What is the role of ACE inhibitors in the treatment of dilated cardiomyopathy?

Updated: Mar 02, 2021
  • Author: Vinh Q Nguyen, MD, FACC; Chief Editor: Gyanendra K Sharma, MD, FACC, FASE  more...
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Use of angiotensin-converting enzyme (ACE) inhibitors is the current criterion standard in the treatment of left ventricular dysfunction. ACE inhibitors have been shown to decrease mortality rates in both symptomatic and asymptomatic patients with left ventricular dysfunction and to reduce readmissions caused by heart failure. The absolute benefits are greater in patients with severe heart failure.

The dosage necessary for maximal benefit has been a matter of debate. One study that investigated low- and high-dose lisinopril found no significant difference in mortality rates, although it did find a difference in a combined endpoint of rehospitalization and death in favor of high-dose lisinopril.

A study by van Veldhuisen et al examined high- and low-dose ACE inhibition using imidapril and demonstrated improved exercise capacity and decreased levels of neurohormonal markers of chronic heart failure (CHF) (atrial and B-type natriuretic peptides). [93] Authorities have generally accepted that maximizing ACE inhibitor therapy is important and should be accomplished in conjunction with other necessary therapies.

The Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS) group in 1987 showed that the addition of enalapril to the conventional treatment of CHF yielded a 31% reduction in mortality rate at 1 year. [94] A similar study by Studies of Left Ventricular Dysfunction (SOLVD) investigators in 1991 revealed a 16% risk reduction. [95] Losartan, an angiotensin II receptor blocker (ARB), also has been effective in decreasing mortality rates.

Other ACE inhibitor trials include the following:

  • Vasodilator Heart Failure Trial II (VHeFT II) (enalapril vs hydralazine plus isosorbide dinitrate): Improved survival better than with combined treatment with hydralazine and isosorbide dinitrate

  • Assessment of Treatment with Lisinopril and Survival in Heart Failure (ATLAS; lisinopril [low and high dose]): Insignificant trend toward reduced mortality rate with high-dose lisinopril and significant reduction in hospitalization [96]

  • Survival and Ventricular Enlargement (SAVE) (captopril vs placebo): Decreased mortality rate, progression of disease, and recurrent myocardial ischemia [97]

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