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The evolving role of angiotensin-converting enzyme inhibition in heart failure: expanding the protective envelope
1Department of Internal Medicine, University of California, San Francisco 94143.
Insights
Angiotensin-converting enzyme (ACE) inhibitors are beneficial for patients with mild-to-severe heart failure. Clinical trials demonstrate their efficacy in improving outcomes for both symptomatic and asymptomatic individuals at risk.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Congestive heart failure (CHF) significantly contributes to morbidity and mortality, affecting millions and leading to numerous annual deaths.
- The understanding of CHF pathophysiology and its temporal evolution has advanced, prompting the investigation of novel therapeutic agents.
- Angiotensin-converting enzyme (ACE) inhibitors emerged as potent antihypertensive agents, spurring research into their role in managing CHF.
Purpose of the Study:
- To review multicenter trials evaluating the efficacy of ACE inhibitors in patients with congestive heart failure.
- To address key clinical questions regarding vasodilator therapy in different stages of heart failure.
- To determine the comparative effectiveness of ACE inhibitors versus hydralazine/isosorbide dinitrate regimens.
Main Methods:
- Systematic review of pivotal multicenter clinical trials focused on ACE inhibitor therapy in heart failure.
- Analysis of trial data to answer specific questions on vasodilator benefits in severe, mild-to-moderate, and asymptomatic heart failure.
- Comparative assessment of ACE inhibitors against hydralazine/isosorbide dinitrate for heart failure treatment.
Main Results:
- ACE inhibitors demonstrate significant benefits in treating mild-to-moderate heart failure.
- Evidence supports the use of ACE inhibitors in severe heart failure, with specific regimens showing superior efficacy.
- ACE inhibitors are also found to be beneficial for asymptomatic patients identified as at risk for developing heart failure.
Conclusions:
- ACE inhibitors represent a cornerstone therapy for a broad spectrum of heart failure patients, from asymptomatic to severe stages.
- The trials reviewed provide clear answers supporting the use of ACE inhibitors over other vasodilator regimens in many cases.
- Further research and clinical application of ACE inhibitors are warranted to reduce CHF-related morbidity and mortality.
Abstract:
Congestive heart failure (CHF) continues to be a major cause of morbidity and mortality; in the United States alone, CHF afflicts 4 million patients, representing about 2% of the adult population; causes or contributes to more than 250,000 deaths yearly; and is the principal or secondary diagnosis in 6% of all hospital discharges. After the discovery of angiotensin-converting enzyme (ACE) inhibitors as potent antihypertensive agents, an increased understanding of the pathophysiology of CHF, in addition to the recognition of heart failure as a process that evolves through time, led to the use of these agents in patients with CHF. Subsequently, a series of multicenter trials systematically explored the role of ACE-inhibitor therapy in heart failure. The purpose of this review is to discuss some of these trials and to describe the answers that they provide to the following questions: Are vasodilators beneficial in the treatment of severe heart failure? Are ACE inhibitors beneficial in mild-to-moderate heart failure? Which vasodilator regimen (ACE inhibitors or hydralazine/isosorbide dinitrate) is more effective? Finally, are ACE inhibitors beneficial in asymptomatic patients at risk of heart failure?