Zahid Hussain Shah, Imran Mehfuz Khan, Ayesha Irshad, Farrukh Ghias, Irshad Hussain Qureshi, Ali Shoaib.
Risk Assessment in Cardiac Failure at High Risk of Hypotension Due to Ace Inhibitor Therapy and Measures to Overcome this Risk.
Pak J Med Health Sci Jan ;12(1):218-21.

Aim: To find out the proportion of patients of cardiac failure who were at high risk of first dose hypotension due to angiotensin converting enzyme inhibitors and to overcome this effect at their initiation of therapy . Study Design: It was an observational study Methods: One hundred adult patients with congestive cardiac failure not taking ACE therapy, who were admitted in Medical Units, Mayo Hospital, Lahore, were registered for this study. Patients were divided into two groups, A and B. Group A had patients who were euvolumic and normonatremic while group B comprised of patients who were hyponatremic and volume depleted due to previous diuretic treatment. Control blood pressure readings were noted. Angiotensin converting enzyme inhibitor (captopril ) was administered in smallest dose(6.25mg). Blood pressure was recorded at 30 minutes, 60 minutes and 90 minutes. First dose hypotension was noted by drop in systolic blood pressure > 20 mmHg from the baseline systolic blood pressure after the 90 minutes of captopril administration or decrease in systolic blood pressure below 90 mmHg irrespective of baseline reading. Results: Out of one hundred patients forty patients (40 %) had first dose hypotension at 30minutes, 44 (44%) patients were observed to have first dose hypotension at 60 minutes while fifty (50%) patients suffered first dose hypotension after 90 minutes. Out of fifty patients of group A, 7 patients were observed to have first dose hypotension after ACE therapy while out of 50 patients of group B, 23 patients had first dose hypotension. Conclusion: ACE inhibitors have an important role in patients with heart failure. First dose hypotension is a common and hazardous side effect of these drugs. However, first dose hypotension can be overcome if the diuretic therapy is stopped approximately 12-24 hours before administering ACE (captopril ) or dose of diuretics reduced. Also hyponatremia and hypovolemia corrected before initiation of ACE inhibitor therapy.

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