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 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. © 2016 the authors. published on behalf of the american heart association,inc.,by wiley blackwell.