Vol. 23, No. 7, July 2000 (Supplement IV)
GARY S. FRANCIS, M.D., Guest Editor
supplement in PDF (170k)
Can We Prevent Congestive Heart Failure? Excerpts from a Symposium [Full text HTML]
G. S. Francis, M.D.
Overview of the Relationship Between Ischemia and Congestive Heart Failure [Full text HTML]
W. J. Remme, M.D., Ph.D.
Ischemic heart disease is the principal etiology of heart failure in the Western world. Preventing ischemic events is an important goal in managing patients with coronary artery disease. Trials involving patients with asymptomatic left ventricular dysfunction after myocardial infarction or heart failure have shown that angiotensin-converting enzyme (ACE) inhibitors reduce the incidence of progressive heart failure, death, and ischemic events. Current evidence suggests that ACE inhibitor therapy also benefits patients with preserved left ventricular function, confirming the relationship between ischemia and heart failure and the benefits of ACE inhibitors in a broad range of high-risk patients.
The Anti-Ischemic Potential of Angiotensin-Converting Enzyme Inhibition: Insights from the Heart Outcomes Prevention Evaluation Trial [Full text HTML]
B. Pitt, M.D.
Therapy with an angiotensin-converting enzyme (ACE) inhibitor is established for reducing excessive blood pressure, reducing mortality in patients with congestive heart failure (CHF), preventing the development of CHF in patients with asymptomatic left ventricular (LV) dysfunction, and preventing death and CHF when initiated early after the onset of acute myocardial infarction (MI). Although these benefits have been attributed largely to hemodynamic mechanisms, recent evidence reveals ACE inhibition as potent in preventing ischemic events and in blocking an array of ischemic processes, including atherogenesis. The Heart Outcomes Prevention Evaluation (HOPE) trial found that the ACE inhibitor ramipril prevented MI and other ischemic events in patients with a broad range of cardiovascular (CV) risks but no LV dysfunction or history of heart failure at baseline. The data from the HOPE trial suggest a greatly expanded role for ramipril in the prevention and management of CV disease.
Class Effects and Evidence-Based Medicine [Full text HTML]
C. D. Furberg, M.D., Ph.D.
Drugs grouped into a therapeutic class based on a common mechanism of action often have considerably different pharmacodynamic and pharmacokinetic properties. Among angiotensin-converting enzyme (ACE) inhibitors, differences include potency, whether the drug is an active compound or requires metabolic activation, lipophilicity, route(s) of elimination, and half-life. Although many clinical effects of ACE inhibitors are likely to be the same, there are possible quantitative differences among ACE inhibitors. Since the concept of "class effect" has no universally accepted definition, and subsequently should not form the basis for the practice of evidence-based medicine, untested drugs of a "class" should be considered unproven drugs.
This supplement was based in part on the symposium "Can We Prevent CHF?", presented at the 1999 annual meeting of the Heart Failure Society. It is sponsored by a grant from Monarch Pharmaceuticals, Inc.
The editorial content of supplements is reviewed by the guest editor and approved by C. Richard Conti, M.D., Editor-in-Chief of the Journal. The findings presented in this supplement are those of the contributors and not necessarily those of the sponsor, the publisher, or the editors of Clinical Cardiology.
Clinical judgment must guide each physician in weighing the benefits of treatment against the risk of toxicity. References made in the articles may indicate uses of drugs at dosages, for periods of time, and in combinations not included in the current prescribing information.