Should aspirin be used with angiotensin-converting enzyme inhibitors in patients with chronic heart failure?

Aspirin and angiotensin-converting enzyme (ACE) inhibitors are widely used in combination to treat a wide spectrum of cardiac disorders. Theoretically, a rationale for interaction between these two agents exists in the possible counterbalancing prostaglandin inhibiting actions of aspirin and the vasodilatory prostaglandin promoting effects of ACE inhibitors. Animal and human studies suggest such an interaction, but most are plagued by small numbers or retrospective designs. Large-scale trials are in progress to address this issue. Until then, the key factor in deciding whether a patient with ischemic heart disease on ACE inhibitor therapy should be placed on aspirin therapy may largely depend on the severity of heart failure. The more severe the heart failure, the more likely an appreciable interaction between aspirin and ACE inhibitors will occur. Treatment with either low-dose aspirin or with alternative agents, such as warfarin or clopidogrel, may be the best therapeutic approach for patients with severe systolic heart failure.