# Enalapril Heart Disease Dose: ACE Inhibitor Heart Disease Protocol
## Key Takeaways
- Enalapril, an ACE inhibitor, is a cornerstone therapy for canine heart failure, particularly myxomatous mitral valve disease (MMVD) and dilated cardiomyopathy (DCM), with a typical target dose of 0.5 mg/kg PO every 12 hours, supported by evidence showing improved survival with q12h dosing.
- In cats, enalapril is used less frequently for heart failure (e.g., end-stage HCM, RCM) at approximately 0.25-0.5 mg/kg PO every 12-24 hours, requiring cautious titration due to increased sensitivity to hypotension.
- Essential monitoring for enalapril therapy includes baseline and serial assessment of renal function (creatinine, SDMA), serum potassium levels, and blood pressure to detect adverse effects like azotemia and hyperkalemia.
- Common adverse effects of enalapril include hypotension, azotemia, hyperkalemia, and gastrointestinal upset, necessitating careful patient selection and monitoring, especially in animals with pre-existing renal disease or those on concurrent diuretic therapy.
- Enalapril is part of a multimodal heart failure management strategy, often combined with diuretics, pimobendan, and spironolactone, with dose adjustments guided by clinical signs, echocardiographic findings, and laboratory parameters.
- Pediatric dosing considerations, informed by human studies (LENA project), highlight the importance of allometric scaling for weight-based enalapril administration in young animals to achieve adequate drug exposure.
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Enalapril is an angiotensin-converting enzyme (ACE) inhibitor used in veterinary medicine to manage heart failure, particularly in dogs with myxomatous mitral valve disease (MMVD) and dilated cardiomyopathy. The target dose for dogs is generally 0.5 mg/kg every 12 hours, though the optimal dose may vary based on the individual patient and disease stage. For cats, enalapril is used at approximately 0.25 to 0.5 mg/kg every 12 to 24 hours. This article provides a comprehensive, evidence-based protocol for enalapril dosing in heart disease, covering the underlying physiology, clinical evidence, monitoring requirements, and safety considerations.
**Owner Triage Summary:** If your pet has been diagnosed with heart disease and prescribed enalapril, follow the veterinarian's dosing instructions exactly. Do not adjust the dose without veterinary guidance. Contact your veterinarian immediately if you notice signs of lethargy, weakness, excessive drooling, vomiting, diarrhea, or collapse, as these may indicate low blood pressure or other adverse effects. This article is educational and is not a substitute for veterinary diagnosis or treatment.
## At a Glance: Enalapril Dosing and Monitoring
| Parameter | Canine ([Dog](/knowledge/veterinary-medicine/clinical-methods/dog)) | Feline ([Cat](/knowledge/veterinary-medicine/clinical-methods/cat)) |
| :--- | :--- | :--- |
| **Typical Starting Dose** | 0.25 - 0.5 mg/kg PO q12h | 0.25 - 0.5 mg/kg PO q12-24h |
| **Target Dose** | 0.5 mg/kg PO q12h | 0.5 mg/kg PO q12-24h |
| **Maximum Dose (Commonly Used)** | 1.0 mg/kg PO q12h | 0.5 mg/kg PO q12h |
| **Primary Use** | Heart failure (MMVD, DCM) | Heart failure (HCM, RCM) |
| **Key Monitoring** | Renal function (SDMA, creatinine), potassium, blood pressure | Renal function, potassium, blood pressure |
| **Common Adverse Effects** | Hypotension, azotemia, hyperkalemia, GI upset | Hypotension, azotemia, hyperkalemia, GI upset |
## Understanding Enalapril in Veterinary Cardiology
Enalapril is a prodrug that is hydrolyzed in the liver to its active metabolite, enalaprilat. Enalaprilat works by competitively inhibiting the angiotensin-converting enzyme, which is responsible for converting angiotensin I to the potent vasoconstrictor angiotensin II. By reducing angiotensin II levels, enalapril causes vasodilation, decreases aldosterone secretion, and reduces sodium and water retention, ultimately decreasing preload and afterload on the failing heart.
