Lessons from recent randomized controlled trials for the management of congestive heart failure

In 1987 the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS) was published, which was a milestone for the treatment of patients with heart failure. The study showed a highly significant reduction in mortality in patients with severe heart failure treated with enalapril in comparison to placebo in combination with conventional treatment for heart failure, including the use of other vasodilators. The improvement in survival was exclusively due to a reduction of progression of pump failure. The incidence of sudden cardiac death was not affected. In 1991 2 studies were published in which patients with mild and moderate heart failure were included. The Second Vasodilator-Heart Failure Trial (V-HeFT II) compared the efficacy of enalapril with the effects of a vasodilator therapy consisting of the combination of hydralazine and isosorbide dinitrate. The study showed a highly significant reduction in mortality in the group of patients on the angiotensin-converting enzyme (ACE) inhibitor. In contrast to CONSENSUS, the benefit on survival was due to a reduction of sudden cardiac death. The second study was the Studies of Left Ventricular Dysfunction (SOLVD) treatment arm trial, which compared enalapril and placebo in combination with standard therapy in symptomatic patients with mild-to-moderate heart failure. The SOLVD treatment trial showed a highly significant improvement in survival on enalapril in comparison with placebo. ACE inhibition resulted in a borderline significant reduction of fatal myocardial infarctions, suggesting an impact of ACE inhibition on the pathogenesis of coronary artery disease. The data available show a clear indication for the treatment of symptomatic patients with mild and moderate-to-severe heart failure with ACE inhibitors as a first-line therapy.