Angiotensin-converting enzyme inhibitors and receptor blockers in heart failure and chronic kidney disease – Demystifying controversies

In clinical setting, congestive heart failure (CHF) and chronic kidney disease (CKD) often co-exist in patients due to common underlying predisposing factors. An intricate equilibrium between the cardiovascular and renal system is maintained through rennin angiotensin–aldosterone axis and autonomic nervous system. Consequent to favorable hemodynamic modification, angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blocking (ARB) therapy have proven to be an indispensable aspect of heart failure management with morbidity and mortality benefit. Additionally, progression to end stage renal failure may be halted by renin angiotensin aldosterone system (RAAS) blockade in patients with preexisting renal dysfunction. However, concern over the safety of RAAS blockade in presence of renal impairment has led to profound underutilization of these drugs in CHF patients with renal insufficiency. This review aims to provide a simplified guide to pathophysiology and management options of this perplexing situation.