### The Renin-Angiotensin-Aldosterone System (RAAS) in Heart Failure
In heart failure, reduced cardiac output triggers a compensatory response from the RAAS. While this response is initially adaptive, chronic activation is maladaptive, leading to:
- **Vasoconstriction:** Increased systemic vascular resistance (afterload), making it harder for the heart to pump blood.
- **Sodium and Water Retention:** Increased blood volume (preload), leading to congestion and edema.
- **Cardiac Remodeling:** Structural changes in the heart, including fibrosis and myocyte hypertrophy, which worsen cardiac function over time.
ACE inhibitors like enalapril interrupt this harmful cascade, providing both symptomatic and disease-modifying benefits. [1]
## Evidence-Based Dosing Protocols in Dogs
The most robust evidence for enalapril dosing in dogs comes from studies on MMVD, the most common acquired heart disease in the species. The drug is also used in the management of dilated cardiomyopathy (DCM).
### Myxomatous Mitral Valve Disease (MMVD)
MMVD is a degenerative disease of the mitral valve, leading to regurgitation and progressive heart enlargement. Enalapril is a cornerstone of therapy in dogs with MMVD, particularly in those with cardiomegaly or congestive heart failure (CHF).
A 2021 retrospective study evaluated the dose-dependent effect of ACE inhibitors on long-term outcomes in dogs with cardiac disease, primarily MMVD. [2] The study, which included 144 dogs, found that a higher ACE inhibitor dose was associated with increased survival from first-onset CHF. In a multivariable analysis, a q12h dosing frequency was a significant predictor of improved survival (hazard ratio [HR], 0.30; 95% CI, 0.10-0.88; P = .03). [2] This study supports the common practice of using a target dose of 0.5 mg/kg every 12 hours, as it provides more consistent ACE inhibition than a once-daily dose.
The study also found no clinically relevant changes in renal function test results, serum electrolyte concentrations, or blood pressure between the initial prescription and the first reevaluation (median, 14 days later). [2] This suggests that, at the doses studied, enalapril is generally well-tolerated in the short term.
### Dilated Cardiomyopathy (DCM)
DCM is a disease of the heart muscle itself, characterized by a dilated, poorly contractile left ventricle. While enalapril is part of the therapeutic protocol, the evidence base is often extrapolated from human medicine and other veterinary studies. The goal of therapy is to reduce afterload and slow the progression of remodeling.
### Practical Dosing Protocol for Dogs
1. **Initial Dose:** Begin with a conservative dose, typically 0.25 mg/kg PO every 12 hours, especially in patients that are ACE inhibitor-naive or have borderline blood pressure.
2. **Titration:** After 1 to 2 weeks, the dose can be increased to the target dose of 0.5 mg/kg PO every 12 hours, provided the patient is tolerating the medication and renal function and electrolytes are stable.
3. **Maximum Dose:** In some cases, doses up to 1.0 mg/kg PO every 12 hours may be used, but this should be done with careful monitoring, as the risk of adverse effects increases.
4. **Administration:** Enalapril can be given with or without food. Consistency is key. If vomiting occurs, giving the medication with a small meal may help.
## Evidence-Based Dosing in Pediatric and Exotic Patients
While the focus is often on adult dogs and cats, enalapril is also used in young animals with congenital heart disease. The European Union-funded 'Labeling of Enalapril from Neonates up to Adolescents' (LENA) project has provided valuable data on the use of enalapril in children, which has implications for veterinary pediatric patients.
### Lessons from the LENA Studies
The LENA studies evaluated the use of enalapril orodispersible minitablets (ODMTs) in children with heart failure due to DCM and congenital heart disease (CHD). [3][4][5] These studies are relevant because they establish age- and weight-based dosing regimens that can be extrapolated to puppies and kittens with similar conditions.
