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MI and ACE inhibitors

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Large-scale trials indicate that in post-MI patients between 5 and 45 lives are saved per 1000 patient years of treatment with ACE inhibitors. Greater efficacy is seen if higher risk groups are treated e.g. patients with heart failure.

Therapeutic trials which have tested the efficacy of ACE inhibitors in the management of acute myocardial infarction include the following:

  • AIRE
  • SAVE
  • CONSENSUS II
  • GISSI-3
  • ISI-4
  • SMILE
  • TRACE
  • OPTIMAAL - actually comparing losartan and captopril

The conclusions are that ACE-inhibitors should be given in the following circumstances:

  • when myocardial infarction is, at any time, complicated by left ventricular failure (AIRE)
  • in the presence of left ventricular dysfunction (SAVE)

It is probably best to start ACE-inhibition about a week after the myocardial infarction (CONSENSUS II vs. AIRE & SAVE). Earlier administration of within 24 hours of infarction is only advisable is the patient is clinically stable and has a systolic blood pressure greater than 100 mm Hg.

Evidence concerning the benefits of ACE-inhibition in stable coronary heart disease and no apparent heart failure is provided in trials such as HOPE and EUROPA.

Notes:

  • a review of randomized controlled trials in patients with coronary artery disease and absence of heart failure or left ventricular dysfunction concluded that ACE inhibitors reduce total mortality and major cardiovascular end points in these patients (1)

Reference:

  1. Danchin N et al.Angiotensin-converting enzyme inhibitors in patients with coronary artery disease and absence of heart failure or left ventricular systolic dysfunction: an overview of long-term randomized controlled trials. Arch Intern Med 2006;166:787-96.

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