Should Aspirin Be Used With Angiotensin-Converting Enzyme
Should Aspirin Be Used With Angiotensin-Converting Enzyme
Aspirin and angiotensin-converting enzyme (ACE) inhibitors are widely used in combination to treat a wide spectrum of cardiac disorders. Theoretically, a rationale for interaction between these two agents exists in the possible counterbalancing prostaglandin inhibiting actions of aspirin and the vasodilatory prostaglandin promoting effects of ACE inhibitors. Animal and human studies suggest such an interaction, but most are plagued by small numbers or retrospective designs. Large-scale trials are in progress to address this issue. Until then, the key factor in deciding whether a patient with ischemic heart disease on ACE inhibitor therapy should be placed on aspirin therapy may largely depend on the severity of heart failure. The more severe the heart failure, the more likely an appreciable interaction between aspirin and ACE inhibitors will occur. Treatment with either low-dose aspirin or with alternative agents, such as warfarin or clopidogrel, may be the best therapeutic approach for patients with severe systolic heart failure.
The most common cause of heart failure with decreased systolic function is ischemic heart disease. Aspirin, through inhibition of platelet aggregation, has become a cornerstone in the treatment of acute coronary syndromes, and primary and secondary prevention studies indicate that aspirin therapy results in improved outcome in patients with coronary artery disease. Angiotensin-converting enzyme (ACE) inhibitors, through a number of actions including improvement in hemodynamics via systemic vasodilation, arrhythmia suppression, and enhanced renal function among others, have been shown to reduce morbidity and mortality in patients with heart failure as well as in patients after myocardial infarction (MI) with left ventricular dysfunction. Considering the broad spectrum of therapeutic indications of aspirin and ACE inhibitors, it has become commonplace to encounter patients with cardiovascular diseases being prescribed both medications with the intention of providing the benefit of both drugs.
However, do the patients truly benefit or are they being subjected to harm from negative interaction between the two agents? Questions regarding the safety of aspirin in patients with heart failure were raised when the Studies of Left Ventricular Dysfunction (SOLVD) trial suggested that patients using ACE inhibitors did not benefit from treatment if aspirin was being administered concomitantly. Since then, the possibility of a negative interaction between ACE inhibitors and aspirin resulting in attenuation of their protective hemodynamic effects has been investigated in numerous clinical studies and post hoc analyses. However, evidence of harm or benefit with aspirin in patients with heart failure remains far from conclusive.
Aspirin and angiotensin-converting enzyme (ACE) inhibitors are widely used in combination to treat a wide spectrum of cardiac disorders. Theoretically, a rationale for interaction between these two agents exists in the possible counterbalancing prostaglandin inhibiting actions of aspirin and the vasodilatory prostaglandin promoting effects of ACE inhibitors. Animal and human studies suggest such an interaction, but most are plagued by small numbers or retrospective designs. Large-scale trials are in progress to address this issue. Until then, the key factor in deciding whether a patient with ischemic heart disease on ACE inhibitor therapy should be placed on aspirin therapy may largely depend on the severity of heart failure. The more severe the heart failure, the more likely an appreciable interaction between aspirin and ACE inhibitors will occur. Treatment with either low-dose aspirin or with alternative agents, such as warfarin or clopidogrel, may be the best therapeutic approach for patients with severe systolic heart failure.
The most common cause of heart failure with decreased systolic function is ischemic heart disease. Aspirin, through inhibition of platelet aggregation, has become a cornerstone in the treatment of acute coronary syndromes, and primary and secondary prevention studies indicate that aspirin therapy results in improved outcome in patients with coronary artery disease. Angiotensin-converting enzyme (ACE) inhibitors, through a number of actions including improvement in hemodynamics via systemic vasodilation, arrhythmia suppression, and enhanced renal function among others, have been shown to reduce morbidity and mortality in patients with heart failure as well as in patients after myocardial infarction (MI) with left ventricular dysfunction. Considering the broad spectrum of therapeutic indications of aspirin and ACE inhibitors, it has become commonplace to encounter patients with cardiovascular diseases being prescribed both medications with the intention of providing the benefit of both drugs.
However, do the patients truly benefit or are they being subjected to harm from negative interaction between the two agents? Questions regarding the safety of aspirin in patients with heart failure were raised when the Studies of Left Ventricular Dysfunction (SOLVD) trial suggested that patients using ACE inhibitors did not benefit from treatment if aspirin was being administered concomitantly. Since then, the possibility of a negative interaction between ACE inhibitors and aspirin resulting in attenuation of their protective hemodynamic effects has been investigated in numerous clinical studies and post hoc analyses. However, evidence of harm or benefit with aspirin in patients with heart failure remains far from conclusive.
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