Pfeffer M A, Braunwald E, Moyé L A, Basta L, Brown E J, Cuddy T E, Davis B R, Geltman E M, Goldman S, Flaker G C
Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115.
N Engl J Med. 1992 Sep 3;327(10):669-77. doi: 10.1056/NEJM199209033271001.
Left ventricular dilatation and dysfunction after myocardial infarction are major predictors of death. In experimental and clinical studies, longterm therapy with the angiotensin-converting--enzyme inhibitor captopril attenuated ventricular dilatation and remodeling. We investigated whether captopril could reduce morbidity and mortality in patients with left ventricular dysfunction after a myocardial infarction.
Within 3 to 16 days after myocardial infarction, 2231 patients with ejection fractions of 40 percent or less but without overt heart failure or symptoms of myocardial ischemia were randomly assigned to receive doubleblind treatment with either placebo (1116 patients) or captopril (1115 patients) and were followed for an average of 42 months.
Mortality from all causes was significantly reduced in the captopril group (228 deaths, or 20 percent) as compared with the placebo group (275 deaths, or 25 percent); the reduction in risk was 19 percent (95 percent confidence interval, 3 to 32 percent; P = 0.019). In addition, the incidence of both fatal and nonfatal major cardiovascular events was consistently reduced in the captopril group. The reduction in risk was 21 percent (95 percent confidence interval, 5 to 35 percent; P = 0.014) for death from cardiovascular causes, 37 percent (95 percent confidence interval, 20 to 50 percent; P less than 0.001) for the development of severe heart failure, 22 percent (95 percent confidence interval, 4 to 37 percent; P = 0.019) for congestive heart failure requiring hospitalization, and 25 percent (95 percent confidence interval, 5 to 40 percent; P = 0.015) for recurrent myocardial infarction.
In patients with asymptomatic left ventricular dysfunction after myocardial infarction, long-term administration of captopril was associated with an improvement in survival and reduced morbidity and mortality due to major cardiovascular events. These benefits were observed in patients who received thrombolytic therapy, aspirin, or beta-blockers, as well as those who did not, suggesting that treatment with captopril leads to additional improvement in outcome among selected survivors of myocardial infarction.
心肌梗死后左心室扩张和功能障碍是死亡的主要预测因素。在实验和临床研究中，血管紧张素转换酶抑制剂卡托普利的长期治疗可减轻心室扩张和重塑。我们研究了卡托普利是否能降低心肌梗死后左心室功能障碍患者的发病率和死亡率。
在心肌梗死后3至16天内，2231例射血分数为40%或更低但无明显心力衰竭或心肌缺血症状的患者被随机分配接受安慰剂（1116例患者）或卡托普利（1115例患者）的双盲治疗，并平均随访42个月。
与安慰剂组（275例死亡，占25%）相比，卡托普利组所有原因导致的死亡率显著降低（228例死亡，占20%）；风险降低19%（95%置信区间，3%至32%；P = 0.019）。此外，卡托普利组致命和非致命重大心血管事件的发生率持续降低。心血管原因导致的死亡风险降低21%（95%置信区间，5%至35%；P = 0.014），严重心力衰竭的发生风险降低37%（95%置信区间，20%至50%；P<0.001），需要住院治疗的充血性心力衰竭风险降低22%（95%置信区间，4%至37%；P = 0.019），复发性心肌梗死风险降低25%（95%置信区间，5%至40%；P = 0.015）。
在心肌梗死后无症状左心室功能障碍的患者中，长期服用卡托普利可提高生存率，并降低重大心血管事件导致的发病率和死亡率。在接受溶栓治疗、阿司匹林或β受体阻滞剂治疗的患者以及未接受这些治疗的患者中均观察到了这些益处，这表明卡托普利治疗可使部分心肌梗死幸存者的预后得到进一步改善。
