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ACE inhibitors have been evaluated in more than 7000 patients with HF who participated in more than 30 placebo-controlled clinical trials39. All of these trials enrolled patients with systolic dysfunction (ejection fraction less than 0.35 to 0.40) who were treated with diuretics, with or without digitalis. These trials recruited many types of patients, including women and the elderly, as well as patients with a wide range of causes and severity of left ventricular dysfunction. However, patients with preserved systolic function, low blood pressure (less than 90 mm Hg systolic), or impaired renal function (serum creatinine greater than 2.5 mg per mL) were not recruited or represented a small proportion of patients who participated in these studies.

Analysis of this collective experience indicates that ACE inhibitors can alleviate symptoms, improve clinical status, and enhance the overall sense of well-being of patients with HF. In addition, ACE inhibitors can reduce the risk of death as well as the combined risk of death or hospitalization. These benefits of ACE inhibition were seen in patients with mild, moderate, or severe symptoms and in patients with or without coronary artery disease.

Practical use of ace inhibitors

Selection of patients

ACE inhibitors should be prescribed without any delay in case of HF due to left ventricular systolic dysfunction with the exclusion of patients with contraindications or unable to tolerate treatment with these drugs.

In general, ACE inhibitors are used together with a beta-blocker (and usually with digitalis). In addition, ACE inhibitors should not be prescribed without diuretics in patients with a current or recent history of fluid retention, because diuretics are needed to maintain sodium balance and prevent the development of peripheral and pulmonary edema40.

ACE inhibitors should be preferred over the use of angiotensin II receptor antagonists or direct-acting vasodilators (e.g., a combination of hydralazine and isosorbide dinitrate41.

Absolute contraindications to the administration of ACEI are previously experienced life- threatening adverse reactions, such as angioedema or anuric renal failure, and pregnancy.

39 Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA 1995;273:1450-6.

40 Richardson A, Bayliss J, Scriven AJ, Parameshwar J, Poole-Wilson PA, Sutton GC. Double-blind comparison of captopril alone against frusemide plus amiloride in mild heart failure. Lancet 1987;2:709-11.

41 Pitt B, Poole-Wilson PA, Segal R, et al. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the Losartan Heart Failure Survival Study ELITEII. Lancet 2000;355:1582-7.

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