DIGOXIN AND ANGIOTENSIN-CONVERTING ENZYME -INHIBITORS IN THE TREATMENT OF CHRONIC CONGESTIVE-HEART-FAILURE

Several controlled studies with the best methodology had showed that d igoxin improves the symptoms of patients with chronic heart failure an d sinus rhythm, whose ventricular systolic function is impaired. The P roved and Radiance studies show that in patients receiving diuretics a nd digoxin, or angiotensin-converting enzyme (ACE) inhibitors, diureti cs and digoxin, the withdrawal of digoxin results in clinical deterior ation and worsening of exercise tolerance. In addition to an inotropic action, digitalis exerts effects in the neurocardiovascular axis, pro duces reduction in plasma norepinephrine, renin, aldosterone, vasopres sin activity and restores a more normal sympathetic-parasympathetic au tonomic balance and baroreceptor function. ACE inhibitors reduce morta lity, improve symptoms and exercise tolerance in patients with chronic heart failure in class IV (Consensus I trial), in class II and III (S OLVD, treatment trial) and prevent the development of heart failure in asymptomatic patients with ejection fraction < 35% (SOLVD, prevention trial). When ACE inhibitors are administered per os, more than 3 days after acute myocardial infarction they reduce mortality, severe heart failure, re-hospitalization, and induce an unexpected reduction of re current myocardial infarction (SAVE trial). However, the early adminis tration, within 2 hours after the onset of chest pain, of ACE inhibito rs by intravenous infusion, does not improve survival; the hypotension may be responsible of increased mortality (Consensus II trial).