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Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Recommendations for use

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".)

Most randomized trials of ACE inhibitors or ARBs started within 24 hours to 16 days following an acute MI showed an improvement in left ventricular ejection fraction (LVEF) at one month to one year. In addition, ACE inhibitors improve survival for at least one year and probably longer. The magnitude of the survival benefit at 12 months is approximately 0.5 percent (12 versus 12.5 percent in the placebo group). (See "Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Clinical trials", section on 'ACE inhibitor effects on cardiac function and mortality'.)

Recommendations for the use of ACE inhibitors and ARBs after MI will be reviewed here. The clinical data supporting the efficacy of these agents in this setting and the possible mechanisms by which ACE inhibitors might act are discussed separately. (See "Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Clinical trials" and "Angiotensin converting enzyme inhibitors in acute myocardial infarction: Mechanisms of action".)

EVIDENCE OF BENEFIT

Evidence from randomized trials of either angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) compared to placebo demonstrates an improvement in mortality. In a meta-analysis of nearly 100,000 patients from four randomized trials in which ACE inhibitor was started within 36 hours of myocardial infarction (MI), 30-day mortality was significantly lower in treated patients compared to controls (7.1 versus 7.6 percent; RR 0.93, 95% CI0.89-0.98). [1]. (See "Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Clinical trials", section on 'ACE inhibitor effects on cardiac function and mortality'.)

Randomized trials such as SAVE or AIRE have specifically evaluated patients with either heart failure or reduced left ventricular ejection fraction (LVEF) and found a significant reduction in the risk of death with ACE inhibitor therapy. (See "Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Clinical trials", section on 'Low ejection fraction' and "Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Clinical trials", section on 'Heart failure'.)

         

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Literature review current through: Oct 2014. | This topic last updated: Oct 22, 2014.
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