• Multicenter, randomized, double-blind, placebo controlled trial
• 4228 patients, age 21-80 with asymptomatic left ventricular dysfunction and not receiving the following for heart failure: diuretics, digoxin or vasodilators.
• However, permitted for the following indications: digoxin (atrial fibrillation), diuretics (hypertension), nitrates (angina).
• Baseline characteristics: mean LVEF 0.28, 67% NYHA class I, 33% NYHA class II, 1/3 had angina, 74% of patients not receiving diuretics of digoxin

• valvular disease requiring surgery, unstable angina, angina with possible revascularization, MI within one month
• severe pulmonary disease, serum creatinine >177 µmol/L
• >80 years of age, any other clinically significant coexisting condition which would shorten or impede completion of trial

• Enalapril 2.5 or 5 mg twice daily, titrated to optimal dose of 10 mg twice daily (as tolerated by patient and physician’s discretion) vs. placebo.
• Follow-up at week 2, 6, month 4 and then every four months until completion of trial – if worsening heart failure, then treatment at determined by the physician

Enala- pril n=2111	Placebo n=2117	Risk Reduc- tion	p
Death from all causes
14.8%	15.8%	8% (-8 - 21%)	0.30
CV death
12.6%	14.1%	12% (-3 - 26%)	0.12
Death or CHF hospitalization
20.6%	24.5%	20% (9 - 30%)	<0.001

• Enalapril also statistically significantly reduced (<0.001): development of CHF by 37%, development of CHF and anti-CHF therapy by 43%, first CHF hospitalization by 36%, multiple CHF hospitalizations by 44%, death or development of HF by 29%
• Median time to development of CHF, 8.3 (placebo) vs. 22.3 months (enalapril) and median time to first CHF hospitalization, 13.2 (placebo) vs. 27.8 months (enalapril)