Prevention

Why?

• Patients on 35 mg of lisinopril daily compared with 5 mg are less likely to die or be hospitalised, or stop medication. Though dizziness, hypotension and worsening renal failure are more common, worsening heart failure and cough is less common with higher doses. ^a
• Patients on 60 mg of enalapril daily compared with 20 mg daily are not clearly less likely to die or be admitted to hospital. ^d

ACE inhibitors reduce death and hospitalisation

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
heart failure a NYHA class II to IV	lisinopril 32.5 mg to 35 mg daily	lisinopril 2.5 mg to 5 mg daily	death or hospitalisation at 45 months	84%	5% (2% to 8%)	24 (15 to 70)
			discontinued medication at 45 months	31%	11% (1% to 20%)	29 (15 to 400)
			worsening heart failure at 45 months	44%	15% (7% to 22%)	15 (10 to 32)
			dizzinesss at 45 months	12%	-57% (-85% to -33%)	-15 (-23 to -11)
			hypotension at 45 months	6.7%	-61% (-100% to -27%)	-25 (-47 to -17)
			worsening renal function at 45 months	7.0%	-41% (-78% to -12%)	-35 (-110 to -21)
			cough at 45 months	13%	20% (3% to 34%)	38 (20 to 260)
			hyperkalaemia at 45 months	3.5%	-82% (-150% to -32%)	-35 (-73 to -23)
			hypokalaemia at 45 months	3.3%	58% (31% to 74%)	52 (34 to 120)

• It reduces death compared with isosorbide-mononitrate and hydralazine ^a and is more cost-effective. ^a

Enalapril reduces death and treatment withdrawal better than isosorbide-mononitrate and hydralazine

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
men with chronic heart failure a	enalapril	isosorbide-dinitrate and hydralazine	death at 2 years	25%	28% (6% to 45%)	14 (8 to 70)
			medication stopped at 5 years	29%	24% (3% to 40%)	15 (8 to 120)