Clinical aspects of the safety profile of angiotensin converting enzyme inhibitors

Angiotensin converting enzyme (ACE) inhibitors represent a therapeutic class largely used in clinical practice for about 40 years and extensively studied globally. They are mainly recommended for treatment of hypertension and heart failure with reduced ejection fraction, but were also effective in patients with myocardial infarction, stroke and diabetes, proving significant reduction of cardiovascular morbidity and mortality. Besides their undeniable benefits, proven by clinical practice and epidemiological studies, the use of these drugs involves some side effects, the most common being persistent cough and recurrent angioedema. The mechanism of these side effects is the increase in plasma and pulmonary bradykinin levels, as consequence of blocking the angiotensin converting enzyme. ACE-induced cough occurs relatively frequently, usually within the first months of treatment, but sometimes later, leading to multiple investigations and different specialist consultations. ACE-induced angioedema has a lower frequency, is influenced by some individual factors and can occur at any time during the treatment with IECA, making difficult to confirm the diagnosis. The aim of our paper is to present the main current clinical aspects regarding the safety profile of ACE inhibitors, the peculiarities and difficulties of diagnosis, some individual risk factors and the main recommendations for therapeutic approach.