Angiotensin converting enzyme inhibition in cardiovascular risk populations: a practical approach to identify the patient who will benefit most

PURPOSE OF REVIEW: Evidence from clinical trials suggests that angiotensin converting enzyme (ACE) inhibition has the broadest impact of any class of drugs in cardiovascular medicine, reducing cardiovascular morbidity and mortality. This beneficial effect varies across different patient populations, however. This review will summarize the current literature about the therapeutic potential of ACE inhibition and provide a practical approach for clinicians to identify patients who benefit most from ACE inhibition. RECENT FINDINGS: ACE inhibition has been shown to benefit patients with heart failure, left ventricular dysfunction, postmyocardial infarction, nephropathy, peripheral vascular disease, diabetes, stroke or transient ischemic attack. The absolute clinical benefit varies across different risk populations, however, depending on the patient characteristics. ACE inhibitors are most effective in patients with an increased cardiovascular risk associated with an activated renin-angiotensin system and less effective in patients with classical cardiovascular risk factors, but without an activated renin-angiotensin system. SUMMARY: We argue that markers of an activated renin-angiotensin system, such as left ventricular dysfunction, left ventricular hypertrophy, renal dysfunction, as assessed by estimated glomerular filtration rate, or urinary albumin excretion, may be used as targets and act as indicators for ACE-inhibition therapy and also for monitoring purposes. This will help clinicians to guide their therapy and identify patients who benefit most from ACE inhibition.