Myocardial infarction: ACE inhibitors reduce mortality and heart failure slightly, but cause hypotension and renal dysfunction.

Clinical bottom line (level 1a)

  1. Patients with a myocardial infarction who receive an ACE inhibitor compared with placebo within 36 hours are less likely to die (NNT = 210 at 30 days) or develop heart failure (NNT = 200 at 30 days) .
  2. However patients on ACE inhibitors are at increased risk of developing persistent hypotension (NNH = 12 at 30 days) , renal dysfunction (NNH = 160 at 30 days) and cardiogenic shock (NNH = 220 at 30 days) .
ACE inhibitor myocardial infarction collaborative group : Circulation 1998; 97: 2202-2212
Expires March 2003

The study

Systematic review of randomised trials of
  • Patients: myocardial infarction
  • Intervention: ACE inhibitors (captopril, enalapril, lisinopril) started within 36 hours from symptom onset and continued for 4 to 6 weeks compared with no routine ACE inhibitor
  • Outcome: death


Articles found in ?English using ?, ? (search terms: ?search strategy )

Selection criteria: see above
Appraisal criteria: not given
Articles excluded if:

  • fewer than 1000 patients randomised


4 studies found involving 98496 patients (CCS-1, CONSENSUS-II, GISSI-3, ISIS-4): 49214 given ACE inhibitor and 49269 given placebo. Individual patient data used in analysis.
No heterogeneity was found.

The evidence

Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
death 30 days 3740
(7.59%)		 3501
(7.11%)		 6%
(2% to 10%)		 0.48%
(0.15% to 0.80%)		 210
(130 to 660)
persistent hypotension 30 days 4573
(9.28%)		 8661
(17.6%)		 -90%
(-96% to -83%)		 -8.32%
(-8.74% to -7.89%)		 -12
(-13 to -11)
renal dysfunction 30 days 315
(0.64%)		 622
(1.26%)		 -98%
(-126% to -73%)		 -0.62%
(-0.75% to -0.50%)		 -160
(-200 to -130)
non-fatal heart failure 30 days 6937
(14.1%)		 6687
(13.6%)		 3%
(0.4% to 6%)		 0.49%
(0.06% to 0.92%)		 200
(110 to 1600)
cardiogenic shock 30 days 1710
(3.47%)		 1934
(3.93%)		 -13%
(-21% to -6%)		 -0.46%
(-0.69% to -0.22%)		 -220
(-450 to -140)

Comments

  1. The authors believe the patients included represent 98% of all randomised patients for these interventions.
  2. Contraindications to ACE treatment were cardiogenic shock or a systolic blood pressure of < 100 mmHg.
  3. A trend towards increased survival was noted in patients who received ACEI early.
  4. Subgroup analysis suggested that patients with an anterior myocardial infarction or tachycardia had greater benefit from ACEI.
  5. Patients >=75 were at increased risk of hypotension and there was no evidence of survival benefit

Citation

  1. ACE inhibitor myocardial infarction collaborative group , : Indications for ACE inhibitors in the early treatment of acute myocardial infarction: systematic overview of individual data from 100 000 patients in randomized trials. Circulation 1998; 97: 2202-2212
Contributor: Chris Ball and Clare Wotton, October 1999
Reviewer: Padmanabhan Badrinath

Clinical Question.
Patient myocardial treatment
Intervention or Exposure early treatment with ACE inhibitors
Outcome death