Sleight P
Cardiac Department, John Radcliffe Hospital, Oxford, England.
Am J Hypertens. 1994 Sep;7(9 Pt 2):102S-105S. doi: 10.1093/ajh/7.9.102s.
Although small trials had suggested unrealistically high benefits from the use of vasodilators in acute myocardial infarction (MI), there was considerable statistical uncertainty about these benefits. Angiotensin-converting enzyme (ACE) inhibitors are clearly beneficial for left ventricular dysfunction after MI, but it was uncertain whether there was risk (from hypotension) for some patients in the early hours of an MI. After the GISSI-3 and International Studies of Infarct Survival (ISIS-4) trials it is now clear that nitrates are safe, but used routinely the small mortality reduction was not statistically significant. In ISIS-4 the results with magnesium were disappointing, with a worrying small excess mortality. On the other hand, routine use of ACE inhibitors in this early phase showed a statistically significant 5 to 10% reduction in mortality. There was greatest benefit in those with more obvious left ventricular damage. Since it is not easy to identify all such patients in the first hours, a policy of initial treatment of all, then later reassessment, is safe and would produce the greatest overall benefit.
尽管小型试验曾表明，在急性心肌梗死（MI）中使用血管扩张剂能带来高得离谱的益处，但这些益处存在相当大的统计不确定性。血管紧张素转换酶（ACE）抑制剂对心肌梗死后的左心室功能障碍显然有益，但对于心肌梗死早期的一些患者而言，是否存在（因低血压导致的）风险尚不确定。在GISSI - 3和心肌梗死存活国际研究（ISIS - 4）试验之后，现在很清楚硝酸盐是安全的，但常规使用时死亡率的小幅降低在统计学上并不显著。在ISIS - 4中，镁的治疗结果令人失望，死亡率有令人担忧的小幅增加。另一方面，在这一早期阶段常规使用ACE抑制剂可使死亡率在统计学上显著降低5%至10%。在左心室损伤更明显的患者中获益最大。由于在最初几个小时内很难识别所有此类患者，因此先对所有患者进行初始治疗，然后再进行重新评估的策略是安全的，并且会产生最大的总体益处。
