Angiotensin-converting–enzyme
(ACE) inhibitors have been the cornerstone
of the treatment for heart failure
and a reduced ejection fraction for nearly 25
years, since enalapril was shown to reduce the
risk of death in two trials.
Long-term treatment
with enalapril decreased the relative risk of
death by 16% among patients with mild-to-moderate
symptoms.2 The effect of angiotensin-receptor
blockers (ARBs) on mortality has been
inconsistent,
and thus, these drugs are recommended
primarily for patients who have unacceptable
side effects (primarily cough) while receiving
ACE inhibitors. Subsequent studies
showed that the use of beta-blockers and mineralocorticoid-
receptor antagonists, when added to
ACE inhibitors, resulted in incremental decreases
in the risk of death of 30 to 35% and 22 to 30%,
respectively