A CLINICAL-TRIAL OF THE ANGIOTENSIN-CONVERTING-ENZYME INHIBITOR TRANDOLAPRIL IN PATIENTS WITH LEFT-VENTRICULAR DYSFUNCTION AFTER MYOCARDIAL-INFARCTION

Background. Treatment with angiotensin-converting-enzyme (ACE) inhibit ors reduces mortality among survivors of acute myocardial infarction, but whether to use ACE inhibitors in all patients or only in selected patients is uncertain. Methods. We screened 6676 consecutive patients with 7001 myocardial infarctions confirmed by enzyme studies. A total of 2606 patients had echocardiographic evidence of left ventricular sy stolic dysfunction (ejection fraction, less than or equal to 35 percen t). On days 3 to 7 after infarction, 1749 patients were randomly assig ned to receive oral trandolapril (876 patients) or placebo (873 patien ts). The duration of follow-up was 24 to 50 months. Results. During th e study period, 304 patients (34.7 percent) in the trandolapril group died, as compared with 369 (42.3 percent) in the placebo group (P=0.00 1). The relative risk of death in the trandolapril group, as compared with the placebo group, was 0.78 (95 percent confidence interval, 0.67 to 0.91). Trandolapril also reduced the risk of death from cardiovasc ular causes (relative risk, 0.75; 95 percent confidence interval, 0.63 to 0.89; P=0.001) and sudden death (relative risk, 0.76; 95 percent c onfidence interval, 0.59 to 0.98; P=0.03). Progression to severe heart failure was less frequent in the trandolapril group (relative risk, 0 .71; 95 percent confidence interval, 0.56 to 0.89; P=0.003). In contra st, the risk of recurrent myocardial infarction (fatal or nonfatal) wa s not significantly reduced (relative risk, 0.86; 95 percent confidenc e interval, 0.66 to 1.13; P=0.29). Conclusions. Long-term treatment wi th trandolapril in patients with reduced left ventricular function soo n after myocardial infarction significantly reduced the risk of overal l mortality, mortality from cardiovascular causes, sudden death, and t he development of severe heart failure. That mortality was reduced in a randomized study enrolling 25 percent of consecutive patients screen ed should encourage the selective use of ACE inhibition after myocardi al infarction.