Comparison of Angiotensin-Converting Enzyme Inhibitor (ACEI) and Angiotensin Receptor Blocker (ARB) for Heart Failure Treatment in Congenital Heart Diseases with Left-to-Right Shunt

Alit Utamayasa, Mahrus Ahmad Rahman, Teddy Ontoseno, Budiono budiono


BACKGROUND: The angiotensin-converting enzyme inhibitors (ACEIs) have become the forefront of heart failure treatment for more than a decade. Currently, angiotensin receptor blockers (ARBs) are thought to have similar effectiveness. This study aimed to compare the impact of captopril, one of ACEI, and valsartan, one of ARB, on clinical presentation and echocardiographic, electrocardiographic, and chest x-ray improvement in patients with left-to-right shunt congenital
heart diseases.

METHODS: This study used a double-blind randomized controlled trial of captopril and valsatran to children with left-to-right shunt congenital heart diseases who suffer from heart failure in the Dr. Soetomo General Hospital, Surabaya, Indonesia. Pediatric heart failure scores, echocardiography, electrocardiography (ECG), and chest photographs were examined at the beginning of the study and after 30 days of treatment.

RESULTS: A decrease in pediatric heart failure scores were showed after the administration of ACEI (7.06±2.04 vs. 4.75±2.43; p<0.0001; 95% CI: −2.98 - 1.65); ARB (6.81±2.25 vs. 3.94±1.98; p<0.0001; 95% CI: −3.76 to 1.98). The echocardiography examination, an increase in left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), % fractional shortening (FS), and left ventricular (LV) dimension occurred after the administration of ACEI and ARB. The values also didn’t significantly differrent between the two groups. The ECG evaluation showed a decrease in heart rate frequency after the administration of ACEI (117.75±14.67 vs. 109.63±17.59; p=0.039; 95% CI: −15.78 to −0.46) and ARB (117.10±21.86 vs.108.6±20.66; p=0.006; 95% CI: −14.17 to −2.83).

CONCLUSION: ARB showed better outcome in clinical condition, echocardiography, ECG, and chest radiographs.

KEYWORDS: captopril, valsartan, heart failure, congenital heart disease, left to right shunt


Full Text:



Hinton RB, Ware SM. Heart failure in pediatric patients with congenital heart disease. Circ Res. 2017; 120: 978-94, CrossRef.

Murni IK, Musa NL. The need for specialized pediatric cardiac critical care training program in limited resource settings. Front Pediatr. 2018; 6: 59, CrossRef.

Yun SW. Congenital heart disease in the newborn requiring early intervention. Korean J Pediatr. 2011; 54: 183-91, CrossRef.

Begg S, Thompson A, Nash R, Tompson A, Peterson G. Cardiac Failure in Children. 17th Expert Committee on the Selection and Use of Essential Medicines. Geneva: WHO; 2009, article.

McMurray JJ, Östergren J, Swedberg K, Granger CB, Held P, Michelson EL, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial. Lancet. 2003; 362: 767-71, CrossRef.

Flynn JT, Meyers KEC, Neto JP, de Paula Meneses R, Zurowska A, Bagga A, et al. Efficacy and safety of the angiotensin receptor blocker valsartan in children with hypertension aged 1 to 5 years. Hypertension. 2008; 52: 222-8, CrossRef.

Läer S, Mir TS, Behn F, Eiselt M, Scholz H, Venzke A, et al. Carvedilol therapy in pediatric patients with congestive heart failure: A study investigating clinical and pharmacokinetic parameters. Am Heart J. 2002; 143: 916-22, CrossRef.

Park MK. Pediatric Cardiology for Practitioners. 5th ed. Philadelphia: Mosby; 2008, NLMID.

Shaffer EM. Quantitative echocardiography. In: Cruz LM, Cayre RO, editors. Echocardiographic Diagnosis of Congenital Heart Disease: An Embryologic and Anatomic Approach. Philadelphia: Lippincott-Raven; 1999. p.85-8, NLMID.

Hartupee J, Mann DL. Neurohormonal activation in heart failure with reduced ejection fraction. Nat Rev Cardiol. 2017; 14: 30-8, CrossRef.

Bhakta S, Dunlap ME. Angiotensin-receptor blockers in heart failure: evidence from the CHARM trial. Clev Clin J Med. 2004; 71: 665-73, CrossRef.

Konstam MA, Kramer DG, Patel AR, Maron MS, Udelson JE. Left ventricular remodeling in heart failure. JACC Cardiovasc Imaging. 2011; 4: 98-108, CrossRef.

Pitt B, Poole-Wilson PA, Segal R, Martinez FA, Dickstein K, Camm AJ, et al. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the Losartan Heart Failure Survival Study ELITE II. Lancet. 2000; 3550: 1582-7, CrossRef.

Cohn JN. Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med. 2001; 345: 1667-75, CrossRef.

Kasama S, Toyama T, Kumakura H, Takayama Y, Ichikawa S, Suzuki T, et al. Addition of valsartan to an angiotensin-converting enzyme inhibitor improves cardiac sympathetic nerve activity and left ventricular function in patients with congestive heart failure. J Nucl Med. 2003; 44: 884-90, PMID.

Yasunari K, Maeda K, Nakamura M, Watanabe T, Yoshikawa J, Hirohashi K. Left ventricular hypertrophy and angiotensin II receptor blocking agents. Curr Med Chem Cardiovasc Hematol Agents. 2005; 3: 61-7, CrossRef.

Mehta PK, Griendling KK. Angiotensin II cell signaling: physiological and pathological effects in the cardiovascular system. Am J Physiol Cell Physiol. 2007; 292: C82-97, CrossRef.

Mori Y, Nakazawa M, Tomimatsu H, Momma K. Long-term effect of angiotensin-converting enzyme inhibitor in volume overloaded heart during growth: a controlled pilot study. J Am Coll Cardiol. 2000; 36: 270-5, CrossRef.

Maggioni AP, Anand I, Gottlieb SO, Latini R, Tognoni G, Cohn JN. Effects of valsartan on morbidity and mortality in patients with heart failure not receiving angiotensin-converting enzyme inhibitors. J Am Coll Cardiol. 2002; 40: 1414-21, CrossRef.

Funabiki K, Onishi K, Dohi K, Koji T, Imanaka-Yoshida K, Ito M, et al. Combined angiotensin receptor blocker and ACE inhibitor on myocardial fibrosis and left ventricular stiffness in dogs with heart failure. Am J Physiol Heart Circ Physiol. 2004; 287: H2487-92, CrossRef.

Picca M, Agozzino F, Pelosi G. Effects of losartan and valsartan on left ventricular hypertrophy and function in essential hypertension. Adv Ther. 2004; 21: 76-86, CrossRef.

Shigenaga A, Tamura K, Dejima T, Ozawa M, Wakui H, Masuda S, et al. Effects of angiotensin II type 1 receptor blocker on blood pressure variability and cardiovascular remodeling in hypertensive patients on chronic peritoneal dialysis. Nephron Clin Pract. 2009; 112: c31-40, CrossRef.

Tonkon M, Awan N, Niazi I, Hanley P, Baruch L, Wolf RA, et al. A study of the efficacy and safety of irbesartan in combination with conventional therapy, including ACE inhibitors, in heart failure. Irbesartan Heart Failure Group. Int J Clin Pract. 2000; 54: 11-4, 16-8, PMID.

Lee VC, Rhew DC, Dylan M, Badamgarav E, Braunstein GD, Weingarten SR. Meta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction. Ann Intern Med. 2004; 141: 693-704, CrossRef.


Indexed by:






The Prodia Education and Research Institute