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Original research
High-dose versus low-dose angiotensin converting enzyme inhibitors in heart failure: systematic review and meta-analysis
  1. Celina Borges Migliavaca1,2,
  2. Cinara Stein1,
  3. Verônica Colpani1,
  4. Bruna Eibel3,4,
  5. Roberta Bgeginski5,
  6. Marcus Vinicius Simões6,
  7. Luiz Eduardo Rohde7 and
  8. Maicon Falavigna1,2
  1. 1Institute for Education and Research, Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
  2. 2Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
  3. 3Post Graduate Program in Health Sciences: Cardiology, Instituto de Cardiologia/Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS, Brazil
  4. 4Fisioterapia, Centro Universitário da Serra Gaúcha, Caxias do Sul, RS, Brazil
  5. 5School of Kinesiology, Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
  6. 6Cardiology Division, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
  7. 7Cardiovascular Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
  1. Correspondence to Dr Celina Borges Migliavaca; celinabm7{at}


Objective To systematically review evidence comparing the effect of low-dose versus high-dose ACE inhibitors (ACEIs) on all-cause and cardiovascular mortality and hospitalisation, functional capacity and side effects in patients with heart failure (HF).

Methods We searched PubMed, Embase, Cochrane CENTRAL and LILACS up to January 2019. We included randomised controlled trials (RCTs) comparing low-dose versus high-dose ACEIs in adults with HF with reduced left ventricular ejection fraction (HFrEF). Study selection and data extraction were performed by two independent reviewers. Risk of bias was assessed with RoB 2.0, and quality of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE). We conducted random effects meta-analysis and trial sequential analysis.

Results We included eight RCTs (5829 patients with HF). In comparison with low-dose ACEIs, high-dose ACEIs showed a non-significant effect on all-cause mortality (8 RCTs, n=5828, relative risk (RR) 0.95, 95% CI 0.88 to 1.02; moderate quality of evidence), cardiovascular mortality (6 RCTs, n=4048, RR 0.93, 95% CI 0.85 to 1.01; moderate quality of evidence), all-cause hospitalisation (5 RCTs, n=5394, RR 0.95, 95% CI 0.82 to 1.10; moderate quality of evidence) and cardiovascular hospitalisation (4 RCTs, n=5242, RR 0.98, 95% CI 0.83 to 1.17; low quality of evidence). High-dose ACEI increased functional capacity (4 studies, n=555, standardised mean difference 0.38, 95% CI 0.20 to 0.55; low quality of evidence) and the risk of hypotension (4 RCTs, n=3783, RR 1.64, 95% CI 1.30 to 2.05; moderate quality of evidence). High-dose ACEI had no effect on dizziness (3 RCTs, n=4994, RR 1.37, 95% CI 0.97 to 1.93; low quality of evidence), but decreased the risk of cough (4 RCTs, n=5146, RR 0.85, 95% CI 0.73 to 0.98; moderate quality of evidence).

Conclusions The magnitude of benefit of using high dose versus low to intermediate doses of ACEIs might be less than traditionally suggested in clinical guidelines. These findings might help clinicians address the complex task of HF management in a more rational and timely fashion, saving efforts to implement strategies with the greatest net clinical benefit.

  • heart failure
  • heart failure treatment
  • angiotensin converting enzyme

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  • Contributors MF, LER and VC had the idea for this article. The concepts of this manuscript were discussed among all authors. BE and RB performed the literature search. CBM and CS conducted data analysis. CBM prepared the initial draft of the manuscript. Substantial revisions were made by all authors. MF and LER supervised the project. CBM and MF are the guarantors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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