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Background. Patients with congestive heart failure have a high mortality rate and are also hospitalized frequently. We studied the effect of an angiotensin-converting-enzyme inhibitor, enalapril, on mortality and hospitalizaron in patients with chronic heart failure and ejection fractions <=0.35.

Methods. Patients receiving conventional treatment for heart failure were randomly assigned to receive either placebo (n = 1284) or enalapril (n = 1285) at doses of 2.5 to 20 mg per day in a double-blind trial. Approximately 90 percent of the patients were in New York Heart Association functional classes II and III. The follow-up averaged 41.4 months.

Results. There were 510 deaths in the placebo group (39.7 percent), as compared with 452 in the enalapril group (35.2 percent) (reduction in risk, 16 percent; 95 percent confidence interval, 5 to 26 percent; P = 0.0036). Although reductions in mortality were observed in several categories of cardiac deaths, the largest reduction occurred among the deaths attributed to progressive heart failure (251 in the placebo group vs. 209 in the enalapril group; reduction in risk, 22 percent; 95 percent confidence interval, 6 to 35 percent). There was little apparent effect of treatment on deaths classified as due to arrhythmia without pump failure. Fewer patients died or were hospitalized for worsening heart failure (736 in the placebo group and 613 in the enalapril group; risk reduction, 26 percent; 95 percent confidence interval, 18 to 34 percent; P<0.0001).

Conclusions. The addition of enalapril to conventional therapy significantly reduced mortality and hospitalizations for heart failure in patients with chronic congestive heart failure and low ejection fractions. (N Engl J Med 1991; 325:293-302.)

: CONGESTIVE heart failure is a major and growing public health problem. About 2 million patients have congestive heart failure in the United States, and the number is expected to increase substantially in the next few decades.1 The one-year mortality ranges from 15 percent among relatively unselected patients2 to 50 percent among those in New York Heart Association functional class IV.3 About 35 percent of all patients with a diagnosis of congestive heart failure are hospitalized every year (unpublished data).

The Veterans Administration Cooperative Vasodilator Heart Failure Trial4 reported a lower mortality in patients with congestive heart failure treated with hydralazine [horizontal ellipsis]

Owned, published, and (C) copyrighted, 1991, by the MASSACHUSETTS MEDICAL SOCIETY