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Angiotensin‐Converting Enzyme Inhibitor Initiation and Dose Uptitration in Children With Cardiovascular Disease: A Retrospective Review of Standard Clinical Practice and a Prospective Randomized Clinical Trial

BACKGROUND: Angiotensin‐converting enzyme inhibitors (ACEIs) are a mainstay of medical management in pediatric cardiology. However, there are no data defining how best to initiate and uptitrate the dose of these medications in children. METHODS AND RESULTS: Retrospective chart review revealed only 2...

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Autores principales: Roche, S. Lucy, Timberlake, Kathryn, Manlhiot, Cedric, Balasingam, Mervin, Wilson, Judith, George, Kristen, McCrindle, Brian W., Kantor, Paul F.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: John Wiley and Sons Inc. 2016
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889193/
https://www.ncbi.nlm.nih.gov/pubmed/27207965
http://dx.doi.org/10.1161/JAHA.116.003230
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author Roche, S. Lucy
Timberlake, Kathryn
Manlhiot, Cedric
Balasingam, Mervin
Wilson, Judith
George, Kristen
McCrindle, Brian W.
Kantor, Paul F.
author_facet Roche, S. Lucy
Timberlake, Kathryn
Manlhiot, Cedric
Balasingam, Mervin
Wilson, Judith
George, Kristen
McCrindle, Brian W.
Kantor, Paul F.
author_sort Roche, S. Lucy
collection PubMed
description BACKGROUND: Angiotensin‐converting enzyme inhibitors (ACEIs) are a mainstay of medical management in pediatric cardiology. However, there are no data defining how best to initiate and uptitrate the dose of these medications in children. METHODS AND RESULTS: Retrospective chart review revealed only 24% of our pediatric cardiology inpatients were discharged on predefined optimal doses of ACEIs and few underwent further dose uptitration in the 8 weeks after hospital discharge. Therefore, 2 alternative protocols for initiation of captopril were compared in a prospective randomized clinical trial. A “rapid uptitration” protocol reached an optimal dose on day 3, whereas the alternative, “prolonged uptitration” protocol, reached an optimal dose on day 9. Forty‐6 patients (54% male) were recruited to the trial, with a median age of 0.7 year (IQR 0.5–2.3 years). Captopril was initiated while in intensive care in 39% of patients and on the cardiology ward in 61%. There were no differences between the protocols in episodes of hypotension, symptomatic hypotension, or indices of renal function. Patients following the rapid protocol reached higher doses of captopril (0.93±0.24 versus 0.57±0.38 mg/kg per dose, P<0.0001) and were more likely to have achieved the predefined target (88% versus 43%, P=0.002) and optimal ACEI doses (80% versus 29%, P=0.001) before discharge. CONCLUSIONS: A protocol of rapid ACEI dose uptitration for infants and children with cardiovascular disease can be introduced safely, even in patients receiving intensive care therapy. Compared with standard clinical practice or with a more prolonged protocol, rapid ACEI dose uptitration achieves a higher dosage in this population with no evident disadvantages. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00742040.
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spelling pubmed-48891932016-06-09 Angiotensin‐Converting Enzyme Inhibitor Initiation and Dose Uptitration in Children With Cardiovascular Disease: A Retrospective Review of Standard Clinical Practice and a Prospective Randomized Clinical Trial Roche, S. Lucy Timberlake, Kathryn Manlhiot, Cedric Balasingam, Mervin Wilson, Judith George, Kristen McCrindle, Brian W. Kantor, Paul F. J Am Heart Assoc Original Research BACKGROUND: Angiotensin‐converting enzyme inhibitors (ACEIs) are a mainstay of medical management in pediatric cardiology. However, there are no data defining how best to initiate and uptitrate the dose of these medications in children. METHODS AND RESULTS: Retrospective chart review revealed only 24% of our pediatric cardiology inpatients were discharged on predefined optimal doses of ACEIs and few underwent further dose uptitration in the 8 weeks after hospital discharge. Therefore, 2 alternative protocols for initiation of captopril were compared in a prospective randomized clinical trial. A “rapid uptitration” protocol reached an optimal dose on day 3, whereas the alternative, “prolonged uptitration” protocol, reached an optimal dose on day 9. Forty‐6 patients (54% male) were recruited to the trial, with a median age of 0.7 year (IQR 0.5–2.3 years). Captopril was initiated while in intensive care in 39% of patients and on the cardiology ward in 61%. There were no differences between the protocols in episodes of hypotension, symptomatic hypotension, or indices of renal function. Patients following the rapid protocol reached higher doses of captopril (0.93±0.24 versus 0.57±0.38 mg/kg per dose, P<0.0001) and were more likely to have achieved the predefined target (88% versus 43%, P=0.002) and optimal ACEI doses (80% versus 29%, P=0.001) before discharge. CONCLUSIONS: A protocol of rapid ACEI dose uptitration for infants and children with cardiovascular disease can be introduced safely, even in patients receiving intensive care therapy. Compared with standard clinical practice or with a more prolonged protocol, rapid ACEI dose uptitration achieves a higher dosage in this population with no evident disadvantages. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00742040. John Wiley and Sons Inc. 2016-05-20 /pmc/articles/PMC4889193/ /pubmed/27207965 http://dx.doi.org/10.1161/JAHA.116.003230 Text en © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell. This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs (http://creativecommons.org/licenses/by-nc-nd/4.0/) License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.
spellingShingle Original Research
Roche, S. Lucy
Timberlake, Kathryn
Manlhiot, Cedric
Balasingam, Mervin
Wilson, Judith
George, Kristen
McCrindle, Brian W.
Kantor, Paul F.
Angiotensin‐Converting Enzyme Inhibitor Initiation and Dose Uptitration in Children With Cardiovascular Disease: A Retrospective Review of Standard Clinical Practice and a Prospective Randomized Clinical Trial
title Angiotensin‐Converting Enzyme Inhibitor Initiation and Dose Uptitration in Children With Cardiovascular Disease: A Retrospective Review of Standard Clinical Practice and a Prospective Randomized Clinical Trial
title_full Angiotensin‐Converting Enzyme Inhibitor Initiation and Dose Uptitration in Children With Cardiovascular Disease: A Retrospective Review of Standard Clinical Practice and a Prospective Randomized Clinical Trial
title_fullStr Angiotensin‐Converting Enzyme Inhibitor Initiation and Dose Uptitration in Children With Cardiovascular Disease: A Retrospective Review of Standard Clinical Practice and a Prospective Randomized Clinical Trial
title_full_unstemmed Angiotensin‐Converting Enzyme Inhibitor Initiation and Dose Uptitration in Children With Cardiovascular Disease: A Retrospective Review of Standard Clinical Practice and a Prospective Randomized Clinical Trial
title_short Angiotensin‐Converting Enzyme Inhibitor Initiation and Dose Uptitration in Children With Cardiovascular Disease: A Retrospective Review of Standard Clinical Practice and a Prospective Randomized Clinical Trial
title_sort angiotensin‐converting enzyme inhibitor initiation and dose uptitration in children with cardiovascular disease: a retrospective review of standard clinical practice and a prospective randomized clinical trial
topic Original Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889193/
https://www.ncbi.nlm.nih.gov/pubmed/27207965
http://dx.doi.org/10.1161/JAHA.116.003230
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