Acute administration of angiotensin converting enzyme inhibitors in thrombolysed myocardial infarction patients is associated with a decreased incidence of heart failure, but an increased re-infarction risk.
BACKGROUND
Ventricular remodeling starts very early after the onset of an acute myocardial infarction (AMI), and can be prevented by ACE-inhibitors. However, very limited data are available on the effect of acute (< 9 hours) treatment with angiotensin converting enzyme (ACE) inhibitors after an AMI on mortality, heart failure and re-infarction. The aim of the present study was to evaluate the effects of acute ACE-inhibitor treatment.


METHODS
We performed a pooled analysis of three very similar randomized, placebo-controlled multi-center trials. In 845 thrombolysed patients with mainly first anterior MI, patients were randomised to acute ACE-inhibitor treatment (< 9 hours after MI) or placebo.


RESULTS
After acute ACE-inhibitor treatment we observed similar 3-months mortality rates, and a significant reduction in the incidence of 3-months heart failure (26.1 vs. 19.3%; RR 0.67; 95% CI 0.45-1.0) as compared to placebo. In contrast, acute ACE-inhibitor treatment was associated with a significant 2.0 times increased 3-months re-infarction risk (7.0 vs. 3.6%; RR 2.0; 95% CI 1.1 to 3.8). Subgroup-analysis showed that patients with small infarct sizes treated with acute ACE-inhibitor (peak CPK < 1000 IU) had a 7.6 times higher re-infarction risk (95% CI 1.7 to 33) than patients with small infarctions treated with placebo.


CONCLUSIONS
Acute ACE-inhibitor treatment in thrombolysed patients with mainly first anterior AMI resulted in a reduction of heart failure and similar mortality, but an increase in re-infarction rates, especially in patients with small infarct sizes. These results warrant caution for the very early use of ACE-inhibitors in smaller infarctions, although this needs to be confirmed in a larger prospective randomised clinical trial.
Voors
Adriaan A
AA
Department of Cardiology, University Hospital Groningen, The Netherlands. a.a.voors@thorax.azg.nl
de Kam
Pieter J
PJ
van den Berg
Maarten P
MP
Borghi
Claudio
C
Hochman
Judith S
JS
van Veldhuisen
Dirk J
DJ
van Gilst
Wiek H
WH
D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage*; D002216:Captopril / Q000008:administration & dosage; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D017328:Fosinopril / Q000008:administration & dosage; D006333:Heart Failure / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D011237:Predictive Value of Tests; D012008:Recurrence; D012307:Risk Factors; D016019:Survival Analysis; D015912:Thrombolytic Therapy; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome
D000806:Angiotensin-Converting Enzyme Inhibitors; D005343:Fibrinolytic Agents; D002216:Captopril; D010959:Tissue Plasminogen Activator; D017328:Fosinopril