ACE inhibitor treatment after myocardial infarction

On the basis of data from controlled trials involving more than 100 000 patients, angiotensin-converting enzyme (ACE) inhibitors are indicated in the routine management of patients with acute myocardial infarction. An overview of trials in which ACE inhibitors were initiated within 24-36 hours in unselected patients showed that five deaths and six cases of progression to non-fatal heart failure could be prevented per 1000 patients treated, and that most of the survival benefit was obtained within the first week of treatment. Furthermore, long-term data from one trial suggest that this benefit is maintained for at least four years. Similarly, trials in which treatment in selected patients was started late after myocardial infarction suggest that 44 deaths and 20 reinfarctions can be prevented per 1000 patients treated. ACE inhibitor treatment should therefore be started within 24-36 hours of acute myocardial infarction in all patients with systolic blood pressure above 100 mmHg and without contraindications. Patients should be re-evaluated after a few weeks, and long-term treatment continued in patients with overt heart failure, extensive left ventricular damage or left ventricular dysfunction.