For patients who cannot tolerate ACE inhibitors, which of the following is used as a secondary option?

For patients who cannot tolerate ACE inhibitors, which of the following is used as a secondary option?

• A. ACE inhibitors
• B. ARB
• C. ARNIs
• D. MRAs

Answer: (B)

When ACE inhibitors can’t be used because of intolerance (like cough or risk of angioedema), the best alternative is to continue RAAS blockade with an ARB. Angiotensin receptor blockers block the same hormonal system downstream, preventing angiotensin II from exerting its harmful effects on blood vessels, the heart, and the kidneys, but without increasing bradykinin in a way that causes the cough or angioedema seen with ACE inhibitors. This provides similar benefits in reducing mortality and hospitalization in heart failure with reduced ejection fraction. ARNI therapy combines an ARB with a neprilysin inhibitor and is reserved for patients who have already been able to tolerate a RAAS blocker; it’s not the first choice when an ACE inhibitor is not tolerated. Mineralocorticoid receptor antagonists add mortality and morbidity benefits but are used on top of an ACE inhibitor or ARB rather than as a substitute for ACE inhibitors. So, the most appropriate secondary option when ACE inhibitors can’t be tolerated is the ARB.

When ACE inhibitors can’t be used because of intolerance (like cough or risk of angioedema), the best alternative is to continue RAAS blockade with an ARB. Angiotensin receptor blockers block the same hormonal system downstream, preventing angiotensin II from exerting its harmful effects on blood vessels, the heart, and the kidneys, but without increasing bradykinin in a way that causes the cough or angioedema seen with ACE inhibitors. This provides similar benefits in reducing mortality and hospitalization in heart failure with reduced ejection fraction.

ARNI therapy combines an ARB with a neprilysin inhibitor and is reserved for patients who have already been able to tolerate a RAAS blocker; it’s not the first choice when an ACE inhibitor is not tolerated. Mineralocorticoid receptor antagonists add mortality and morbidity benefits but are used on top of an ACE inhibitor or ARB rather than as a substitute for ACE inhibitors.

So, the most appropriate secondary option when ACE inhibitors can’t be tolerated is the ARB.