ACE inhibitors and ARBs in chronic heart failure: the established,the expected,and the pragmatic

ACE inhibitors have been shown to reduce mortality, reduce hospitalization, reduce symptoms, and increase exercise capacity in patients with heart failure and a large heart (low ejection fraction). The evidence is overwhelming. There are some subgroups of patients, such as the very elderly and those with a normal ejection fraction, where uncertainty still exists. The combination of a diuretic and an ACE inhibitor is currently the proper treatment of congestive heart failure; a beta-blocker should be added in selected patients. The evidence for the efficacy of ARB is less persuasive and, for the present, this class of drug should be prescribed only when an ACE inhibitor cannot be tolerated. The results of the trials emphasize an emerging problem in medicine, namely how to evaluate a new treatment that may be as efficacious as current therapy but with fewer side-effects. Proving equivalence in efficacy will be difficult, requiring large studies comparing new drugs with the best current treatment. The most common etiology of heart failure is coronary heart disease. If further studies provide more support for the idea that ACE inhibitors prevent ischemic episodes and delay the onset of heart failure, then a new indication for ACE inhibitors will be the prevention of heart failure.