summarize the major results of the different studies published concerning the interaction between ACE-Is and aspirin. Compared to previous studies, ours has several specific features. First, it is a single-center study with the same kind of management used for all patients with CHF. Although it is a retrospective analysis, the data were collected prospectively, and the population represents consecutive patients referred to our institution. Thus, there is less likelihood of a selection bias, as might be observed in mortality trials. In addition, the number of patients (three patients) lost to follow-up was very low. Second, for the vast majority of the patients, the presence of coronary artery disease was assessed by coronary angiography, which was not required in other studies to define the cardiomyopathy. Thus, we knew exactly the coronary status of our patients. Third, all our patients had CHF that was related to left ventricular systolic dysfunction. The CONSENSUS II,4
the GUSTO-1/EPILOG trials,6
and the meta-analysis of the ACE-I Myocardial Infarction Collaborative Group13
involved patients with acute myocardial infarction with or without left ventricular systolic dysfunction. In these studies, if patients had heart failure, it was CHF, which has a different pathophysiology than acute chronic heart failure, as in our patients. In the GUSTO-1 study, no patient had CHF, and in the EPILOG study there were only 394 patients with LVEF ≤ 45%, of whom 164 had used a combination of aspirin and ACE-Is. Our patients with ischemic cardiomyopathy had stable coronary artery disease. Patients with recent acute coronary syndromes or recent coronary revascularization were not included in the study because cardiopulmonary exercise testing is always performed with patients in a stable condition. In the BIP registry, the 464 patients with heart failure were defined with an NYHA classification of grade 2 or greater.12
It is possible that in some patients, dyspnea was related to left ventricular diastolic dysfunction or to noncardiac diseases. Similarly, in several other studies, systematic echocardiography was not required to define CHF.18–20
In the Heart Outcomes Prevention and Evaluation study,17
patients with atherosclerosis who were at risk for an ischemic event were included in the study, but patients with CHF were excluded. All of our patients had systolic dysfunction with a LVEF of ≤ 45%.