Efficacy and safety of high-dose lisinopril in chronic heart failure patients at high cardiovascular risk, including those with diabetes mellitus. Results from the ATLAS trial

Cardiomyopathy and heart failure in diabetes

Patients with insulin resistance or type 2 diabetes have a particularly high risk for heart failure and a poor prognosis once they develop heart failure. The choice of drugs for the management of heart failure in these patients should be directed at changing the natural history of the disease. The various drugs available for the treatment of heart failure, including ACE inhibitors and beta-adrenergic blockers, are known to be beneficial and should be given as first-line agents. Aggressive risk-factor modification and tight blood pressure and glycemic control are crucial. Much work is needed to establish the safety and efficacy of various oral antidiabetic agents, especially the TZDs, for which the theoretic benefits are substantial and overall morbidity and mortality impact remain ill-defined.

Dose response of ACE inhibitors: implications of the SECURE trial

The choice of the appropriate dosage of ACE inhibitor in clinical practice is an important one. The available evidence suggests that in chronic heart failure as well as in chronic coronary artery disease, high doses of angiotensin-converting enzyme (ACE) inhibitor are more effective than low ones. The current recommended clinical approach is to target ACE inhibitor dosing regimens to be similar to those used in the clinical trials, which demonstrated mortality and morbidity benefits. When titrated appropriately, ACE inhibitors are generally well tolerated and target doses can be achieved and maintained in the majority of patients with atherosclerotic vascular disease, with or without heart failure.