• Michel Komajda, Beatrix Lutiger, Hugo Madeira, Kristian Thygesen, Marco Bobbio, Per Hildebrandt, Wybren Jaarsma, Günter Riegger, Lars Rydén, Armin Scherhag, Jordi Soler-Soler, Willem J Remme, and CARMEN investigators and co-ordinators.
• Institut de Cardiologie, Centre Hospitalier GH Pitié-Salpêtrière, 47-83 Bld de l'Hôpital, 75013, Paris Cedex 13, France. Veronique.villareal@chups.jusssieu.fr
• Eur. J. Heart Fail. 2004 Jun 1; 6 (4): 467-75.

BackgroundManagement guidelines for heart failure recommend ACE-I and beta-blockers. The perception of difficult up-titration might have added to the slow uptake of beta-blockers despite their mortality and morbidity benefits.AimsCARMEN offered a possibility to study safety and tolerability of enalapril against carvedilol and their combination.MethodsFive hundred and seventy-two patients were blindly up-titrated on carvedilol (target 25 mg bid) and/or enalapril (target 10 mg bid), and continued for 18 months. In the combination arm, carvedilol was up-titrated before enalapril.ResultsThere was no group related difference in adverse events during up-titration. Withdrawal rates were 31, 30 and 30%, and serious adverse events 28, 29 and 34% in the combination, carvedilol and enalapril arms. Mortality was similar in all groups (all-cause N=14, 14 and 14; cardiovascular N=9, 13 and 14). All-cause and cardiovascular hospitalizations occurred in 26, 27 and 32%, and in 12, 16 and 22% in the combination, carvedilol and enalapril arms, respectively.ConclusionThe safety profile was similar in all treatment arms. In contrast to common perception, there was no difference in tolerability between the ACE-I and carvedilol. This result is even more remarkable as the high prestudy use of ACE-I (65%) might have introduced a bias by selecting ACE-I tolerant patients, who were only switched from their former ACE-I to enalapril.

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