Therapy

Why?

• ACE inhibitors reduce death and non-fatal heart failure, but increases the risk of persistent hypotension, renal dysfunction and cardiogenic shock. ^a
• It is cost-effective ^a
• Fewer patients with LV dysfunction die ^a , reinfarct ^a or develop heart failure ^a or atrial fibrillation ^a , but the risk of hypotension and renal failure is increased. ^a

ACE inhibitors started within 36 hours reduces death and heart failure

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
myocardial infarction a	ACE inhibitor started within 36 hours and continued for 4 to 6 hours	no ACE inhibitor	death at 30 days	7.6%	6% (2% to 10%)	210 (130 to 660)
			non-fatal heart failure at 30 days	14%	3% (0.4% to 6%)	200 (110 to 1600)
			persistent hypotension at 30 days	9.2%	-90% (-97% to -84%)	-12 (-13 to -11)
			renal dysfunction at 30 days	0.64%	-98% (-126% to -73%)	-160 (-200 to -130)
			cardiogenic shock at 30 days	3.5%	-13% (-21% to -6%)	-220 (-450 to -140)

ACE inhibitors reduce death, heart failure and reinfarction in patients with reduced LV function

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
myocardial infarction and clinical heart failure a	ramipril	placebo	death at 6 months	23%	25% (10% to 37%)	18 (11 to 46)
			severe or resistant heart failure at 6 months	18%	3.9% (0.65% to 7.1%)	26 (14 to 160)
			severe adverse effects(hypotension, renal failure, syncope) at 6 months	64%	5.6% (1.5% to 10%)	17 (10 to 67)
myocardial infarction and asymptomatic LV dysfunction a	captopril	placebo	death at 3.5 years	25%	17% (3% to 29%)	24 (13 to 140)
			severe heart failure at 3.5 years	16%	34% (18% to 47%)	18 (12 to 38)
			hospitalised with heart failure at 3.5 years	17%	20% (2% to 34%)	29 (16 to 260)
			recurrent MI at 3.5 years	15%	22% (3% to 37%)	30 (16 to 220)
myocardial infarction and impaired LV function a	trandolapril	placebo	atrial fibrillation at 2 years	5.3%	48% (13% to 69%)	39 (22 to 170)