Patient’s Alopecia Linked to Common Heart Failure Drug

Last month,  the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America released new heart failure (HF) treatment guidelines. The updated recommendations for treating patients with chronic symptomatic HF with reduced ejection fraction include the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) or angiotensin receptor-neprilysin inhibitor (ARNI) in conjunction with evidence-based beta-blockers and aldosterone antagonists.¹ 

Both ACE inhibitors and ARBs are considered mainstay therapies for heart failure management, although the new guidelines indicate replacement with ARNI is recommended to further reduce morbidity and mortality, unless the patient has a history of angioedema.¹ While adverse effects such as angioedema occur in <1% of patients who take an ACE inhibitor, other side effects such has hyperkalemia and increased serum creatinine are more common. Though information is limited, another potential side effect associated with ACE inhibitor use may be alopecia as evidenced by the patient in this latest case.²

The patient, a 53-year-old male, presented to an HF clinic for management of cardiomyopathy; past medical history included non-sustained ventricular tachycardia, hypertension, irritable bowel syndrome, and Hashimoto thyroiditis. Transthoracic echocardiogram (TTE), performed at another institution 2 months prior, showed moderate left ventricular dilation with reduced left ventricular ejection fraction (LVEF) of 30–35%. His list of medications included the following:

• Acetaminophen 325mg PRN for pain
• Aspirin 81mg daily
• Carvedilol 12.5mg twice daily (started before initial visit to HF clinic)
• Lisinopril 2.5mg daily (started before initial visit to HF clinic)
• Cetirizine 10mg daily
• Levothyroxine sodium 112mcg daily
• Multivitamin daily

At the HF clinic, a plan to up-titrate the patient’s carvedilol was initiated and after biweekly up-titration, the patient reached a target dose of carvedilol 25mg twice daily. A repeat TTE 6 months later showed an estimated LVEF of 35%; the patient underwent implantable cardiac defibrillator placement a month later. For the next 8 months, all medications were tolerated without complaint until the third visit to the clinic where the patient reported alopecia on his right temporal side; follow-up labs (including thyroid hormone level and serum thyroxine level) were unremarkable. At this visit, clinicians decided to discontinue the lisinopril and replace it with losartan 12.5mg daily; the patient was also instructed to take coenzyme Q-10 100mg daily to his increase his energy level.