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: → ACE Inhibitors

• 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.

• 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.

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

→ Hypertension Module

• Mortality benefit • Reduced hospitalization • Strong evidence base (SOLVD trial)

Core GDMT therapy.

→ Heart Failure Module

• Reduces remodeling • Improves survival

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.

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

Dose adjustment required in renal impairment.

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

Check: • Serum creatinine • Potassium

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

Small creatinine increase is expected.

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

Higher hyperkalemia risk with: • Spironolactone • Eplerenone • ARBs • Potassium supplements

Avoid ACE + ARB combination.

✔ 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:

→ ACE Inhibitors → Lisinopril → ARBs → Return to CV Modules