Class IIa recommendations
Angiotensin converting enzyme inhibitors (ACEI) or Angiotensin II receptor blockers (ARB) can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: A and C respectively)
PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION WHO HAVE NOT DEVELOPED SYMPTOMS (STAGE B)
Patients who, despite being asymptomatic, had a myocardial infarction or have evidence of left ventricular dysfunction are at considerable risk of developing HF.
The likelihood of developing clinical HF can be diminished by the use of therapies that reduce the risk of additional injury, the process of remodeling, and the progression of left ventricular dysfunction.
In patients who are experiencing an acute MI, the infusion of a fibrinolytic agent or the use of percutaneous coronary intervention can decrease the risk of developing HF, and these interventions can reduce the risk of death, especially in patients with a prior myocardial injury (see specific section of syllabus). Patients with an acute infarction, as well as those with a history of MI and normal cardiac function, also benefit from the administration of both a beta-blocker2 and either an ACEI3 or ARB4, which can decrease the risk of reinfarction or death when initiated within days after the ischemic event, especially in patients whose course is complicated by HF. Combined neurohormonal blockade (beta-blocker and ACEI or ARB) produces additive benefits5.
In patients asymptomatic with left ventricular systolic dysfunction, due to a remote ischemic injury or to a non-ischemic cardiomyopathy6, long-term treatment with an ACE inhibitor has been shown to delay the onset of symptoms and decrease the combined risk of death and hospitalization for HF.
2 Chadda K, Goldstein S, Byington R, Curb JD. Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. Circulation 1986;73:503-10.
3 Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Lancet 1993;342:821-8.
4 Pfeffer MA, McMurray JJ, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 2003;349:1893-906.
5 Vantrimpont P, Rouleau JL, Wun CC, et al, for the SAVE Investigators. Additive beneficial effects of beta-blockers to angiotensin-converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) Study. J Am Coll Cardiol 1997;29:229-36.
6 Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigators. N Engl J Med 1992;327:685-91.