[Role of angiotensin-converting enzyme inhibitors in the treatment of heart failure in the 21st century].
The angiotensin converting enzyme (ACE) inhibitors have progressively stood out in a large population of heart failure patients as a gold-standard treatment, in relation with their beneficial effects on mortality and morbidity. In a recent meta-analysis published in the Lancet collecting 12,763 patients, Flather demonstrates global mortality decrease of 25% compared to placebo. This risk reduction not only concerns the mortality due to heart failure but also that due to myocardial infarction. The same goes for the morbidity. Thus, in international as well as European recommendations, ACE-inhibitors are indicated as a first lane treatment in heart failure due to systolic LV dysfunction. Nonetheless several questions remain unanswered. The ACE-inhibitors are under-utilised, not only they are under-prescribed (only 60% of heart failure patients benefit from them) but also when prescribed, the dosage (comparing to those used in clinical trials) is generally as low as the half expected. This under-utilisation seems to be related to the side effects as renal failure, hypotension or more often due to the concern of their occurrence especially in the elderly and in those with other concomitant morbidities. They are actually related in part to an under-estimation of the benefit/risk ratio. The ATLAS study suggests that high doses of ACE-inhibitors are associated with a deeper reduction of morbidity without significant differences compared to low doses concerning global mortality or side effects. However this study compared very high (extreme) doses to low ones and comparison between heavy- and mid-doses remains to be performed. After the HOPE study, new indications appear promising: heart failure with preserved systolic function; patients with risk factors without heart failure: risk reduction of subsequent heart failure and reduction of mortality. Tolerance of their association with beta-blocking agents. In conclusion, the optimisation of the ACE-inhibitors treatment goes through a wider prescription with higher doses, probably extended to new indications.
Gibelin
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Service de cardiologie, hôpital Pasteur, BP 69, 30, avenue de la Voie Romaine, 06002 Nice.
D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000494:pharmacology / Q000627:therapeutic use*; D002303:Cardiac Output, Low / Q000188:drug therapy* / Q000401:mortality; D004305:Dose-Response Relationship, Drug; D006801:Humans; D015201:Meta-Analysis as Topic; D009203:Myocardial Infarction / Q000401:mortality / Q000517:prevention & control; D010818:Practice Patterns, Physicians'; D013599:Systole
D000806:Angiotensin-Converting Enzyme Inhibitors
Place des inhibiteurs de l'enzyme de conversion de l'angiotensine dans le traitement de l'insuffisance cardiaque au XXIe siècle.