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Renal and Electrolyte Complications of Congestive Heart Failure and Effects of Therapy With Angiotensin-Converting Enzyme Inhibitors
James R. Oster, MD;
Barry J. Materson, MD
Arch Intern Med. 1992;152(4):704-710.
Abstract
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Blood pressure declines in virtually all patients with severe congestive heart failure given an angiotensin-converting enzyme (ACE) inhibitor, but hypotension is of concern only if symptomatic. Acute renal insufficiency induced by an ACE inhibitor is due to reduced renal perfusion pressure together with blockade of angiotensin ll-induced constriction of the efferent arteriole. Risk factors (or markers) for renal failure include hyponatremia, hypotension, volume contraction. Hyponatremia is an index of increased hemodynamic impairment, marked activation of the renin-angiotensin-aldosterone axis, and poor prognosis. Preventive measures for both ACE inhibitor— associated hypotension and renal insufficiency include withholding diuretics for a few days, initiating therapy with very small doses of ACE inhibitors, and cautious dose titration. Therapy for both hypotension and renal insufficiency involves increasing dietary sodium intake and reducing the dosage of, or temporarily discontinuing, the diuretic. The ACE inhibitor may have to be given at reduced dosage or discontinued for a time. If discontinuation is deemed necessary, administration of these survival-prolonging medications should be reinitiated after a brief respite whenever possible.
(Arch Intern Med. 1992;152:704-710)
Author Affiliations
From the Medical and Research Services, Veterans Affairs Medical Center, Miami, Fla, and the Department of Medicine, University of Miami School of Medicine.
Footnotes
Accepted for publication September 10, 1991.
Reprint requests to Nephrology Section (111C1), VA Medical Center, 1201 NW 16th St, Miami, FL 33125 (Dr Oster).
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