Effect of enalapril on myocardial infarction and unstable angina in patients with low ejection fractions

Abstract

An association between raised renin levels and myocardial infarction has been reported. We studied the effects of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, on the development of myocardial infarction and unstable angina in 6797 patients with ejection fractions < or = 0.35 enrolled into the two Studies of Left Ventricular Dysfunction (SOLVD) trials. Patients were randomly assigned to placebo (n = 3401) or enalapril (n = 3396) at doses of 2.5-20 mg per day in two concurrent double-blind trials with the same protocol. Patients with heart failure entered the treatment trial (n = 2569) and those without heart failure entered the prevention trial (n = 4228). Follow-up averaged 40 months. In each trial there were significant reductions in the number of patients developing myocardial infarction (treatment trial: 158 placebo vs 127 enalapril, p < 0.02; prevention trial: 204 vs 161 p < 0.01) or unstable angina (240 vs 187 p < 0.001; 355 vs 312, p < 0.05). Combined, there were 362 placebo group patients with myocardial infarction compared with 288 in the enalapril group (risk reduction 23%, 95% CI 11-34%; p < 0.001). 595 placebo group patients developed unstable angina compared with 499 in the enalapril group (risk reduction 20%, 95% CI 9-29%, p < 0.001). There was also a reduction in cardiac deaths (711 placebo, 615 enalapril; p < 0.003), so that the reduction in the combined endpoint of deaths, myocardial infarction, and unstable angina was highly significant (20% risk reduction, 95% CI 14-26%; p < 0.0001). Enalapril treatment significantly reduced myocardial infarction, unstable angina, and cardiac mortality in patients with low ejection fractions.

Effect of statins and ACE inhibitors alone and in combination on clinical outcome in patients with coronary heart disease

“…Various mechanisms 20,21 have been proposed to explain the decrease in ischemic events seen with ACEIs in heart failure patients with or without CHD 22,23 or those with preserved left ventricular function. 24 The Trandolapril Cardiac Evaluation (TRACE) Study 25 reported that long-term treatment with trandolapril in patients with reduced left ventricular function soon after MI significantly reduced the risk of overall mortality, mortality from cardiovascular causes, sudden death and the development of severe heart failure.…”

Secondary prevention of heart disease amongst patients with lipid abnormalities: practice and trends in the United States

“…In addition there is compelling evidence that aspirin use is remarkably protective, particularly in view of its low cost, in patients with established disease. For those with impaired ventricular contraction, growing evidence supports the routine use of angiotensin converting enzyme inhibitors which appear to prevent progression to heart failure and, surprisingly, to prevent the recurrence of myocardial infarction [50,51] : possibly this is because control of hypertension provides modest protection against heart attack [52]. Smoking cessation reduces the rate of cardiovascular events, although the magnitude and the time to realization of such benefits is controversial.…”

Czech and Slovak spirapril intervention study (CASSIS)

“…ACE inhibitors prevent the progression of left ventricular systolic dysfunction. They may lead to a decrease in the incidence of myocardial infarction and unstable angina pectoris [14][15][16].…”