Should all patients with congestive heart failure and dilated cardiomyopathy be treated with vasodilators?

From the discussion of these questions, several conclusions seem firm, whereas other issues await resolution. Patients with severe CHF should be treated with diuretics, digoxin, and an ACE inhibitor. In mild and moderate CHF, a diuretic should be combined with either digoxin or an ACE inhibitor--usually the latter. However, most of these patients would benefit from receiving all three drugs. Patients with asymptomatic left ventricular systolic dysfunction are at jeopardy for progressive deterioration. Angiotensin converting enzyme inhibitors and, possibly, direct vasodilators may prevent progression. In initiating vasodilator therapy, ACE inhibitors usually should be the agent of choice. Exceptions may be patients with ongoing ischemia in whom nitrates are an appropriate alternative and those who are poor candidates because of hypotension, renal insufficiency, or hyperkalemia.