NICE guidance - use of ACE inhibitors post myocardial infarction (MI)
Last edited 12/2020 and last reviewed 12/2020
NICE have issued guidance as to the use of ACE inhibitors post myocardial infarction (1):
- people who present acutely with an MI should be offered an ACE inhibitor
as soon as they are haemodynamically stable. Continue the ACE inhibitor indefinitely
- titrate the ACE inhibitor dose upwards at short intervals (for example,
every 12-24 hours) before the person leaves hospital until the maximum tolerated
or target dose is reached
- if it is not possible to complete the titration during this time, it
should be completed within 4-6 weeks of hospital discharge
- if it is not possible to complete the titration during this time, it
should be completed within 4-6 weeks of hospital discharge
- combined treatment with an ACE inhibitor and an angiotensin II receptor blocker (ARB) should not be offered to people after an MI, unless there are other reasons to use this combination
- after an MI patients who are intolerant to ACE inhibitors should be offered
an ARB instead of an ACE inhibitor
- offer an ACE inhibitor to people who have had an MI more than 12 months
ago. Titrate to the maximum tolerated or target dose (over a 4-6-week period)
and continue indefinitely
- offer people who have had an MI more than 12 months ago and who are intolerant to ACE inhibitors an ARB instead of an ACE inhibitor
NICE recommends that all patients with left ventricular dysfunction should be taking an ACE inhibitor (2,3,4):
- ACE inhibitor therapy and beta blocker therapy are both first line
- offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first
- measure serum sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor, and after each dose increment
- measure blood pressure before and after each dose increment of an ACE inhibitor
- once the target or maximum tolerated dose of an ACE inhibitor is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell (4)
- alternative treatments if ACE inhibitors are not tolerated
- measure serum sodium and potassium, and assess renal function, before and after starting an ARB and after each dose increment
- measure blood pressure after each dose increment of an ARB. Follow the recommendations on measuring blood pressure, including measurement in people with symptoms of postural hypotension, in the NICE guideline on hypertension in adults
- once the target or maximum tolerated dose of an ARB is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell (4)
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