Heart Failure

Which patients with heart failure should be treated with angiotensin-converting–enzyme (ACE) inhibitors?
ACE inhibitors are the first-line therapy for patients with systolic heart failure; therapy should be initiated promptly after diagnosis and continued indefinitely. ACE inhibitors increase the ejection fraction modestly and reduce ventricular size, symptoms, hospitalization, and overall mortality. ACE inhibitors also reduce the risk of myocardial infarction.

When should spironolactone be used in patients with heart failure?
In a large, placebo-controlled, randomized trial in which patients received spironolactone in addition to a diuretic, digoxin, and an ACE inhibitor, a reduction in symptoms and in hospital admissions, and a 30% reduction in mortality, were seen among patients with severe systolic heart failure (NYHA class III or IV). Therefore, the addition of an aldosterone antagonist should be considered for any patient who remains in NYHA class III or IV, despite treatment with a diuretic, an ACE inhibitor (or angiotensin-receptor blocker [ARB]), and a beta-blocker.

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Teaching topics from the New England Journal of Medicine - Vol. 362, No. 3, January 21, 2010