Myocardial Infarction
Optimising Drug Therapy

• Check List for Drug Therapy

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• Clopidogrel
• Clopidogrel alone only slightly better than aspirin alone
• Clopidogrel with aspirin better than aspirin alone after an acute coronary event
• Clopidogel with aspirin probably is better than aspirin alone in stable coronary disease

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• Warfarin
• Warfarin- instead of (or as well as) aspirin for secondary prevention

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• Beta-blockers
• After MI
• After large MI
• In heart failure

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• ACE-inhibitors
• After MI
• After large MI
• Use maximal dosages in heart failure
• For most patients after MI

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• Aldosterone antagonists
• Spirinolactone in heart failure

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• Lipid modifying therapy after MI

ACE inhibitors post-myocardial infarction.

A number of trials have been done using ace-inhibitors post-myocardial infarction.

Before the publication of the HOPE trial many of us concluded that we could select patients that needed ace-inhibitor therapy based on occurrence of heart failure or assessment of left ventricular function, usually with echocardiography.

The TRACE study results gives us some idea of the magnitude of benefit from ace-inhibitor therapy in patients with a low ejection fraction after myocardial infarction. In this study, high risk patients were defined on the basis of echocardiography.

Like other studies the benefit of therapy (in this instance with trandalopril) was manifest within the first few weeks of treatment, the magnitude of benefit increased with longer follow-up. After 4 years the ACE group had a mortality of 34.7% and the placebo group 42.3%, the mortality curves diverged early. Only about twelve patients with an ejection fraction below 40% need to be treated for four years to prevent one death.

All subgroups seemed to benefit, including those on betablockers.

It is important that ace-inhibitor therapy is maximised over a few weeks in these high-risk patients who have the most to gain from this therapy.

The results of the HOPE and EUROPA trials indicates we should consider ace-inhibitor therapy in all patients with atherosclerotic disease.

Hitesh Patel, Cardiologist
2/6/04

Reference:
A clinical trial of the angiotensin converting enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction, NEJM 1995;333:1670-6