Angiotensin-converting enzyme inhibitors and angiotensin II type I receptor blockers in the management of congestive heart failure patients: what have we learned from recent clinical trials?

Purpose of review Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and alclosterone antagonists have all been shown to decrease the morbidity and mortality related to heart failure. The population of patients with a diagnosis of heart failure represents a heterogeneous group, ranging from asymptomatic left ventricular dysfunction to chronic decompensation with advanced heart failure; and the clinical roles of these agents can vary within this diverse heart failure population. This article will review the recent developments pertaining to renin-angiotensin-alclosterone system modulation therapy and help to clarify some of the relevant issues surrounding the role and relevance of these drugs in the currently established multi-drug regimen of heart failure patients. Recent findings Clinical trials such as OPTIMAAL, VALIANT and EPHESUS have added insight into the role of angiotensin II receptor blockers and aldosterone in the post-myocardial infarct heart failure patient. The CHARM series has provided new information into the role of angiotensin II receptor blocker therapy in patients who are angiotensin-converting enzyme intolerant and those with heart failure and normal ejection fraction. In addition further data is now available about the benefits and risks when considering a strategy of either angiotensin-converting enzyme plus angiotensin II receptor blocker or angiotensin-converting enzyme plus aldactone in chronic heart failure patients. Summary Important recent clinical trials have helped to add insight on the role of renin-angiotensin-alclosterone system in heart failure. Choosing between a class of drug or particular strategy depends on knowledge of the patient populations studied in clinical trials as well as the inherent risks involved.