The renin-angiotensin agents are very important in both chronic heart failure
and in acute management of high blood pressure.
We know that these agents reduce morbidity and mortality in heart failure.
They reduce aldosterone secretion and water retention
and they also reduce total peripheral resistance
or vascular resistance through its antihypertensive effects.
I've listed here all of the ACE inhibitors. And here are all of the ARBs.
Now the angiotensin receptor blockers have been in studies shown to be non-inferior to ACE inhibitors.
You'll generally find on the wards that cardiologist favor ACE inhibitors
and the ARBs are favored by everyone else.
I don't think there's really a right answer in ACE versus ARB.
The direct renin inhibitors such as aliskiren,
are relatively new medications that are not currently recommended in the treatment of heart failure.
Let's move on to the beta blockers.
Remember that in heart failure we only use beta blockers once the patient has been stabilized.
Beta-blockers may actually be harmful in acute heart failure
because it may suppress cardiac function.
Beta blockers work by two major ways. First of all, they reduce heart rate
and increase the stroke volume.
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.
It also reduces overall mortality and progression of chronic heart failure.
Carvedilol is the favorite beta blocker in heart failure.
Major studies have shown reduction of morbidity and mortality.
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.
Nebivolol is a newer beta blocker that has just come recently to the United States and Canada
and has been in Europe for several years. It has actions on nitric oxide.
At this point in time, it's relatively investigational in the US and Canada,
but there's a lot of experience in Europe which shows that it does quite well.