Baur L H, Schipperheyn J J, van der Wall E E, van der Velde E A, Schalij M J, van Eck-Smit B L, van der Laarse A, Voogd P J, Sedney M I, Reiber J H, Bruschke A V
Department of Cardiology, Leiden University Medical Center, The Netherlands.
Eur Heart J. 1997 Aug;18(8):1313-21. doi: 10.1093/oxfordjournals.eurheartj.a015444.
The present study was designed to evaluate the effects of early angiotensin converting enzyme (ACE) inhibition on left ventricular enlargement in patients with anterior wall infarction following reperfusion therapy.
Seventy-one consecutive patients with an anterior wall myocardial infarction were randomly allocated to enalapril (n = 36) or placebo (n = 35). All patients received either thrombolytic therapy (n = 46) or underwent primary coronary angioplasty (n = 25). Medication was started within 48 h admission to hospital and continued for 48 weeks. The process of left ventricular remodelling was assessed with two-dimensional echocardiography at 3 weeks and 1 year after the acute onset, and was related to the severity of the residual stenosis of the infarct-related artery.
Baseline left ventricular ejection fraction was 39.2% +/- 8.7%. During the study period left ventricular end-diastolic volume index increased from 48.2 +/- 9.9 ml.m-2 to 54.6 +/- 12.2 ml.m-2 at 3 weeks, and to 59.4 +/- 17.0 ml.m-2 after 1 year I control patients (P < 0.001). In the enalapril-treated patients, left ventricular end-diastolic volume index increased from 50.0 +/- 16.1 to 57.7 +/- 19.3 ml.m-2 at 3 weeks, and to 61.9 +/- 22.7 ml.m-2 after 1 year (P < 0.001). Both at 3 weeks and after 1 year, no overall differences in left ventricular volumes were observed between the enalapril and the placebo group (both ns). However, patients with a residual stenosis severity of > or = 70% in the infarct-related artery (n = 43) showed significant attenuation of remodelling by enalapril (n = 22) when compared to placebo (n = 21). In patients on enalapril, left ventricular end-diastolic volume index increased from 47.0 +/- 13.0 to 53.7 +/- 17.7 ml.m-2 compared to 48.0 +/- 9.6 to 60.3 +/- 16.3 ml.m-2 in control patients (P < 0.03). Also diastolic filling parameters were significantly improved in patients with > or = 70% residual stenosis.
In patients with an anterior wall infarction and a severe residual infarct-related coronary artery stenosis following reperfusion, treatment with enalapril prevents the process of left ventricular remodelling. As left ventricular dilatation is an early process we suggest that treatment with ACE inhibition should be started as soon as possible in this group of patients.
本研究旨在评估早期血管紧张素转换酶（ACE）抑制对再灌注治疗后前壁梗死患者左心室扩大的影响。
71例连续性前壁心肌梗死患者被随机分为依那普利组（n = 36）和安慰剂组（n = 35）。所有患者均接受溶栓治疗（n = 46）或直接冠状动脉成形术（n = 25）。在入院48小时内开始用药并持续48周。在急性发作后3周和1年时，用二维超声心动图评估左心室重构过程，并与梗死相关动脉残余狭窄的严重程度相关。
基线左心室射血分数为39.2%±8.7%。在研究期间，对照组患者左心室舒张末期容积指数在3周时从48.2±9.9 ml·m-2增加到54.6±12.2 ml·m-2，1年后增加到59.4±17.0 ml·m-2（P < 0.001）。在依那普利治疗的患者中，左心室舒张末期容积指数在3周时从50.0±16.1增加到57.7±19.3 ml·m-2，1年后增加到61.9±22.7 ml·m-2（P < 0.001）。在3周时和1年后，依那普利组和安慰剂组之间左心室容积均未观察到总体差异（均无统计学意义）。然而，梗死相关动脉残余狭窄严重程度≥70%的患者（n = 43）中，与安慰剂组（n = 21）相比，依那普利组（n = 22）的重构明显减轻。在接受依那普利治疗的患者中，左心室舒张末期容积指数从47.0±13.0增加到53.7±17.7 ml·m-2，而对照组患者从48.0±9.6增加到60.3±16.3 ml·m-2（P < 0.03）。残余狭窄≥70%的患者舒张期充盈参数也有显著改善。
在前壁梗死且再灌注后梗死相关冠状动脉严重残余狭窄的患者中，依那普利治疗可防止左心室重构过程。由于左心室扩张是一个早期过程，我们建议在这类患者中应尽早开始ACE抑制治疗。
