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March, 1989 - The importance of the RAS in heart failure, along with the big benefits of vasodilation, has led to wide use of ACE inhibitors to treat heart failure. ACE inhibitors are the only class of vasodilator drugs that strongly protect heart failure patients from death.
Title: Angiotensin-converting enzyme inhibitors in heart failure
Authors: Borek M, Charlap S, Frishman WH
Source: Med Clin North Am 1989 Mar;73(2):315-338
PMID: 2645479, UI: 89142735
May, 1994 - We now have conclusive proof that ACE inhibitors reduce risk of death, complications, and symptoms in patients with low EF and heart failure. ACE inhibitors should be routinely used in all heart failure patients.
Routine ACE inhibitor use increases survival and reduces hospitalizations for heart failure and ischemic events. The reduction in costs by using these drugs is likely to offset the cost of the drugs. Therefore, ACE inhibitors should be started as early as possible in patients with left ventricle dysfunction.
Title: Role of angiotensin converting enzyme inhibitors in patients with left ventricular dysfunction and congestive heart failure
Authors: McKelvie R, McConachie D, Yusuf S
Source: Eur Heart J 1994 May;15 Suppl B:9-13
PMID: 8076660, UI: 94357241
May, 1995 - Many people survive a heart attack (MI) but are left with an ejection fraction under 40%. These patients usually get not only an ACE inhibitor but also aspirin to decrease risk of another MI. New data suggest that adding aspirin to Vasotec can raise afterload, which isn't good.
This study had 20 patients with class 2 or 3 heart failure symptoms, known CAD and an average ejection fraction of 25%. Patients were given Vasotec (5 to 10mg daily) plus placebo for 4 weeks followed by Vasotec plus aspirin (250mg daily) for 4 more weeks.
We measured blood pressure, heart size, and did urine analysis. Blood pressure, noradrenaline level, and angiotensin II levels were the same after 4 weeks of Vasotec treatment with aspirin, compared to Vasotec with placebo. Vasotec treatment reduced heart size at 8 weeks.
While the interaction of aspirin and Vasotec in heart failure patients is complex, this study shows no evidence that aspirin reduces enalapril's benefit on afterload. It does suggest that while adding aspirin to enalapril may be harmless, it may not be very helpful in reducing further risk of heart attack.
Title: Combining salicylate and enalapril in patients with coronary artery disease and heart failure.
Authors: Baur LHB; et al, Br Heart J 1995 Mar; 73:227-236.
Published in Journal Watch: Cardiology 1 May 1995
September 1, 1999 - An ACE inhibitor could prevent heart attacks and strokes in high-risk patients. Researchers presented the results of a ramapril trial in Barcelona, and said the drug reduced risk of heart attacks and strokes in high-risk patients by 20 to 30%.
Doctors tested ramipril on 9,500 patients in 19 countries during the HOPE study. They were so impressed by the results that they stopped the 5 year trial six months early. People who survive a heart attack or stroke have an increased risk of having another one. Doctors think ramipril can prevent many future problems in these patients.
All of the patients who took part in the study were 55 or older and had suffered previous cardiovascular conditions such as a heart attack or stroke, or had other risk factors such as diabetes or smoking, which made them more susceptible to further problems. Ramipril not only prevented subsequent heart attacks and strokes, but also reduced the need for heart bypass surgery and hospital stays.
December 8, 2000 - Jon's Note: I am adding this personal experience as a prelude to this study because I credit a dose of 40mg Vasotec twice a day with preventing my needing a heart transplant. My cardiac output dropped to critical levels very quickly without any warning signs besides shortness of breath (no edema). Only the fact that my CHF specialist doesn't mess around and ordered an immediate echo showed the drop in my heart function. My Vasotec was raised to 40mg twice a day for 2 to 3 months after I refused transplant. I could not sustain that dose but after the 2 to 3 months at 40mg twice a day, my cardiac output significantly improved, and my dose was reduced to 20mg twice a day. Later I was switched to Monopril.
Enalapril (Vasotec) doses over 20mg per day may not improve survival in CHF patients, according to Greek researchers. Dr. John Nanas' team studied 248 patients with advanced CHF. They gave patients maximum tolerated doses of enalapril, either up to 20mg per day or up to 60mg per day. Both patient groups were similar in all respects at the study's start.
After 12 months of followup, 18% of patients in both groups had died. Heart class had improved from 2.6 to 1.9 in both groups. Differences between the groups in average heart rate and ejection fraction were not considered significant.
In an editorial, Dr. Francois Delahaye and Dr. Guy deGevigney review several dose-related trials of enalapril, along with this study. They say that "with all trials put together, the conclusion is that enalapril doses higher than 20mg per day are not more effective but that we should always try to reach a dose of 20mg per day (10mg twice daily) of enalapril in CHF patients."
Source: J Am Coll Cardiol 2000;36:2090-2097
All information on this site is opinion only. All concepts, explanations, trials, and studies have been re-written in plain English and may contain errors. I am not a doctor. Use the reference information at the end of each article to search MedLine for more complete and accurate information. All original copyrights apply. No information on this page should be used by any person to affect their medical, legal, educational, social, or psychological treatment in any way. I am not a doctor. This web site and all its pages, graphics, and content copyright © 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004 Jon C.