In a 2024 study on children with heart failure due to CHD, the average enalapril dose was 0.098 mg/kg (range, 0.06-0.17 mg/kg) in ACE inhibitor-naive patients and 0.15 mg/kg (range, 0.07-0.3 mg/kg) in pretreated patients. [3] After 8 weeks of treatment, there were significant improvements in the modified Ross score (a measure of heart failure severity) and left ventricular diastolic dimension z-score. [3] This study demonstrates that lower, weight-based doses of enalapril can be effective in young patients.
A population pharmacokinetic analysis from the LENA studies emphasized the importance of allometric scaling for dosing in children. [4] This means that doses should be calculated based on body weight, but the relationship is not linear. Smaller patients may require a higher dose per kilogram of body weight compared to larger patients to achieve the same exposure. This is a critical consideration for veterinary practitioners treating puppies and kittens.
### Acceptability and Adherence
The LENA studies also highlighted the importance of drug formulation. The orodispersible minitablets showed 100% acceptability in children, which is a key factor for adherence. [5] In veterinary medicine, this translates to the importance of using a formulation that is easy to administer to a puppy or kitten. Compounded liquid formulations or splitting tablets may be necessary, but ensuring the entire dose is consumed is critical for efficacy.
## Enalapril in Feline Heart Disease
Enalapril is used less frequently in cats than in dogs, largely because the most common feline heart disease, hypertrophic cardiomyopathy (HCM), is a primary diastolic disease where the benefit of ACE inhibition is less clear. However, enalapril may be used in cats with:
- **End-stage HCM:** When systolic failure develops.
- **Restrictive Cardiomyopathy (RCM):** A less common but severe form of feline heart disease.
- **Systemic Hypertension:** To help control blood pressure, though amlodipine is usually the first-line agent.
For cats, the typical dose is 0.25 to 0.5 mg/kg PO every 12 to 24 hours. Cats are more sensitive to the hypotensive effects of ACE inhibitors, so a lower starting dose and slower titration are recommended. Monitoring of renal function and potassium is essential, as cats are prone to azotemia and hyperkalemia.
## Comparative Efficacy: Enalapril vs. Other RAAS Inhibitors
Enalapril is often compared to other drugs that target the RAAS, including angiotensin receptor blockers (ARBs) like telmisartan and valsartan, and angiotensin receptor-neprilysin inhibitors (ARNIs) like sacubitril/valsartan.
### Enalapril vs. Telmisartan
A 2023 randomized controlled trial (the TRIUMF trial) compared telmisartan to enalapril in human patients with heart failure with reduced ejection fraction (HFrEF) and moderate chronic kidney disease (CKD). [6] The study found that telmisartan was associated with less worsening of renal function and fewer dose reductions or discontinuations compared to enalapril. [6] This is an important consideration for veterinary patients with concurrent cardiac and renal disease. While telmisartan is used in veterinary medicine, primarily as an antiproteinuric agent, its role in treating heart failure is still being defined.
### Enalapril vs. Sacubitril/Valsartan (ARNI)
Sacubitril/valsartan is a combination drug that has shown superiority over enalapril in human heart failure trials. [7][8] In the PARADIGM-HF trial, sacubitril/valsartan reduced the risk of cardiovascular death and heart failure hospitalization compared to enalapril. [9][10] However, this drug is not yet widely used in veterinary medicine, and the evidence base for its use in dogs and cats is limited.
A 2024 meta-analysis compared sacubitril/valsartan to equivalent doses of ACE inhibitors (including enalapril 20 mg twice daily) and found no statistical difference in outcomes of total mortality, cardiovascular mortality, and worsening heart failure when the doses were equivalent. [8] This suggests that achieving an adequate dose of an ACE inhibitor is critical, and that the benefits of ARNI may be partly related to the higher equivalent doses used.
