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A that also received the usual treatment for CHF, including digitalis, diuretics, and low-sodium diet, etc. In addition, there was a reduction in hospitalization for CHF in the ACE inhibitor group, as well as a reduction s you know, there have not, as yet, been any long-term clinical trials to answer the question regarding benefits of antihypertensive therapy with angiotensin converting enzyme (ACE) inhibitors or calcium channel blockers (CCB). in myocardial infarctions (MI) . There are several studies presently underway. There are A minority of patients in these trials were hypertensome data, however, in subsets of patients that demonsive—2,653 compared to 4,100 who were normotenstrate benefit with the ACE inhibitors and some controsive. In the subset of hypertensive subjects, there was versial data regarding the CCB. also a significant reduction in CHF, but other endTable 1 lists the clinical trials that have shown a point reductions that were statistically significant in benefit for reducing cardiovascular disease in treated the normotensive group failed to reach statistical sighypertensives. A statistically significant reduction in nificance in the hypertensive group; MI, angina, and morbidity and mortality from stroke, coronary artery total mortality were not reduced significantly in the disease, congestive heart failure (CHF) , and total carhypertensive subjects. There were some reductions, diovascular disease has been demonstrated. All of and it is quite possible that a study that included more these trials were diureticor b-blocker-based, and hypertensive patients would have yielded significant four compared a diuretic and a b-blocker. results. When cardiac endpoints were combined the ACE inhibitor-treated group showed a significant deRESULTS OF ACE INHIBITOR THERAPY IN crease (P õ .003) compared to placebo (Figure 1) . PATIENT SUBSETS The Survival and Ventricular Enlargement (SAVE) The use of ACE inhibitors has clearly improved the trial studied patients who had suffered a myocardial outlook for patients with CHF due to systolic dysfuncinfarction and had ejection fractions õ 40% in the tion and for patients with type I diabetic nephropathy. postinfarction period. Some had symptomatic heart In the Studies of Left Ventricular Dysfunction (SOLVD) failure, some did not. Captopril was the ACE inhibitor trial, patients with CHF, symptomatic or asymptomatic, that was used in this placebo-controlled trial. Signifiwith ejection fractions õ 35% who received an ACE cant risk reductions for death from cardiovascular inhibitor (enalapril ) in additional to a diuretic and digicauses, for recurrent MI, and for death from CHF were talis experienced a statistically significant reduction (P noted in the ACE inhibitor group. õ .0036) in mortality, compared to the placebo group Whether or not systolic dysfunction occurred after a myocardial infarction or whether it occurred for other reasons, the use of an ACE inhibitor ( in addition to a diuretic or digitalis in most instances) has been shown From the Cleveland Clinic Foundation, Cleveland, Ohio. Address correspondence and reprint requests to Ray W. Gifford, to prolong life, prevent recurrent CHF, and in some Jr., MD, Consultant, Department of Nephrology and Hypertension, cases prevent MI. Cleveland Clinic Foundation, 9500 Euclid Ave., KK30, Cleveland, OH 44195. A metaanalysis of 16 randomized trials demon-

Has the Use of Angiotensin Converting Enzyme Inhibitors and Calcium Channel Blockers Improved the Outcome for Hypertensive Patients?