To evaluate the influence of the
angiotensin-converting enzyme inhibitor,
enalapril (2.5 to 40 mg/day), on the prognosis of severe
congestive heart failure, defined as New York Heart Association functional class IV, a double-blind study was undertaken in which 253 patients were randomized to receive either placebo (n = 126) or
enalapril (n = 127) in addition to conventional treatment, including
vasodilators. Follow-up averaged 188 days (range 1 day to 20 months). The reduction in crude mortality within 6 months (primary objective) was 40% in the
enalapril-treated group (from 44 to 26%, p = 0.002) and within 1 year 31% (p = 0.001). By the end of the study, 68 subjects in the placebo group and 50 in the
enalapril group had died--a reduction of 27% (p = 0.003). The entire reduction in total mortality (50%) was found in patients dying from progressive
heart failure, whereas no difference was seen in the incidence of
sudden cardiac death. There was a significant improvement in New York Heart Association classification in the
enalapril group, together with a reduction in heart size and a reduced requirement for other
heart failure medication. It is concluded that the addition of
enalapril to conventional
therapy in patients with severe
congestive heart failure can reduce mortality and improve symptoms. The effect seems to be due to a reduction in death from progression of
heart failure.