ACE Inhibitors:When-and For Which Patients?

Q:Should I avoid angiotensin-converting enzyme (ACE) inhibitors in my patients with progressive renal insufficiency? A:This issue is extremely bothersome to clinicians. ACE inhibitors represent a dual-edged sword with respect to their impact on renal function. On one hand, major clinical trials have clearly demonstrated their benefit in patients with congestive heart failure (CHF) and in patients with diabetic and nondiabetic renal disease. In multiple large clinical trials, ACE inhibitors reduce the risk of hospitalizations and death in patients with severe systolic dysfunction. In patients with proteinuric renal disease, ACE inhibitors significantly reduce proteinuria and slow the rate of progressive loss in renal function. Multiple benefits have been observed in older patients with cardiovascular disease, with or without hypertensionand with and without renal disease.1 These data, taken together, suggest that a significant segment of the population may benefit from this class of agents.