Prescribing dilemmas: angiotensin-converting enzyme inhibitors for heart failure in an older patient

This case example explores how uncertainty can arise when interpreting clinical guidelines to prescribe for older patients with heart failure. 

A list of the skills required to manage such situations, mapped to the Royal Pharmaceutical Society’s ‘Competency framework for all prescribers’, can be found at the end of this article.

Case presentation

A 91-year-old male patient diagnosed with chronic heart failure (HF) with reduced ejection fraction was reviewed by a pharmacist in a specialist HF clinic. He was taking the angiotensin-converting enzyme (ACE) inhibitor ramipril and beta-blocker bisoprolol to treat the HF with reduced ejection fraction, in accordance with National Institute for Health and Care Excellence (NICE)^​1​ and European Society of Cardiology (ESC) guidelines^​2​. 

The monitoring of ramipril was conducted in accordance with NICE and NHS Specialist Pharmacy Service (SPS) guidance, which included assessing the patient’s renal function, urea, electrolytes and blood pressure^​1,3​. The urea and electrolytes were within normal limits and the estimated creatinine clearance was 65 mL/min, consistent with his baseline.

His recent home blood pressure reading was 119/68mmHg, close to his baseline, and his heart rate was 71bpm. Additionally, the patient reported no symptoms of dizziness or light-headedness. In the HF clinical assessment, which assessed his cardiac rhythm, cognitive and nutritional health, he showed no signs of dehydration, fluid overload or HF decompensation. His functional capacity was assessed using the New York Heart Association (NYHA) score^​1​, which is used to classify HF, and he was found to be class 1 (no limitation of physical activity).

The dilemma

NICE and ESC guidelines recommend titrating ACE inhibitors to the maximum tolerated dose — for ramipril, the target dose is 10mg once daily (preferably split into two doses)^​1,2​. However, the patient was prescribed 5mg of ramipril once daily. It is important to titrate ACE inhibitors to their maximum tolerated dose because evidence shows that the higher doses provide more significant benefits in managing HF. Both NICE and ESC guidelines emphasise that reaching the target dose improves patient outcomes, including symptom control, reduced hospitalisations and decreased mortality risk^​2​. Increasing the ramipril dose would allow the patient to achieve the full therapeutic benefits. However, increasing the dose also comes with an increased risk of side effects, such as hypotension, hyperkalaemia and renal impairment^​4​. 

The lack of evidence regarding the efficacy of ACE inhibitors in older patients with HF is a significant issue^​5​. Older patients are often excluded from clinical trials for several reasons, such as arbitrary age limits, presence of multiple comorbidities and the high prevalence of polypharmacy^​6​. As a result, it becomes challenging to determine the true benefits of ACE inhibitors for this group of patients. Without robust data specific to older individuals, decisions are based on extrapolation from younger individuals, which do not fully account for the risks associated with ageing^​5​.

Older individuals are particularly vulnerable to adverse drug reactions owing to factors including diminished renal and hepatic function, polypharmacy and other comorbidities^​7​. The primary risks associated with increasing the ramipril dose for this patient included the potential for acute kidney injury, hyperkalaemia and a heightened risk of falls. Falls and fall-related injuries are a prevalent and significant issue for older adults. Individuals aged 65 years and above are at the highest risk of falls, with 30% of those aged over 65 years and 50% of those aged over 80 years experiencing at least one fall per year^​7​. The impact of falling extends beyond physical harm, which leads to distress, pain, injury, loss of confidence, reduced independence and even death. Falls can also affect the family members and caregivers of those who experience them^​8​. Therefore, risk of falls in older people should be carefully considered when adjusting medicines that may affect blood pressure renal function, electrolyte levels or cognitive function.

It is essential to take a patient-centred and holistic approach when making decisions involving the patient in the process whenever possible. While it is essential to prescribe evidence-based HF treatments to all patients, considerations must be made for the complexities of treating older adults^​7​ — their response to treatment may differ from expectations. A more holistic approach to care for older, frailer patients with HF may prove to be more beneficial than the typical target-driven approach often used for younger patients^​7​.

Consultation

During this consultation, potential changes to the ramipril dosage were discussed, including the associated risks and benefits as described above. It was explained that increasing the ramipril dose could optimise the 91-year-old male patient’s HF outcomes and reduce the risk of hospitalisations. However, this could also increase the risk of side effects, particularly by lowering the patient’s blood pressure further and potentially increasing the risk of falls. The patient was then encouraged to express his feelings and was given time to consider the decision. His primary concern was the risk of falling, as he lived alone and highly valued his independence. 

