Supramaximal Titrated Inhibition of RAAS in Dilated Cardiomyopathy

Inclusion criteria

• Diagnosis of dilated cardiomyopathy
• Left ventricular ejection fraction < 35%
• NYHA Functional classes of II-IV
• Symptomatic but not rapidly deteriorating 1 month before enrollment
• Signed informed consent

Exclusion criteria

• Contradictions and intolerance of the studied drugs:

• supine systolic arterial blood pressure < 90 mmHg,
• renal artery stenosis >50%,
• pregnancy or lactation,
• impaired renal function (estimated glomerular filtration rate < 60 ml/min/1.73m2,
• impaired liver function (total bilirubin >2 times upper limit of normal,
• serum aspartate AST or alanine ALT >3 times the upper limit of normal),
• hemoglobin less than 8 mg/dl, hyperkalaemia (serum potassium >5.5mmol/l),
• obstructive lung disease,
• advanced atrioventricular block,
• any co-morbidity with impact on survival, and
• known intolerance to benazepril, valsartan and metoprolol succinate;
• HF secondary to a known cause:

• coronary artery disease based on coronary angiography (≥50% stenosis in ≥1 of the major coronary arteries) and/or a history of myocardial infarction or angina pectoris,
• acute or subacute stage of myocarditis,
• primary valve disease,
• diabetes mellitus,
• excessive use of alcohol or illicit drugs;
• Expected or performed cardiac resynchronization therapy and heart transplantation.