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ACEIs are first line treatment for NYHA classes I - IV
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ARBs are considered second line agents when an ACEI is not tolerated secondary to a cough and rarely angioedema
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Cough should be assessed and clearly documented prior to initiation of ACEI
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If cough is determined to be secondary to ACEI use ( e.g. resolves upon discontinuation or recurs on re-challenge), and is bothersome enough to warrant reassessment of therapy, it should be documented
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If titration of dose is limited by hypotension:
- - Reassess diuretic use
- - Consider staggering dosing with other vasoactive agents or dosing at bedtime
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Compliance is increased with once daily strategy
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Given that the main side effects of ACEIs and ARBs are renal dysfunction and hyperkalemia, assessment of other medications and factors that precipitate these effects are warranted:
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1. Renal dysfunction: NSAIDs and COX - 2 inhibitors.
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2. Hyperkalemia: combination therapy, spironolactone, potassium supplements, potassium-sparing diuretics (triazide, dyazide, triamterene, amiloride), salt substitutes (No Salts, Half Salt), dietary K+.