### Enalapril in Combination Therapy
Enalapril is often used in combination with other heart failure medications, such as pimobendan, diuretics (furosemide, torsemide), and spironolactone. A 2025 study in dogs with MMVD evaluated a fixed-dose combination tablet containing torsemide, pimobendan, enalapril, and spironolactone. [11] The study found that both the fixed-dose combination and a compounded powder of the same drugs led to significant improvements in clinical signs and echocardiographic parameters over 56 days. [11] This highlights the importance of a multi-modal approach to managing heart failure.
## Monitoring the Enalapril Patient
Monitoring is a critical component of the ACE inhibitor heart disease protocol. The goals of monitoring are to:
- Assess therapeutic efficacy.
- Detect adverse effects early.
- Adjust the dose as the patient's condition changes.
### Baseline Assessment
Before starting enalapril, a veterinarian should obtain:
- **Complete Blood Count (CBC):** To rule out other diseases.
- **Serum Biochemistry Profile:** To evaluate renal function (creatinine, SDMA, BUN) and electrolytes (potassium).
- **Urinalysis:** To assess urine concentrating ability and protein loss.
- **Blood Pressure Measurement:** To establish a baseline and rule out hypotension.
- **Echocardiography:** To confirm the diagnosis and assess the severity of heart disease.
### In-Hospital Monitoring
For patients with acute heart failure, enalapril is often started in the hospital. Blood pressure should be monitored closely after the first dose, especially in ACE inhibitor-naive patients. A transient decrease in blood pressure is expected, but a significant drop (e.g., systolic pressure < 90 mmHg in dogs) may necessitate dose reduction or discontinuation.
### Reevaluation Protocol
A common reevaluation protocol is as follows:
1. **1 to 2 Weeks Post-Initiation:** Recheck blood pressure, renal function (creatinine, SDMA), and potassium. This is the most critical time to identify adverse effects.
2. **3 to 6 Months:** Recheck clinical signs, blood pressure, and renal function. An echocardiogram may be repeated to assess cardiac remodeling.
3. **Every 6 to 12 Months:** Routine monitoring of renal function and electrolytes is recommended for stable patients on long-term therapy.
### Key Parameters to Watch
- **Creatinine and SDMA:** A mild increase in creatinine (up to 30% from baseline) is acceptable and often reflects the hemodynamic changes caused by the drug. A more significant increase, or a rise in SDMA, may indicate worsening renal function.
- **Potassium:** Hyperkalemia is a potential adverse effect. If potassium rises above the normal range, dietary modification or dose adjustment may be needed.
- **Blood Pressure:** Hypotension can cause lethargy, weakness, and syncope. If systolic blood pressure falls below 100 mmHg in dogs or 110 mmHg in cats, a dose reduction should be considered.
## Adverse Effects and Safety Considerations
Enalapril is generally well-tolerated, but adverse effects can occur, particularly at higher doses or in patients with underlying conditions.
### Common Adverse Effects
- **Hypotension:** This is the most common adverse effect, especially during the first few days of therapy.
- **Azotemia:** Worsening renal function tests, particularly in patients with pre-existing kidney disease or those receiving high doses of diuretics.
- **Hyperkalemia:** More common in patients with renal insufficiency or those also receiving potassium-sparing diuretics (e.g., spironolactone).
- **Gastrointestinal Upset:** Vomiting, diarrhea, and anorexia may occur, especially when starting the medication.
### Adverse Effects in Murine Models
A 2024 study in murine heart failure models compared a novel cysteine protease inhibitor to enalapril. [1] While the study focused on the efficacy of the new drug, it also provided data on the effects of enalapril. The study noted that enalapril, when given at the same dose as the new drug, was less effective at attenuating adverse remodeling and cardiac dysfunction. [1] This does not indicate an adverse effect of enalapril, but rather highlights the ongoing search for more effective therapies.
### Contraindications
Enalapril is contraindicated in patients with:
- **Known hypersensitivity to ACE inhibitors.**
- **History of angioedema.**
- **Hypotension** (systolic blood pressure < 90 mmHg).
