Renkin J
Division of Intensive Care, University of Louvain Medical School, St Luc University Hospital, Brussels, Belgium.
J Hypertens Suppl. 1996 Dec;14(6):S15-9.
Beneficial effect has been reported from angiotensin converting enzyme (ACE) inhibition after acute myocardial infarction (AMI) in several experimental and large clinical studies showing improvements in haemodynamics, left ventricular remodelling and mortality. However, this benefit has not been prospectively evaluated after AMI effectively reperfused using current coronary recanalization techniques.
The clinical relevance of reperfusion therapies including thrombolysis or percutaneous transluminal coronary angioplasty relates to their ability to limit infarct size and left ventricular dysfunction and reduce infarct-related morbidity and mortality. The clinical issue is to determine whether ACE inhibitors should be routinely proposed as an adjunct therapy in patients with a patent infarct-related vessel after AMI.
Three placebo-controlled randomized trials addressed this issue in evaluating the left ventricular remodelling process (i.e. left ventricular volumes and ejection fraction changes) during a 3 to 4-month follow-up period. The Captopril and Thrombolysis Study and the Captopril plus Tissue plasminogen activator after Myocardial Infarction trials failed to show any significant preventive effect of early captopril therapy on remodelling in patients admitted for anterior AMI and treated with conventional use of streptokinase and alteplase, respectively. In the Salvage from Perindopril in Reperfused Infarction Trial, no beneficial effect on global left ventricular remodelling was observed from perindopril therapy in a population with effective myocardial reperfusion confirmed at angiography and moderately depressed left ventricular function. However, in this study ACE inhibition seemed to favourably alter remodeling in a subgroup of AMI patients with anterior location and large infarct size despite successful reperfusion.
Recommendation for ACE inhibition as a routine adjunct therapy to reperfusion techniques is not supported by current data on short-term left ventricular function changes.
在多项实验和大型临床研究中，急性心肌梗死（AMI）后使用血管紧张素转换酶（ACE）抑制剂已显示出有益效果，包括血流动力学改善、左心室重构减轻及死亡率降低。然而，在采用当前冠状动脉再通技术实现有效再灌注的AMI后，这种益处尚未得到前瞻性评估。
包括溶栓或经皮腔内冠状动脉成形术在内的再灌注治疗的临床意义在于其限制梗死面积和左心室功能障碍以及降低梗死相关发病率和死亡率的能力。临床问题是确定AMI后梗死相关血管通畅的患者是否应常规使用ACE抑制剂作为辅助治疗。
三项安慰剂对照随机试验在3至4个月的随访期内评估左心室重构过程（即左心室容积和射血分数变化）时探讨了这一问题。卡托普利与溶栓研究以及心肌梗死后卡托普利加组织纤溶酶原激活剂试验未能显示早期卡托普利治疗对分别接受链激酶和阿替普酶常规治疗的前壁AMI患者的重构有任何显著预防作用。在培哚普利挽救再灌注梗死试验中，对于血管造影证实心肌有效再灌注且左心室功能中度降低的人群，培哚普利治疗未观察到对整体左心室重构有有益作用。然而，在这项研究中，尽管再灌注成功，但ACE抑制似乎对前壁梗死且梗死面积大的AMI患者亚组的重构有有利影响。
目前关于短期左心室功能变化的数据不支持将ACE抑制作为再灌注技术的常规辅助治疗的推荐。
