Angiotensin II receptor blockers for long-term management of acute coronary syndromes

The effect of angiotensin II receptor blockers (ARBs) following myocardial infarction has not been studied as extensively as the effect of angiotensin converting enzyme inhibitors (ACEIs); therefore, ACEIs remain the treatment of choice. An ARB may be considered for patients who are intolerant of ACEI.

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

If an ARB is appropriate, suitable regimens for long-term management of acute coronary syndromes are1:

1candesartan 4 mg orally, daily, increasing to maximum 32 mg daily candesartan candesartan candesartan

OR

1eprosartan 400 mg orally, daily, increasing to maximum 600 mg daily eprosartan eprosartan eprosartan

OR

1irbesartan 75 mg orally, daily, increasing to maximum 300 mg daily irbesartan irbesartan irbesartan

OR

1losartan 25 mg orally, daily, increasing to maximum 100 mg daily losartan losartan losartan

OR

1olmesartan 10 mg orally, daily, increasing to maximum 40 mg daily olmesartan olmesartan olmesartan

OR

1telmisartan 40 mg orally, daily, increasing to maximum 80 mg daily telmisartan telmisartan telmisartan

OR

1valsartan 20 mg orally, twice daily, increasing to maximum 160 mg twice daily2. valsartan valsartan valsartan

Titrate to the maximum tolerated dose and continue the ARB 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 ARB; for more information see Renin-angiotensin system inhibitors for HFrEF.

The combination of an ACEI with an ARB is not recommended except with specialist advice.

1 At the time of writing, candesartan, eprosartan, irbesartan, losartan and olmesartan 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, valsartan is only approved by the Australian Therapeutic Goods Administration (TGA) for post–myocardial infarction left ventricular failure or left ventricular systolic dysfunction. See the TGA website for current information.Return