ROLE OF CONVERTING-ENZYME INHIBITORS IN THE TREATMENT OF HEART-FAILURE

Treatment with angiotensin-converting enzyme inhibitors has proved to be effective in relieving symptoms of congestive heart failure. With recognition of the high mortality rate that accompanies heart failure, the question has arisen whether angiotensin converting enzyme inhibitors may also improve survival. Early trials of the vasodilator combination hydralazine plus nitrates (V-HeFT trial) showed a strong trend toward a reduction in mortality, and a subsequent trial of the angiotensin converting enzyme inhibitor enalapril in a population of patients with endstage heart failure (CONSENSUS trial) showed a highly significant reduction in the mortality. The SOLVD trial was begun in 1986 to determine whether enalapril could reduce morbidity and mortality in patients with mild to moderate congestive failure (primarily New York Heart Association classes II and m), as well as in asymptomatic patients with a low ejection fraction. This report presents the results in patients with symptoms of congestive failure who were studied in the SOLVD treatment trial. A total of 2,569 patients were recruited into the trial, with an average follow up period of 41.4 months. There was a 16% reduction in mortality in the enalapril treated group compared with that of patients receiving placebo (p = 0.0036), as well as a 26% reduction in the combined end point of death plus hospital admission for congestive failure (p < 0.0001). Compared with placebo, enalapril significantly reduced the incidence of death due to progressive heart failure but apparently had no effect on sudden death. The results clearly indicate that the angiotensin converting enzyme inhibitor enalapril can reduce both morbidity and mortality in symptomatic congestive heart failure. However, the mechanism of action of angiotensin converting enzyme inhibitors remains to be fully established.