WHAT IS THE ROLE OF ANGIOTENSIN-CONVERTING ENZYME-INHIBITORS IN CONGESTIVE-HEART-FAILURE AND AFTER MYOCARDIAL-INFARCTION

OBJECTIVE: TO discuss the controversies surrounding the choice of angi otensin-converting enzyme (ACE) inhibitor, and the timing, dosage, and duration of ACE inhibitor therapy for congestive heart failure (CHF) and after myocardial infarction (MI). The beneficial effects of ACE in hibition in patients with CHF and after MI are reviewed, Human clinica l trials are reviewed and their clinical implications are discussed. D ATA SOURCES: MEDLINE searches (1985-1995) identified human clinical tr ials and review articles. DATA EXTRACTION: Landmark human clinical tri als with morbidity and mortality end points were included. The validit y of the study data were assessed on the basis of study methods, popul ation characteristics, and statistical power. DATA SYNTHESIS: ACE inhi bitors exert beneficial effects in patients with CHF by hemodynamic an d neurohormonal mechanisms. The attenuation of ventricular remodeling that occurs with ACE inhibition does not fully explain the results of clinical trials in patients after MI. Routine determination of ejectio n fraction to guide ACE inhibitor therapy is not as important as the p atient's clinical status, Clinicians should titrate the chosen ACE inh ibitor on the basis of hemodynamic response to target doses used in ma jor clinical trials. Because the beneficial effects of ACE inhibitors appear to be a class effect, choice of an agent should include cost co nsiderations and the results of clinical trials.CONCLUSIONS: ACE inhib itors reduce morbidity and mortality in selected CHF and post-MI patie nts. Patients with symptomatic CHF benefit most from ACE inhibitor the rapy, and it should be continued indefinitely. Treatment effects in as ymptomatic patients are delayed, The role of ACE inhibitor therapy in preventing morbidity and mortality in asymptomatic patients with prese rved ventricular function requires further study.