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What does ATLAS really tell us about "high" dose angiotensin-converting enzyme inhibition in heart failure?
J M Nicklas1, J N Cohn, B Pitt
1Department of Medicine, University of Michigan Medical Center, Ann Arbor, USA.
Insights
The Assessment of Treatment with Lisinopril and Survival (ATLAS) trial showed minimal benefits of high-dose angiotensin-converting enzyme (ACE) inhibitors for heart failure. Physicians should use intermediate ACE inhibitor doses based on prior trials, not ATLAS high-dose targets.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- The Assessment of Treatment with Lisinopril and Survival (ATLAS) trial results are frequently cited to support high-dose angiotensin-converting enzyme (ACE) inhibitor therapy for heart failure.
- Previous placebo-controlled trials established the efficacy of intermediate ACE inhibitor doses.
Purpose of the Study:
- To evaluate the comparative benefits of high-dose versus low-dose ACE inhibition in heart failure treatment.
- To provide evidence-based recommendations for ACE inhibitor dosing in heart failure management.
Main Methods:
- Analysis of data from the ATLAS trial comparing high-dose versus low-dose lisinopril.
- Comparison of ATLAS findings with results from previous placebo-controlled trials of ACE inhibitors in heart failure.
Main Results:
- The ATLAS trial demonstrated only small relative benefits between high-dose and low-dose ACE inhibition.
- Intermediate ACE inhibitor doses, effective in prior trials, may offer comparable or superior benefits to high-dose regimens.
Conclusions:
- Physicians should continue prescribing ACE inhibitors for heart failure based on effective target doses from placebo-controlled trials.
- The high-dose target used in the ATLAS trial is not recommended as the primary basis for ACE inhibitor prescription in heart failure.
Abstract:
The Assessment of Treatment with Lisinopril and Survival (ATLAS) results have been widely quoted by proponents advocating the use of "high" doses of angiotensin-converting enzyme (ACE) inhibitors for the treatment of heart failure. In ATLAS, however, the relative benefits of "high" versus "low" dose ACE inhibition were small. Intermediate doses of ACE inhibitors proven effective in previous placebo-controlled trials provide benefit that appears likely to equal or exceed the benefit from "high" dose ACE inhibition. Therefore, we recommend that physicians continue to prescribe ACE inhibitors for patients with heart failure based on the target doses used in the placebo-controlled trials and not on the "high" dose target used in ATLAS.