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Use of Angiotensin-Converting Enzyme Inhibitors in Heart Failure

Objective: To review the literature discussing the use of angiotensin-converting enzyme (ACE) inhibitors in the treatment of heart failure. Data Sources: English-language journal articles. Study Selection: Representative articles discussing the effects of ACE inhibitors on hemodynamics, symptoms, and survival. Data Extraction: Studies selected for review in the text were based on study design and clinical endpoints. Data Synthesis: Heart failure results in a series of compensatory responses that, although effective acutely, are ultimately maladaptive. A major mediator in this process is angiotensin II. The production of angiotensin II is dependent on the ACE. Inhibition of this enzyme by ACE inhibitors results in fewer symptoms, improved hemodynamic function, and prolonged survival in patients with heart failure. Conclusions: ACE inhibitors are beneficial in improving the survival of patients with symptomatic heart failure and of patients who have recently had an acute myocardial infarction (MI) and subsequently have a reduced ejection fraction. There appears to be no advantage for immediately initiating ACE-inhibitor therapy within the first few hours of an MI episode. With respect to patients with a reduced ejection fraction without symptoms of heart failure, current data suggest that ACE inhibitors delay the onset of symptoms of heart failure, reduce the need for hospitalization, and may possibly improve survival.