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Angiotensin-converting enzyme inhibition therapy in heart failure: Practical guidelines

At present, captopril is the only vasodilator indicated for the treatment of congestive heart failure. It is increasingly being used to treat those patients who are nonresponsive to conventional therapy with digitalis and diuretics. Patients most likely to benefit from captopril therapy are those with left heart failure caused by myocardial damage (i.e., dilated cardiomyopathies) and left ventricular overload disorders. The drug allows the practitioner to directly block the renin-angiotensinaldosterone system and to counteract vasoconstriction and fluid retention mechanisms, which are critical factors in the syndrome of heart failure. Working through several mechanisms, the most important of which is to inhibit the angiotensin-converting enzyme (ACE), captopril has been proved to increase exercise capacity and to alleviate the symptoms (dyspnea and orthopnea, fatigue, edema) associated with CHF. In this use, captopril has produced reductions in arrhythmia, decreases in diuretic requirements, and improvements in renal function. The role of this ACE inhibitor in prolonging the lives of CHF patients has not yet been established, although preliminary suggestions of a beneficial effect from uncontrolled evaluations appear promising.