Effect of certain angiotensin-converting enzyme inhibitors on mortality in heart failure: A multiple-propensity analysis

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Heart failure is a major and growing public health problem in United States. There is a substantial evidence about efficacy of angiotensin-converting enzyme inhibitors (ACEIs) in heart failure (HF); however, there is no conclusive evidence on the relative effectiveness of individual ACEIs.


To evaluate the effect of individual ACEIs on mortality using multiple-propensity score analysis in a large real-world population.


The study was a retrospective analysis of a national cohort of patients with HF identified from the Department of Veterans Affairs. A multiple-propensity score analysis was used to balance 47 baseline patient characteristics between different nontissue ACEIs. The effect of different ACEIs on time to death was assessed using a propensity score-weighted, multivariable Cox proportional hazard model.


The study included 139,994 patients with 69.50% (97,293) on lisinopril, 21.79% (30,503) on fosinopril, 8.41% (11,775) on captopril, and 0.30% (423) on enalapril. Propensity scores balanced nearly all differences between different ACEI groups. Fosinopril (hazard ratio [HR] = 0.739, 95% confidence interval [CI]: 0.686–0.797) and lisinopril (HR = 0.818, 95% CI: 0.766–0.874) were significantly associated with reduced mortality as compared with captopril. Similar mortality was observed with enalapril (HR = 0.944, 95% CI: 0.675–1.320) as compared with captopril.


In patients with HF, fosinopril and lisinopril were associated with lower mortality as compared with captopril. However, the results of this observational study should be interpreted with caution, and need to be replicated and confirmed in studies for which HF severity data are available.

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