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Secondary prevention: improving outcomes following myocardial infarction
  1. Aldo P Maggioni
  1. ANMCO Research Centre, Via La Marmora 34, 50121 Firenze, Italy
  1. Dr Maggioni email: maggioni{at}

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In the first five years of the 1990s, the role of angiotensin converting enzyme (ACE) inhibitors in the treatment of patients with myocardial infarction was investigated in a series of large controlled trials involving more than 100 000 patients (table1).1

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Table 1

Trials with ACE inhibitors in patients with acute myocardial infarction. Over five years, more than 100 000 patients with acute MI were randomised to ACE inhibitors

The early use of ACE inhibitors after acute myocardial infarction (MI) has been investigated in four trials (CONSENSUS II, GISSI 3, ISIS 4, and CCS 1) involving more than 98 000 patients with treatment initiated within 24–36 hours from the onset of MI symptoms.2-5

Five of the trials (SAVE, AIRE, TRACE, and SOLVD prevention and treatment trials) involving a total of over 11 000 patients investigated the effects of late treatment with ACE inhibitors in patients with left ventricular dysfunction or failure.6-10

Early unselected trials

An overview of the early, unselected trials showed that 30 days after MI, patients allocated to ACE inhibitors had a significant reduction in mortality from 7.6% to 7.1% (p = 0.004), which corresponds to five lives saved per 1000 patients treated.1 11

In addition, there was a significantly lower rate of non-fatal congestive heart failure episodes, with a reduction from 15.2% among patients allocated to control, to 14.6% among patients allocated to ACE inhibitors (p = 0.01). This corresponds to the prevention of six cases of non-fatal heart failure per 1000 patients treated.1 11

Unexpectedly, the benefit of ACE inhibitors was achieved very early after the start of treatment; 239 fewer deaths were observed during the first 30 days in the group receiving ACE inhibitors than among those patients allocated to control. Of these 239 deaths, 200 were saved in the first week after the beginning of treatment and the onset of …

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