1. Heart Failure- Evidence for use of ace inhibitors & betablockers ACE Inhibiitors CONSENSUS(NEJM 87) & SOLVED (NEJM 91) included in Metaanalysis 7000pts Decreased risk of mortality Most benefit with EF<25% Trend towards reduced MI, sudden cardiac death & CVA Doses Rx in primary care were lower than recommended ALTAS ’99higher doses of lisinopril did better with SE’s not increased on higher doses 2.5-5 mg /day vs 32.5-35- 8% lower death(p=0.128 & 24%less hospitalisations(p=0.002)

2. ARB(angiotensin 2 antagonist) ELITE (evaluation of losartan in elderly) Lancet 97 ELITE 1 – less morbitity & mortality than captopril Death & hospitalisation for heart failure 9.4% (losa.) Vs 13.2% (capt) NNT 26 Elite 2 (lancet 2000) Insufficient datat to recommend ARB as 1 st line Rx Stuides on going about using these in conjunction with Ace inhibitors

3. Beta blockers Originally CI Cardiac Insufficiency Bisoprolol Study 2 (Fundadam Clin Pharm 97)relative risk reduction 35 % in NYHA 3-5 Carvedilol Heart Failure study (NEJM 96)- mortality rate over an average 6.5/12 3.2 Vs 7.8% in control MERIT-HF Lancet 99 Metoprolol (CR/XL randomised intervention Relative risk reduction 94%, improved survival, functional class & well being when added to standard Rx