Maciejewicz Janusz, Maziarz Andrzej, Celibała Rafał, Wiśniewski Mariusz, Wiśniewska Małgorzata
Oddział Kardiologii Szpital Specjalistyczny im. J. Dietla 31-121 Kraków, ul. Skarbowa 1.
Przegl Lek. 2003;60(2):80-4.
The objective of this paper was to evaluate potential beneficial effects of combined treatment with slow-release nitrates and angiotensin converting enzyme inhibitors (ACE) on left ventricular remodeling and exercise capacity in patients after acute myocardial infarction. In this study, 141 patients (aged 34 to 74, mean 56.6 years) with sufficient circulation received combined treatment with 24 hour nitroglycerin infusion followed by oral nitrates (isosorbide mononitrate 50 mg OD) from day 2 day 42 after myocardial infarction and ACE inhibitor (captopril 25 mg BID or enalapril 5 mg BID versus placebo) from day 10 to day 42. On days 10 and 42, echocardiographic examination was carried out and recorded on an optical disc. Simultaneously, on the same days, the treadmill exercise test (modified Bruce protocol) was performed. In the echocardiographic study the left ventricular endodiastolic and endosystolic volumes (biplane Simpson formula), ejection fraction, left ventricular wall motion score and left ventricular mass index were analyzed. Treadmill test criteria, used in the study, included exercise duration time and workload (METS). For each patient the data obtained examination II and I were measured and the differences in their values were classified. The obtained results were analyzed with one-way and three-way ANOVA test. A Kruskal-Wallis test was also used in one variable analysis. Results were analyzed after repartition of patients into groups according type of treatment (angiotensin converting ing enzyme inhibitor or placebo), infarct location (anterior or inferior wall) and enzyme level (CPK < 2000 IU/L or CPK > 2000 IU/L). A p value < 0.1 was considered statistically significant. In a single factor analysis ANOVA proved that the patients treated with nitrates and captopril showed greater improvement in exercise capacity (in METS) than patients treated with enalapril or placebo (+1.26 captopril, +0.2 enalapril and +0.29 placebo, p = 0.043). In addition, a decrease in left ventricular mass index was evident only in patients treated with angiotensin converting enzyme inhibitor (placebo +7.37 gm/m2, captopril -12.17 gm/m2, enalapril -10.14 gm/m2, p = 0.0032). The triple factor analysis ANOVA test revealed that the change in endodiastolic left ventricular volume depends on combination of three factors: infarct location, type of treatment and level of cardiac enzymes (p = 0.009). A decrease in left ventricular endodiastolic volume between day 42 and 10 was observed only in patients with inferior wall infarct and CPK level < 2000 IU/L, irrespective of treatment type and in patients with inferior wall infarct and CPK level > 2000 IU/L treated with angiotensin enzyme inhibitor. We noticed also that heart failure, considered as contraindication to randomization, was in addition the most frequent (up to day 10) cause for study termination and initiation of treatment with angiotensin enzyme inhibitor.
本文的目的是评估缓释硝酸盐与血管紧张素转换酶抑制剂（ACE）联合治疗对急性心肌梗死后患者左心室重构和运动能力的潜在有益影响。在本研究中，141例（年龄34至74岁，平均56.6岁）循环状况良好的患者在心肌梗死后第2天至第42天接受24小时硝酸甘油静脉输注，随后口服硝酸盐（单硝酸异山梨酯50 mg，每日一次），并在第10天至第42天接受ACE抑制剂（卡托普利25 mg，每日两次或依那普利5 mg，每日两次，与安慰剂对照）治疗。在第10天和第42天，进行超声心动图检查并记录在光盘上。同时，在同一天进行平板运动试验（改良Bruce方案）。在超声心动图研究中，分析左心室舒张末期和收缩末期容积（双平面Simpson公式）、射血分数、左心室壁运动评分和左心室质量指数。本研究中使用的平板试验标准包括运动持续时间和工作量（代谢当量）。对每位患者测量检查II和I获得的数据，并对其值的差异进行分类。所得结果采用单因素和三因素方差分析进行分析。在单变量分析中也使用了Kruskal-Wallis检验。根据治疗类型（血管紧张素转换酶抑制剂或安慰剂）、梗死部位（前壁或下壁）和酶水平（肌酸磷酸激酶<2000 IU/L或肌酸磷酸激酶>2000 IU/L）将患者重新分组后分析结果。p值<0.1被认为具有统计学意义。在单因素分析中，方差分析证明，与接受依那普利或安慰剂治疗的患者相比，接受硝酸盐和卡托普利治疗的患者运动能力（代谢当量）改善更大（卡托普利组增加1.26，依那普利组增加0.
