INFARCT-RELATED HEART-FAILURE - THE CHOICE OF ACE-INHIBITOR DOES NOT MATTER

Angiotensin converting enzyme (ACE) inhibitors are effective across th e whole spectrum of heart failure from mild to severe hut there are li ttle data on the use of ACE inhibitors specifically in patients with p ostinfarct heart failure. Pharmacological properties that might potent ially be relevant to the choice of drug after myocardial infarction in clude differences in metabolism, possession of a sulphydryl group, tis sue binding, duration of action, and side effect profile. Of these dur ation of action is probably the most important, as longer acting drugs generally cause more prolonged first-dose hypotension than shorter ac ting agents and first-dose hypotension is a particular concern in the early postinfarct period. In the SAVE study captopril was effective in reducing mortality and delaying the onset of symptomatic heart failur e after myocardial infarction. Similarly, ramipril reduced mortality i n the AIRE study. In contrast, enalapril was largely ineffective in CO NSENSUS II. These differences result largely from study design and do not indicate an inherent superiority of captopril or ramipril over ena lapril. Nonetheless, a short-acting agent should probably be used for the initial dose in postinfarct heart failure to minimize the risks of prolonged hypotension. This aside, the choice of agent is far less im portant than appropriate patient selection and appropriate maintenance dosages.