advice.

1 At the time of writing, enalapril, fosinopril and quinapril are not approved by the Australian Therapeutic Goods Administration (TGA) for this indication. See the TGA website for current information.Return
2 At the time of writing, trandolapril is only approved by the Australian Therapeutic Goods Administration (TGA) for post–myocardial infarction left ventricular dysfunction. See the TGA website for current information.Return