Alternatives to ACE Inhibitors.

For patients who are intolerant of ACE inhibitors, alternative medications are available. The combination of hydralazine and nitrates also decreases mortality for patients with systolic dysfunction HF. Angiotensin II receptor antagonists (A II)

are another promising alternative therapy for patients who cannot use ACE inhibitors. Current clinical trials will help clarify the role of these drugs alone or in combination with an ACE inhibitor. Angiotensin II blocking drugs do not affect bradykinin

levels and thus do not induce angioedema and cough to the same extent as ACE inhibitors. The first and second generation calcium channel blockers such as nifedipine, diltiazem, and nicardipine may worsen systolic dysfunction symptoms due to negative inotropic effects and a tendency to increase sympathetic tone. In one large trial (PRAISE-1), amlodipine did not increase mortality among patients with HF due to nonischemic cardiomyopathy. Although dihydropypridine calcium channel blockers should not be used as specific primary treatment for systolic dysfunction HF, amlodipine can be considered for patients with continued hypertension on ACE inhibitors and diuretics or those with symptomatic ischemia not controlled by nitrates and/or beta-blockers.