Angiotensin-converting enzyme inhibitors and angiotensin II type I receptor blockers in the management of congestive heart failure patients: what have we learned from recent clinical trials?

PURPOSE OF REVIEW: Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and aldosterone antagonists have all been shown to decrease the morbidity and mortality related to heart failure. The population of patients with a diagnosis of heart failure represents a heterogeneous group, ranging from asymptomatic left ventricular dysfunction to chronic decompensation with advanced heart failure; and the clinical roles of these agents can vary within this diverse heart failure population. This article will review the recent developments pertaining to renin-angiotensin-aldosterone system modulation therapy and help to clarify some of the relevant issues surrounding the role and relevance of these drugs in the currently established multi-drug regimen of heart failure patients.

RECENT FINDINGS: Clinical trials such as OPTIMAAL, VALIANT and EPHESUS have added insight into the role of angiotensin II receptor blockers and aldosterone in the post-myocardial infarct heart failure patient. The CHARM series has provided new information into the role of angiotensin II receptor blocker therapy in patients who are angiotensin-converting enzyme intolerant and those with heart failure and normal ejection fraction. In addition further data is now available about the benefits and risks when considering a strategy of either angiotensin-converting enzyme plus angiotensin II receptor blocker or angiotensin-converting enzyme plus aldactone in chronic heart failure patients.

SUMMARY: Important recent clinical trials have helped to add insight on the role of renin-angiotensin-aldosterone system in heart failure. Choosing between a class of drug or particular strategy depends on knowledge of the patient populations studied in clinical trials as well as the inherent risks involved.