ACE inhibitors before or after heart failure?

Heart failure is a progressive disease and once the process has started it continues with further deterioration of cardiac function or ends in sudden death. In many patients changes within the heart start to develop long before clinical symptoms occur. The left ventricle goes through a number of adaptions-remodelling-to compensate for increased pressure or volume load or subsequent myocardial infarction. Several of these compensatory changes have prognostic implications and indicate increased risk of clinical heart failure or cardiac events. Thus, increased left ventricular dimensions, volume and mass together with reduced systolic function are all markers of poor prognosis. Treatment with angiotensin-converting enzyme (ACE) inhibitors before the onset of clinical heart failure has been shown to improve prognosis. Identification of individuals at high risk is difficult since signs and symptoms of heart failure are often lacking. A strategy to find these patients must use objective methods to characterise the state of the left ventricle. It is likely that not only patients with significant reduction of systolic function but also other signs of impaired left ventricular dysfunction will benefit from treatment with ACE inhibitors. Only by preventive treatment may we be able to decrease the number of patients with new onset of clinical heart failure.