OBJECTIVES: ACE inhibitors are a potent therapy for congestive heart failure associated with left ventricular dysfunction and hypertension. Taking a hospital perspective, we report an update of a previous analysis of the health economic consequences of treating these hypertensive patients with enalapril in the Canadian setting. METHODS: A decision analytic model was used to project survival probabilities and hospitalization rates beyond the trial observation period (5 years) using a secondary analysis of a subset of 1917 hypertensive patients with or without overt symptoms of congestive heart failure from the Studies of Left Ventricular Dysfunction (SoLVD). Patients who had HBP, defined by either an elevated systolic (140 mm Hg) or diastolic (90 mm Hg) blood pressure were selected for this study. We updated the model with Canadian cost inputs for fatal and non-fatal hospitalization, ambulatory care, death outside of the hospital, and enalapril for year 2003. Costs and benefits were discounted at a 5% annual rate. RESULTS: Over a projected 5-year period, patients treated primarily with enalapril twice-daily gained 0.18 life-years and experienced 0.4 fewer hospitalizations per patient compared to those receiving placebo. Over their lifetimes, patients treated with enalapril were projected to gain 2.14 life-years and experience 0.36 fewer hospitalizations. The incremental cost-utility ratios for enalapril versus placebo shown net cost savings of CAN$2309 over 5 years and CAN$3552 per QALY gained over patients' lifetimes. For the subset of patients with overt symptoms of congestive heart failure, enalapril was cost saving in both the 5-year and lifetime projections. These results were not sensitive to changes in model parameters. CONCLUSION: Enalapril treatment for hypertensive patients with left ventricular dysfunction is projected to extend life expectancy, reduce hospitalizations, and to be either cost saving or highly cost-effective in Canada.