- **Acute renal failure** or severe pre-existing azotemia (use with extreme caution).
- **Pregnancy** (can cause fetal toxicity).
### Drug Interactions
- **Diuretics:** Can potentiate the hypotensive and azotemic effects of enalapril.
- **Potassium-Sparing Diuretics (Spironolactone):** Increase the risk of hyperkalemia.
- **Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):** Can reduce the antihypertensive effect of enalapril and increase the risk of renal toxicity.
- **Other Vasodilators:** Can cause additive hypotension.
## Special Populations and Conditions
### Enalapril in Chagas Disease
Chagas disease, caused by the parasite *Trypanosoma cruzi*, is a significant cause of heart failure in endemic areas of Latin America. A 2026 clinical trial evaluated the efficacy of sacubitril/valsartan compared to enalapril in patients with heart failure due to Chagas disease. [7] The study used a target dose of enalapril of 10 mg twice daily. [7] This is a lower target dose than what is used in other heart failure trials, reflecting the need for caution in this specific population. While Chagas disease is not a common concern in North American veterinary practice, it is a relevant consideration for veterinarians in endemic regions or those seeing imported dogs.
### Enalapril in Cardiotoxicity Prevention
Enalapril is being investigated for its role in preventing cardiotoxicity from anthracycline chemotherapy. The PROACT trial protocol, published in 2022, outlines a study that will use enalapril at a starting dose of 2.5 mg twice daily, titrating up to a maximum of 10 mg twice daily, in human patients receiving anthracycline-based chemotherapy. [12] This is relevant to veterinary oncology, as dogs and cats receiving doxorubicin are at risk for cardiotoxicity. The use of enalapril as a cardioprotectant in veterinary patients is an area of active interest, though evidence is still limited.
### Enalapril in Polycystic Kidney Disease
A 2021 study in a rat model of polycystic kidney disease (PKD) evaluated the effect of enalapril in combination with paricalcitol. [13] The study found that the combination of paricalcitol and enalapril reduced systolic blood pressure and heart-body weight ratio compared to vehicle and enalapril alone. [13] However, the combination also caused hypercalcemia and did not alter kidney cyst growth. [13] This study is relevant for veterinary patients with PKD, particularly cats, as it highlights the potential cardiovascular benefits of RAAS inhibition but also the need for careful monitoring of calcium and renal function.
## The Role of Enalapril in a Comprehensive Heart Failure Protocol
Enalapril is not a standalone therapy for heart failure. It is one component of a comprehensive treatment plan that may include:
- **Diuretics (Furosemide, Torsemide):** To manage congestion and edema.
- **Pimobendan:** A positive inotrope and vasodilator that is a mainstay of therapy for canine MMVD.
- **Spironolactone:** An aldosterone antagonist that provides additional RAAS blockade.
- **Dietary Modification:** A low-sodium diet is often recommended.
- **Exercise Restriction:** To reduce stress on the heart.
The decision to use enalapril, and at what dose, should be based on the specific diagnosis, the stage of the disease, and the presence of concurrent conditions. For example, a dog with asymptomatic MMVD and moderate cardiomegaly may benefit from enalapril, while a dog with acute, severe CHF may require more aggressive therapy with diuretics and pimobendan first.
## Emergency Red Flags: When to Seek Immediate Veterinary Care
If your pet is on enalapril, seek immediate veterinary care if you observe any of the following:
- **Collapse or syncope (fainting).**
- **Severe lethargy or weakness.**
- **Difficulty breathing or coughing.**
- **Pale or blue-tinged gums.**
- **Vomiting or diarrhea that persists for more than 24 hours.**
- **Decreased urine output.**
- **Sudden loss of appetite.**
These signs may indicate a severe adverse reaction to the medication, progression of the underlying heart disease, or a concurrent illness.
