Factors to consider in selecting an angiotensin-converting-enzyme inhibitor

The results of clinical studies of the use of angiotensin-converting-enzyme (ACE) inhibitors in a variety of cardiovascular and renal disorders are reviewed, with emphasis on evidence-based formulary decision-making. In evaluating agents for formulary inclusion, efficacy, safety, dosing, and cost are considered. ACE inhibitors have been investigated in thousands of patients in clinical trials, so an evidence-based approach to their use is appropriate. All ACE inhibitors are effective antihypertensive agents and are generally well tolerated. Thus, in formulary decisions, once-daily dosing and good 24-hour blood pressure control are important considerations to ensure efficacy and patient compliance. ACE inhibitors are key in the prevention and management of heart failure but are underused for these indications. The rationale for use of ACE inhibitors after myocardial infarction is discussed, as is evidence of separate antihypertensive and renoprotective effects of ACE inhibitors. Evidence for the use of ramipril in patients at high risk for cardiovascular events, from the Heart Outcomes Prevention Evaluation Study (HOPE), is reviewed. Clinical trial results provide evidence that some ACE inhibitors have renoprotective and vasculoprotective effects and improve outcomes of patients with a variety of cardiovascular disorders; differences among the ACE inhibitors should be considered in formulary decision-making.