From the Istituto di Ricerche Farmacologiche "Mario Negri,"
Milan, Italy.
Correspondence to Dr Maria Grazia Franzosi, ACE Inhibitor Collaborative Group, GISSI Coordinating Centre, Istituto di Ricerche Farmacologiche "Mario Negri," Via Eritrea 62, 20157 Milano, Italy. E-mail depcardio{at}irfmn.mnegri.it
Background—Several large-scale
trials have demonstrated improved survival with
ACE-inhibitor therapy started during acute myocardial
infarction. A systematic overview was conducted to resolve
uncertainties regarding time of initiation, time course of effect, and
identification of patients in whom the benefits or the risks may
be greater.
Methods and Results—This overview aimed to include individual
data from all randomized trials involving more than 1000 patients in
which ACE-inhibitor treatment was started in the acute
phase (0 to 36 hours) of myocardial infarction and continued for a
short time (4 to 6 weeks). Data were available for 98 496 patients
from 4 eligible trials, and the results were consistent among
the trials. Thirty-day mortality was 7.1% among patients allocated to
ACE inhibitors and 7.6% among control subjects,
corresponding to a 7% (SD, 2%) proportional reduction (95% CI, 2%
to 11%; 2P<0.004). This represented
avoidance of
Conclusions—These results support the use of ACE
inhibitors early in the treatment of acute MI, either to a
wide range of patients or selectively in patients with anterior MI and
in those at increased risk of death.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Indications for ACE Inhibitors in the Early Treatment of Acute Myocardial Infarction
Systematic Overview of Individual Data From 100 000 Patients in Randomized Trials
5 (SD, 2) deaths per 1000 patients, with most of the
benefit observed within the first week. The proportional benefit was
similar in patients at different underlying risk. The absolute benefit
was particularly large in some high-risk groups (ie, Killip class 2 to
3, heart rate 
100 bpm at entry) and in anterior MI.
ACE-inhibitor therapy also reduced the incidence of
nonfatal cardiac failure (14.6% versus 15.2%, 2P=0.01)
but was associated with an excess of persistent hypotension (17.6%
versus 9.3%, 2P<0.01) and renal dysfunction (1.3%
versus 0.6%, 2P<0.01).
Key Words: ACE inhibitors • myocardial infarction • trials • systematic overview
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