Overview: the role of angiotensin-converting enzyme inhibitors in cardiovascular therapy

Angiotensin-converting enzyme (ACE) inhibitors favorably modify control mechanisms that are disturbed in hypertension and congestive heart failure, principally, but perhaps not exclusively, through reduction in angiotensin II levels. Pharmacodynamic actions are vasodilation, increased sodium excretion, and lowering of blood pressure. Investigations with captopril and enalapril in the treatment of hypertension indicate efficacies comparable to each other and to current step 1 and 2 agents. Enalapril is more potent than captopril and has a longer duration of action. The hemodynamic mechanism of action is reduction in peripheral vascular resistance. Addition of a diuretic potentiates blood pressure lowering and proportion of patients responding. When used in congestive heart failure, ACE inhibitors exert a balanced vasodilator effect on arterial and venous beds and do not induce tachycardia or fluid retention. Cardiac output is increased whereas systemic vascular resistance, central pressures, and systemic blood pressure are reduced acutely and chronically. Although captopril is associated with certain side effects, possibly resulting from the sulfhydryl group in its structure, this profile has not been encountered thus far in clinical investigations with enalapril. The effects of ACE inhibitors on the natural histories of hypertension (independent of blood pressure lowering) and congestive heart failure are yet to be determined.