Moderate
Enalapril × Metoprolol
Angiotensin-converting enzyme inhibitors (ACEi)×Selective β1-adrenoceptor blockers
Mechanism
Target combination in heart failure with reduced ejection fraction and in arterial hypertension. Synergistic reduction of blood pressure, preload, and afterload.
Symptoms
On starting, in older or hypovolaemic patients: symptomatic hypotension, dizziness, fatigue. Metoprolol bradycardia is amplified as sympathetic activation drops.
Management
Start both drugs at minimal doses with up-titration every 2 weeks to target. Check standing/sitting BP, heart rate, creatinine and potassium at 2 weeks. In heart failure, the goal is maximum tolerated dose; the RCT evidence base is extensive.
Sources
- Lexicomp: Lexicomp Drug Interactions (2024)– Wolters Kluwer Clinical Drug Information, Inc. Lexi-Interact Online, 2024
- Pharmaceutical Press: Stockley's Drug Interactions, 12th edition (2024)– Preston CL (ed.). Stockley's Drug Interactions. 12th ed. London: Pharmaceutical Press; 2024