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Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Clinical trials

Author
Guy S Reeder, MD
Section Editor
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Deputy Editor
Gordon M Saperia, MD, FACC

INTRODUCTION

A number of therapies are beneficial in the management of patients with acute myocardial infarction (MI), including revascularization with either percutaneous coronary intervention or fibrinolysis, aspirin, beta blockers, statins, and either angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). (See "Overview of the acute management of ST elevation myocardial infarction" and "Overview of the acute management of unstable angina and non-ST elevation myocardial infarction".)

The evidence supporting the efficacy of ACE inhibitors and ARBs in this setting will be reviewed here. Recommendations for the use of ACE inhibitors and ARBs after MI, the use of ACE inhibitors in patients with heart failure due to systolic dysfunction, and the mechanisms by which ACE inhibitors might act are discussed separately. (See "Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Recommendations for use" and "Angiotensin converting enzyme inhibitors in acute myocardial infarction: Mechanisms of action" and "ACE inhibitors in heart failure with reduced ejection fraction: Therapeutic use".)

ACE INHIBITOR EFFECTS ON CARDIAC FUNCTION AND MORTALITY

Most randomized trials have demonstrated that angiotensin converting enzyme (ACE) inhibitor therapy with captopril, enalapril, ramipril, trandolapril, or zofenopril started within 24 hours to 16 days following an acute myocardial infarction (MI) improves the left ventricular ejection fraction (LVEF) at one month to one year [1-14]. In these studies, the great majority of patients had an ST elevation MI (STEMI); data are limited in patients with a non-ST elevation MI (NSTEMI) [10]. In addition, most patients were treated with either fibrinolytic therapy or no reperfusion; data in patients who underwent percutaneous coronary intervention (PCI) for MI are limited.

The administration of an ACE inhibitor is also associated with an important improvement in patient survival. Large (50 lives saved per 1000 patients treated) mortality benefits post-MI have been demonstrated in patients with low LVEF, heart failure (HF), or anterior MIs. Smaller benefits (five lives saved per 1000 treated) have been found in low-risk patients.

The benefits derived from ACE inhibition in high-risk patients are generally greater than those achieved by other therapeutic interventions. As an example, a meta-analysis of the nine largest randomized prospective trials comparing intravenous fibrinolysis versus placebo demonstrated approximately 30 lives were saved per 1000 patients treated who presented within six hours of symptom onset. However, the effect of these other interventions are additive to those associated with ACE inhibition.

                 

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Literature review current through: Jul 2016. | This topic last updated: Apr 5, 2016.
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