Renin-Angiotensin Agents and Beta Blockers – Heart Failure and Angina Management

00:01 The renin-angiotensin agents are very important in both chronic heart failure and in acute management of high blood pressure.

00:09 We know that these agents reduce morbidity and mortality in heart failure.

00:14 They reduce aldosterone secretion and water retention, and they also reduce total peripheral resistance or vascular resistance through its antihypertensive effects.

00:24 I've listed here all of the ACE inhibitors. And here are all of the ARBs.

00:30 Now, the angiotensin receptor blockers have been in studies shown to be "non-inferior" to ACE inhibitors.

00:37 You'll generally find on the wards that cardiologists favor ACE inhibitors, and the ARBs are favored by everyone else.

00:45 I don't think there is really a right answer in ACEi versus ARB.

00:49 The direct renin inhibitors are a relatively new class that I discussed in my hypertension lecture, we don't have a lot of great information on heart failure at this time.

00:58 Now, it's still maybe useful and beneficial in heart failure. But at this point in time, in 2016, it's not routinely used.

01:08 Let's move on to the beta blockers. Remember that in heart failure, we only use beta blockers once the patient has been stabilized.

01:16 Beta blockers may actually be harmful in acute heart failure because it may suppress cardiac function.

01:23 Beta blockers work by two major ways. First of all, they reduce heart rate and increases stroke volume.

01:31 That's because when you reduce heart rate, the heart has more time to fill, and as it has more time to fill, each stroke will become more efficient and powerful.

01:41 It also reduces overall mortality and progression of chronic heart failure.

01:46 Carvedilol is the favourite beta blocker in heart failure. Major studies have shown reduction of morbidity and mortality.

01:54 Carvedilol has all alpha, beta, and beta 2 effects, so it's a very effective agent, and it's very well tolerated in heart failure.

02:05 Nebivolol is a newer beta blocker that is just come recently to the United States and Canada and has been in Europe for several years.

02:12 It has actions on nitric oxide. At this point in time, it's relatively investigational in the US and Canada, but there is a lot of experience in Europe which shows that it does quite well.