The safety of enalapril upward titration in chronic heart failure

We investigated the safety of enalapril, an ACE inhibitor, upward titration in chronic heart failure with ejection fraction (EF) ≤0.40. Eleven patients who received digitalis, diuretics and enalapril (5 mg over 4 weeks) were enrolled and divided to two groups. Four patients were kept or enalapril 5 mg (Maintenance group) and seven patients were titrated upward to 10 mg (Titration group). These medications were continued for 3 months. There were no significant changes with regard to average values of 24h blood pressure, average counts of ventricular premature beats, left ventricular EF, left ventricular end-diastolic dimension (LVDd) and LVDs in either of the two groups. Although neurohormonal levels in the Maintenance group did not change significantly, brain natriuretic peptide (BNP) in the Titration group decreased significantly. There were no dropout patients in the Titration group, because the upward titration of enalapril did not decrease blood pressure and did not cause any adverse effects. Taking the results of the ATLAS study into account, we strongly support the suggestion that enalapril should be titrated upward in chronic heart failure with SBP≥90 mmHg.