Volume 1, Number 3, September 2000

Early initiation of ACE inhibitor treatment after acute myocardial infarction - a missed therapeutic opportunity?
William Stephen Waring

There is a wealth of evidence supporting the use of ACE inhibitors in patients who have suffered a previous myocardial infarction and who have evidence of impaired left ventricular systolic dysfunction, in the presence or absence of clinically overt cardiac failure. The slowed progression of deteriorating cardiac performance and improved survival are closely associated with attenuation of cardiac remodelling, and this benefit is likely to continue with long-term treatment. Over recent years, substantial evidence has now accrued in favour of initiation of ACE inhibitor treatment within 24 hours to unselected myocardial infarction patients. A lower incidence of cardiac failure and improved survival are evident even within the first 24 hours, and the benefits of short-term early treatment persist for up to at least one year after myocardial infarction. Early treatment is associated with more frequent severe hypotension, necessitating careful patient selection and monitoring during treatment. Mechanisms underlying the benefits of very early treatment are probably related to attenuation of sympathetic nervous activity and/or anti-ischaemic effects, and there is no clear evidence advocating continued ACE inhibitor treatment beyond four to six weeks in patients with preserved left ventricular systolic function. Early initiation of ACE inhibitor treatment within 24 hours of myocardial infarction provides the opportunity to save lives, even in addition to other secondary prevention including aspirin, thrombolytic treatment and beta-blockade. Early initiation of ACE inhibitor treatment is an essential part of clinical care that should be delivered to all patients after myocardial infarction, to achieve maximal reduction of morbidity and mortality in this high-risk period.

JRAAS 2000;1:245-251.

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