Table 1.

Guideline recommendations for RAASi treatment of heart failure, chronic kidney disease, and diabetes mellitus^a

Disease state	Recommendation	Source of recommendation	Level of recommendation	Strength of evidence
Heart failure with reduced ejection fraction	In patients with history of MI and reduced EF, ACEIs or ARBs should be used to prevent HF	ACC/AHA18	I	A
	ACEIs are recommended in patients with HFrEF (LVEF ≤40%) and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality	ESC19 ACC/AHA18	I	A
	ARBs are recommended in patients with HFrEF with current or prior symptoms who are ACEI-intolerant, unless contraindicated, to reduce morbidity and mortality	ESC19 ACC/AHA18	I	A
	Addition of an ARB may be considered in persistently symptomatic patients with HFrEF who are already being treated with an ACEI and a beta-blocker in whom an aldosterone antagonist is not indicated or tolerated	ESC19 ACC/AHA18	IIb	A
	MRAs are recommended in patients with NYHA class II to IV HF and who have LVEF of ≤35%, unless contraindicated, to reduce morbidity and mortality	ESC19 ACC/AHA18	I	A
	MRAs are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF ≤40% who develop HF symptoms or who have a history of DM, unless contraindicated	ACC/AHA18	I	A
Chronic kidney disease	For prevention of CKD progression, suggest an ARB or ACEI be used in diabetic adults with CKD and UAE 30 to 300 mg/24 h	KDIGO20, 21	2	D
	For prevention of CKD progression, recommend an ARB or ACEI be used in both diabetic and nondiabetic adults with CKD and UAE >300 mg/24 h	KDIGO20, 21	1	B
	Do not routinely discontinue RAASi (ACEI, ARB, MRA, direct renin inhibitor) in people with GFR <30 ml/min/1.73 m2 as they remain nephroprotective	KDIGO22, 23	NA	NA
	In the population ≥18 years of age with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status	JNC 824, 25	Moderate recommendation	B
Diabetes mellitus	Pharmacological therapy for patients with DM and HTN should comprise a regimen that includes either an ACEI or an ARB	ADA26		B
	Either an ACEI or ARB is suggested for the treatment of diabetic nephropathy patients with modestly elevated UAE (30–299 mg/day) and is recommended for those with UAE >300 mg/day	ADA27		B: UAE 30–299 mg/day A: UAE >300 mg/day
Resistant hypertension	MRAs should be considered, if no contraindication exists	ESH/ESC28 JNC 824	IIa	B

ACC, American College of Cardiology; ACEI, angiotensin-converting enzyme inhibitor; ADA, American Diabetes Association; AHA, American Heart Association; ARB, angiotensin receptor blocker; CKD, chronic kidney disease; DM, diabetes mellitus; EF, ejection fraction; ESC, European Society of Cardiology; ESH, European Society of Hypertension; GFR, glomerular filtration rate; HF, heart failure; HFrEF, HF with reduced EF; HTN, hypertension; JNC, Joint National Committee; KDIGO, Kidney Disease Improving Global Outcomes; LVEF, left ventricular ejection fraction; MI, myocardial infarction; MRA, mineralocorticoid receptor antagonist; NA, not applicable; NYHA, New York Heart Association; RAASi, renin-angiotensin-aldosterone system inhibitor; UAE, urine albumin excretion.

^aRecent data suggest ACEIs are possibly superior to ARBs for kidney failure, cardiovascular death, and all-cause mortality in patients with CKD.¹⁵