## Limitations and When to Contact a Veterinarian
This article provides a general overview of enalapril dosing and monitoring. It is not a substitute for professional veterinary advice. The information presented here cannot predict how an individual animal will respond to this medication. Breed-specific variations in drug metabolism, the severity of the underlying heart disease, and the presence of other health problems can all influence the appropriate dose and the risk of adverse effects.
**You should always contact your veterinarian before starting, stopping, or changing the dose of any medication.** Only a veterinarian can perform the necessary diagnostic tests to determine the underlying cause of your pet's heart disease and develop a safe and effective treatment plan. The dose of enalapril must be tailored to your pet's specific needs, and any adjustments should be made under veterinary supervision.
## Frequently Asked Questions
### 1. What is the standard enalapril heart disease dose for dogs?
The standard target dose for dogs is 0.5 mg/kg administered orally every 12 hours. However, the starting dose is often lower (0.25 mg/kg q12h) and is gradually increased based on the patient's tolerance and response to therapy. [2]
### 2. How long does it take for enalapril to start working in a dog with heart disease?
Enalapril begins to lower blood pressure within 1 to 2 hours after oral administration, with peak effects seen in 4 to 6 hours. However, the full clinical benefits, such as improved exercise tolerance and reduced coughing, may take several weeks of continuous therapy to become apparent.
### 3. Can enalapril be given to a cat with heart disease?
Yes, enalapril can be used in cats, but it is less commonly prescribed than in dogs. It is typically used at a dose of 0.25 to 0.5 mg/kg every 12 to 24 hours. Cats are more sensitive to its blood pressure-lowering effects, so a lower starting dose and careful monitoring are required.
### 4. What are the most common side effects of enalapril in dogs?
The most common side effects include low blood pressure (hypotension), which can cause lethargy and weakness, and mild increases in kidney values (creatinine, SDMA) and potassium. Gastrointestinal upset, such as vomiting or diarrhea, can also occur.
### 5. How should enalapril be stored?
Enalapril tablets should be stored at room temperature (between 20°C and 25°C or 68°F and 77°F), in a tightly sealed container, and protected from moisture and light. Keep the medication out of reach of children and pets.
### 6. What should I do if I miss giving my dog a dose of enalapril?
If you miss a dose, give it as soon as you remember. However, if it is almost time for the next scheduled dose, skip the missed dose and resume the regular dosing schedule. Do not give a double dose to make up for a missed one.
### 7. Can enalapril be used in dogs with kidney disease?
Enalapril should be used with caution in dogs with kidney disease. It can cause or worsen azotemia (elevated kidney values). However, it may also be beneficial in some cases of protein-losing kidney disease. Close monitoring of kidney function and electrolytes is essential if it is used.
### 8. Is enalapril the same as other ACE inhibitors like benazepril?
Enalapril and benazepril are both ACE inhibitors, but they have different pharmacological properties. Benazepril is primarily excreted via the bile, making it a preferred choice in patients with severe renal impairment. Enalapril is excreted by the kidneys, so its clearance may be reduced in patients with kidney disease. Your veterinarian will choose the most appropriate ACE inhibitor based on your pet's individual needs.
