====== Enalapril ======

Enalapril is an ACE inhibitor used in hypertension and heart failure.  
It was one of the original ACE inhibitors studied in major heart failure trials.

Class:
→ [[cardio:raas:acei|ACE Inhibitors]]

----

===== Mechanism of Action =====

• Inhibits Angiotensin-Converting Enzyme (ACE)
• ↓ Angiotensin II
• ↓ Aldosterone
• ↑ Bradykinin

Net Effects:
• ↓ Systemic vascular resistance (afterload)
• Mild ↓ preload
• ↓ Ventricular remodeling
• ↓ Blood pressure

Mechanistically similar to other ACE inhibitors.

----

===== Unique Features =====

• Prodrug → converted in liver to active form (enalaprilat)
• Available in IV form (enalaprilat)
• Slightly shorter duration than lisinopril

Enalaprilat (IV) is useful in inpatient settings.

----

===== Indications =====

==== Hypertension ====
• Effective first-line therapy
• Particularly beneficial in diabetes or CKD

→ [[cardio:hypertension:start|Hypertension Module]]

----

==== Heart Failure (HFrEF) ====
• Mortality benefit
• Reduced hospitalization
• Strong evidence base (SOLVD trial)

Core GDMT therapy.

→ [[cardio:heart_failure:start|Heart Failure Module]]

----

==== Post-Myocardial Infarction ====
• Reduces remodeling
• Improves survival

----

===== Dosing =====

Hypertension:
• Start: 5 mg once or twice daily
• Typical range: 10–40 mg daily (once or divided)

Heart Failure:
• Start: 2.5 mg twice daily
• Target: 10–20 mg twice daily

Often dosed twice daily.

----

===== Pharmacokinetics =====

• Prodrug → converted to enalaprilat
• Hepatic activation
• Renally cleared
• Half-life ~11 hours

Dose adjustment required in renal impairment.

----

===== Adverse Effects =====

• Dry cough
• Hyperkalemia
• Hypotension (especially first dose)
• Angioedema (rare)
• Mild creatinine elevation

----

===== Monitoring =====

Check:
• Serum creatinine
• Potassium

Recheck labs 1–2 weeks after initiation or dose adjustment.

Small creatinine increase is expected.

----

===== Contraindications =====

• Pregnancy
• History of ACE inhibitor–induced angioedema
• Bilateral renal artery stenosis

----

===== Drug Interactions =====

Higher hyperkalemia risk with:
• [[cardio:hf:spironolactone|Spironolactone]]
• [[cardio:hf:eplerenone|Eplerenone]]
• ARBs
• Potassium supplements

Avoid ACE + ARB combination.

----

===== Clinical Pearls =====

✔ Classic ACE inhibitor with strong HF data  
✔ Prodrug (converted to enalaprilat)  
✔ IV formulation available (enalaprilat)  
✔ Often dosed twice daily  
✔ Monitor potassium and renal function  

----

Related:

→ [[cardio:raas:acei|ACE Inhibitors]]  
→ [[cardio:raas:lisinopril|Lisinopril]]  
→ [[cardio:raas:arb|ARBs]]  
→ [[cardio:start|Return to CV Modules]]