Circulation, Vol 90, 1731-1738, Copyright © 1994 by American Heart Association
JD Rutherford, MA Pfeffer, LA Moye, BR Davis, GC Flaker, PR Kowey, GA Lamas, HS Miller, M Packer and JL Rouleau
BACKGROUND: In the Survival and Ventricular Enlargement (SAVE) trial,
recurrent myocardial infarction (MI) was the most important predictor of a
poor outcome and conferred a sevenfold increase in risk of death. The
purpose of this study was to determine the predictors of recurrent MI in
study participants and to examine the influence of the
angiotensin-converting enzyme inhibitor captopril on this and other
myocardial ischemic events. METHODS AND RESULTS: The 2231 patients had
survived the acute phase of MI (3 to 16 days) and had a radionuclide
ventricular ejection fraction < or = 40%. Patients were randomly
assigned to receive double-blind treatment with either placebo or captopril
and were followed for an average of 42 months. The influence of captopril
on recurrent MI, cardiac revascularization procedures, and hospitalization
with unstable angina was examined. The likelihood of recurrent MI was
greater in patients with an MI or functional disability before the index
infarction and higher systolic pressure (all P < .001) but was not
influenced by baseline left ventricular ejection fraction. Therapy with
captopril reduced the risk of development of recurrent MI by 25% (95%
confidence intervals, 5% to 40%; P = .015) and the risk of death after
recurrent MI by 32% (95% confidence intervals, 4% to 51%; P = .029).
Captopril-assigned patients were also less likely to require cardiac
revascularization procedures (P = .010), but hospitalization for unstable
angina was unaltered. When all three of these major coronary ischemic
events were considered together, captopril therapy reduced the risk (14%
risk reduction; 95% confidence intervals, 0% to 26%; P = .047).
CONCLUSIONS: In post-MI patients with asymptomatic left ventricular
dysfunction, long-term administration of captopril reduced recurrence of MI
and the need for cardiac revascularization but had no influence on the rate
of hospitalization with a discharge diagnosis of unstable angina. The
finding that the recurrence of MI was independent of left ventricular
ejection fraction suggests that captopril could be useful in preventing
recurrent MI in patients with more preserved left ventricular function. The
need for cardiac revascularization was reduced in patients receiving
long-term captopril therapy, suggesting either an anti- ischemic effect or
the ability of the angiotensin-converting enzyme inhibitor to modify the
atherosclerotic process in survivors of MI.
ARTICLES
Effects of captopril on ischemic events after myocardial infarction. Results of the Survival and Ventricular Enlargement trial. SAVE Investigators
Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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