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Original research
Long-term survival benefit of ramipril in patients with acute myocardial infarction complicated by heart failure
  1. Jianhua Wu1,2,
  2. Alistair S Hall3,
  3. Chris P Gale4
  4. on behalf of the AIREX Study Investigators
  1. 1 School of Dentistry, University of Leeds, Leeds, UK
  2. 2 Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
  3. 3 Medicine, Leeds Institute for Genetics Health and Therapeutics, Leeds, UK
  4. 4 Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
  1. Correspondence to Professor Alistair S Hall, Medicine, Leeds Institute for Genetics Health and Therapeutics, Leeds LS1 3EX, UK; a.s.hall{at}


Aims ACE inhibition reduces mortality and morbidity in patients with heart failure after acute myocardial infarction (AMI). However, there are limited randomised data about the long-term survival benefits of ACE inhibition in this population.

Methods In 1993, the Acute Infarction Ramipril Efficacy (AIRE) study randomly allocated patients with AMI and clinical heart failure to ramipril or placebo. The duration of masked trial therapy in the UK cohort (603 patients, mean age=64.7 years, 455 male patients) was 12.4 and 13.4 months for ramipril (n=302) and placebo (n=301), respectively. We estimated life expectancy and extensions of life (difference in median survival times) according to duration of follow-up (range 0–29.6 years).

Results By 9 April 2019, death from all causes occurred in 266 (88.4%) patients in placebo arm and 275 (91.1%) patients in ramipril arm. The extension of life between ramipril and placebo groups was 14.5 months (95% CI 13.2 to 15.8). Ramipril increased life expectancy more for patients with than without diabetes (life expectancy difference 32.1 vs 5.0 months), previous AMI (20.1 vs 4.9 months), previous heart failure (19.5 vs 4.9 months), hypertension (16.6 vs 8.3 months), angina (16.2 vs 5.0 months) and age >65 years (11.3 vs 5.7 months). Given potential treatment switching, the true absolute treatment effect could be underestimated by 28%.

Conclusion For patients with clinically defined heart failure following AMI, ramipril results in a sustained survival benefit, and is associated with an extension of life of up to 14.5 months for, on average, 13 months treatment duration.

  • acute myocardial infarction
  • heart failure

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  • Twitter @cpgale3

  • Collaborators See AIRE and AIREX investigators.10, 11

  • Contributors JW contributed to analysis, interpretation and drafted the manuscript; ASH contributed to conception and study design, data acquisition and interpretation and critically revised the manuscript; CPG contributed to conception and study design, interpretation and drafted the manuscript. All authors gave final approval and agreed to be accountable for all aspects of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval This is a secondary analyses of long-term follow-up cohort, therefore an ethics approval is not required and patients were not involved in this study. The study complies with the Declaration of Helsinki.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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