Fundamental role of angiotensin-converting enzyme inhibitors in the management of congestive heart failure.

Angiotensin-converting enzyme (ACE) inhibition therapy has now become firmly ensconced in the modern therapeutic approach to all stages of congestive heart failure (CHF), including the early presymptomatic phase. Although its benefit is abundantly proven as add-on therapy in established CHF, after digitalis and diuretics, smaller and shorter studies have shown that, as second-line therapy and combined with diuretics, it may be preferable to digoxin with an undoubted benefit in postinfarction failure. As first-line therapy in early presymptomatic CHF, the evidence is also good, based on the prevention arm of the Studies of Left Ventricular Dysfunction (SOLVD), albeit in predominantly postinfarction patients, and on the Survival and Ventricular Enlargement (SAVE) study on postinfarction patients. ACE inhibitors given prophylactically or therapeutically helped to prevent clinical heart failure in the SOLVD and SAVE studies. These data suggest a role for ACE inhibitors as effective first-line monotherapy in early heart failure, acting on left ventricular function to avoid or lessen unfavorable remodeling. There are some contraindications or cautions for the use of ACE inhibitors in CHF, such as preexisting hypotension, high-renin states such as bilateral renal artery stenosis with hypertensive heart failure, aortic stenosis combined with CHF, overdiuresis with excess sodium depletion, and significant preexisting renal failure. ACE inhibition therapy may have deleterious effects on renal function in heart failure, for example, by decreasing the glomerular filtration rate.(ABSTRACT TRUNCATED AT 250 WORDS)