Am Fam Physician. 2002 May 1;65(9):1742-1752.
to the editor: We read with great interest the review article entitled “Spironolactone in Left-Sided Heart Failure: How Does it Fit in?”1 However, we were surprised by the notable omission of perindopril (Aceon) in Table 4 (“Agents used to decrease mortality in patients with heart failure”) and by the equally notable appearance of moexipril (Univasc) in the context of heart failure. The majority of review articles relating to pharmacotherapy that have appeared in American Family Physician are balanced and accurate; although the review by Margo and colleagues1 is generally informative, we feel that a brief comment is warranted.
A thorough review of the biomedical literature (Ovid Technologies, Medline 1963 through September 2001) regarding the role of moexipril in heart failure yields a single citation of moexipril use in induced ischemic heart failure in rats.2 Conversely, although perindopril is not labeled by the U.S. Food and Drug Administration for the treatment of congestive heart failure, its ability to ameliorate mild to moderate or severe3 heart failure4 of both ischemic and nonischemic origin is well established in fairly large randomized placebo-controlled trials. Further, determining the most effective angiotensin-converting enzyme (ACE) inhibitor in heart failure requires a critical assessment of these data because the biology of ACE inhibition in the setting of heart failure5 varies within the ACE-inhibitor drug class.6
We agree with the authors1 that spironolactone can be beneficial in improving the neurohormonal and biophysical properties of the peripheral vasculature in the physiopathology of heart failure, and may exhibit synergy with tissue type ACE inhibitors. However, the disparity in the evidence base for individual ACE inhibitors should be considered by authors and practicing physicians.
1. Margo KL, Luttermoser G, Shaughnessy AF. Spironolactone in left-sided heart failure: how does it fit in?. Am Fam Physician. 2001;64:1393–9,1399
2. Stauss HM, Zhu YC, Redlich T, Adamiak D, Mott A, Kregel KC, et al. Angiotensin-converting enzyme inhibition in infarct-induced heart failure in rats: bradykinin versus angiotensin II. J Cardiovasc Risk. 1994;1:255–62.
3. Flammang D, Waynberger M, Chassing A. Acute and long-term efficacy of perindopril in severe chronic congestive heart failure. Am J Cardiol. 1993;71:48E–56E.
4. Cleland JG, Tendera M, Adamus J, Freemantle N, Gray CS, Lye M, et al. Perindopril for elderly people with chronic heart failure: the PEP-CHF study. The PEP investigators. Eur J Heart Fail. 1999;1:211–7.
5. Sami MH. Distinctive properties of perindopril among converting enzyme inhibitors in congestive heart failure. Can J Cardiol. 1994;10(Suppl D):13D–6D.
6. Thuillez C, Richard C, Loueslati H, Auzepy P, Giudicelli JF. Systemic and regional hemodynamic effects of perindopril in congestive heart failure. J Cardiovasc Pharmacol. 1990;15:527–35.
editor's note: This letter was sent to the authors of “Spironolactone in left-sided heart failure: how does it fit in?,” who declined to reply.
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