ROLE OF CONVERTING-ENZYME INHIBITORS IN THE TREATMENT OF HEART-FAILURE

Treatment with angiotensin-converting enzyme inhibitors has proved to be effective in relieving symptoms of congestive heart failure. With r ecognition of the high mortality rate that accompanies heart failure, the question has arisen whether angiotensin converting enzyme inhibito rs may also improve survival. Early trials of the vasodilator combinat ion hydralazine plus nitrates (V-HeFT trial) showed a strong trend tow ard a reduction in mortality, and a subsequent trial of the angiotensi n converting enzyme inhibitor enalapril in a population of patients wi th endstage heart failure (CONSENSUS trial) showed a highly significan t reduction in the mortality. The SOLVD trial was begun in 1986 to det ermine whether enalapril could reduce morbidity and mortality in patie nts with mild to moderate congestive failure (primarily New York Heart Association classes II and m), as well as in asymptomatic patients wi th a low ejection fraction. This report presents the results in patien ts with symptoms of congestive failure who were studied in the SOLVD t reatment trial. A total of 2,569 patients were recruited into the tria l, with an average follow up period of 41.4 months. There was a 16% re duction in mortality in the enalapril treated group compared with that of patients receiving placebo (p = 0.0036), as well as a 26% reductio n in the combined end point of death plus hospital admission for conge stive failure (p < 0.0001). Compared with placebo, enalapril significa ntly reduced the incidence of death due to progressive heart failure b ut apparently had no effect on sudden death. The results clearly indic ate that the angiotensin converting enzyme inhibitor enalapril can red uce both morbidity and mortality in symptomatic congestive heart failu re. However, the mechanism of action of angiotensin converting enzyme inhibitors remains to be fully established.