ANGIOTENSIN-CONVERTING ENZYME-INHIBITION IN MYOCARDIAL-INFARCTION .2.CLINICAL ISSUES AND CONTROVERSIES

Over the past 10 years, several clinical studies have concluded that, in patients already receiving conventional therapies, angiotensin-conv erting enzyme (ACE) inhibitors further reduce the risk of death follow ing myocardial infarction (MI). Post-MI ACE inhibitors have proven to be effective as long term therapy in high risk patients as well as whe n used for much shorter periods in a broad patient population. However , while considerable mortality data have been collected, the effects o f ACE inhibitors post-MI on other cardiovascular outcomes have not bee n as well documented. In addition, a number of issues regarding the mo st effective use of these agents remain unresolved. This paper, the se cond of two parts, focuses on the clinical issues and controversies su rrounding the use of ACE inhibitors following acute MI. The effects of ACE inhibitors on the outcomes of sudden death, nonsudden death, recu rrent angina, mitral regurgitation and left ventricular dysfunction ar e reviewed and potential mechanisms of action are proposed. In additio n, ACE inhibitor therapy is discussed in terms of patient selection cr iteria, choice of agent, optimal dosing regimen, concomitant use of ot her therapies and relative costs of treatment. Finally, potential mech anisms of action of ACE inhibitors are proposed for each of the outcom es examined.