Role and optimal dosing of angiotensin-converting enzyme inhibitors in heart failure

Based on overwhelming data demonstrating reduced morbidity and mortality, ACE inhibitors form a mainstay of therapy in all patients with symptomatic left ventricular systolic dysfunction. Furthermore, ACE inhibitors may be beneficial in the prevention of heart failure in patients with high-risk cardiovascular profiles. However, definite benefit from the use of ACE inhibitors in all patients with heart failure and preserved ejection fraction has not been demonstrated. Even though ACE inhibitors probably have a class effect in patients who have heart failure, it is recommended that ACE inhibitors that have been shown to reduce morbidity and mortality in clinical trials (captopril, enalapril, lisinopril, and ramipril) be used because studies have clearly defined a dose for these agents that is effective in modifying the natural history of the disease. Attempts should be made to up titrate patients to target doses of ACE inhibitors that have been used in clinical trials, if tolerated.