Angiotensin-converting enzyme inhibitors in heart failure: new strategies justified by recent clinical trials.

New information suggests that heart failure treatment strategies should change. Indeed, angiotensin-converting enzyme (ACE) inhibitors now should be considered first-line therapy in some instances. It is important, therefore, to review results of recently completed mortality end-point trials of ACE inhibitors in patients with congestive heart failure and asymptomatic left ventricular dysfunction. In the Treatment Trial of Studies of Left Ventricular Dysfunction (SOLVD), addition of enalapril to baseline therapy significantly improved prognosis in patients with mild to moderate heart failure. These results extend the findings of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS), and indicate that ACE inhibition is beneficial to patients with all grades of overt congestive heart failure. In the Prevention Trial of SOLVD, and the Survival and Ventricular Enlargement Study (SAVE), therapy with enalapril or captopril improved prognosis among patients with, generally, asymptomatic left ventricular dysfunction. In particular, the risk of development of overt heart failure was reduced. Importantly, a marked anti-ischaemic effect of ACE inhibition was identified in both the SOLVD and SAVE trials. Clinical data amassed in nearly 9000 patients identify a substantial role for ACE inhibition in patients with all grades of symptomatic heart failure as well as in those with asymptomatic left ventricular dysfunction (such as often follows a myocardial infarction). Data support early intervention with ACE inhibitor therapy alone in asymptomatic cardiac failure and triple combination therapy (ACE inhibitor, diuretic, digoxin) in patients with symptomatic congestive heart failure.