100 QUESTIONS IN CARDIOLOGY

53 Which patients with impaired ventricles should

receive an ACE inhibitor? What are the survival

advantages? Do AT1-receptor antagonists confer

the same advantages?

Lionel H Opie

Not all impaired left ventricular (LV) function is an indication for

ACE-inhibitor treatment. Specifically, left ventricular hyper-

trophy due to hypertension or aortic stenosis may be associated

with diastolic dysfunction, yet ACE inhibition is only one of

several therapies that will regress LV hypertrophy, even though

some believe that for this purpose it is one of the best. Similarly,

the defects of ventricular function seen in hypertrophic cardio-

myopathy are not a clear indication for ACE inhibition.

The following patients shouldbe treated with an ACE inhibitor

Symptomatic patients

All patients with clinically diagnosed heart failure should receive

an ACE inhibitor. The survival advantages are consistent

(mortality reduction of about 20%) and far outweigh the

relatively small risk of serious side effects. In post-infarct

clinically diagnosed heart failure, ACE inhibition reduced

mortality by 27% at an average follow up of 15 months, and 36%

with a mean follow up of nearly 5 years.^1

Post-infarct patients without overt heart failure but with impaired

left ventricular systolic function

These patients should receive an ACE inhibitor. This will give

them benefit even in the absence of symptoms, as shown in the

SOLVD prevention trial.^2 Most patients were post-infarct, and

most were New York Heart Association (NYHA) class 1, despite

the low ejection fraction of 35% or less.

Benefit to risk ratios

In the SAVE study^3 of post-infarct patients with an ejection

fraction of 40%, the chief treatment-related adverse effects of