Myocardial infarction: asymptomatic left ventricular dysfunction: ACE inhibitors reduced mortality, heart failure and recurrent MI.

Clinical bottom line (level 1b)

  1. Patients with a recent myocardial infarction and asymptomatic left ventricular dysfunction who took captopril compared with placebo were less likely to die (NNT = 24 at 3.5 years) , develop heart failure (NNT = 18 at 3.5 years) or have a further MI (NNT = 30 at 3.5 years) .
Pfeffer et al: New England Journal of Medicine 1992; 327 (10): 669-677
Expires March 2003

The study

Double-blinded concealed randomised trial with intention-to-treat
Setting: 112 acute hospitals, USA and Canada

2231 patients (aged 21 to 80; mean 59, 83% male) with myocardial infarction and asymptomatic left ventricular dysfunction (ejection fraction < 40% on radionuclide ventriculography)

Excluded if
  • <21 or >80 years old
  • < 3 days or > 16 days after infarction
  • relative contraindication to ACE inhibitor or need for an ACE inhibitor to treat symptomatic congestive heart failure or systemic hypertension
  • creatinine > 221 micromol/l
  • unstable course after infarction


    • Control Group: (n = 1116, 1116 analysed): placebo
    Experimental Group: (n = 1115, 1115 analysed): captopril initially a test dose of 6.25 mg gradually increased to 50 mg three times a day if tolerated
    Patients with recurrent ischaemic discomfort or a positive exercise test had angiography and revascularisation if required.
    100% followed for 3.5 years

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    death 3.5 years 275
    (24.6%)    		 228
    (20.5%)    		 17%
    (3% to 29%)    		 4.19%
    (0.73% to 7.66%)    		 24
    (13 to 140)
    severe heart failure 3.5 years 179
    (16.0%)    		 118
    (10.6%)    		 34%
    (18% to 47%)    		 5.46%
    (2.65% to 8.27%)    		 18
    (12 to 38)
    hospitalised with heart failure 3.5 years 192
    (17.2%)    		 154
    (13.8%)    		 20%
    (2% to 34%)    		 3.39%
    (0.39% to 6.39%)    		 29
    (16 to 260)
    recurrent myocardial infarction 3.5 years 170
    (15.2%)    		 133
    (11.9%)    		 22%
    (3% to 37%)    		 3.30%
    (0.46% to 6.14%)    		 30
    (16 to 220)

    Comments

    1. Patients on captopril had more cough, dizziness, alteration in taste and diarrhoea.
    2. The use of aspirin, thrombolytics, beta-blockers, diuretics and digoxin was similar for both groups.

    Citation

    1. Pfeffer MA, Braunwald E, Moye LA, et al: Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the Survival and Ventricular Enlargement (SAVE) Trial. New England Journal of Medicine 1992; 327 (10): 669-677
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    Contributor: Chris Ball and Clare Wotton, February 2000
    Reviewer:

    Clinical Question.
    Patient myocardial infarction and left ventricular dysfunction
    Intervention or Exposure captopril
    Comparison placebo
    Outcome death, heart failure, recurrent myocardial infarction