Department of Medicine, Section of Cardiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
Am J Cardiol. 2010 May 1;105(9):1229-34. doi: 10.1016/j.amjcard.2009.12.032. Epub 2010 Mar 11.
Controversy exists regarding whether all patients with acute myocardial infarction (AMI) benefit from angiotensin-converting enzyme inhibitors (ACEIs). We examined the association between ACEI treatment and mortality in a large, unselected population of patients with AMI. The present study included 105,224 patients with AMI who were not treated with ACEIs on admission. A logistic regression analysis, including 33 variables, calculated a propensity score for each patient to estimate the probability of receiving ACEIs at discharge, given the background. The association between ACEI treatment at discharge and the 1-year outcome was evaluated in prespecified subgroups using the Cox regression analyses, adjusting for the propensity score and medications at discharge. A total of 38,395 patients (36.5%) received ACEIs at discharge. After adjustment, ACEI treatment was associated with a 24% reduction in mortality (relative risk 0.76, 95% confidence interval 0.73 to 0.80). The benefit was largest in patients with a history or present signs of heart failure. In patients without heart failure, a significant benefit of ACEI treatment was seen only in patients with renal dysfunction (relative risk 0.69, 95% confidence interval 0.54 to 0.88). In the whole group, the risk of AMI decreased by 7% (relative risk 0.93, 95% confidence interval 0.90 to 0.96), with a larger effect seen in patients with ST-segment elevation AMI or systolic left ventricular dysfunction. In conclusion, in unselected patients with AMI, ACEI treatment was associated with a reduction in 1-year mortality, mainly in patients with heart failure or renal dysfunction, and a small reduction in the risk of reinfarction, mainly in patients with ST-segment elevation AMI or systolic left ventricular dysfunction.
关于急性心肌梗死（AMI）患者是否均能从血管紧张素转换酶抑制剂（ACEI）治疗中获益，目前尚存争议。本研究旨在观察 ACEI 治疗与 AMI 患者死亡率之间的关系。
该研究纳入了 105224 例未在入院时接受 ACEI 治疗的 AMI 患者。采用包含 33 个变量的 logistic 回归分析计算每位患者出院时接受 ACEI 治疗的倾向评分，以评估背景因素对 ACEI 治疗的影响。采用 Cox 回归分析调整倾向评分和出院时的药物治疗后，在预设亚组中评估 ACEI 治疗与 1 年结局的相关性。
共有 38395 例（36.5%）患者在出院时接受 ACEI 治疗。校正混杂因素后，ACEI 治疗可使死亡率降低 24%（相对危险度 0.76，95%置信区间 0.73 至 0.80）。心力衰竭病史或现患心力衰竭的患者中 ACEI 治疗的获益最大。在无心力衰竭的患者中，仅肾功能不全的患者 ACEI 治疗具有显著获益（相对危险度 0.69，95%置信区间 0.54 至 0.88）。在全组患者中，AMI 风险降低了 7%（相对危险度 0.93，95%置信区间 0.90 至 0.96），ST 段抬高型 AMI 或左心室收缩功能障碍患者的获益更大。
综上，在 AMI 患者中，ACEI 治疗与 1 年死亡率降低相关，主要获益人群为心力衰竭或肾功能不全患者，与再梗死风险降低相关，主要获益人群为 ST 段抬高型 AMI 或左心室收缩功能障碍患者。
