Opie L H
Cardiovasc Drugs Ther. 1994 Jun;8(3):469-72. doi: 10.1007/BF00877924.
Recent studies have strengthened the arguments for the use of angiotensin-converting enzyme (ACE) inhibitors in the early postinfarct period. Those with clinically detectable heart failure, and hence at highest risk, will benefit most, as shown in the AIRE study, but those at lower risk with left ventricular dysfunction still have some benefit, theoretically through ventricular remodeling. In patients in the very early stages of acute myocardial infarction, three trials have shown discordant results. In CONSENSUS-II, intravenous enalaprilat followed by oral enalapril gave no benefit, rather causing excess hypotension and a possible increase in mortality. In ISIS-4 and GISSI-3, mortality improved by 0.46% and 0.8%, respectively, with risk reductions of 9% and 11%. Added transdermal nitrate in GISSI-3 gave a total reduction of 17%. In view of the risk of hypotension (20% in ISIS-4, compared with placebo 10%), very early ACE inhibition will probably only be used for selected patients. Logically, one target group would be those seen 7-24 hours after the onset of symptoms, particularly 7-12 hours, at which time captopril alone gave a reduction of 14.5% in risk. These mortality differences compare favorably with those recently found when comparing tPA and streptokinase in the GUSTO study.
近期研究进一步支持了在心肌梗死后早期使用血管紧张素转换酶（ACE）抑制剂的观点。正如AIRE研究所示，那些临床上可检测到心力衰竭、因而风险最高的患者将获益最大，但左心室功能不全风险较低的患者理论上通过心室重塑也仍有一定益处。在急性心肌梗死极早期的患者中，三项试验得出了不一致的结果。在CONSENSUS-II研究中，静脉注射依那普利拉随后口服依那普利并无益处，反而导致过度低血压并可能增加死亡率。在ISIS-4和GISSI-3研究中，死亡率分别降低了0.46%和0.8%，风险降低了9%和11%。GISSI-3研究中加用经皮硝酸酯使总体风险降低了17%。鉴于存在低血压风险（ISIS-4研究中为20%，而安慰剂组为10%），极早期使用ACE抑制剂可能仅适用于特定患者。从逻辑上讲，一个目标人群是症状发作后7 - 24小时、特别是7 - 12小时就诊的患者，此时单独使用卡托普利可使风险降低14.5%。这些死亡率差异与近期GUSTO研究中比较tPA和链激酶时发现的差异相比具有优势。
