[Treatment by angiotensin converting enzyme inhibitors after myocardial infarction. What did the clinical trials teach us?].
Most clinical trials of angiotensin converting enzyme inhibitors after myocardial infarction have shown an improved outcome with reduction of morbidity and mortality. In comparable groups of patients, the results are concordant with a decrease in mortality which is all the more significant and early in severe infarction with serious haemodynamic consequences. The clinician has a new arm in his therapeutic arsenal either for use in the acute phase of all cases of myocardial infarction but for only a short period of 4 to 6 weeks after which the treatment is withdrawn when the anatomical sequellae are more moderate, or for use in selected cases for longer periods (patients with severe infarction with cardiac failure and/or severe left ventricular dysfunction). The second attitude has the advantage of treating a selected population which will derive greater benefits. In all cases, treatment should be started orally at low doses, and the dose must be increased rapidly do attain the target dosage under close clinical and biological surveillance. When the classical contraindications are respected, ACE inhibitors seem to be well tolerated even at the relatively high dosages recommended after myocardial infarction. Hypotension and, more rarely, renal failure, are the two most common complications leading to withdrawal of treatment, but neither of these side effects was associated with increased mortality in any of the clinical trials. The mechanisms by which ACE inhibitors exert these beneficial effects after myocardial infarction are not only their haemodynamic effects and their role in ventricular remodelling, but also probably by a vascular protective action which, if confirmed, would further increase the indications of this therapeutic class in cardiovascular diseases.
Guéret
P
P
Fédération de cardiologie, hôpital Henri-Mondor, Créteil.
Garot
J
J
Barnier
P
P
D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D006333:Heart Failure / Q000517:prevention & control; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000517:prevention & control; D007022:Hypotension / Q000209:etiology; D007676:Kidney Failure, Chronic / Q000209:etiology; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality; D018579:Patient Selection; D011379:Prognosis; D013997:Time Factors
D000806:Angiotensin-Converting Enzyme Inhibitors
Traitement par inhibiteurs de l'enzyme de conversion après infarctus du myocarde. Qu'avons-nous appris des grands essais?