Improving outcome after acute myocardial infarction: what is the role of ACE inhibitors?

Acute myocardial infarction continues to be the number 1 killer in industrialised countries. While the more widespread use of thrombolytic therapy has made a dramatic impact on patient survival, changes in long-term prognosis after discharge from hospital have not improved radically and 5-year mortality remains at over 30%. The single most important determinant of survival in the long term is left ventricular function. The process of ventricular dilatation and remodelling begins early after infarction. While such changes may initially go unrecognised clinically, without intervention progressive functional impairment will ensue and the majority of patients will develop signs and symptoms of heart failure, which carries a worse prognosis than many forms of cancer. ACE inhibitors act on both the haemodynamic and neurohormonal mechanisms in heart failure. Several large-scale clinical trials have clearly demonstrated that early use of these agents in stable patients who are not hypotensive or in cardiogenic shock can reduce significantly the development of heart failure and death. A strategy for the early initiation of ACE inhibitor therapy is proposed to improve survival in AMI patients.