Expert consensus document on angiotensin converting enzyme inhibitors in cardiovascular diseaseThe Task Force on ACE-inhibitors of the European Society of Cardiology

Abstract

ESC Committee for Practice Guidelines (CPG), Silvia G. Priori (Chairperson) (Italy), Maria Angeles Alonso García (Spain), Jean-Jacques Blanc (France), Andrzej Budaj (Poland), Martin Cowie (UK), Veronica Dean (France), Jaap Deckers (The Netherlands), Enrique Fernandez Burgos (Spain), John Lekakis (Greece), Bertil Lindahl (Sweden), Gianfranco Mazzotta (Italy), Keith McGregor (France), João Morais (Portugal), Ali Oto (Turkey), Otto A. Smiseth (Norway) Document Reviewers, Maria Angeles Alonso García (CPG Review Coordinator) (Spain), Diego Ardissino (Italy), Cristina Avendano (Spain), Carina Blomström-Lundqvist (Sweden), Denis Clément (Belgium), Helmut Drexler (Germany), Roberto Ferrari (Italy), Keith A. Fox (UK), Desmond Julian (UK), Peter Kearney (Ireland), Werner Klein (Austria), Lars Köber (Denmark), Giuseppe Mancia (Italy), Markku Nieminen (Finland), Witold Ruzyllo (Poland), Maarten Simoons (The Netherlands) Kristian Thygesen (Denmark), Gianni Tognoni (Italy), Isabella Tritto (Italy), Lars Wallentin (Sweden) Guidelines and Expert Consensus documents aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and by different organisations and other related societies. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents. In spite of the fact that standards for issuing good quality Guidelines and Expert Consensus Documents are well defined, recent surveys of Guidelines and Expert Consensus Documents published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. The ESC Committee for Practice Guidelines (CPG) supervises and coordinates the preparation of new Guidelines and Expert Consensus Documents produced by Task Forces, expert groups or consensus panels. The chosen experts in these writing panels are asked to provide disclosure statements of all relationships they may have which might be perceived as real or potential conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. The Committee is also responsible for the endorsement of these Guidelines and Expert Consensus Documents or statements. The Task Force has classified and ranked the usefulness or efficacy of the recommended procedure and/or treatment and the Level of Evidence as indicated in the tables below: Class I. Evidence and/or general agreement that a given procedure/treatment is beneficial, useful and effective. Class II. Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the procedure/treatment. Class IIa. Weight of evidence/opinion is in favour of usefulness/efficacy. Class IIb. Usefulness/efficacy is less well established by evidence/opinion. Class III*. Evidence or general agreement that the treatment is not useful/effective and in some cases may be harmful. *Use of class III is discouraged by the ESC. Level of Evidence A. Data derived from multiple randomised clinical trials or meta-analyses. Level of Evidence B. Data derived from a single randomised clinical trials or non-randomised studies. Level of Evidence C. Consensus of opinion of the experts and/or small studies. The renin-angiotensin system plays a major role in cardiovascular disease and during the past decade extensive research investigated the possible clinical benefit of the use of angiotensin converting enzyme inhibitors (ACE-I) in different clinical conditions. Accordingly, these agents have been recommended for the treatment of heart failure, hypertension, and acute and chronic myocardial infarction. The aim of this document is to review the rationale and clinical evidence for the use of ACE-I in patients with cardiovascular disease. The Task Force members for the Angiotensin Converting Enzyme Inhibitors in Cardiovascular Disease were nominated by the Committee for Practice Guidelines (CPG) of the European Society of Cardiology (ESC). A specific literature search was carried out for original articles in peer review journals included in Medline. In addition, the ESC as well as the American Heart Association/American College of Cardiology guidelines with reference to the use of ACE-I were carefully reviewed. Most of the previ