## Sources
[1] [Efficacy of a cysteine protease inhibitor compared with enalapril in murine heart failure models.](https://pubmed.ncbi.nlm.nih.gov/39381741/)
[2] [Retrospective evaluation of a dose-dependent effect of angiotensin-converting enzyme inhibitors on long-term outcome in dogs with cardiac disease.](https://pubmed.ncbi.nlm.nih.gov/34387901/)
[3] [Clinical and Hemodynamic Outcomes with Enalapril Orodispersible Minitablets in Young Children with Heart Failure Due to Congenital Heart Disease.](https://pubmed.ncbi.nlm.nih.gov/39274188/)
[4] [Population Pharmacokinetic Analysis of Enalapril and Enalaprilat in Newly Treated Children with Heart Failure: Implications for Safe Dosing of Enalapril (LENA Studies).](https://pubmed.ncbi.nlm.nih.gov/40461938/)
[5] [Acceptability and Palatability of Novel Orodispersible Minitablets of Enalapril in Children up to the Age of 6 with Heart Failure.](https://pubmed.ncbi.nlm.nih.gov/39941586/)
[6] [Telmisartan versus EnalapRil In heart failure with redUced ejection fraction patients with Moderately impaired kidney Functions; randomized controlled trial: "TRIUMF trial".](https://pubmed.ncbi.nlm.nih.gov/37552407/)
[7] [Sacubitril/Valsartan vs Enalapril in Heart Failure Due to Chagas Disease: An Open-Label, Multicenter Randomized Clinical Trial.](https://pubmed.ncbi.nlm.nih.gov/41335448/)
[8] [Sacubitril/valsartan compared to equivalent/sub-equivalent dose angiotensin receptor blocker or angiotensin-converting enzyme inhibitor in heart failure with reduced ejection fraction: a meta-analysis of randomized trials.](https://pubmed.ncbi.nlm.nih.gov/38597935/)
[9] [Clinical Characteristics and Outcomes of Patients With Heart Failure With Reduced Ejection Fraction and Chronic Obstructive Pulmonary Disease: Insights From PARADIGM-HF.](https://pubmed.ncbi.nlm.nih.gov/33522249/)
[10] [Effect of sacubitril/valsartan vs. enalapril on changes in heart failure therapies over time: the PARADIGM-HF trial.](https://pubmed.ncbi.nlm.nih.gov/34101308/)
[11] [Clinical evaluation of a novel fixed-dose combination tablet (Sentorphil(®) ForteGold) versus compounded powdered medications in dogs with myxomatous mitral valve disease: a randomized, double-blind study.](https://pubmed.ncbi.nlm.nih.gov/40874198/)
[12] [Preventing cardiotoxicity in patients with breast cancer and lymphoma: protocol for a multicentre randomised controlled trial (PROACT).](https://pubmed.ncbi.nlm.nih.gov/36585130/)
[13] [Effect of Early and Delayed Commencement of Paricalcitol in Combination with Enalapril on the Progression of Experimental Polycystic Kidney Disease.](https://pubmed.ncbi.nlm.nih.gov/34821697/)
[14] [Angiotensin II/Angiotensin I Ratio as a New Pharmacodynamic Parameter for Population Modelling in Healthy Adults and Children with Heart Failure Treated with Enalapril.](https://pubmed.ncbi.nlm.nih.gov/41155980/)
[15] [Prescription Pattern in Angiotensin Receptor Neprilysin Inhibitor is Associated with Heart Failure Events.](https://pubmed.ncbi.nlm.nih.gov/36685156/)
[16] [Effectiveness of Polypill for Prevention of Cardiovascular Disease (PolyPars): Protocol of a Randomized Controlled Trial.](https://pubmed.ncbi.nlm.nih.gov/32894967/)
[17] [Safety and efficacy of ARNI (valsartan/sacubitril) vs ACEI (enalapril) in acute heart failure - A prospective observational study.](https://pubmed.ncbi.nlm.nih.gov/35483448/)
[18] [Optimal Therapeutic Strategy Using Sacubitril/Valsartan in a Patient with Systolic Heart Failure and Chronic Kidney Disease - An Initial Case Report in Japan.](https://pubmed.ncbi.nlm.nih.gov/34470986/)
[19] [Canagliflozin Ameliorates Myocardial Fibrosis and Cardiac Function in Chronic Heart Failure: A Dose-Independent Therapeutic Approach.](https://pubmed.ncbi.nlm.nih.gov/40785031/)
[20] [Sacubitril/valsartan versus enalapril on exercise capacity in patients with heart failure with reduced ejection fraction: A randomized, double-blind, active-controlled study.](https://pubmed.ncbi.nlm.nih.gov/33992607/)
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