Nicolosi G L, Latini R, Marino P, Maggioni A P, Barlera S, Franzosi M G, Geraci E, Santoro L, Tavazzi L, Tognoni G, Vecchio C, Volpi A
GISSI-3 Coordinating Center, Milano, Italy.
Eur Heart J. 1996 Nov;17(11):1646-56. doi: 10.1093/oxfordjournals.eurheartj.a014747.
Left ventricular dilatation and a low ejection fraction after acute myocardial infarction are independent indicators of a poor prognosis. ACE inhibitors have been shown to decrease left ventricular dilatation after myocardial infarction. In the GISSI-3 trial, patients were randomly assigned, within 24 h of onset of myocardial infarction symptoms, to 6 weeks of treatment with lisinopril, nitroglycerin, both or neither, in an open, 2 x 2 factorial design. The study showed that early treatment in relatively unselected patients with lisinopril decreases mortality at 6 weeks and severe left ventricular dysfunction. We assessed (1) the prognostic value of pre-discharge 2-D echocardiographic variables, and (2) the effects of lisinopril on the progression of left ventricular dilatation.
2-D echocardiograms were available pre-discharge in 8619 GISSI-3 trial patients discharged alive. In 6405 of these patients, a 2-D echocardiographic study was also available at 6 weeks, and at 6 months. Pre-discharge end-diastolic and end-systolic volumes, and ejection fraction predicted 6-month mortality and non-fatal clinical congestive heart failure (P < 0.01). The increase in left ventricular volumes over time was significantly reduced by 6 weeks' lisinopril treatment in patients with wall motion asynergy pre-discharge of > or = 27%. Patients with wall motion asynergy < 27% showed no dilatation and lisinopril did not affect volumes at 6 months. Patients randomized to lisinopril also had smaller volumes after withdrawal of treatment at 6 weeks. Lisinopril did not affect left ventricular ejection fraction.
2-D echocardiography independently contributes to pre-discharge risk stratification in terms of 6-month mortality and clinical heart failure after myocardial infarction, and early, short-term treatment with lisinopril in unselected myocardial infarction patients attenuates left ventricular dilatation; an effect evident in patients with larger infarcts. These results probably only partly explain the effect of lisinopril on total mortality concentrated in the first week after infarction.
急性心肌梗死后左心室扩张和低射血分数是预后不良的独立指标。已证明血管紧张素转换酶抑制剂可减少心肌梗死后的左心室扩张。在GISSI-3试验中，心肌梗死症状发作后24小时内，患者被随机分配接受赖诺普利、硝酸甘油、两者联合或两者均不治疗，为期6周，采用开放的2×2析因设计。该研究表明，在相对未经过筛选的患者中，早期使用赖诺普利治疗可降低6周时的死亡率和严重左心室功能障碍。我们评估了（1）出院前二维超声心动图变量的预后价值，以及（2）赖诺普利对左心室扩张进展的影响。
8619例GISSI-3试验中存活出院的患者出院前有二维超声心动图检查结果。其中6405例患者在6周和6个月时也进行了二维超声心动图研究。出院前的舒张末期和收缩末期容积以及射血分数可预测6个月时的死亡率和非致命性临床充血性心力衰竭（P<0.01）。在出院前壁运动不协调≥27%的患者中，6周的赖诺普利治疗可显著减少左心室容积随时间的增加。壁运动不协调<27%的患者未出现扩张，赖诺普利在6个月时对容积无影响。随机接受赖诺普利治疗的患者在6周停药后容积也较小。赖诺普利不影响左心室射血分数。
二维超声心动图在心肌梗死后6个月死亡率和临床心力衰竭方面对出院前风险分层有独立贡献，在未经过筛选的心肌梗死患者中早期、短期使用赖诺普利可减轻左心室扩张；在梗死面积较大的患者中这种效果明显。这些结果可能仅部分解释了赖诺普利对梗死第一周集中出现的总死亡率的影响。