Although the patient recognised the importance of managing his HF, the patient felt his condition was stable and had no recent episodes of HF decompensation; however, his main concern was the increased risk of falls and the possibility of being admitted to hospital following a fall. Ultimately, a shared decision was reached to continue with his current ramipril dosage of 5mg once daily and have a follow-up appointment in six months.

Appropriate monitoring and additional actions agreed

The patient was provided with guidance on what to do if he encountered any issues before the follow-up appointment, which includes reporting symptoms of worsening HF, such as breathlessness, fatigue or ankle or abdominal swelling^​1​. 

Given the patient’s stable HF, sick-day advice was discussed, which included temporarily holding off the administration of ramipril for 24–48 hours if the patient experiences symptoms such as diarrhoea or vomiting^​1​. This recommendation helps prevent dehydration and acute kidney injury. In addition to medicines adjustments, lifestyle advice was also provided to the patient in line with NICE guidelines^​1​. The advice included dietary recommendations, focusing on reducing salt intake and maintaining proper fluid balance to avoid complications, such as dehydration or fluid overload. The importance of regular low-intensity physical activity was also emphasised, as it can improve overall cardiovascular health and functional capacity in HF patients^​1​. By discussing these lifestyle modifications, the goal was to support the patient in managing his condition holistically and improve both his physical health and quality of life. The pharmacist also ensured that the patient was referred to a supervised exercise-based cardiac rehabilitation programme, as recommended by NICE guidelines^​1​.

Follow up

Six months later, at the follow-up HF review, the patient’s condition had remained stable. His HF symptoms had not worsened and his blood pressure was recorded at 109/67mmHg, which continued to be within an acceptable range for him. The patient reported no issues, with no significant falls or recent hospital admissions. Given his stable condition and absence of any concerning symptoms, no changes were made to his medication regimen. Subsequently, continued monitoring and a follow-up appointment were recommended. The patient was also encouraged to maintain his current lifestyle modifications, including dietary advice and regular exercise, as part of his ongoing management plan.

Reflective practice

Reflecting on this case, I feel confident that a patient-centred approach led to a positive outcome. The patient’s HF remained stable and he did not experience any significant falls or hospital admissions. By involving the patient in the decision-making process and addressing his concerns about the potential risks, such as the possibility of falls, we were able to come up with a treatment plan that was suited to his individual needs and preferences.

In cases of HF management, especially in older patients with comorbidities, it is essential to balance the benefits of treatment, such as optimising HF outcomes with the risks of side effects, including acute kidney injury and falls. This case highlighted the importance of closely considering national guidelines, while also factoring in individual characteristics such as age, frailty and quality of life^​1,2​. 

When prescribing medicines such as ramipril, particularly in older patients, a systematic approach to decision-making is essential. I consulted existing guidelines and considered the risks and benefits of increasing the dosage. The patient’s primary concern was his risk of having a fall, which was an important factor in the final decision to maintain his current dose of ramipril. This dosage emphasises the importance of a holistic approach, where patient preferences and safety are central to the decision-making process.

I took into consideration that his HF was stable when I provided sick day rules to prevent acute kidney injury. In patients with unstable HF, the decision to hold the ACE inhibitor would be more complex as it could lead to a risk of hospitalisation owing to decompensation; however, in this case, with his stable condition, the recommendation to temporarily hold ramipril in the event of vomiting or diarrhoea was appropriate to protect kidney function.

I also offered personalised advice when discussing lifestyle changes, particularly physical activity. Considering the patient’s age (91 years), I asked about his current level of physical activity and learned that he enjoyed taking short walks to buy his local newspaper. This information allowed me to tailor exercise recommendations to his abilities, ensuring the advice was both realistic and supportive of his independence. It can be easy to offer generic advice based solely on national guidance without fully considering what is achievable for the patient. In this case, by taking the patient’s lifestyle into account, I was able to provide advice that was practical. Rather than recommending intensive exercise routines, I focused on making physical activity an enjoyable part of his daily life. I encouraged him to continue with his regular walks and suggested that he could gradually increase the distance if he felt comfortable. This approach not only supported his HF management but also helped ensure that physical activity remained a sustainable and enjoyable part of his routine.

In future cases, I would continue to prioritise a patient-centred approach, balancing evidence-based guidelines with individual patient concerns. Furthermore, I would ensure thorough documentation of the decision-making process and collaborate with the wider healthcare team to ensure comprehensive care for the patient.