From the Guidelines
ACE inhibitors should be given in acute myocardial infarction (MI) to improve survival, particularly in patients with reduced left ventricular ejection fraction (LVEF), as they have been shown to reduce mortality, heart failure development, and recurrent MI 1.
Key Considerations
- ACE inhibitors should be started within the first 24 hours of an acute MI in hemodynamically stable patients, particularly those with anterior infarction, pulmonary congestion, or left ventricular ejection fraction less than 40% 1.
- Common ACE inhibitors used include captopril, enalapril, lisinopril, or ramipril, and should be started at low doses and gradually titrated upward as tolerated 1.
- Before initiating therapy, clinicians should check blood pressure, renal function, and potassium levels to minimize the risk of adverse effects 1.
- Angiotensin receptor blockers (ARBs) can be used as an alternative in patients who cannot tolerate ACE inhibitors due to cough or angioedema 1.
Benefits of ACE Inhibitors
- Reduce mortality rates in patients with MI or who recently had an MI and have LV systolic dysfunction 1.
- Improve long-term survival by preventing adverse cardiac remodeling and reducing afterload 1.
- Decrease the risk of heart failure development and recurrent MI 1.
Important Notes
- The use of ACE inhibitors in acute MI is supported by multiple studies, including the SAVE trial, which demonstrated a reduction in mortality, recurrent MI, and heart failure hospitalization in patients with LVEF <40% 1.
- The VALIANT trial showed that losartan was noninferior to captopril in patients with MI complicated by LVSD, HF, or both, providing an alternative option for patients who cannot tolerate ACE inhibitors 1.
From the FDA Drug Label
- 3 Reduction of Mortality in Acute Myocardial Infarction In hemodynamically stable patients within 24 hours of the onset of symptoms of acute myocardial infarction, give lisinopril tablets 5 mg orally, followed by 5 mg after 24 hours, 10 mg after 48 hours and then 10 mg once daily. The GISSI-3 study was a multicenter, controlled, randomized, unblinded clinical trial conducted in 19,394 patients with acute myocardial infarction (MI) admitted to a coronary care unit Patients randomized to lisinopril received 5 mg within 24 hours of the onset of symptoms, 5 mg after 24 hours, and then 10 mg daily thereafter.
Ace inhibitors are given in acute MI. The dosage is 5 mg orally within 24 hours of the onset of symptoms, followed by 5 mg after 24 hours, 10 mg after 48 hours, and then 10 mg once daily 2 2.
From the Research
Use of ACE Inhibitors in Acute Myocardial Infarction
- ACE inhibitors are given in acute myocardial infarction (MI) to improve survival and reduce morbidity, as demonstrated by several large-scale trials 3, 4, 5, 6.
- The benefits of ACE inhibitors in acute MI are thought to be due to their ability to reduce remodeling of the heart after infarct expansion, as well as their effects on preventing further myocardial infarction 7.
- Studies have shown that ACE inhibitors can reduce 30-day mortality by 7% compared to control subjects, with the greatest benefit observed in high-risk groups such as those with anterior MI, Killip class 2-3, and heart rate > 100 bpm at entry 3.
- The use of ACE inhibitors in acute MI has been increasing over time, with one study showing an increase from 14.0% in 1994 to 17.3% in 1996 5.
- Concomitant use of aspirin does not appear to affect the clinical benefits of ACE inhibitors in acute MI, with similar proportional reductions in 30-day mortality observed in patients taking aspirin and those not taking aspirin 6.
- The decision to use ACE inhibitors in acute MI should be based on individual patient characteristics, including the presence of heart failure, ventricular dysfunction, and other high-risk features 4, 7.