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The clinical diagnosis of heart failure is independent of aetiology. Treatment strategies are aimed at alleviation of symptoms with diuretics and digoxin, and the improvement of cardiac function and prognosis with vasodilators and angiotensin converting enzyme (ACE) inhibitors. The impact of aetiology on management has largely been ignored. Recent clinical trials have indicated that patients with idiopathic dilated cardiomyopathy may respond differently from those with left ventricular dysfunction due to ischaemic heart disease.
ACE inhibitors
Early studies of ACE inhibitors recruited patients according to the severity of symptoms or degree of left ventricular dysfunction without specifying cause. However, two studies suggested that the benefit of ACE inhibition was greater in patients with heart failure caused by non-ischaemic cardiomyopathy. The Second Veteran’s Cooperative Administration trial found a reduction in annual mortality rate to 14.1% in those with coronary artery disease and 10.7% in those without underlying ischaemia when treated with enalapril.1 In one of the SOLVD studies, treatment with enalapril resulted in a 12% risk reduction for death compared to placebo in patients with an ischaemic cause for left ventricular dysfunction, compared with a …