Effects of ACE inhibition on the hypertrophied heart-implications for reversal and prognosis: An updated review

Abstract

The primary aim of antihypertensive treatment is to reduce (normalize) the increased risk of cardiovascular complications. Most patients with established hypertension have a hypertensive cardiac disorder, when this becomes pronounced enough to be classed as clinically recognized left ventricular hypertrophy, it is the most powerful independent risk factor for cardiovascular complications. It is therefore logical to assume that reversal of left ventricular hypertrophy (reduction in left ventricular mass) is a desirable therapeutic goal in the treatment of hypertension. Angiotensin-converting enzyme (ACE) inhibitors have been particularly effective in reversing hypertensive cardiac hypertrophy, and two metaanalyses have indicated that they may be more effective than other therapies. There is, however, only one controlled longterm study of ACE inhibition in previously untreated patients. In this study, enalapril was significantly better than hydrochlorothiazide, and this superior efficacy was more dependent on the blocking of the renin-angiotensin system than the hemodynamic unloading per se. Angiotensin II has been reported to stimulate ventricular hypertrophy and remodeling, and it is interesting to consider the favorable experimental and clinical results with ACE inhibitors, including the unexpected but nonetheless important reduction in ischemic events in heart failure studies, in which a majority of patients had coronary disease. In this perspective, the remodeling of the remaining viable myocardium after myocardial infarction is similar to the development of a hypertensive cardiac hypertrophy. In conclusion, the potential of ACE inhibitors to reverse cardiovascular damage has been demonstrated clinically and experimentally. Taken together with the new evidence that ACE inhibitors reduce mortality and morbidity after myocardial infarction and in cardiac failure, these data suggest not only a cardioprotective but also a cardioreparative potential for ACE inhibitor-based treatment. Such benefit can also be important in a broader cardiovascular perspective, for instance, in the hypertensive patient with left ventricular hypertrophy and/or coronary heart disease.