Key Points
- Angiotensin receptor blockers or ARBs are recommended in patients with heart failure with reduced ejection fraction (LVEF <40%) who are intolerant of ACE inhibitors due to cough
- ARBs have been shown in clinical trials to decrease the combined endpoint of cardiovascular mortality and hospitalization for heart failure
- ARB should be considered in patients with a mild reduction in ejection fraction (LVEF 41–49%) , if an ACE inhibitor is contraindicated or not tolerated
- Assess blood pressure, renal function, and serum potassium within 1 to 2 weeks after starting an ARB
- Angioedema is a rare but serious adverse effect of ACE inhibitors but some patients may also react to ARBs-particularly in people of African decent
- The recommended ARBs for heart failure therapy are candasartan, losartan, and valsartan
Using STEPPED CARE for ARBs
Candasartan
- Initial dose: 4 mg PO QD
- Step one: 8 mg PO QD
- Step two: 16 mg PO QD
- Step three: 32 mg PO QD
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Notes: Increase dose to next step every 2 weeks
Valsartan
- Initial dose: 20 mg PO BID
- Step one: 40 mg PO BID
- Step two: 80 mg PO BID
- Step three: 160 mg PO BID
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Notes: Increase dose to next step every 2 weeks
Losartan
- Initial dose: 25 mg PO QD
- Step one: 50 mg PO QD
- Step two: 100 mg PO QD
- Step three: 150 mg PO QD
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Notes: Increase dose to next step every 2 weeks