Use of angiotensin-converting enzyme inhibitors in heart failure with preserved left ventricular systolic function

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This study was conducted to provide evidence of an association between angiotensin-converting enzyme (ACE) inhibitor use and clinical outcomes among patients with congestive heart failure (CHF) and preserved left ventricular (LV) systolic function who are treated in the community setting, and to compare the magnitude and direction of these associations among the subset with preserved function to the subset with LV contractile dysfunction. Seven hundred sixty-three hospital survivors who had measurement of systolic function were identified from among a series of consecutive patients with CHF admitted to 10 community hospitals. They were prospectively followed-up for 6 months after discharge to track death, hospital readmission, and quality of life. Outcomes were stratified by ACE inhibitor use among those with preserved systolic function, defined as an LV ejection fraction (EF) ≥40% or qualitatively normal contractility, and among those with systolic dysfunction, defined as an EF ≤39% or qualitatively abnormal contractility. ACE inhibitor prescription rates were higher among the 413 patients with LV contractile dysfunction than among the 350 with preserved function (77% vs 54%, p < 0.0001). Drug-treated and untreated patients were similar in many ways, although lower serum creatinine levels, lower EF, and a higher prevelance of high blood pressure characterized those receiving ACE inhibitors. After adjusting for these and other covariables, ACE inhibitor use among the group with normal function was associated with a trend for a lower risk of death and delayed time to hospital readmission but not absolute rates of rehospitalization. By comparison, ACE inhibition among those with impaired systolic function was associated with trends for lower risk of death and rehospitalization. These data suggest that ACE inhibition may be of benefit when CHF occurs in the context of preserved or normal LV systolic function. Large, multicenter, prospective randomized trials to better test this hypothesis are warranted.