to the editor: We read with great interest the review article entitled “Spironolactone in Left-Sided Heart Failure: How Does it Fit in?”¹ However, we were surprised by the notable omission of perindopril (Aceon) in Table 4 (“Agents used to decrease mortality in patients with heart failure”) and by the equally notable appearance of moexipril (Univasc) in the context of heart failure. The majority of review articles relating to pharmacotherapy that have appeared in American Family Physician are balanced and accurate; although the review by Margo and colleagues¹ is generally informative, we feel that a brief comment is warranted.

A thorough review of the biomedical literature (Ovid Technologies, Medline 1963 through September 2001) regarding the role of moexipril in heart failure yields a single citation of moexipril use in induced ischemic heart failure in rats.² Conversely, although perindopril is not labeled by the U.S. Food and Drug Administration for the treatment of congestive heart failure, its ability to ameliorate mild to moderate or severe³ heart failure⁴ of both ischemic and nonischemic origin is well established in fairly large randomized placebo-controlled trials. Further, determining the most effective angiotensin-converting enzyme (ACE) inhibitor in heart failure requires a critical assessment of these data because the biology of ACE inhibition in the setting of heart failure⁵ varies within the ACE-inhibitor drug class.⁶

We agree with the authors¹ that spironolactone can be beneficial in improving the neurohormonal and biophysical properties of the peripheral vasculature in the physiopathology of heart failure, and may exhibit synergy with tissue type ACE inhibitors. However, the disparity in the evidence base for individual ACE inhibitors should be considered by authors and practicing physicians.