[How should ACE inhibitors be used in myocardial infarction?]

Based on the results of large clinical trials, ACE inhibitors are established as routine treatment after acute myocardial infarction accompanied by heart failure. Pathophysiologically, the benefit of ACE inhibitors has been attributed to an effect on remodelling of the left ventricle. In the past decade, it has been suggested that ACE inhibitors might have other important mechanisms of action and accordingly be useful for other conditions than those they have been used for until now.

We reviewed clinical studies of ACE inhibitors with special emphasis on the use of these agents in the acute phase of myocardial infarction and in the follow-up period. These studies were assessed together with the recently published Heart Outcomes Prevention Evaluation (HOPE) study.

In the HOPE study it was found that ACE inhibition protected against cardiovascular events in patients at high risk due to atherosclerotic disease, but without dysfunction of the left ventricle. The effect is most likely a retarding of the atherothrombotic process in the coronary arteries.

The latest results are important for clinical practice. Other post-infarction patients than those with myocardial failure may benefit from treatment with ACE inhibitors. We also discuss the timing of ACE inhibitor treatment, the importance of an adequate ACE inhibitor dose, and combination with other treatment regimens used in secondary prevention.