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Evaluation of the safety of enalapril in the treatment of heart failure in the very old

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Summary

We have introduced enalapril, in doses equal to or less than the 2.5 mg currently recommended, as an adjuvant to digoxin and diuretics in 17 patients of mean (SD) age 83 (5) years with severe heart failure. Only eleven patients tolerated its introduction. Unlike those reported in younger patients, all but one of the adverse drug reactions occurred 8 h or more after the first dose. Aged patients started on ACE inhibitors should be observed in hospital until stabilized on a maintenance dose. Three patients had an adverse reaction which differed in nature from those previously reported: acute confusional state, ataxia and mesenteric ischaemia.

Ten patients were discharged on 5 mg or 10 mg maintenance doses of enalapril. In nine of them improvement on triple therapy was sustained for a minimum of three months. ACE inhibition was lost in the other patient when her compliance with enalapril therapy fell to around 75%: monitoring compliance is essential when ACE inhibitors are used in low dosages.

Enalapril was withdrawn during follow up in three patients because of symptoms of mesenteric ischaemia and in four because of dramatic deterioration of renal function. One of the latter was found subsequently to have severe bilateral atheromatous renal artery stenosis. When isosorbide dinitrate was substituted for enalapril, symptoms of mesenteric ischaemia resolved and renal function returned to baseline. Continuing surveillance for adverse effects is essential in patients of this age group with severe heart failure, and the risk of occult renal artery stenosis requires regular biochemical screening during follow up.

The benefit to cost ratio of ACE inhibitors might be improved in aged patients by their use at an earlier stage in the natural history of heart failure, when perfusion of essential organs is not grossly impaired, but carefully monitored trials would be necessary to establish this.

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Authors and Affiliations

  1. Northwick Park Hospital and Therapeutics in the Elderly, Research Group, Clinical Research Centre, Harrow, Middlesex, UK

    C. J. A. O'Neill, S. G. Bowes, C. M. Sullens, M. J. Denham, R. J. Dobbs & S. M. Dobbs

  2. Northwick Park Hospital and Therapeutics in the Elderly, Division of Medical Statistics, Clinical Research Centre, Harrow, Middlesex, UK

    J. P. Royston

  3. Northwick Park Hospital and Therapeutics in the Elderly, Physiology and Pharmacology, Hatfield Polytechnic Academic Group, Hatfield, Hertfordshire, UK

    W. B. Hunt

Authors
  1. C. J. A. O'Neill
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  2. S. G. Bowes
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  3. C. M. Sullens
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  4. J. P. Royston
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  5. W. B. Hunt
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  6. M. J. Denham
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  7. R. J. Dobbs
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  8. S. M. Dobbs
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O'Neill, C.J.A., Bowes, S.G., Sullens, C.M. et al. Evaluation of the safety of enalapril in the treatment of heart failure in the very old. Eur J Clin Pharmacol 35, 143–150 (1988). https://doi.org/10.1007/BF00609243

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  • DOI: https://doi.org/10.1007/BF00609243

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