Randomized trials have shown that angiotensin converting enzyme (ACE) inhibitor therapy leads to symptomatic improvement, reduced hospitalization, and enhanced survival in patients with heart failure (HF) and systolic dysfunction [1-8]. Therefore, ACE inhibitors are an important component of standard HF therapy in patients with current or prior symptoms of HF and depressed left ventricular systolic function.
The clinical data supporting the use of ACE inhibitors in patients with HF will be reviewed here. The mechanisms of action of these agents in HF, their role in patients with diastolic dysfunction, their use in patients with asymptomatic systolic dysfunction, and the efficacy of angiotensin II receptor blockers are discussed separately. (See "Angiotensin converting enzyme inhibitors and receptor blockers in heart failure: Mechanisms of action" and "Treatment and prognosis of diastolic heart failure" and "Evaluation and management of asymptomatic left ventricular systolic dysfunction" and "Angiotensin II receptor blocker and neprilysin inhibitor therapy in heart failure due to systolic dysfunction".)
An overview of the treatment of HF due to systolic dysfunction is discussed separately . (See "Overview of the therapy of heart failure due to systolic dysfunction".)
BENEFIT OF ACE INHIBITORS
General efficacy — Angiotensin converting enzyme (ACE) inhibitors are recommended to treat heart failure (HF) due to systolic dysfunction because multiple, large, prospective, randomized trials have consistently demonstrated a significant reduction in mortality (table 1) [1-5] as well as alleviation of symptoms and improvement in clinical status [6-8]. The benefit of ACE inhibitors has been demonstrated in all severities of symptomatic HF and in patients with asymptomatic left ventricular (LV) dysfunction; a benefit has also been demonstrated after myocardial infarction (MI).
A meta-analysis evaluated five trials (three starting during the first one to three weeks post-MI) involving 12,763 patients with LV ejection fraction (LVEF) ≤35 percent or <40 percent and/or clinical HF. ACE inhibition had the following benefits :