How do ACE inhibitors reduce mortality in patients with left ventricular dysfunction with and without heart failure: remodelling, resetting, or sudden death?

The benefits of ACE inhibitors as standard treatment for patients with overt heart failure due to ventricular dilatation and systolic dysfunction are proved beyond reasonable doubt, at least when a diuretic has been used to control symptoms. More recent studies have suggested that ACE inhibitors may delay or prevent the onset of heart failure requiring diuretics in patients with obviously impaired ventricular function.' 2 However, although the benefits of ACE inhibitors in clinical practice are well established, the mechanisms underlying the beneficial effect at the cellular, organ, and clinical level are poorly characterised. Other articles in this supplement have dealt with the more basic mechanisms underlying ACE inhibitor action. In this article we reevaluate the clinical nature of left ventricular remodelling and consider to what extent it accounts for the beneficial effects of ACE inhibitors on outcome in patients with established ventricular dysfunction with or without heart failure.