INDICATIONS FOR ACE-INHIBITORS IN THE EARLY TREATMENT OF ACUTE MYOCARDIAL-INFARCTION - SYSTEMATIC OVERVIEW OF INDIVIDUAL DATA FROM 100,000 PATIENTS IN RANDOMIZED TRIALS

Background-Several large-scale trials have demonstrated improved survi val with ACE-inhibitor therapy started during acute myocardial infarct ion. A systematic overview was conducted to resolve uncertainties rega rding time of initiation, time course of effect, and identification of patients in whom the benefits or the risks may be greater. Methods an d Results-This overview aimed to include individual data from all rand omized trials involving more than 1000 patients in which ACE-inhibitor treatment was started in the acute phase (0 to 36 hours) of myocardia l infarction and continued for a short time (4 to 6 weeks). Data were available for 98496 patients from 4 eligible trials, and the results w ere consistent among the trials. Thirty-day mortality was 7.1% among p atients allocated to ACE inhibitors and 7.6% among control subjects, c orresponding to a 7% (SD, 2%) proportional reduction (95% CI, 2% to 11 %; 2P < 0.004). This represented avoidance of approximate to 5 (SD, 2) deaths per 1000 patients, with most of the benefit observed within th e first week. The proportional benefit was similar in patients at diff erent underlying risk. The absolute benefit was particularly large in some high-risk groups tie, Killip class 2 to 3, heart rate greater tha n or equal to 100 bpm at entry) and in anterior MI. ACE-inhibitor ther apy also reduced the incidence of nonfatal cardiac failure (14.6% vers us 15.2%, 2P = 0.01) but was associated with an excess of persistent h ypotension (17.6% versus 9.3%, 2P < 0.01) and renal dysfunction (1.3% versus 0.6%, 2P < 0.01). Conclusions-These results support the use of ACE inhibitors early in the treatment of acute MI, either to a wide ra nge of patients or selectively in patients with anterior MI and in tho se at increased risk of death.