A review of evidence of benefits from ACE inhibitors in heart failure compared with AT(1) receptor blockers and other therapies

A number of large controlled trials have shown that angiotensin-converting enzyme (ACE) inhibitors reduce mortality and morbidity in patients with chr onic heart failure, and can prevent the development of heart failure in asy mptomatic patients with left ventricular dysfunction. Research has shown, h owever, that regardless of the evidence proving the benefits of ACE inhibit ors in the management of heart failure, they are still under-used in clinic al practice. In their place, newer treatments, such as AT(1) receptor block ers, are being prescribed, despite the lack of conclusive evidence demonstr ating their benefits in the management of heart failure. It is therefore re commended that ACE inhibitors should be first-line therapy in all patients with heart failure, unless contraindications are present. The results of th e Assessment of Treatment with Lisinopril and Survival (ATLAS) Study sugges t that the highest tolerated doses should be used to achieve maximum benefi t (up to 35 mg of lisinopril). AT(1) receptor blockers should be reserved f or those patients who are unable to tolerate ACE inhibitors. Recent studies suggest that betablockers may provide additional benefits in patients with Class II-III heart failure, and that the addition of spironolactone should be considered in patients with severe (Class IV) heart failure.