Skip to content
evident
Original paper
1991NEJMCardiology

SOLVD Treatment

Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure

RCTHFrEF

On this page

Overview

Enalapril reduced mortality in symptomatic HFrEF.

Clinical takeaway

SOLVD Treatment is foundational HFrEF evidence: neurohormonal blockade with ACE inhibition improves survival, not just symptoms.

Key result

All-cause mortality was 35.2% with enalapril vs 39.7% with placebo (risk reduction 16%; 95% CI 5-26%; P=0.0036).

Practice impact

ACE inhibitors became core disease-modifying therapy for HFrEF.

Evidence

Study design

Randomized, double-blind, placebo-controlled trial.

Enrollment

2,569

Follow-up

Mean 41.4 months.

Geography

United States, Canada, Belgium

Clinical question

Does enalapril improve survival in patients with symptomatic left ventricular systolic dysfunction?

Population

  • Patients with congestive heart failure and left ventricular ejection fraction <=35%.

Intervention

Enalapril 2.5-20 mg daily added to conventional therapy.

Comparator

Placebo added to conventional therapy.

Primary outcome

All-cause mortality.

Enalapril reduced mortality in symptomatic patients with reduced ejection fraction.

Relative risk reduction / 16 / 95% CI 5-26% / p=0.0036

Key results

  • All-cause mortality was lower with enalapril: 35.2% vs 39.7%; risk reduction 16%; 95% CI 5-26%; p=0.0036.
  • Deaths due to progressive heart failure were reduced (risk reduction 22%; 95% CI 6-35%), with little apparent effect on arrhythmic deaths without pump failure.
  • Death or hospitalization for worsening heart failure was reduced (risk reduction 26%; 95% CI 18-34%; p<0.0001).
  • Hospitalization for heart failure was reduced.

Harms

  • ACE inhibitor cough, hypotension, hyperkalemia, renal function changes, and rare angioedema require monitoring.

Clinical Use

Practice impact

  • Established ACE inhibitors as survival-improving therapy for symptomatic HFrEF.

Applicability

  • Symptomatic HFrEF patients who can tolerate RAAS inhibition.

Limitations

  • Pre-beta blocker, ARNI, MRA, and SGLT2 era.
  • Modern therapy often uses ARNI instead of ACE inhibitor when tolerated.

Common misinterpretations

  • Do not treat ACE inhibitors as only blood-pressure drugs in HFrEF; their role is disease modification.

Related evidence

PARADIGM-HF - Later TrialMERIT-HF - Same Disease

Citation

SOLVD Investigators, Yusuf S, Pitt B, Davis CE, Hood WB, Cohn JN. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med. 1991;325(5):293-302. doi:10.1056/NEJM199108013250501

The addition of enalapril to conventional therapy significantly reduced mortality and hospitalizations for heart failure in patients with chronic congestive heart failure and reduced ejection fractions.